Chapter 24 - Musculoskeletal

List things to ask when collecting subjective data

• recent weight gain? (more weight = more stress on joints)

• jaw pain? (possible TMJ issue)

• pain by joints/muscles?

• past injuries/surgeries?

• recent immunizations? (can cause temp joint stiffness)

• chronic diseases? (some increase risk of bone/joint issues)

• menopause hx? (increases osteoporosis risk)

• family hx?

• exercise + activity level?

• meds?

• smoking/alc/caffeine use? (increases osteoporosis risk)

• diet/nutrition?

• sun exposure?

• occupation?

• ADL limitations?

• hx of bone density testing?

Describe how bone vs fracture pain would feel

Bone pain - dull, deep, throbbing

Fracture pain - sharp, worsens w/ movement

What’s the difference b/w osteoarthritis and rheumatoid arthritis?

Osteoarthritis - unilateral joint pain, morning stiffness improving w/ movement

Rheumatoid arthritis - bilateral joint pain, swelling, prolonged morning stiffness

What is fribromyalgia?

widespread musculoskeletal pain w/ fatigue, sleep, or mood disturbances

What diseases increase the risk for bone and joint issues?

Diabetes, sickle cell anemia, lupus

What deficiencies increase the risk for osteoporosis?

reduced calcium and vitamin D

T/F - a sedentary lifestyle contributes to muscle atrophy and bone loss

True

What medications impact the musculoskeletal system?

Steroids - bone loss

Diuretics - electrolyte imbalance leads to muscle weakness

Statins - possible myopathy

What foods increase the risk for gout?

High purine foods and alcohol

What type of scan is the gold standard for diagnosing bone-related conditions?

DEXA scan (Dual-Energy X-ray Absorptiometry)

What is osteoporosis?

Low bone density that occurs when bone forming cells can’t keep pace w/ bone destroying cells (osteoclasts break down faster than osteoblasts can build)

What are some health promotion/prevention tips for osteoporosis?

• screening!! (dexa for females 65+ or anyone at risk)

• weight bearing exercise

• avoid smoking/secondhand smoke)

• increase calcium and vitamin D intake

Is bone loss obvious or a silent process?

Silent until first fracture occurs

Spinal fractures can cause what two things?

Height loss and kyphosis/dowager hump

What is plumb line posture?

Neutral standing alignment where a vertical line (plumb line) passes thru key bony landmarks, minimizing stress on muscles and joints

When inspecting posture, what are some objective data points to note?

• Kyphosis - exaggerated thoracic curve (common w/ aging)

• Lordosis - exaggerated lumbar curve (seen in preg, obesity)

• Scoliosis - lateral spinal curvature

• Flattened lumbar curve - maybe herniated disk

• Uneven hips - maybe unequal leg lengths

When inspecting gait, what are some objective data points to notes?

• uneven weight bearing

• inability to stand on heels or toes

• toes point inward or outward

• limping gait

• shuffling gait (maybe parkinsons - do further neuro assess)

• propulsive gait (leaning forward)

• wide-based gait

What tool can be used for ROM measurment?

Goniometer

When assessing the joints, what are some objective data points to notes?

• redness, heat, swelling - could mean inflammation or bursitis

• visible deformities

• TMJ weakness/pain/crepitus

• pain during squeeze test - could mean rheumatoid or psoriatic arthritis

• anatomic snuffbox tenderness - could mean scaphoid fracture

What are some major joint abnormal findings?

• Cysts (ganglion cyst)

• Fracture

• Rheumatoid arthritis

  • Boutonniere deformity

  • Swan-neck deformity

• Carpal tunnel syndrome

• Osteoarthritis

  • Heberden nodes

  • Bouchard nodes

What are some special tests done in the musculoskeletal assessment? And what do they test for?

• Straight leg raise (SLR): tests for herniated disc

• Leg length discrepancy: tests for scoliosis

• Phalen test + Tinel test: tests for carpal tunnel syndrome

• Ballottement test: assesses knee joint effusion

• Romberg test: assesses balance

What is the difference b/w active and passive range of motion (ROM)?

Active ROM - pt moves joint independently

Passive ROM - nurse moves joint for pt while pt remains relaxed; used when pt can’t move joint independently

What does active ROM vs passive ROM tell us?

Active ROM evaluates muscle + joint function

Passive ROM evaluates whether movement limitation is more related to joint restriction rather than muscle weakness

Limited active ROM but normal passive ROM may mean the problem is ______

muscle weakness

Both active ROM and passive ROM being limited may mean _____

joint stiffness, pain, or structural restriction

Describe the muscle strength grading scale

5/5 - normal strength; full active movement against full resistance

4/5 - slight weakness; active movement against some resistance

3/5 - moderate weakness, active movement against gravity only

2/5 - poor strength, movement possible only w/ gravity remove (passive assistance required)

1/5 - severe weakness, slight muscle contraction present but no movement

0/5 - paralysis (obviously), no muscle contraction detected

Describe key features of osteoarthritis

• gradual onset, usually begins later in life

• little or no swelling

• sx usually limited to one set of joints

• sx begin unilaterally then may spread b/c of compensation

• morning stiffness goes away with activity and lasts less than 1hr

Describe key features of rheumatoid arthritis

• rapid onset, can begin at any point in life

• autoimmune dx

• painful, swollen, stiff joints

• affects body symmetrically

• morning stiffness lasts longer than 1hr

Describe key features of gout

• sudden onset, often during night

• redness, pain at base of big toe

• limited ROM, development of tophi possible

• urate crystals accumulate in joint

• tx: ice, elevation, diet low in purines, exercise, NSAIDs, corticosteroids, meds that target uric acid production/excretion

What are some foods high in purine that ppl w/ gout should avoid?

• certain seafood (sardines, mussels, scallops)

• red meat

• beer

• sugary drinks

• certain veggies (asparagus, cauliflower, spinach, mushroom, green peas)

• certain legumes (beans, lentils, peas)

List major older adult considerations regarding the musculoskeletal system

• kyphosis common w/ aging

• increased fall risk d/t impaired sense of proprioception

• may have slower movements, reduced flexibility, decreased muscle strength, reduced tendon elasticity

• osteoporosis is more common

What are abnormal findings of the hands and wrists?

• acute rheumatoid arthritis

• ganglion cyst

• osteoarthritis

• tenosynovitis

• thenar atrophy

What are abnormal findings of the feet and toes?

• acute gouty arthritis

• flat feet (pes planus)

• callus

• corn

• hallux valgus

• hammer toe

• plantar wart

Gout commonly affects which toe? Why?

The 1st MTP joint - big toe

B/c the cooler temp in the big toe promotes uric acid crystal deposition AND the microtrauma that occurs while walking further irritates the joint