Skeletal MedSurg

Care of the Patient with Musculoskeletal Disorders

Instructor: Jennifer Knowlton, MSN, RN

Date: 2/26 Revised

Review of Anatomy & Physiology

  • The skeletal and muscular systems work together to help the body move.

Skeletal System

  • Components:

    • Bone Tissue
    • Cartilage
    • Fibrous connective tissue, including ligaments which connect one bone to another

  • Functions:

    • Protects organs from injury.
    • Flat and irregular bones contain and protect red bone marrow
    • Long bones contain yellow bone marrow (mostly fat, serving as stored energy)
    • Acts as a storage site for excess calcium

Muscular System

  • Components:

    • Skeletal muscle
    • Fibrous connective tissue (tendons that connect muscle to bone)
    • Fascia

  • Functions:

    • Moves the skeleton
    • Contributes to heat production
    • Assists blood return from the legs through muscular compression on the leg veins

Synovial Joints

  • Articular Cartilage:

    • Lines each joint surface to provide a smooth surface.

  • Joint Capsule:

    • Contains synovial fluid.

  • Bursae:

    • Many synovial joints have bursae, which are sacs of synovial fluid located between the joint and tendon, facilitating tendon movement.

Nursing Assessment

History Assessment

  • Inquire about:
    • Pain
    • Altered sensation (paresthesia)
    • Injury/trauma
    • Disease process
    • Nutrition
    • Medications
    • Personal/social/family history

Inspection

  • Check for:
    • Posture
    • Gait
    • Deformity
    • Range of motion

Palpation

  • Evaluate:
    • Temperature
    • Swelling
    • Nodules
    • Muscle strength
    • Crepitus
    • Tenderness

Fall Assessment

  • Check if the fall was related to:
    • Dizziness, orthostatic hypotension, drug interactions, rushing to bathroom (UTI or diarrhea?), or sensory difficulties (seeing or hearing)
    • Motor vehicle accident or other trauma.
    • Consider the whole patient.

Post-Fall Assessment

  • Investigate post-fall:
    • Are there any undetected internal injuries?
    • Assess the affected part: compare with the opposite side and check for neurovascular impairment (CSM - Circulation, Sensation, and Movement), including capillary refill.

Six P’s of Neurovascular Damage

  • Signs of nerve and blood supply damage:
    • Pallor
    • Pulse changes
    • Paresthesia
    • Pain
    • Paralysis
    • Poikilothermia
  • Also assess for edema and anatomical deformities using anatomically correct terminology (e.g., external rotation, internal rotation, flexion).

Ambulation Assessment

  • Evaluate:
    • Posture
    • Gait
    • Assistance needs (1, 2, or 3 devices)

Pain and Discomfort Assessment

  • Assess regarding:
    • Relation to underlying disorder
    • Immobility-related pain
    • Pain from treatment complications.

Pain Characteristics

  • Location, intensity, quality, and aggravating/soothing factors:
    • Muscle pain: aching/soreness
    • Bone pain: aching/boring
    • Bony prominence pressure: burning.

Behavioral Changes Assessment

  • Changes may result from:
    • Pain, undiagnosed head injuries, immobility, or complications
    • Altered sensory perception from immobilization can lead to misjudging distances.

Skin Assessment

  • Skin related to immobility:
    • Report petechiae: tiny dark red pinpoints that may develop on the chest or trunk, indicating fat embolism.

Laboratory Tests

  • Alkaline Phosphatase:

    • Elevated levels may indicate bone tumors or healing fractures (Highly specific marker of bone-forming activity of osteoblasts).

  • Erythrocyte Sedimentation Rate (ESR):

    • Indicates inflammation.

  • Calcium and Phosphorus Levels:

    • Responsible for maintaining proper bone rigidity and density.

  • Uric Acid:

    • Measures end product of purine metabolism, relevant for gout diagnosis.

  • Rheumatoid Factor:

    • Used to detect rheumatoid arthritis.

  • Muscle Enzymes:

    • Creatine Kinase (CK-MM) indicates muscle damage.

Diagnostic Studies

Standard Imaging

  • X-ray:

    • Basic imaging for fractures and structural abnormalities.

  • Bone Density Scans:

    • Identify bone strength and risk of osteoporosis.

  • Computed Tomography (CT) Scan:

    • Focuses on specific slices of bone or soft tissue, with or without contrast.

  • Magnetic Resonance Imaging (MRI):

    • More accurate than CT for soft tissue, uses electromagnets, conducted with or without contrast.

Special Imaging

  • Myelogram:

    • Dye injected into the subarachnoid space for spinal cord visualization.
    • Post-procedure care:
    • Lie down for 2-4 hours after
    • Do not lie flat for 24 hours (Head of Bed 30-45 degrees)
    • Monitor for headaches and increase fluid intake.

  • Nuclear Medicine Scans (Bone Scan):

    • Utilizes radioactive material to visualize bones and tissues.
    • Used to detect metastatic disease, osteomyelitis, and unexplained bone pain
    • “Hot spots” indicate irregularities in bones.

  • Arthrocentesis:

    • Aspiration of synovial fluid for analysis
    • Patient education includes care instructions for open wounds and potential corticosteroid injection.

  • Arthroscopy:

    • Surgical procedure usually performed under local anesthesia, often as an outpatient procedure.
    • Post-op Restrictions:
    • Mobility restrictions to be provided at discharge.

  • Nerve Conduction Studies (EMG):

    • Measures electrical impulses in muscles to diagnose diseases or nerve damage.
    • No prep needed for patients, but slight discomfort is common.

Traumatic Injuries

Strains

  • Definition: Injury to a muscle or tendon when stretched or pulled beyond capacity.
    • Severity:
    • Mild, Moderate, Severe.

Sprains

  • Definition: Injuries to the ligaments surrounding a joint, often caused by twisting movements.