Chapter 21

Musculoskeletal basic

• Tendons

  • Connects muscle to bones

Muscle types

• Skeletal muscles

  • Called voluntary muscles

    • Control body movements by contracting and relaxing

      • aka you can control these muscles

  • Skeletal muscles work together

    • one muscle moves the bone in one direction, other moves it back

      • ex: biceps, you can flex and contract when you bend at the elbow

        • Flexion

          • Act of bending or condition of being bent

          • Makes angle smaller

        • Extension

          • Increases angle between parts of body at joint

        • Adduction

          • Moving body part away from midline of body

• Smooth Muscles

  • Involuntary muscles

    • Controlled automatically, not under person’s conscious control

  • Make up walls of organs, such as bladder and uterus

  • Has ability to stretch without putting much stress on muscle

• Cardiac muscles

  • Involuntary muscles

  • Found only in heart

  • Contract and relax between 60-100 bpm

Bones

• Long bones

  • Rigid connective tissues that make up skeleton

  • Long bones include:

    • humerus

    • femur

• Short bones

  • Short bones include:

    • Carpals

    • Tarsals

• Flat bones:

  • Flat bones include:

    • Sternum

    • Scapula

    • Cranial

• Irregular bones

  • Irregular bones include:

    • Vertebrae

Joints

• Joints

  • Found where two bones come together (articulate)

  • Provide movement and flexibility

• Immovable joints

  • Unable to move these joints

    • Bones of cranium

      • Joints of skull bones are called sutures

• Slightly movable joints

  • Bones that allow for limited range of motion between connected bones

    • Pubic joint during childbirth

• Movable joints

  • Able to Move joints without much limited range of motion

  • Include:

    • Hip and shoulder joints

      • ball-socket joints

    • Elbow and knee joints

      • hinge joints

Function of musculoskeletal system

• Shape and form to body

• Maintain posture

• Permits movement

• Protects internal organs

• Stores calcium and phosphorus

• Produces heat

• Produces some blood cells

Changes in the musculoskeletal system due to aging

• Why changes

  • Joints undergo degenerative changes

  • Results in stiffness, pain and loss of range of motion

• Muscles weaken and lose tone

• Bones lose calcium

  • Bones become porous and brittle

• Joints are less flexible and stiffer

  • Slows normal body movements and decreases range of motion

• Height is gradually lost

  • Due to shrinkage of space between vertebrae of spine

• Loss of muscle mass

  • Causes weight loss

Common disorders of musculoskeletal system

• Muscular Dystrophy (MD)

  • Hereditary, progressive disease

  • Causes various disabilities

    • Muscle atrophy

      • Muscles waste away

      • Decrease in size of muscles and weakness

    • Muscular dystrophy

      • Causes weakness, stiffness, and twitching of hands and arms

      • People with MD might be confined to a wheelchair

  • MD is a genetic disorder caused by a specific gene

    • Generally appears at birth/during childhood

    • Duchenne’s MD is more common in males

    • No cure for MD

  • Care for people with MD

    • Allow time for movement

    • Give frequent skin care to prevent ulcers

      • People with MD might not get up as much, creating higher risk of pressure ulcers

    • Reposition residents often to prevent contractures

      • Contracture: permanent shortening of connective tissue

    • Perform range of motion exercise

    • Assist with ADLs while encouraging independence

  • What to report to the nurse

    • Red skin

    • Pale skin

    • Signs of beginning of pressure ulcer

    • Stiffness in muscles

    • Pain, swelling, burning in legs

    • Swallowing problems

    • Symptoms of UTI

    • Constipation

    • Pneumonia

    • Shortness of breath

    • Change of BP

    • Pulse changes

• Pressure ulcer stages

  • Stage 1:

    • Intact skin with redness of localized area

    • Dark pigmented skin might not have visible blanching

      • Color would differ from surrounding area

  • Stage 2:

    • Partial thickness

    • Loss of dermis

    • Shallow opening

    • Ulcer with red pink wound bed without slough

      • Could also present as intact or open/ruptured serum-filled blister

  • Stage 3:

    • Full thickness and tissue loss

    • Subcutaneous fat might be visible, bone, tendon, or muscles are not exposed

    • Slough may be present, doesn’t obscure depth of tissue loss

    • Might include undermining and tunneling

  • Stage 4:

    • Full thickness

    • Tendon or muscles exposed

    • Often includes undermining and tunneling

• Osteoporosis

  • Condition where bones lose density

  • Causing bones to be brittle and easily broken

    • Caused by:

      • Lack of calcium in diet

      • Loss of estrogen

      • Lack of regular exercise

      • Reduced mobility

      • Age

  • More common in women

    • Signs and symptoms:

      • Lower lack pain

      • Loss of height

      • Fractures

      • Stooped posture

    • Osteoporosis treatment:

      • Medication

        • Take weekly, monthly, or yearly

        • Comes in pill or injectible form

        • Oral medication requires that person to remain upright for 30-60 minutes after taking

      • Exercise:

        • Allowing resident enough time to move

        • Resident must be repositioned carefully

        • Encourage ambulation and keep canes/walkers close by

        • Any decline in activity or movement should be reported to nurse

      • Supplements:

        • Calcium and VD

• Osteopenia

  • Bones lose density

  • Not enough to be classified as osteoporosis

• Arthritis

  • Inflammation of joints

  • Decreased mobility may also result

• Osteoarthritis (OA)

  • Also called degenerative arthritis/degenerative joint disease (DJD)

  • Familary common

  • Cushiony cartilage between bones and pads at end of bones begins to slowly erode

  • Cartilage also loses elasticity

  • Without padding of cartilage, bones begin to rub together

  • Causing:

    • Pain

    • Redness

    • Swelling

    • Stiffness

    • Limited motion

  • If condition worsens, area may become deformed

  • Typically occurs with aging 

    • Also due to previous joint injury

  • Affects weight bearing joints:

    • Hips and knees

    • Joints in fingers

    • Thumbs

    • Spine

  • Cold, damp weather can increase pain and stuffiness

• Rhumatoid Arthritis

  • Form of arthritis that may become crippling

    • Affects special membrane that lines joint capsule called synovial membrane

    • Causing:

      • Stiffness

      • Swelling

      • Intense pain

      • Deformities that can be severe and disabling

    • Stages of Rhumatoid Arthritis:

      • Stage 1:

        • Bodily mistakenly attacks joint tissue

      • Stage 2:

        • Body makes antibodies and joints begin to swell up

      • Stage 3:

        • Joints become bent and deformed

        • Fingers become crooked

        • Misshapen joints can press of nerves and cause nerve pain

      • Stage 4:

        • If not treated, no joint remains at all, joint is essentially fused

    • Symptoms:

      • Fever

      • Fatigue

      • Weight loss

      • Synovial membrane may become destroyed

      • Occurs when joint becomes fixed and unable to move

      • Develops in middle age, but can affect all ages

    • Treatment

      • Rest and controlled exercise

      • ROM exercises

      • Anti-inflammatory meds

        • ibuprofen

      • Pain releiving meds

      • Heat medication

      • Joint replacement (with serious deformity)

    • Care guidelines for arthritis

      • Assist with exercise program

      • Let nurse know before exercise if pain meds are needed

      • Be positive and supportive

      • Report pain, stiffness, swelling, reduced ability to perform ROM exercises, or decline in activity

• Fibromyalgia

  • Disorder with no absolute cause

  • Can occur before surgery, infection, or extreme stress

    • Symptoms:

      • Widespread pain

      • Fatigue

      • Sleep disturbances

      • Problems with thinking and memory

      • Depression

  • Cannot be cured

    • Treatment:

      • Meds

      • Exercises

      • Complementary and alternative therapies

• Bursitis:

  • Bursae (Tiny sacs of fluid found near joints) becomes inflamed

  • Tissues around joint may become painful, swollen, and tender.

  • Joints most affected:

    • Shoulder

    • Elbow

    • Hip

    • Knee

  • Treatments:

    • Application of ice

    • Immobilization to rest of joint

    • Use of anti-inflammatory and pain meds

    • Removing fluid from joint with needle might be necessary

    • Cortisone injection

    • Risky for infection, antibiotics may be ordered

• Amputation

  • May be necessary due to:

    • Disease

    • Diabetes

    • Cancer

    • Injury

    • Traumatic events

      • Car accidents or working with machinery

  • Post op:

    • May close immediately or left open for a few days

  • Prosthesis

    • Artificial devides replacing a body party

      • Used to improve function/appearance

      • Created specifically for each amputee

      • Can take weeks to make and costs tens of thousands of dollars

      • People who have stumps may require special wheelchairs

  • Transplants of body parts

    • One serious complication of transplants is rejection of surgically-attached part

    • May need meds for rest of life to prevent rejection of transplanted body part

      • Immuno blockers

  • Guidelines for amputation and prosthesis care

    • Be careful when handling prostheses

    • Apply special compression bandages or stump shrinkers as ordered

    • Change socks often and Place sock seams facing outside to prevent abrasions

    • Give regular skincare to avoid complications with stump

    • Clean and dry socket of prosthesis when removed

    • Before applying prosthesis, make sure areas is completely dry

    • Report:

      • Redness or swelling

      • Drainage

      • Bleeding

      • Sores

      • Stump phantom pain/sensation

      • Reduced ability to move extremity

      • Cyanosis

      • Problems with prostheses

  • Pillows cannot be used under/between limbs of amputees

Fractures

• Fracture

  • Usually caused by Trauma or accident

  • Can occur spontaneously due to diseases such as osteoporosis

  • Elderly are more prone to falling

  • Falling is common cause

  • Fracture types:

    • Closed/simple:

      • Skin is closed

      • Bone is in place

    • Hairline:

      • Skin is closed, bone has fine line in it

    • Open/compound:

      • Skin is open

      • Bone may come through skin

    • Greenstick:

      • Skin is usually closed

      • Fracture is incomplete    

        • Only one side of bone is broken

    • Comminuted:

      • Skin is open or closed

      • Bone is fractured in two or more separate places

    • Compression

      • Fracture occurs in spine

      • Skin usually closed

• Pathological fracture

  • Fracture occurring due to bone weakened by disease

  • Causes:

    • Tumors

    • Metastatic cancer

    • Infection

• Important point about fractures

  • Symptoms:

    • Pain

    • Swelling

    • Bruising

  • Generally diagnosed by X-ray or MRI scan

  • Treatment:

    • Bone must be set in place

    • Heals in normal alignment

  • Takes 4-8 weeks to heal

    • Elderly take longer

Healing/Protocols

• Sling

  • Bandage/piece of material suspended from neck

  • Made for Holding and supporting a forearm

    • Helps reduce swelling by keeping arm elevated

    • NA should make sure arm is comfortable and properly elevated

• RICE protocol

  • R:

    • Rest

      • Don’t put weight on injury

  • I:

    • Ice

      • Put ice using towel

      • Don’t put ice directly on skin

      • 20 min on, 20 min off

  • C

    • Compress

      • Hold extremity in place

      • Can use elastic bandage

  • E:

    • Elevate

      • Prevents and reduces swelling

      • Put above level of heart

• Elastic bandages

  • Deep dressing in place

  • Compression

  • Provides protection

  • Decreases swelling from injuries

  • Must be wrapped around snugly

  • Must be smooth and wrinke-free

  • Applying elastic bandages:

    • 1. Identify yourself

    • 2. Wash hands

      • 2a. Explain procedure to resident

    • 3. Provide privacy

    • 4. Adjust bed to safe level

    • 5. Avoid trauma of pain

    • 6. Assist resident into Supine position

      • Supine means flat on back

    • 7. Expose only part to be bandaged

    • 8. Wrap extremity from beginning at spot furthest from heart

      • Returning circulation towards heart, allowing fluid to flow to heart and out of area

    • 9. Wrap bandage once around beginning spot, turn over tip so anchor is made

    • 10. Wrap once more where anchor lies, then slowly wrap overlapping spirals up extremity

    • 11. Smooth out entire bandage, remove wrinkes

    • 12. Secure bandage with pin

    • 13. Straighten all lines

    • 14. Remove and reapply bandage as needed

    • 15. Make resident comfortable

    • 16. Return bed to lowest position

    • 17. Leave call light within residents reach

    • 18. Wash hands

    • 19. Report any changes to nurse, including:

      • Changes in temperature

      • Color skin

      • Resident comments sensation changes

• Cast care

  • Pad edges as needed

  • Don’t get cast wet, keep dry

  • Extremity might need to be elevated

  • Help with ROM as needed

  • Allow movement time

  • Assist with use of cane, walker, or crutches

• Bed cradle

  • Reduces pressure from bed linens

• Compartment syndrome

  • Tight dressings/closure of fascial defect

  • Pressure from extremity expands, causing circulation to be cut off

  • Report nurse immediately

    • Numbness

    • Tightness

    • Increased swelling

    • Complains cast is too tight

    • Pain

    • Burning

    • Pressure

    • Cyanosis

    • Pale skin

    • If resident uses sharp object inside cast

Replacements/Treatment

• Total Hip Replacement (THR)

  • Surgical replacement of head of femur and socket

  • Can’t be adducted more than 90 degrees

• Total knee replacement guidelines

  • Apply special stockings to prevent blood clots

  • Don’t perform exercises unless trained and ordered

  • Assist with coughing and deep breathing exercises as ordered

  • Encourage fluids to Prevent UTIs

  • Ask nurse for pain meds prior to moving/positioning

• (Total knee replacement)Notify Nurse immediately if:

  • Incisions are red, draining, bleeding, or warm

  • Increase in pain/burning sensation

    • Especially on operated side or in calves

  • Fever or other change in vital signs

  • Numbness or singling

  • Edema of leg

  • Cyanosis

  • Reduced mobility in extremity

• Continuous passive motion (CPM) Machines

  • May be used for those who have had total knee replacements

  • Move joints with ROM

  • Notify nurse if resident complains of pain/discomfort or if extremity moves out of proper place

• Traction

  • Method of keeping bones in place after fractures

  • Weights and pulleys keep bones in place

  • Report numbness or tingling

Weight bearing

• Full weight-bearing

  • Resident can bear full weight on both legs

• Partial weight-bearing

  • Resident is able to support some body weight on one/both legs

• None-Weight Bearing

  • Resident unable to touch floor or support any body weight