Musculoskeletal Nursing Lecture & Lab Logistics – Comprehensive Study Notes

Upcoming Schedule, Exams & Remediation

• Monday
  • Doctor-test + Pharm B remediation collected by substitute.
  • Afternoon: Complete Formative “Prophet/Profit” assignment (≈45 Qs).
• Thursday (same week)
  • Return to take the class exam covering current unit.
• When faculty returns (following Monday)
  • Begin Neuro & Sensory units consecutively.
  • Practical Lab (must meet clock-hour requirements) integrated into these units.

Lab/Practical Check-Off Plan (Neuro vs. Sensory)

• Half the class: Neuro assessment with focus on the 12 cranial nerves.
• Other half: Sensory assessment (eyes & ears).
• Assignment to system = random draw “from a hat.”
• Testing logistics
  • Morning: practice → instructor sign-off → afternoon/evening test-off.
  • High enrollment ⇒ may spill into lunch or after-school slots.
  • Faculty split: Lead instructor will grade Neuro; Ms. Anderson grades Sensory.
• Students may need to practice during lunch/after class—plan ahead.

Class Culture & Advising

• High anxiety acknowledged—“calm yourselves.”
• Mid-term grade checks begin after 3rd–4th test; 5–10 min one-on-one conferences if needed.
• Students encouraged to self-reflect early if grades lag.

Musculoskeletal System: Anatomy & Physiology Review

• Skeletal tissues
  • Bone: osteocytes, periosteum, collagen matrix, calcium-phosphate salts.
  • Cartilage: cushions bone-to-bone articulations.
  • Ligaments: bone ↔ bone.
  • Tendons: muscle ↔ bone.
  • Fascia: tough membrane supporting muscles & tendons.
• Muscular tissue (≈30\text{–}40\% body mass)
  • Voluntary (skeletal) muscles drive movement.
  • Produce heat via shivering & activity.
  • Aid venous return from lower extremities (“muscle pump”).
• Synovial joints
  • Lined with synovial membrane; filled with synovial fluid & bursae → friction reduction.
  • Susceptible to infection (e.g., MSSA → synovitis) & degeneration (bone-on-bone).
• Axial skeleton highlights
  • 8 cranial bones protecting brain.
  • Vertebral column: cervical → thoracic → lumbar → sacral → coccygeal; normal curves vs. scoliosis/kyphosis/lordosis.
  • Thoracic cage: 12 rib pairs + sternum shielding heart, lungs, liver, spleen.

Core Functions of the Musculoskeletal System

• Protection (skull, rib cage).
• Mobility & posture.
• Hematopoiesis (within marrow).
• Mineral storage (primary depot for Ca²⁺ & Pᵢ).

Hormonal & Nutritional Influences

• Bone growth regulators
  • Growth hormone, thyroxine (T₄), sex steroids (estrogen/testosterone).
• Required nutrients: Ca²⁺, vitamin D, vitamin A, vitamin C, phosphorus, magnesium.
  • Good sources: dairy, salmon, leafy greens (spinach, kale, collards), fortified milk.
  • \text{Ca}^{2+} absorption enhanced in presence of vitamin D (sunlight or supplements).

Aging-Related Changes

• Bone: ↓ density, ↑ porosity (osteopenia → osteoporosis) especially post-menopausal women (↓ estrogen).
• Muscle: ↓ mass & strength; slower contraction/relaxation.
• Connective tissue: ↓ elasticity of ligaments/tendons/cartilage → stiffness, ↓ ROM.
• Posture/Gait: kyphosis, shortened stature (↓ inter-vertebral space).
• Functional outcomes: impaired mobility, pain, ↑ fall & fracture risk.

Concept Focus: Mobility vs. Immobility

• Hazards of immobility
  • Contractures, muscle atrophy, joint stiffness.
  • Venous stasis → \text{DVT}/\text{VTE} risk & possible fat embolus after long-bone Fx.
  • ↓ pulmonary expansion, pressure ulcers, constipation.
• Contributing situations
  • Fracture, severe pain, neurological deficits, obesity, amputation, chronic illness.
  • Electrolyte imbalance (e.g., hyponatremia → weak nerve firing).
• Nursing goals: promote safe mobility, manage pain, teach ROM, assistive devices, fall prevention.

Subjective Data Collection

• Chief complaint: mechanism of injury (fall, MVC, sports, occupational, assault).
• Pain history: onset, character, intensity, aggravating/relieving factors, meds taken.
• Functional inquiry: ADL limits (bathing, cooking, walking, lifting).
• Occupation & recreation: repetitive lifting (warehouse, nursing), prolonged driving, athletics → specific injuries.
• Family history: osteoporosis, osteoarthritis (DJD), rheumatoid arthritis, scoliosis, muscular dystrophies, sarcomas.
• Nutritional & lifestyle: Ca²⁺/Vit D intake, smoking (impairs bone), ETOH, obesity.
• Medication review
  • Bone-affecting: steroids, statins (myopathy), diuretics (electrolyte loss), anticoagulants (bleeding risk), chemotherapy, bisphosphonates, hormones.

Objective Physical Assessment (Head-to-Toe)

• INSPECTION
  • Posture, symmetry, deformities, swelling, discoloration, muscle wasting, assistive devices.
  • Gait analysis: speed, stride, arm swing, balance, use of aids.
• PALPATION
  • Bones/joints: tenderness, crepitus ("click" = bone-on-bone), warmth, edema.
  • Muscle tone & bulk.
• RANGE OF MOTION (ROM) & STRENGTH
  • Active & passive ROM; grade strength 0\text{–}5.
  • Functional tests: grip squeeze, push/pull against resistance, plantar/dorsi-flexion.
• NEUROVASCULAR (CMS) CHECK
  • Color (pallor/cyanosis), Motion (wiggle digits, ROM), Sensation (numbness, tingling).
  • Pulses: femoral, popliteal, posterior tibial, dorsalis pedis, radial, ulnar; compare bilaterally.
  • Capillary refill < 3\text{ s}.
  • Temperature (cool = poor perfusion).

Common Disorders & Key Points

• Osteoporosis
  • Risk factors: female, >50\,y, Caucasian/Asian, family hx, small frame, smoking, alcohol, low Ca²⁺/Vit D, sedentary, steroids, thyroid excess.
  • Prevention: DEXA scan >50\,y, weight-bearing exercise, Ca²⁺/$VitD$, bisphosphonates (e.g., alendronate/Fosamax – take AM, full glass H₂O, sit upright ≥30\text{ min}).
• Osteoarthritis (DJD)
  • Risk factors: age, obesity, joint overuse/trauma, genetics; NOT systemic inflammation.
  • Sx: pain ↑ with use, morning stiffness <30\text{ min}, crepitus.
• Gout (gouty arthritis)
  • Hyper-uricemia >8\,mg/dL; uric acid crystal (tophi) deposition, typically 1st MTP joint; red, hot, swollen, exquisitely tender.
  • Tx: allopurinol (maintenance), colchicine (acute), NSAIDs, ↓ purine diet, ↑ hydration.
• Osteomyelitis
  • Bone infection (often Staph) → requires 6\text{–}8 wk IV antibiotics; monitor WBC, ESR, CRP.
• Synovitis / Septic joint
  • Immediate arthrocentesis + IV antibiotics.
• Rhabdomyolysis
  • Severe muscle breakdown → ↑ myoglobin (>70\,ng/mL) → tea-colored urine, risk AKI.
  • Tx: aggressive IV NS \ge 200\,mL/h (unless HF), monitor CK, K⁺, renal labs.
• Emergent vascular complications after fracture
  • Absent pulse, cool extremity, ↑ pain, paresthesia → notify provider (compartment syndrome/fat embolus risk).

Diagnostic Studies & Normal Values

• Blood Labs
  • Calcium 8.0\text{–}10.0\,mg/dL (hypercalcemia → lethargy, ↓ DTRs, N/V).
  • Phosphorus 2.5\text{–}4.5\,mg/dL (often inverse to Ca²⁺).
  • Alkaline Phosphatase (ALP): \approx 25\text{–}140\,U/L (↑ bone turnover or liver Dz).
  • Creatine Kinase (CK-MM): ↑ with muscle injury; CK-MB for cardiac.
  • Myoglobin \le 90\,ng/mL; peaks 8–12 h post-injury.
  • CRP/ESR: nonspecific inflammation.
  • Uric Acid: Men 4.4\text{–}7.6, Women 2.3\text{–}6.6\,mg/dL.
• Imaging & Procedures
  • Plain radiograph: fracture, alignment.
  • CT ± contrast (assess iodine allergy vs. seafood myth; premedicate with Benadryl if prior reaction).
  • MRI (no metal). Good for soft tissue, ligaments, herniated discs.
  • DEXA (bone density): T-score ≥-1 normal, -1 to -2.5 osteopenia, <-2.5 osteoporosis.
  • Bone Scan (nuclear: thallium/gallium) → metastasis, occult Fx, osteomyelitis.
  • Ultrasound: tendon tears, effusions.
  • Arthrocentesis: aspirate synovial fluid → cell count, crystals, culture.
  • Arthroscopy: scope & repair inside joint.
  • EMG/NCV: evaluates electrical conduction (e.g., carpal tunnel – median nerve).
  • Bone marrow biopsy (posterior iliac crest) for malignancy work-up.

Medications & Their Musculoskeletal Impact

• Bisphosphonates (alendronate): strengthens bone, GI/esophageal precautions.
• Steroids: chronic use → bone loss, muscle wasting.
• Statins: risk myopathy/rhabdomyolysis.
• Diuretics: electrolyte shifts (K⁺, Ca²⁺) → cramps, weakness.
• Anticoagulants/Antiplatelets: monitor for bleeding in casts, bruising, petechiae.
• Pain control: NSAIDs (watch renal/GI), opioids (fall risk, constipation).
• Gout agents: allopurinol, colchicine.
• Vitamin/Mineral supplements: Ca²⁺ 500–600 mg per dose (max absorb), Vit D 800\text{–}1000\,IU daily.

Nursing Interventions & Patient Education

• Safety
  • Remove loose rugs, improve lighting, use grab bars; Life-Alert for elders.
  • Teach body mechanics, use of gait belt, lifts.
• Cast/Splint Care
  • Plaster: heavy, takes 24\text{–}72\,h to dry; handle with palms.
  • Fiberglass: lighter, dries within 30\text{–}60\,min, breathable.
  • Elevate, ice first 24–48 h, CMS checks q1\text{–}2 h, never stick objects inside.
• Traction/External Fixator
  • Maintain weights free-hanging, pin-site care.
• Post-Op/Immobilized Pt
  • DVT prophylaxis: Lovenox, SCDs, early mobilization, hydration.
  • Monitor for fat embolus (long-bone Fx): SOB, petechiae on chest, neuro changes.
• Pain & Mobility
  • Pre-medicate before PT/ROM.
  • Teach walker/cane: cane on strong side; stairs “up with the good, down with the bad.”
  • Encourage weight-bearing exercise as tolerated (walking, resistance bands, water aerobics).
• Nutrition
  • Adequate protein (post-op), calcium/vit D, hydration (esp. gout, rhabdo).
• Monitoring Labs & Red Flags
  • Rising Ca²⁺, CK, or myoglobin; falling Hgb (bleed); absent pulses, cool limb → call HCP.

Sample NCLEX-Style Priorities Reviewed

• Absent distal pulse, cool extremity after fracture = emergency (possible compartment syndrome)
• Seafood allergy ≠ absolute CT contrast contraindication; ask about prior iodine contrast reaction.
• Muscle strength tests: grip squeeze, foot push against resistance (NOT blinking/coughing).
• In geriatrics: expect ↓ muscle mass & posture changes, but NOT ↑ strength.

Ethical & Practical Links

• Delegation: LPN collects focused data (neurovascular checks), RN interprets & plans.
• Interdisciplinary: may refer to PT/OT, dietician, social services for home safety.
• Health Promotion: community education on fall prevention, osteoporosis screening, ergonomic workplace design.