Musculoskeletal System
Musculoskeletal System
Functions of the Musculoskeletal System
Protection of vital organs
Framework to support the body
Facilitates movement and aids in returning blood to the heart
Reservoir of immature blood cells and essential minerals
Hematopoiesis: Production of red blood cells
Age-Related Changes
Bones: Thinned intervertebral discs, compressed vertebral bodies
Muscles: Decreased activity and nutritional deficiencies → decreased muscle strength
Joints: Cartilage thinning
Endocrine: Menopausal women have decreased estrogen
Diagnostic Tests
X-ray: Bone density, texture, erosion, widening, narrowing, irregularity
CT (Computed Tomography): Detailed imaging (with or without contrast), useful for tumors, soft tissue, ligaments, and tendons
MRI (Magnetic Resonance Imaging): Uses magnetic fields and radio waves for visualizing bone, soft tissue, muscles, ligaments, cartilage, and herniated discs
Contrast: A fluid injected or ingested to enhance imaging visualization
Fractures
Definition: Break in the continuity of the bone
Causes: Direct blows, crushing force, sudden twisting motion, extreme muscle contraction
Manifestations: Acute pain, loss of function, deformity, shortening, crepitus, edema, and ecchymosis
Emergency Management
ABC: Airway, Breathing, Circulation
Immobilize the fracture
Neurovascular Assessment: 6 P’s - Pain, Polkilothermia, Pallor, Pulselessness, Paresthesia, Paralysis
Cover open wounds with sterile dressings
Complication Alert:
Compartment Syndrome: Increased pressure in a confined space compromises blood flow and tissue perfusion.
Pain is the first sign; loss of pulse is the last.
Complications of Fractures
Fat Embolism:
Fat from bone marrow enters vasculature → impaired organ perfusion
Key Finding: Cutaneous petechiae (pinpoint hemorrhages on trunk/upper extremities)
DVT (Deep Vein Thrombosis):
Key Finding: Increased pain and substantial swelling in affected extremity
Pulmonary Embolism:
Key Findings: SOB, chest pain, confusion (impaired perfusion)
Infection:
Common post-fracture infection: Osteomyelitis (bone infection)
Treatment: Long-term antibiotic therapy
Shock:
Includes hypovolemic and hemorrhagic shock
Compartment Syndrome:
Managed with a fasciotomy (surgical decompression with excision of the fascia)
Delayed Union/Nonunion:
Delayed Union: Fracture not healed within 6 months
Nonunion: Fracture that never heals
Avascular Necrosis:
Blood flow disruption → tissue and bone death
Common in hip fractures
Treatment: Bone graft or total hip replacement
Collaborative Care
Radiologic studies to rule out underlying issues
Medications to manage symptoms:
Anti-ulcer medications: e.g., Protonix
1234444444444444444444444=-0-12Anticoagulants: e.g., Enoxaparin (Lovenox)
Antibiotics: e.g., Cefazolin (Ancef)
Analgesics: e.g., Tylenol, NSAIDs, Naproxen, Ibuprofen, Ketorolac (Toradol)
Surgery
Indications: Unstable fractures, deformity, joint disease, necrosis, infection, tumors
External Fixation:
Pins placed above and below fracture site
Common for significant soft tissue damage
Nursing Implications:
Assess pin sites, wounds, bowel sounds, lung sounds, neurovascular status
Positioning: Elevate affected extremity
Physical therapy: Weight-bearing status guidance, use of durable medical equipment (DME)
Internal Fixation (ORIF):
Bones manually aligned and stabilized with screws, nails, or plates
Nursing Implications:
Assess incision site, bowel sounds, lung sounds, neurovascular status
Positioning: Elevate affected extremity
Physical therapy: Early mobilization, weight-bearing status,
Purpose: Used to reduce and immobilize fractures
Types:
Fiberglass:
Pros: Lightweight, stronger than plaster, facilitates radiologic imaging, dries within 30 minutes
Cons: More expensive, does not mold as well as plaster
Plaster:
Con: Takes about 24-72 hours to dry
Neurovascular Assessment: Should be completed before, during, and after application by assessing the 6 P’s
Additional Injuries
Sprain: Injury to the ligament and tendons caused by twisting or hyperextension of a joint
Strain: Injury to a muscle or tendon from overuse, overstretching, or excessive stress
Contusion: Bleeding into soft tissue resulting from blunt force
Nursing Implications for Injury Management
Decrease swelling
Pain management
PRICE Mnemonic:
Protection
Rest
Ice: Recommended for the first 24-48 hours, then PRN
Compress
Elevate
Trauma Complications
Primary Prevention: Before injury event
Secondary Prevention: During the injury event
Tertiary Interventions: Optimizing outcomes post-injury
Unintentional and intentional injuries may result from sudden external force to tissues
The Pump (Cardiac Considerations)
Pulmonary Embolism: Blood clot in the pulmonary artery
Manifestations: SOB, impending doom, chest pain, anxiety, sweating
Dysrhythmias:
PVCs: Caused by caffeine, nicotine, alcohol, ischemia, infarct, exercise, fever, hypervolemia, HF, tachycardia
V Tach: Caused by ischemia, infarct, HF, hypoxia, acidosis, dig toxicity, hypokalemia
V Fib: No atrial activity; caused by electrical shock, Brugada syndrome
The Pipes (Vascular Considerations)
Preventing Complications:
Urinary Stasis: Bladder scan, Foley catheter, intermittent catheterization, Flomax or Oxybutynin
Pressure Ulcer: Frequent repositioning (q2h), air mattress, foam dressing, pillows, barrier cream
DVT: Anticoagulants, TED hose, Sequential Compression Devices (SCDs)
Constipation: Early mobilization, increased hydration, laxatives
The Fluid (Circulatory Considerations)
The body balances fluid between interstitial, intravascular, and intracellular spaces.
In hemorrhagic and hypovolemic shock, the body shifts fluid to compensate for intravascular losses.
Hypovolemic Shock:
Patho: Decreased venous return → decreased preload → decreased contractility → decreased cardiac output → hypoperfusion
Treatment: Replace the type of volume lost
Tissue Oxygenation
Causes:
Too little oxygen delivered to cells (low O2 sats, low Hgb, low HR)
Increased oxygen demand (fever, burns, fractures, agitation)
Capillary occlusion (edema, vasoconstriction, clotting, hypovolemia)
Cell inability to use oxygen (overwhelming cellular death)
Lactic Acid: Indicator of hypoperfusion, tissue ischemia, and anaerobic metabolism
Nursing Implications
Ensure proper body alignment
Perform frequent neurovascular assessments
Prevent foot drop
Promote proper nutrition
Use log rolling for spinal injuries
Encourage range of motion (ROM) exercises
Hip Fracture
Surgery Types:
Total Hip Replacement (THR): Open reduction and internal fixation.
Hemiarthroplasty: Replacement of femoral head with prosthesis.
IM Nailing: Closed reduction with percutaneous stabilization.
Key Clinical Manifestations:
Pain in the hip or groin.
Shortening of the affected leg.
External rotation of the leg.
Severe blood loss.
Nursing Implications:
Medication Management for pain.
Neurovascular Assessment (e.g., circulation, sensation).
Antiembolism Stockings/Pneumatic Compression Device for DVT prevention.
Exercise & Weight Bearing:
Depending on fracture stability, the weight-bearing status may vary (non-weight bearing, touch down, weight bearing as tolerated).
Hip Precautions:
No sitting > 90 degrees.
Avoid crossing legs or bending > 90 degrees.
Use abduction pillow to maintain proper leg alignment.
Durable Medical Equipment (DME):
Shower chair, rolling walker, or crutches as needed.
Prevention:
Encourage weight-bearing exercises (30 minutes, 3-5 times a week).
Promote a calcium-rich diet and vitamin D supplementation to support bone health.
Calcium: 1000-1200 mg/day (adults).
Vitamin D: 600 IU (younger adults), 800-1000 IU (older adults).
Traction (e.g., Bucks Traction):
Purpose: Decrease muscle spasms, realign the fracture.
Nursing Care:
Ensure proper alignment.
Prevent skin breakdown.
Assess neurovascular status.
Prevent infection.
Ensure weights hang freely without touching the floor.
Low Back Pain
Collaborative Care:
Common among nursing professionals due to physical demands.
Causes: Mechanical injury, degenerative disorders, obesity, smoking, referred pain.
Clinical Manifestations:
Pain, muscle spasms, altered gait.
Neurologic symptoms (e.g., numbness, tingling).
Nursing Considerations:
Education: Teach proper body positioning (e.g., pillow under knees when lying).
Body Mechanics: Encourage lifting with knees bent, raise the bed when assisting the patient.
Lifestyle:
Smoking cessation plan.
Maintain weight within 10% of ideal body weight.
Recommend supportive shoes (avoid high heels and flip-flops).
Exercise:
Encourage low-stress aerobics, conditioning exercises, yoga, and walking.
Diagnostic Testing:
Radiologic studies (e.g., lumbar x-rays, CT, MRI, myelogram) to identify underlying causes.
Medications:
Tylenol, NSAIDs, muscle relaxants for pain relief.
Additional Support:
Rehabilitation or referral to a spine specialist if needed.
Herniated Intervertebral Disk
Definition:
Rupture of the cartilage surrounding the intervertebral disk with protrusion of the nucleus pulposus (the gel-like center of the disk).
Manifestations:
Pain: Usually in the back or neck, can radiate to other areas like the legs (sciatica).
Limited Mobility: Difficulty in movement due to pain and stiffness.
Neurological Deficits: May include numbness, tingling, or weakness in the affected area (can affect the legs, arms, or both depending on the location of the herniated disk).
Nursing Implications:
Education:
Teach patients about proper body mechanics and posture.
Avoid activities that increase pressure on the spine (e.g., lifting heavy objects, twisting motions).
Teach ergonomics for daily tasks like sitting, standing, and bending.
Body Position:
The Williams position is recommended for comfort: lying with the knees bent, and a pillow under the knees while in bed to reduce pressure on the lower back.
Medication Management:
Pain management: NSAIDs, muscle relaxants, or opioids for severe pain.
Corticosteroids may be used for inflammation relief.
Neuropathic pain medications like gabapentin or pregabalin for nerve-related pain.
Surgical Interventions (if conservative treatments fail):
Laminectomy: Removal of the lamina (part of the vertebra) to relieve pressure on the nerves.
Spinal Fusion: Fusing two or more vertebrae together to stabilize the spine.
Microdiscectomy: Minimally invasive procedure to remove part of the herniated disk.
Percutaneous Laser Decompression: Laser treatment to vaporize part of the herniated disk.
Direct Current Stimulation: Used to reduce pain by stimulating the nerves.
External Bone Stimulation: Aids in bone healing, often used in fusion procedures.
Disk Prosthesis: Replacement of the damaged disk with a synthetic one to preserve motion.
Nursing Considerations:
Post-surgical Care:
Monitor for complications such as infection, bleeding, or nerve damage.
Ensure proper positioning to avoid strain on the spine after surgery.
Encourage early mobilization and gradual physical therapy to restore mobility.
Monitor pain levels and provide appropriate pain relief.
Myasthenia Gravis
Myasthenia Gravis (MG)
Definition:
Autoimmune disorder that impairs the transmission of acetylcholine at the myoneural junction, leading to muscle weakness.
Clinical Manifestations:
Diplopia (double vision).
Ptosis (drooping eyelids).
Facial weakness.
Generalized weakness: Affects voluntary muscles.
Dysphonia (difficulty speaking).
Dysphagia (difficulty swallowing).
Diagnosis:
Acetylcholinesterase Inhibitor Test (Tensilon test):
Tensilon is injected IV. If symptoms like facial/muscle weakness and ptosis improve within 5 minutes, the test is positive.
Side effects: Bradycardia, asystole, bronchoconstriction, sweating, cramping.
Emergency management: Have atropine available to treat side effects.
Ice Test:
An ice pack is placed over the eye for 1 minute. If ptosis improves, MG is suspected. This is often used for patients with cardiac conditions or asthma.
Repetitive Nerve Stimulation (RNS):
Measures a decrease in action potential, indicating impaired neuromuscular transmission.
Electromyography (EMG):
Detects delayed or failed neuromuscular transmission. It is 99% accurate but can be uncomfortable for the patient.
MRI:
Used to identify an enlarged thymus, which can be the site of acetylcholine receptor antibody production.
Collaborative Care:
Medical Management:
Therapeutic Plasma Exchange: Removes antibodies from the blood by separating blood cells from plasma and replacing plasma with a substitute. It provides short-term relief.
Thymectomy: Removal of the thymus gland. This can result in complete remission but may take up to 3 years for full benefits.
Medications:
Anticholinesterase medications (e.g., Pyridostigmine): Help improve neuromuscular transmission.
Immunosuppressive therapy: Reduces the production of antibodies attacking acetylcholine receptors.
Intravenous Immune Globulin (IVIG): Provides short-term improvement in symptoms by modulating immune function.
Nursing Implications:
Education:
Emphasize timely medication adherence to prevent muscle weakness and avoid missed doses.
Encourage energy conservation by establishing routines with rest periods throughout the day.
Symptom Diary: Patients should keep track of symptoms, triggers, and changes to help guide management.
Educate about speech therapy for those with dysphagia, which may improve swallowing and communication.
Monitoring:
Assess for respiratory difficulties, especially during exacerbations.
Observe for side effects from medications like anticholinesterase inhibitors.
Collaborative Care:
Involve speech therapy to assist with dysphagia and improve swallowing safety.
Physical therapy may help manage weakness and improve mobility.
Key Points:
No cure for MG, but symptoms can be managed.
Key treatment includes medication (anticholinesterase, immunosuppressive), plasma exchange, and thymectomy.
Patient education is crucial to managing symptoms and maintaining quality of life.
Guillain-Barré Syndrome (GBS)
Definition:
Guillain-Barré Syndrome (GBS) is an autoimmune disorder in which the body's immune system attacks the peripheral nerve myelin, leading to inflammatory demyelination. This results in muscle weakness, sensory changes, and in severe cases, respiratory failure.
Clinical Manifestations:
Muscle weakness: Often starts in the lower extremities and ascends upward.
Diminished reflexes: Hyporeflexia or absent reflexes in the lower limbs.
Paresthesia: Numbness or tingling in the hands and feet.
Pain: Aching or cramping pain in muscles.
Respiratory failure: Due to muscle weakness affecting the diaphragm and intercostal muscles, leading to difficulty breathing.
Symptoms typically start after a viral illness (e.g., gastrointestinal or respiratory infection), often about 2-3 weeks prior to the onset of GBS symptoms.
Diagnosis:
History of viral illness: A common feature preceding the onset of GBS.
No definitive test: Diagnosis is primarily clinical based on history and physical examination.
Clinical progression: Ascending weakness, diminished reflexes, and possible respiratory failure.
Other tests that may help:
Lumbar puncture: Can show albuminocytologic dissociation (elevated protein with normal white blood cells in the cerebrospinal fluid).
Electromyography (EMG) and nerve conduction studies can confirm slowed nerve conduction, though they are not diagnostic on their own.
Collaborative Care:
Acute phase management:
ICU admission is often required due to the risk of respiratory failure and cardiovascular instability.
Intubation: Preemptively recommended before respiratory failure sets in, especially if the patient shows signs of dyspnea or hypoxemia.
Therapeutic Plasma Exchange (TPE) and IV Immunoglobulin (IVIG) are the main treatments for reducing the number of circulating autoantibodies and decreasing inflammation in the peripheral nerves. Both are effective in managing the acute phase of GBS.
Cardiac monitoring: Continuous ECG monitoring is recommended due to autonomic dysfunction, which can lead to cardiac arrhythmias and blood pressure instability.
Medication:
Anticoagulants: Given the risk of immobility and deep vein thrombosis (DVT) in GBS patients, anticoagulants may be used to prevent clot formation.
IV therapy to support blood pressure, as patients may experience hypotension due to autonomic dysfunction.
Nursing Considerations:
Airway management: Prepare for possible intubation if respiratory decline is evident.
Monitoring: Continuous monitoring of vital signs, including respiratory rate, oxygenation, and cardiovascular status, is critical.
Pain management: Medications such as analgesics and nerve pain medications (e.g., gabapentin) may be required to manage discomfort and neuropathic pain.
Mobility assistance: GBS often leads to immobility and weakness, so physical therapy and assistance with positioning and transfers will be needed.
Psychosocial support: GBS can be a prolonged illness, requiring emotional support and education for both the patient and their family.
Key Points:
GBS is often preceded by a viral illness.
Diagnosis is primarily clinical; there is no definitive test.
Intubation and cardiac monitoring are essential in the acute phase.
Therapeutic plasma exchange and IVIG help reduce circulating antibodies.
Early recognition and intervention are key to preventing complications, especially respiratory failure.
Multiple Sclerosis (MS)
Definition:
Multiple Sclerosis (MS) is an autoimmune disorder that causes progressive demyelination of the central nervous system (CNS), which includes the brain, spinal cord, and optic nerves. This leads to impaired nerve conduction and a variety of neurological symptoms.
Risk Factors:
Gender: More common in women than men.
Age: Typically diagnosed between ages 20-40.
Genetic factors: Specific genetic markers, such as interleukin-7 and interleukin-2, are associated with increased risk.
Environmental factors: A history of viral infections and lack of Vitamin D.
Lifestyle: Smoking is a known risk factor for MS.
Clinical Manifestations:
Fatigue: A common symptom that can significantly impact daily functioning.
Depression: Emotional changes due to both the disease and its impact on quality of life.
Weakness: Often in the limbs.
Numbness: Particularly in the extremities.
Coordination and Balance Issues: Difficulty walking, dizziness, and loss of balance.
Spasticity: Muscle stiffness and spasms.
Pain: Neuropathic pain can occur in various parts of the body.
Diplopia: Double vision caused by demyelination of the optic nerves.
Uhthoff's sign: Worsening of symptoms with increased body temperature, often seen during exercise or hot weather.
Bowel/Bladder Dysfunction: Incontinence or difficulty emptying the bladder and bowels.
Cognitive Impairment: Difficulty with memory, concentration, and problem-solving.
Diagnosis:
MRI: Shows plaques or areas of demyelination in the brain and spinal cord.
CSF Analysis: Cerebrospinal fluid (CSF) analysis may show elevated protein levels and an increased number of white blood cells (WBCs), which are indicative of inflammation in the CNS.
Collaborative Care:
Education: Focus on preventing complications and managing symptoms.
Urinary Tract Infections (UTIs): Encourage increased fluid intake and assist with bladder elimination. Positioning the patient by placing their hand on the abdomen over the bladder can help promote emptying.
Cognitive Impairment: Encourage the use of routines and reorient the patient when necessary to aid memory and cognition.
Fatigue: Help the patient create a daily routine that includes rest periods to prevent exacerbation of fatigue.
Safety: Remove barriers in the home and use durable medical equipment (DME) to help the patient maintain mobility and independence.
Supportive Services: Various therapies may be needed to improve quality of life, including:
Speech Therapy: For issues with speech and swallowing.
Physical Therapy: To maintain mobility and prevent muscle atrophy.
Occupational Therapy: To help with activities of daily living and adaptive equipment.
Psychosocial support: Counseling or support groups to help patients cope with the emotional impact of the disease.
Medication Management:
Immunosuppressants: Used to manage the autoimmune aspect of MS by reducing inflammation and preventing further damage.
Corticosteroids: Help manage acute exacerbations by reducing inflammation.
Muscle Relaxants: To control spasticity and muscle stiffness.
Laxatives: For managing constipation, a common issue in MS.
Nursing Management:
Patient Education: Emphasize the importance of adherence to medications, maintaining a routine, and avoiding triggers that could worsen symptoms (e.g., heat, stress).
Monitoring: Regularly assess the patient for changes in cognitive function, motor skills, and bowel/bladder function.
Symptom management: Focus on pain management, fatigue management, and muscle spasticity.
Safety: Assess for fall risks and assist with mobility needs.
Key Points:
MS is a chronic and progressive autoimmune disease affecting the CNS.
MRI and CSF analysis are key diagnostic tools.
Fatigue, cognitive impairment, and motor weakness are common manifestations.
Early diagnosis and symptom management are critical to improve quality of life.
A multidisciplinary approach is essential, including therapies for speech, physical, and occupational needs.