Chapter 44 Care of the Patient with a Musculoskeletal Disorder

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Chapter 44Care of the Patient with a Musculoskeletal Disorder


Overview of Anatomy and Physiology

• Functions of the skeletal system Support

• Skeleton provides body framework support internal tissues and organs

Protection• Skeleton forms cagelike structures

Protects internal structureso Cranium protects brain, ribs and sternum protects

heart and lungs Movement

• Skeletal muscles attached to bones, bones provide leverage for movement

• Muscle contracts, it exerts pull on the bone and movement occurs



• Functions of the skeletal system Mineral storage

• Calcium and phosphorus• Not enough are taken in by the body, the bone will

release these minerals

Hematopoiesis• Blood formation takes place in the red bone marrow

Red bone marrow – spongy bone found in the long ends of the long bones

Red bone marrow as a person ages will convert to yellow which consist of mainly fat cells



• Structure of bones Four classifications based on form and shape

• Long Found in extremities

• Short Found in hands and feet

• Flat Found in skull and sternum

• Irregular Make up vertebrae (backbone)


Figure 44-2

Skeleton, anterior view. (From Thibodeau, G.A., Patton, K.T. [1997]. The human body in health and disease. [2nd ed.]. St. Louis: Mosby.)


Figure 44-3

Skeleton, posterior view. (From Thibodeau, G.A., Patton, K.T. [1997]. The human body in health and disease. [2nd ed.]. St. Louis: Mosby.)



• Articulations (joints) Allow movement Three types according to degree of movement

• Synarthrosis—no movement• Amphiarthrosis—slight movement• Diarthrosis—free movement

• Divisions of the skeleton Axial skeleton

• Consist of skull, spine, thorax Appendicular skeleton

• Consists of upper and lower extremities


Figure 44-1

Structure of a freely movable (diarthrotic) joint.

(From Thibodeau, G.A., Patton, K.T. [2004]. Structure and function of the body. [12th ed.]. St. Louis: Mosby.)



• Functions of the muscular system Motion (for movement)

• Result from contraction and relaxation of muscles Maintenance of posture Production of heat

• 85% of body heat is produced by muscle contraction Contraction results in return of venous blood and

lymph to the right side of the heart Voluntary vs involuntary control



• Skeletal muscle structure Epimysium

• Connective tissue that surrounds each skeletal muscle Perimysium Endomysium

Epimysium connects/joins with perimysium and endomysium extending beyond the muscle to form a tendon

• Tendons anchor muscles to bone


Figure 44-5

Anterior view of the body (From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)


Figure 44-6

Posterior view of the body.

(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)



• Nerve and blood supply Blood vessels provide a constant supply of oxygen

and nutrition and nerve cells/fibers supply a constant source of information

NMJ, ACh, AChase, synaptic cleft• Muscle contraction

Muscle stimulus—when a muscle cell is adequately stimulated, it will contract (“all or non” law)

Muscle tone—skeletal muscles are in a constant state of readiness for action

Types of body movements—flexion, extension, abduction, adduction, rotation, supination, pronation, dorsiflexion, and plantar flexion


Laboratory and Diagnostic Examinations

• RADIOGRAPHIC STUDIES Diagnostic study for musculoskeletal system integrity

• Radiographic, roentgenographic• Commonly known as: x-ray examination or diagnostic

imaging Reveals joint fluids, irregularity of joint with spur formation,

changes in size of joint contour Determine fractures Ask if patient is pregnant Laminography or planography

• Also known as body section roentgenography Useful in locating small cavities, foreign bodies, and lesions

overshadowed by opaque structures Scanography

• Allows accurate measurement of bone’s length



• RADIOGRAPHIC STUDIES – cont’d Myelogram

• Injection of radiopaque dye in subarachnoid space at lumbar spine

Determines herniated disk syndrome or tumors• Allergic reaction in people allergic to iodine & seafood• Most common discomfort is headache

Nuclear scanning• Done in the nuclear medicine department• Nursing precaution:

1. written consent of patient 2. radioactive isotope won’t affect family/visitors 3. follow instructions outlined by nuke med dept



• RADIOGRAPHIC STUDIES – cont’d Magnetic resonance imaging (MRI)

• Detects pathologic conditions of cerebrum and SC• Detects herniated disk• Give detailed pictures of fluid-filled soft tissue and blood

vessels• Patient prep: no metallic objects• Patient with metal prosthesis such as heart valves,

orthopedic screws or cardiac pacemakers • Need to be motionless

May use sedative if extremely anxious or patient is claustrophobic



• RADIOGRAPHIC STUDIES – cont’d Computed axial tomography (CT or CAT scan)

• Body sections can be examined from many angles• 3-D picture of structure is made• Iodine contrast dye sometimes used• Locating injuries to tendons, ligaments, tumors and fractures• Preparation:

1. signed consent 2. any allergies 3. NPO 3-4 hours prior to test 4. VS as baseline 5. void before test 6. remove jewelries and hair pins 7. lie still during test



• RADIOGRAPHIC STUDIES – cont’d Bone scan

• Detects metastatic and inflammatory bone disease• Administer IV nuclides 2-3 hours prior to test• Drink fluids next 2-3 hours to aid renal clearance of

radioisotope not picked up by bone• Areas of concentrated nucleotide uptake represent

tumor or other abnormality



• Endoscopic examination Lighted tube is used to visualize inside of body cavity Preparation: similar to surgical prep

• 1. signed consent form• 2. pre-op checklist-remove jewelry, dentures, contacts• 3. NPO 6-12 hours before• 4. premed maybe given-atropine and sedative• 5. encouraged to void• 6. VS taken and recorded• 7. bed rest with side rails up after premed given



• Endoscopic examination – cont’d Arthroscopy

• Direct visualization of joints• Accomplishes the following:

Exploration of joint to determine presence of disease process

Drainage of fluid Removal of damage tissue or foreign bodies

• Commonly done in knee joint Visualizes: synovium, articular surfaces, meniscus



• Endoscopic examination – cont’d Endoscopic spinal microsurgery

• Treat spinal column disorder Herniated disk Spinal stenosis Spinal deformities

o Scoliosiso kyphosis



• Aspiration Obtain specimen of body fluid Sterile technique Biopsy at the same time Nursing interventions

• 1. consent form signed• 2. reinforcing physician’s explanation of procedure• 3. immobile during procedure• 4. void before procedure• 5. sterile technique• 6. emotional support• 7. sterile pressure dressing to puncture site• 8. assist with collecting, labeling and transport• 9. observe emotional and physical distress after procedure



• Aspiration-cont’d Synovial fluid aspiration

• Arthrocentesis Diagnosing trauma, SLE, gout, OA, and RA Normal-straw colored, clear, slightly cloudy Trauma or disease process

o Cloudy, milky, yellow, green, gray Support joint with pillow rest up to 12 hours



• Electrographic procedure Electromyogram (EMG)

• Insert electrodes in muscle so electrical activity can be heard, seen on oscilloscope, recorded on paper

• Nerves can be observed for neuropathy• Muscles observed for myopathy• Electromyography used to detect chronic low back pain

based on muscle fatigue pattern



• Laboratory tests Calcium Erythrocyte sedimentation rate (ESR) Lupus erythematosus (LE) preparation Rheumatoid factor (RF) Uric acid (blood)

Study table 44-3, pg 1372


General Nutritional Needs/Modifications

• Osteoporosis Nutrition

• Low calcium intake• Low vitamin D intake• High phosphate intake

Carbonated beverages• Inadequate calories

o => reduces nutrients needed for bone remodeling



• Osteoporosis – cont’d Nutritional factors contribute to its’ development Balanced diet

• Adequate calories and nutrients to maintain: Bone, calcium and vitamin D

• Vitamin D For calcium absorption For normal bone mineralization

• Dietary calcium and vitamin D Must be adequate to maintain bone remodeling and body

function• Source of calcium and vitamin D

Fortified milk (cup of milk = 300-mg of calcium)



• Osteoporosis – cont’d Recommended adequate intake (AI) level of calcium

• 9 y/o to 19 y/o is 1300 mg/day To maximize peak bone mass

• 19 y/o to 50 y/o is 1000 mg/day• 51 years and older is 1200 mg/day

Estimated daily intake is 300 to 500 mg Recommended adult vitamin D intake is 400 to 600 IU

per day Inadequate calcium and vitamin D intake over time

• Result in development of osteoporosis



• Osteoporosis – cont’d Protection against bone demineraliztion

• Balanced diet rich in calcium and vitamin D• Increased calcium intake during adolescence, young

adulthood, and middle years• 3 glasses of skim milk daily (food high in calcium)• Calcium supplements (caltrate, citrocal)

Taken with food or beverages high in vit C to promote absorption

S/E of calcium supplement: abdominal distention and constipation



• Osteomalacia Cause is malabsorption

• Increase doses of vitamin D, with supplemental calcium• Exposure to sunlight

UV radiation to transform cholesterol substance (7-dehydrocholesterol) present in skin to vitamin D



• Osteomalacia Cause is dietary origin

• Diet with adequate protein and increased calcium and vitamin D is provided

• Dietary sources of calcium and vitamin D Fortified milk and cereals, eggs, chicken livers

• High doses of vitamin D is toxic• Vitamin D raises concentration of calcium and

phosphorus in ECF makes these ions available for bone mineralization



• Paget’s Disease (osteitis deformans) Disorder of localized rapid bone turnover commonly

• Skull, femur, tibia, pelvic bones, vertebrae Assymptomatic patient

• Managed with adequate calcium and vitamin D in the diet and periodic monitoring

• Osteomyelitis Infection of the bone General supportive measure

• Hydration, diet high in protein and vitamins, correction of anemia

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Chapter 44 Care of the Patient with a Musculoskeletal Disorder