Assessment of musculoskeletal in Nursing of patients
- 1. ASSESSMENT OF MUSCULO-SKELETAL SYSTEM BRANCH- MEDICAL– SURGICAL NURSING UNIT – 10 TITLE – DISORDERS OF MUSCULO-SKELETAL SYSTEM TOPIC- ASSESSMENT OF MUSCULO-SKELETAL SYSTEM
- 2. Nursing Assessment Health History InitialInterview Assessment Data Pain Altered Sensations
- 3. Past health history-these includes TB, polio, DM, parathyroid problems, soft tissue infection, & neuromuscular disabilities. Possible sources of bacterial infection, such as ears, tonsils or GU and trauma. Medications- regarding prescription, OTC, herbal products & nutritional supplements. Women should be question about their menstrual hx. , use of hormone therapy, CA and vitamin D supplements are important for postmenopausal women. HEALTH HISTORY
- 4. Surgery or othertreatments- past hospitalizations from musculoskeletal problems. Functional health patterns- = Nutritional- metabolic pattern-dietary supplements. = Elimination- = Activity-exercise-require assistance in completing ADL.= sleep-rest- difficulty sleeping. = Cognitive-perceptual- musculoskeletal pain HEALTH HISTORY
- 5. HEALTH HISTORY Functional Healthpatterns con’t Functional Health patterns con’t….. = Self-perception-self-concept-changes in MS system-posture, walking,etc… = Role- relationship- live alone, effect on work. = Sexuality-reproductive-sexual concerns. = coping-stress tolerance- problems such as pain or immobility. = value-belief- cultural & religious practices.
- 6. 5P’s Assessment forOrthopedic Patients Symmetric comparison: Pain- location, severity Pulse- distal to injury, check bilaterally. Parasthesias- numbness, tingling, compare bilaterally. Sensaton check Pallor- check skin color and temp. Paralysis- Assess mobility, watch for foot drop, compartment syndrome.
- 7. RISK FACTORS Autoimmune disorders Calciumdeficiency Degenerative conditions Falls Hyperuricemia Infection
- 8. RISK FACTORS (Continued) Medications Metabolicdisorders Neoplastic disorders Obesity Postmenopausal states Trauma and injury
- 9. Nursing Assessment Physical Assessment Posture Gait BoneIntegrity Joint Function Muscle Strength & Size Skin Neurovascular Status
- 10. Assessment of the MusculoskeletalSystem Physical examination: * Inspection Inspection-use of an assistive devices such as walker. Observe general body build, muscle configuration, & symmetry of joint movement. Note for swelling, deformity, nodules or masses & discrepancies in limb length or muscle size.
- 11. Assessment of the MusculoskeletalSystem Physical Examination con,t Physical Examination con,t… * Palpation Palpation: of both muscles & joints allows for evaluation of skin temperature, local tenderness, swelling and crepitation. * Gait, motion of spine- Gait, motion of spine- smoothness, rhythm, limpimg, unsteady. Note height of shoulders, iliac crests, gluteal folds, shoulder & hip symmetry. Note for lumbar lordosis( concavity of the spine), kyphosis-(excessive curvature of thoracic spine), scoliosis (deviation to L or right)
- 12. Assessment of the MusculoskeletalSystem Upper extremities- Upper extremities- evaluate muscle strength. If joint motion compromised or painful-exam for fluid (effusion), increase temperature (inflammation). Passive movements elicits crunching noise (crepitus)-exam for nodules. Lower extremities- Lower extremities- evaluate muscle action, ROM, pulses( femoral, tibial, dorsalis pedis).reflexes- (patellar, achilles, babinski)
- 13. Assessment of the MusculoskeletalSystem Muscle Strength scale 0 No detection of muscular contraction 1 A barely detectable flicker or trace of contraction with observation or palpation. 2 Active movement of body part with elimination of gravity. 3 Active movement against gravity only and not against resistance 4 Active movement against gravity & some resistance 5 Active movement against full resistance without evident fatigue (Normal muscle strength)
- 14. Assessment of the MusculoskeletalSystem Injured extremity- Observe for bleeding- arterial (spurts), venous (steady), bones (oozes, oily). Pressure over main artery-if pressure at the site does’nt work. Check for deformities- if can’t move= need attention.
- 15. Diagnostic Evaluation Imaging Procedures X-ray ComputedTomography (CT) Magnetic Resonance Imaging (MRI) Arthrography Bone Densitometry
- 16. Diagnostic Evaluation Nuclear Studies BoneScan Endoscopic Studies Arthroscopy Other Studies Arthrocentesis Electromyography Biopsy Laboratory Studies (CBC) Urinalysis (Calcium) Blood Chemistry Serum Calcium Serum Phosphate Uric Acid Serum Creatinine LDH, SGOT, CPK
- 17. Assessment of the MusculoskeletalSystem Diagnostic tests: Diagnostic tests: X-ray- determine density of the bone. Arthrogram- visualization of joint structure & movement. Diskogram- vizualization of intervertebral disk abnormalitiy. Sinogram- visualizes course of sinus & tissues involved. CT- to identify soft tissue & bone abnormalities, and various MS trauma. MRI- to view soft tissue- useful in the dx. Of ligament tears, osteomyelitis, disk disease.
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- 19. ARTHROGRAM visualization of joint structure& movement. Arthrogram of the Knee
- 20. Assessment of the MusculoskeletalSystem Bone Mineral Density (BMD) measurements: Dual energy x-ray absorptiometry (DEXA)- allows assessment of bone density with minimal radiation exposure- to monitor changes in bone density with treatment. Qualitative ultrasound (QUS)- evaluates density, elasticity & strength of patella & calcaneus using ultrasound rather than radiation.
- 21. Assessment of the MusculoskeletalSystem Radioisotope Studies Radioisotope Studies: Bone scan- Bone scan- injection of radioisotopes that is taken up by bone, then scan entire body for degree of uptake-related to blood flow. Increased uptake- osteoporosis, Ca of the bone, fractures. Decreased uptake-avascular necrosis.
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- 23. Assessment of the MusculoskeletalSystem Endoscopy Endoscopy: Arthroscopy- insertion of arthroscope into joint (usually knee) for visualization of structure and contents. It can be used for exploratory surgery (removal of loose bodies & biopsy) and dx. of abnormalities of meniscus, articular cartilage, ligaments, or joints capsule. Other structures that can be visualized include-shoulder, elbow, wrist, jaw, hip and ankle.
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- 25. Assessment of the MusculoskeletalSystem Invasive Procedures: Invasive Procedures: Arthrocentesis- incision or puncture of joint capsule to obtain sample of synovial fluid from joint cavity or to remove excess fluid. Useful in dx. Of joint inflammation, infection, and subtle fractures. Electromyogram (EMG)- evaluates electrical potential associated with skeletal muscle contraction-useful in providing information related to lower motor neuron dysfunction and primary muscle disease.
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- 27. ELECTROMYOGRAPHY (EMG) From MouradLA (1991) Orthopedic disorders. St. Louis: Mosby.
- 28. MYELOGRAM From Herlihy B,Maebius NK: The human body in health and illness, Philadelphia, 2000, W.B. Saunders.
- 29. BONE OR MUSCLEBIOPSY Muscle Biopsy Showing Polymyositis
- 30. Assessment of the MusculoskeletalSystem Muscle enzymes- Muscle enzymes- used to distinguish between muscle weakness that is due to nerve innervation problems and dystrophic disease of the muscle itself. The level of enzymes reflects the progress of the disorder and the effectiveness of treatment. Example- Creatine kinase (CK),aldolase.
- 31. Assessment of the MusculoskeletalSystem Serologic Studies Serologic Studies: Rheumatoid factor(RF)- assess presence of autoantibody (RF) in serum. Erythrocyte sedimentation rate (ESR)- index of inflammation. Antinuclear antibody (ANA)- assesses presence of antibodies capable of destroying nucleus of body’s tissue cells. Anti-DNA antibody- detects serum antibodies that react with DNA. It is the most specific test for systemic lupus erythematosus.
- 32. Assessment of the MusculoskeletalSystem Mineral Metabolism: Mineral Metabolism: Alkaline phosphatase-produced by osteoblast of bone-needed for mineralization of organic bone matrix. Normal: 20 to 90 U/L (0.3 to 2,7 mmol/L). Calcium- bone primary organ for calcium storage. Normal: 9 to 11 mg/dl (2.3 to 2.7 mmol/L). Phosphorus- amount present indirectly related to calcium metabolism. Normal: 2.8 to 4.5 mg/dl (0.9 to 1,5 mmol/L)
- 33. Assessment of the MusculoskeletalSystem Miscellaneous: Thermograpgy- uses infrared detector, which measures degree of heat radiating from skin surface. Useful in investigation of cause of inflamed joint and in following up pt.’s response to antiinflammatory drug therapy. Plethysmography- Study records variatios in volume & pressures of blood passing through tissues. Nosspecific. Somotosensory evoked potebtial (SSEP)-evaluates evoked potential of muscle contractions. Help to identify neuropathy and myopathy.
Editor's Notes
- #6 Assess skin frequently for pressure, friction, injury at least q 2 h Need to support limb.
- #18 DESCRIPTION A commonly used procedure to diagnose disorders of the musculoskeletal system IMPLEMENTATION Handle injured area carefully Administer analgesics as prescribed prior to the procedure particularly if the client is in pain Remove any radiopaque objects, such as jewelry Shield client’s testes, ovaries, or pregnant abdomen The client must lie still during an x-ray Inform the client that exposure to radiation is minimal and not dangerous Health care provider is to wear a lead apron if staying in the room with the client
- #19 A radiographic examination of the soft tissues of the joint structures used to diagnose trauma to the joint capsule or ligaments A local anesthesia is used for the procedure A contrast medium or air is injected into the joint cavity and the joint is moved through range of motion as a series of x-rays are taken IMPLEMENTATION Inform the client to fast from food and fluids for 8 hours prior to the procedure Assess the client for allergies to iodine or seafood prior to the procedure Obtain a consent form Inform the client of the need to remain as still as possible, except when asked to reposition Minimize the use of the joint for 12 hours following the procedure IMPLEMENTATION Instruct the client that the joint may be edematous and tender for 1 to 2 days after the procedure and may be treated with ice packs and analgesics as prescribed Inform the client that if edema and tenderness last longer than 2 days to notify the physician If knee arthrography was performed, an Ace bandage over the knee may be prescribed for 3 to 4 days If air was used for injection, crepitus may be felt in the joint for up to 2 days From Johnson LL (1981) Diagnostic and surgical orthroscopy: the knee and other joints (2nd ed.). St. Louis: Mosby.
- #22 Radioisotope is injected IV and will collect in areas that indicate abnormal bone metabolism and some fractures, if they exist The isotope is excreted in the urine and feces within 48 hours and is not harmful to others IMPLEMENTATION Hold fluids for 4 hours prior to the procedure Obtain a consent form Remove all jewelry and metal objects Following the injection of the radioisotope, the client must drink 32 ounces of water (if not contraindicated) to promote renal filtering of the excess isotope From 1 to 3 hours after the injection, have the client void, and then the scanning procedure is performed Inform the client of the need to lie supine during the procedure and that the procedure is not painful No special precautions are required after the procedure because a minimal amount of radioactivity exists in the radioisotope Monitor the injection site for redness and swelling Encourage oral fluid intake following the procedure
- #24 Provides an endoscopic examination of various joints Articular cartilage abnormalities can be assessed, loose bodies can be removed, and the cartilage trimmed A biopsy may be performed during the procedure IMPLEMENTATION Instruct the client to fast for 8 to 12 hours prior to the procedure Obtain a consent form Administer pain medication as prescribed postprocedure An elastic wrap should be worn for 2 to 4 days as prescribed postprocedure Instruct the client that walking without weight bearing is usually permitted after sensation returns but to limit activity for 1 to 4 days as prescribed following the procedure Instruct the client to elevate the extremity as often as possible for 2 days following the procedure, and to place ice on the site to minimize swelling Reinforce instructions regarding the use of crutches, which may be used for 5 to 7 days postprocedure when walking Advise the client to notify the physician of fever, increased knee pain, or if edema continues for more than 3 days postprocedure
- #26 Involves aspirating synovial fluid, blood, or pus via a needle inserted into a joint cavity Medication may be instilled into the joint if necessary to alleviate inflammation Obtain a consent form Apply a compress bandage postprocedure as prescribed Instruct the client to rest the joint for 8 to 24 hours postprocedure Instruct the client to notify the physician if a fever or swelling of the joint occurs
- #27 Measures electrical potential associated with skeletal muscle contractions Needles are inserted into the muscle and recordings of muscular electrical activity are traced on recording paper through an oscilloscope IMPLEMENTATION Obtain a consent form Instruct the client that the needle insertion is uncomfortable Instruct the client not to take any stimulants or sedatives 24 hours prior to the procedure Inform the client that slight bruising may occur at the needle insertion sites
- #28 DESCRIPTION Injection of dye or air into the subarachnoid space to detect abnormalities of the spinal cord and vertebrae Preprocedure - Obtain a consent form Provide hydration for at least 12 hours before the test Assess for allergies to iodine Premedicate for sedation as prescribed POSTPROCEDURE Perform vital signs and neurological assessment frequently as prescribed If a water-based dye is used, elevate the head 15 to 30 degrees for 8 hours as prescribed If an oil-based dye is used, keep the client flat 6 to 8 hours as prescribed If air is used, keep the head lower than the trunk Force fluids and monitor I&O
- #29 May be done during surgery or through aspiration, or punch or needle biopsy IMPLEMENTATION Obtain a consent form Monitor for bleeding, swelling, hematoma, or severe pain Elevate the site for 24 hours following the procedure to reduce edema Apply ice packs as prescribed following the procedure to prevent the development of a hematoma Monitor for signs of infection following the procedure Inform the client that mild to moderate discomfort is normal following the procedure