1. N124IN Spring 2013 Camille Jackson, MSN, RN

2.  Skeletal and muscular systems work together for movement ◦ Also need nervous, cardiovascular, respiratory systems  Skeleton: framework ◦ Voluntary muscles attached to skeleton ◦ Joints: articulations in between bones  Muscle contraction: bone is pulled and joint angle is altered

3.  Skeletal system tissues ◦ Bone tissue  Protects organs and tissues from mechanical injury  Stores calcium ◦ Cartilage  Covers most joint surfaces ◦ Fibrous connective tissue  Forms ligaments

4.  Muscular system tissues ◦ Skeletal (aka striated, voluntary) muscle  Skeleton movement and stabilization  Heat production  Blood return from legs ◦ Fibrous connective tissue  Forms tendons ◦ Fasciae  Enclose individual muscles

5.  Bone Tissue ◦ Osteocytes ◦ Osteoblasts ◦ Osteoclasts  Bone ◦ Compact ◦ Spongy ◦ Periosteum

7.  Proper Nutrition ◦ Provides raw materials for bone production  Calcium  Phosphorus  Protein  Vitamins A, D, C  Hormones ◦ Growth hormone-anterior pituitary gland ◦ Thyroxine-thyroid gland ◦ Insulin-pancreas ◦ Parathyroid-parathyroid gland ◦ Calcitonin-thyroid gland ◦ Estrogen & testosterone

8.  206 bones ◦ Axial skeleton  Skull, vertebral column, rib cage ◦ Appendicular skeleton  Arms/legs, shoulder, pelvic girdles

10.  8 cranial bones ◦ Frontal, 2 parietal, 2 temporal, occipital, sphenoid, ethmoid  14 facial bones  3 auditory bones in both middle ear cavities  Sutures: joints between cranial bones and most of the facial bones

12.  Vertebrae are individual bones in vertebral column ◦ 7 cervical vertebrae  Atlas is first vertebra and articulates with occipital bone  Atlas creates pivot joint with axis (second vertebra) ◦ 12 thoracic ◦ 5 lumbar ◦ 5 sacral (fused together to make sacrum) ◦ 4 or 5 coccygeal (fused together to make coccyx)

14.  Functions ◦ Supports trunk, head ◦ Contains and protects spinal cord ◦ Intervertebral foramina: openings where spinal nerves and blood vessels enter/exit ◦ Allows for movement

15.  12 rib pairs and the sternum ◦ 7 true rib pairs ◦ 3 false ribs ◦ 2 floating ribs  Functions ◦ Protects heart, lungs, upper abdominal organs ◦ Muscles pull rib cage up and out with breathing

16.  Freely movable joints  Articular cartilage: along bone’s joint surface  Joint capsule: fibrous connective tissue that makes a sheath around joint  Synovial membrane: lines joint capsule and secretes synovial fluid into joint cavity  Bursae: synovial fluid sacs

18.  Tendons: fibrous connective tissue that attaches muscles to bones ◦ Origin: attachment that is more stationary ◦ Insertion: attachment that is more movable  Contraction ◦ Muscle contracts, muscle shortens, pulls bone  Pulls on insertion and moves bone in certain direction  Agonist: muscle that is making bone move in certain direction  Antagonist: opposite function of agonist  Synergistic muscles: muscles that function similarly or cooperate together

19.  Nerve impulse results in acetylcholine release ◦ Acetylcholine moves across synaptic cleft  Acetylcholine attaches to acetylcholine receptors on sarcolemma (on muscle fiber membrane)  Sarcolemma becomes permeable to sodium ions  Sodium ions move into cell  Electrical impulse/action potential is created along sarcolemma  Reactions occur in sacromeres (internal units of contraction)  Actin protein filaments move over myosin protein filaments  Sarcomere shortens

20. The Aging Musculoskeletal System Bone Calcium Loss Fractures Articular Cartilage Wears Down Joint Stiffness Joint Pain Muscle Strength declines Falls

21.  Muscle mass and strength decline  Number of muscle cells decrease  Elasticity of ligaments, tendons, cartilage decrease  Smaller intervertebral spaces  Gait and posture changes

22.  Age related changes can lead to: ◦ Impaired mobility ◦ Increased risk of falls ◦ Pain  Let’s try some Nursing diagnoses!! ◦ Impaired mobility r/t…….. ◦ Risk of falls r/t…….. ◦ Pain r/t………

23.  History  Physical Assessment  Psychosocial Assessment  Frequent neurovascular assessments may be needed

24.  Injury-how and when it happened  Occupation and activities  Risk factors for musculoskeletal injuries  Family history  Current health status  Diet history  Information specific to the patient’s musculoskeletal problems  Previous diagnoses, pain/stiffness/tenderness, meds, treatments, procedures

25.  Inspection  Palpation  Range of motion  Assess muscle size, strength, shape, tone  Physical therapy and occupational therapy assess patient further in depth

26.  Neurovascular assessments ◦ Color ◦ Temperature ◦ Pain ◦ Movement ◦ Sensation ◦ Pulses ◦ Capillary refill

27.  Assess for withdrawal  Assess pain effects  Assess coping ability

28.  Mr. Smith, age 80, is brought to the emergency department with a fractured left hip. He is positioned for comfort while you collect data.  1. What information should you obtain in Mr. Smith’s history?  2. What should be assessed in Mr. Smith’s physical examination?

29.  Laboratory Tests ◦ Calcium(8.5-10.5 mg/dL)/phosphorus(2.6-4.5 mg/dL)  Inverse relationship normally  Disorders can make both increase or decrease  Hypercalcemia  May be related to metastatic bone disease or extended immobilization  Hypocalcemia  May be related to poor dietary intake. Can lead to osteoporosis

30.  Laboratory Tests, cont. ◦ Alkaline Phosphatase (ALP)  Male: 45-115 units/L; Female: 30-100 units/L  ALP increases may indicate a bone abnormality  ALP increases when new bone is formed

31.  Laboratory Tests, cont. ◦ Myoglobin (50-120 µg/mL)  Protein in striated muscle (skeletal/cardiac)  Makes muscle reddish color  Serum levels increase with skeletal or cardiac muscle damage (MI)

32.  Laboratory Tests, cont. ◦ Muscle Enzymes  Enzymes that are released into bloodstream with muscle tissue damage  Creatine kinase (CK)  Male: 60-400 units/L; Female: 40-150 units/L  Aldolase (ALD)  Aspartate aminotransferase (AST)  Lactate dehydrogenase (LDH)  Specific muscle disease (muscular dystrophy, polymyositis, dermatomyositis) result in enzyme increase

33.  Laboratory Tests, cont. ◦ Uric Acid  Male: 4.4-7.6 mg/dL; Female: 2.3- 6.6 mg/dL  Normally in blood  Gout results when uric acid crystals precipitate on tendons, articular cartilage, tissues  Serum levels increase with gout

34.  Radiographic Tests ◦ Standard X-Rays  Can show bone density, texture, alignment alterations, bone relationship alterations, erosion, swelling, intactness  Can help identify some soft tissue damage  Patient education: remain still

35.  Radiographic Tests, cont. ◦ Computed Tomography (CT)  Assists in diagnosing issues related to joints or vertebrae  Contrast may or may not be used  Patient education:  Remain still  Scanner will surround them

36.  Radiographic Tests, cont. ◦ Bone Density Screening  Measures bone strength and weight-bearing capabilities  Bone density measured by dual- energy x-ray absorptiometry (DEXA)  http://www.youtube.com/watch?v= 7EkK1oMK5A8 http://www.youtube.com/watch?v= 7EkK1oMK5A8

37.  Radiographic Tests, cont. ◦ Arthrography  X-ray of synovial joint ◦ Myelogram  Contrast medium inserted into subarachnoid space  Provides for visualization of spine and spinal cord  Patient education:  Tell patients they might be in a head down position for a short time  Assess headache/nausea after procedure

38.  Other Tests ◦ Magnetic Resonance Imaging (MRI)  Used to diagnose musculoskeletal issues, particularly those related to soft tissue  More accurate than CT with vertebral column diagnoses  Contrast may or may not be used  MRI contraindications: pacemakers, surgical clips, internally implanted metal object

39.  Other Tests, cont. ◦ Nuclear Medicine Scans: Bone Scan  Radioactive material is used to visualize the skeleton  Radioisotope injected into patient 2-3 hours prior to scan  Radioisotope is attracted to bone and thus, moves toward bone tissue  Physician assesses for “hot spots”  Signifies concentrated radioactive substance

41.  Other Tests, cont. ◦ Gallium and Thallium Scans  Like bone scan  Radioactive element injected  More specific, sensitive  Gallium moves to bone, brain and breast tissue  Thallium helps evaluate bone cancer

42.  Other Tests, cont. ◦ Arthroscopy  Allows for direct visualization of joint  Same-day surgery  Local or light general anesthesia is used  Several small incisions made  Joint is distended with saline  Scope inserted  Scope helps with visualization and repair

43.  Other Tests, cont. ◦ Arthroscopy, cont.  PACU Nursing considerations:  Assess limb’s neurovascular status  Have patient exercise leg if arthroscopy was only diagnostic  Give pain medication  Assess for and educate patient on:  Thrombophlebitis  Infection  Increased joint pain

44.  Other Tests, cont. ◦ Bone or Muscle Biopsy  Bone or muscle tissue is surgically removed for examination  Can diagnose cancer, infection, inflammation or damage, malignant hyperthermia  Biopsy may be open or closed

45.  Other Tests, cont. ◦ Bone or Muscle Biopsy  Nursing considerations:  Assess biopsy site  Assess pain  Don’t allow movement of area for 8- 12 hours  Assess vital signs  Neurovascular assessments  Wound care if open biopsy

46.  Other Tests, cont. ◦ Ultrasonography  Sound waves can be used to find:  Osteomyelitis, soft tissue disorders, joint injuries, surgical hardware  Conducting matter applied over area  Transducer moved over area  Images recorded on ultrasound machine  Patient education:  Jelly-like matter will feel cold

47.  Other Tests, cont. ◦ Arthrocentesis  Diagnostic or therapeutic  Diagnostic: noninflammatory conditions, septic arthritis, crystal detection, hemarthrosis  Therapeutic: relieves pressure, decreases pain, enhances mobility  Joint’s synovial fluid is aspirated via needle  Nursing considerations:  Assess site for bruising, bleeding, redness, warmth  Monitor for infection, inflammation, hemarthrosis

48.  Other Tests, cont. ◦ Nerve Conduction Studies  Electromyography (EMG) measures electrical impulses of muscle  Can help diagnose muscle disease, nerve damage  Patient education:  Educate on procedure  Inform patient to remove all jewelry  Inform patient to not apply lotions prior to test  Inform patient that discomfort and bruising can occur at study site

49.  Mr. Allan, age 45, comes to the emergency room with extreme pain in his lower back. The pain radiates down his right buttock & down the back of his leg to his knee. He tells you that he hurt his back picking up a box in the warehouse where he works.  1. What other information should you obtain from Mr. Allan?  2. What is a probable cause of Mr. Allan’s pain?  3. What tests, procedures, & treatments may be done for Mr. Allan’s condition?  4. How might this injury impact Mr. Allan’s life?  5. Mr. Allan is to receive morphine 10 mg by intramuscular injection. You have available morphine 15 mg/mL. How many milliliters will you give?