1. Medical-Surgical Nursing Care Third Edition CHAPTER Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby The Musculoskeletal System and Assessment 41

2. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Directory Classroom Response System Lecture Note Presentation

3. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 1 In reviewing an x-ray report that states “distal epiphyseal fracture of the radius,” the nurse correctly interprets this as meaning a fracture:

4. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 1 Choices 1.close to the elbow. 2.of the shaft of the radius. 3.at the wrist end of the bone. 4.that has broken the skin.

5. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 1 Choices 1.close to the elbow. 2.of the shaft of the radius. 3.at the wrist end of the bone. 4.that has broken the skin.

6. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Rationale Outcome 1. The epiphysis is the broad end of the bone; distal indicates the end further away from the trunk of the body. Close to the elbow would be proximal, not distal. The epiphysis is near the ends of the bone, not on the shaft. “Compound” is the word indicating the skin has been broken.

7. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 2 The physician’s orders for a client after hip replacement surgery are to maintain the operative leg in a position of abduction. The nurse positions the client:

8. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 2 Choices 1.with the legs together and bent at a 60° angle. 2.on the side, with the knees bent. 3.supine, with the knees crossed. 4.with the leg positioned away from the center of the body.

9. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 2 Choices 1.with the legs together and bent at a 60° angle. 2.on the side, with the knees bent. 3.supine, with the knees crossed. 4.with the leg positioned away from the center of the body.

10. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Rationale Outcome 2, 3. Abduction is movement of the extremity away from the midline of the body. Legs together is not abduction. “On the side” implies the legs are together, which is not abduction. Having the knees crossed is not abduction.

11. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 4 When assessing range of motion of the client’s knee, the nurse notes a grating sound. This is appropriately charted as:

12. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 4 Choices 1.crepitus. 2.synovitis. 3.erythema. 4.inflammation.

13. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 4 Choices 1.crepitus. 2.synovitis. 3.erythema. 4.inflammation.

14. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Rationale Outcome 4. Crepitus is a grating sensation or sound Synovitis is inflammation, not a sound. Erythema is redness, not a noise. Inflammation is not a grating sound; crepitus is.

15. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 5 The nurse preparing a client for a bone scan provides which of the following instructions?

16. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 5 Choices 1.You should have nothing to eat for 8 to 12 hours before the procedure. 2.When the injection is given, you will be instructed to drink four to six glasses of water. 3.After the procedure, it is important to avoid close contact with others for 4 hours to avoid exposing them to radiation. 4.This test is noninvasive; no special preparation is required.

17. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Question 5 Choices 1.You should have nothing to eat for 8 to 12 hours before the procedure. 2.When the injection is given, you will be instructed to drink four to six glasses of water. 3.After the procedure, it is important to avoid close contact with others for 4 hours to avoid exposing them to radiation. 4.This test is noninvasive; no special preparation is required.

18. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby NCLEX-PN ® Rationale Outcome 5. Drinking a large quantity of water after injection of the radioisotope promotes its distribution. The client can eat and drink before and during the procedure. No special radiation precautions are necessary because the amount of radioactivity is small. This is an invasive procedure that requires informed consent.

19. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Learning Outcomes 1.Describe the structure and function of the musculoskeletal system. 2.Identify age-related changes in the musculoskeletal system. 3.Perform and document focused assessment of the musculoskeletal system.

20. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Learning Outcomes 4.Recognize alterations in musculoskeletal structure and/or function. 5.Provide nursing care for clients undergoing diagnostic tests for musculoskeletal system disorders.

21. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Bones Human skeleton has 206 bones Provide structure and support for soft tissue Protect vital organs

22. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Figure 41-1 Bones of the human skeleton.

23. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Figure 41-2 Classification of bones by shape.

24. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Bones Compact bone –Smooth and dense –Forms shaft of long bones and outside layer of other bones Spongy bone –Contains spaces –Spongy sections contain bone marrow

25. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Bone Marrow Red bone marrow –Found in flat bones of sternum, ribs, and ileum –Produces blood cells and hemoglobin Yellow bone marrow –Found in shaft of long bones –Contains fat and connective tissue

26. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Joints (Articulations) Area where two or more bones meet Holds skeleton together while allowing body to move

27. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Joints Synarthrosis –Immovable (e.g., skull) Amphiarthrosis –Slightly movable (e.g., vertebral joints) Diarthrosis or synovial –Freely movable (e.g., shoulders, hips)

28. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Synovial Joints Found at all limb articulations Surface covered with cartilage Joint cavity covered with tough fibrous capsule Cavity lined with synovial membrane and filled with synovial fluid

29. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Ligaments Bands of connective tissue that connect bone to bone Either limit or enhance movement Provide joint stability Enhance joint strength

30. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Tendons Fibrous connective tissue bands that connect bone to muscles Enable bones to move when muscles contract

31. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Muscles Skeletal (voluntary) –Allows voluntary movement Smooth (involuntary) –Muscle movement controlled by internal mechanism –e.g., muscles in bladder wall and GI system Cardiac (involuntary) –Found in heart

32. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skeletal Muscle 600 skeletal muscles Made up of thick bundles of parallel fibers Each muscle fiber made up of smaller structure myofibrils Myofibrils are strands of repeating units called sarcomeres

33. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Skeletal Muscle Skeletal muscle contracts with the release of acetylcholine The more fibers that contract, the stronger the muscle contraction

34. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Changes in Older Adult Musculoskeletal changes can be due to: –Aging process –Decreased activity –Lifestyle factors

35. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Changes in Older Adult Loss of bone mass in older women Joint and disk cartilage dehydrates causing loss of flexibility contributes to degenerative joint disease (osteoarthritis); joints stiffen, lose range of motion

36. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Changes in Older Adult Cause stooped posture, changing center of gravity Elderly at greater risk for falls Endocrine changes cause skeletal muscle atrophy Muscle tone decreases

37. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Assessment Health history Chief complaint Onset of problem Effect on ADLs Precipitating events, e.g., trauma

38. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Assessment Examine complaints of pain for location, duration, radiation character (sharp dull), aggravating, or alleviating factors Inquire about fever, fatigue, weight changes, rash, or swelling

39. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Physical Examination Posture Gait Ability to walk with or without assistive devices Ability to feed, toilet, and dress self Muscle mass and symmetry

40. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby

41. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby

42. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Physical Examination Inspect and palpate bone, joints for visible deformities, tenderness or pain, swelling, warmth, and ROM Assess and compare corresponding joints Palpate joints knees and shoulder for crepitus

43. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Physical Examination Never attempt to move a joint past normal ROM or past point where patient experiences pain Bulge sign and ballottement sign used to assess for fluid in the knee joint Thomas test performed when hip flexion contracture suspected

44. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Figure 41-4 Checking for the bulge sign.

45. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Figure 41-5 Checking for ballottement.

46. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Diagnostic Tests Blood tests Arthrocentesis X-rays Bone density scan CT scan MRI Ultrasound Bone scan

47. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Bone Scan Nuclear medicine procedure in which amount of radioactive isotope taken up by bones is evaluated Abnormal bone scans show hot spots due to malignancies or infection Cold spot uptakes show areas of bone that are ischemic

48. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third Edition Burke Mohn-Brown Eby Arthroscopy Flexible fiberoptic endoscope used to view joint structures and tissues Used to identify: –Torn tendon and ligaments –Injured meniscus –Inflammatory joint changes –Damaged cartilage