N124IN Spring 2013

Camille Jackson, MSN, RN

 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
 Skeletal system tissues
◦ Bone tissue
 Protects organs and tissues from
mechanical injury
 Stores calcium
◦ Cartilage
 Covers most joint surfaces
◦ Fibrous connective tissue
 Forms ligaments
 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
 Bone Tissue
◦ Osteocytes
◦ Osteoblasts
◦ Osteoclasts
 Bone
◦ Compact
◦ Spongy
◦ Periosteum
 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
 206 bones
◦ Axial skeleton
 Skull, vertebral column, rib cage
◦ Appendicular skeleton
 Arms/legs, shoulder, pelvic
girdles
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
 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)
 Functions
◦ Supports trunk, head
◦ Contains and protects spinal
cord
◦ Intervertebral foramina:
openings where spinal nerves
and blood vessels enter/exit
◦ Allows for movement
 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
 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
 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
 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
 The Aging
Musculoskeletal
System

Bone Articular Muscle

Calcium Cartilage Strength
Loss Wears Down declines

Joint
Fractures Joint Pain Falls
Stiffness
 Muscle mass and strength decline
 Number of muscle cells decrease
 Elasticity of ligaments, tendons,
cartilage decrease
 Smaller intervertebral spaces
 Gait and posture changes
 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………
 History
 PhysicalAssessment
 Psychosocial Assessment
 Frequent neurovascular
assessments may be needed
 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
 Inspection
 Palpation
 Range of motion
 Assess muscle size, strength,
shape, tone
 Physical therapy and occupational
therapy assess patient further in
depth
 Neurovascular assessments
◦ Color
◦ Temperature
◦ Pain
◦ Movement
◦ Sensation
◦ Pulses
◦ Capillary refill
 Assess for withdrawal
 Assess pain effects
 Assess coping ability
 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?
 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
 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
 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)
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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
 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?