Transcript Musculoskeletal Assessment, Diagnostics - Practicum-in-HST-I

Musculoskeletal System
Assessment, Diagnostic Tests, and
Treatments
Prevention Strategies For Injury
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Sports Training
Seat Belt use
Child Safety Seat use
Airbag use
Motorcycle education and protective
equipment
• Fall prevention
• Proper body mechanics
• Can you think of others?
Musculoskeletal System Function
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Scaffolding/Support
Protection of vital organs
Locomotion
Production of RBC
Storage of minerals
Musculoskeletal Structures
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Skin
Muscles
Bones
Tendons
Ligaments
Cartilage
Musculoskeletal Structures Skin
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Holds all structures together
Barrier function
Protects underlying structures
Subcutaneous tissue
– Fat
– Fascia
Musculoskeletal Structures -Muscle
• Composed of specialized cells with ability
to contract
• Voluntary (Skeletal)
– Conscious control
– Allows mobility
• Smooth (Bronchi, GI tract, blood vessels)
– Controlled by ANS
– Able to alter inner lumen diameter
• Cardiac
– Contracts rhythmically on its own
Musculoskeletal Structures
• Tendons
– Bands of connective tissue binding muscles to
bones
• Cartilage
– Connective tissue covering the epiphysis
– Surface for articulation
• Ligaments
– Connective tissue supporting joints
– Attach bone ends to each other
Bones
• Structural form for body
• Protection
• Point of attachment for tendons, ligaments,
cartilage and muscles
• Allows for movement
• Storage of minerals
• Produce red blood cells
Joints
• Points of articulation between bones
• Fused/Fibrous
– Sutures
• Between bones of skull
• Synovial
– Fluid filled chamber which lubricates articulated
surfaces
– Allow for movement
• gliding, flexion, extension, abduction, adduction,
circumduction, rotation
Musculoskeletal
Assessment
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Health History:
Pain
Altered Sensation (paresthia)
Limited Motion
Personal History (health problems, family
history)
• Dietary Habits
• Medications
Pain Assessment
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Pain Assessment
PQRST Method for Pain Assessment
P = Provokes
– What causes pain?
– What makes it better?
– Worse?
Q = Quality
– What does it feel like?
– Is it sharp?
– Dull?
– Stabbing?
– Burning?
– Crushing? ( Try to let patient describe the pain, sometimes they say what they think
you would like to hear. )
R = Radiates
– Where does the pain radiate?
– Is it in one place?
– Does it go anywhere else?
– Did it start elsewhere and now localized to one spot?
S = Severity
– How severe is the pain on a scale of 1 - 10?
( This is a difficult one as the rating will differ from patient to patient. )
T = Time
– Time pain started?
– How long did it last?
Physical Exam
Inspection:
Full range of motion of all joints
Symmetry
Posture (lordosis, scoliosis, kyphosis)
Gait
Muscles-atrophy, strength (0-5 scale, 5 being normal
strength),tenderness/soreness, guarding
Joints/Bones-contractures, crepitus Head and neck:
temporomandibular joint; crepitus
Neurovascular checks (5Ps on next slide)
Height, Weight
Nutritional status
Neurovascular Checks
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PAIN
PULSE
PALLOR
PARASTHESIA (pins and needles)
PARALYSIS
Muscle Strength-ask patient to
squeeze hand, push against you.
Atrophy-wasting away
Contracture-a permanent shortening
(as of muscle, tendon, or scar tissue)
producing
deformity
or
distortion
Foot Drop
Hip Contracture
Crepitus-grating, crackling or popping
sounds and sensations experienced
under the skin and joints.
Musculoskeletal System- Diagnostic
tests:
X-ray
Arthrogram-X-ray images taken after
injection of contrast material into the
joint.
Arthroscopy-Visual examination of the
inside of a joint with an endoscope
and television cameras.
Bone Density Test-Low energy x-ray
absorption to measure bone mass
(DEXA-dual energy x-ray
absorptiometry)
Electromyography (EMG)-Process of
recording the strength of muscle
contraction as a result of electrical
stimulation.
Bone Marrow Biopsy/Aspirate
Musculoskeletal System – Dx Tests
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.
Musculoskeletal System - Tests
• Muscle enzymes- used to distinguish between muscle
weakness that is due to nerve innervation problems and
dystrophic disease of the muscle itself.
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The level of enzymes reflects the progress of the disorder and
the effectiveness of treatment.
• Example- Creatine kinase (CK),aldolase.
Musculoskeletal System – Dx Tests
• Serologic Studies:
• Rheumatoid factor(RF)- Serum is tested for the presence of an
antibody found in patients with rheumatoid arthritis.
• Erythrocyte sedimentation rate (ESR)-Measures the rate at
which erythrocytes settle to the bottom of a test tube.
Elevated ESR is associated with inflammatory disorders like
arthritis, tumors or infection.
• Serum Calcium-Measurement of calcium in the blood.
Calcium
• Calcium is the most common mineral in the body and
one of the most important. The body needs it to build
and fix bones and teeth, help nerves work, make
muscles squeeze together, help blood clot, and help
the heart to work. Almost all of the calcium in the body
is stored in bone. The rest is found in the blood.
• Normally the level of calcium in the blood is carefully
controlled. When blood calcium levels get low
(hypocalcemia), the bones release calcium to bring it
back to a good blood level. When blood calcium levels
get high (hypercalcemia), the extra calcium is stored in
the bones or passed out of the body in urine and stool.
Vitamin D
• Vitamin D promotes calcium absorption in the gut
and maintains adequate serum calcium and
phosphate concentrations to enable normal
mineralization of bone. It is also needed for bone
growth. Without sufficient vitamin D, bones can
become thin and brittle. Vitamin D is naturally
present in a few foods, added to others, and
available as a dietary supplement. It is also
produced endogenously when ultraviolet rays
from sunlight strike the skin and trigger vitamin D
synthesis. Cod liver oil has been used as a
vitamin D supplement for years.
Health Promotion/Illness Prevention Osteoporosis
• Ensure adequate calcium intake.
• Avoid sedentary life style.
• Continue program of weight-bearing
exercises.
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Osteoporosis
Osteoporosis—Treatment
• Bone cannot be restored to normal but therapy to
prevent further loss
• Fluoride supplements to promote bone deposits
• Estrogen replacement therapy
• Bisphosphates (Fosamax) to inhibit osteoclast activity
and bone resorption
• Calcitonin to decrease bone resorption
Drug Therapy
Osteoporosis
• Parathyroid hormone
• Calcium and vitamin D
Diet Therapy
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Dietary supplements of calcium and vit D
Protein
Magnesium
Vitamin K
Trace minerals
Avoid alcohol and caffeine
Fall Prevention
• Hazard-free environment
• High-risk assessment
• Hip protectors that prevent hip fracture in case
of a fall
• Hospital care: ID of patient as a fall risk (arm
band, color coded socks), bed in low position,
side rails up, call light and belongings within
reach, bed alarms, placement close to nurses
station, patient instruction, bedside commode,
assist with ambulation, frequent monitoring.
Fall Prevention
Fall Risk/Use of Restraints
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A hospital's decision to use restraints on patients is a difficult one, involving
complex issues which can pose significant risks to a hospital. A hospital may be
sued for negligence for not taking adequate precautions to protect impaired,
elderly, incapacitated or unstable patients. On the other hand, hospitals also
have been sued for false imprisonment when patients were restrained against
their wishes.
Federal Medicare regulations and policies, as well as the Joint Commission on
the Accreditation of Healthcare Organizations (JCAHO), impose restrictions on
how facilities may use physical or chemical restraints. Most states also have
laws regarding patient restraints. Although the statutes differ slightly from
state to state, such laws generally require the restraint to be:
Authorized in writing by a physician.
Used for only a specified period of time.
Applied only by a physician or other qualified licensed nurse or personnel
under the supervision of the physician.
Restraints
• The liability risk in using restraints can be reduced significantly
if the hospital has a written policy that is stated clearly and
followed consistently. A written policy helps hospital
personnel understand when restraints can and cannot be
used.
• A patient should never be restrained solely for the
convenience of the hospital staff or as punishment. Such
punitive or convenience restraint use is prohibited expressly
by most state laws, Medicare regulations and JCAHO
standards.
Types of Restraints
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Chemical
Wrist/ankle
Lap belts
Posey vest
Mittens
Bed rails
Wrist/Ankle Restraints
Restraints
Posey Vest
Lap Belt
Fractures
• A fracture is a break or
disruption in the continuity of a
bone.
Fracture
• Closed
– Overlying skin intact
• Open
– Wound extends from body surface to fracture
site
– Produced either by bones or object that
caused Fx
– Danger of infection
– Bone end not necessarily visible
WRIST FRACTURE
Fractures—Signs and Symptoms
• Some clearly present (compound fracture) or obvious
deformity
• Swelling, tenderness, altered sensation
• Inability to move limb
• Crepitus
– Grating sound heard if ends of bone fragments move over e/other
• Pain immediately after injury
– Can be delayed if nerve damage in area
• Diagnostic Tests
– X-rays
Stages of Bone Healing
• Hematoma formation within 48 to 72 hr after
injury
• Hematoma to granulation tissue
• Callus formation
• Osteoblastic proliferation
• Bone remodeling
• Bone healing completed within about 6
weeks; up to 6 months in the older person
Problems Associated with
Musculoskeletal Injuries
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Hemorrhage
Interruption of Blood Supply
Disability
Instability
Soft Tissue injury
Complications associated with
Fractures
• Hemorrhage
– Possible loss within first 2 hours
• Tib/Fib - 500 ml
• Femur - 500 ml
• Pelvis - 2000 ml
• Interruption of Blood Supply
– Compression on artery
• decreased distal pulse
– Decreased venous return
Acute Compartment Syndrome
• Serious condition in which increased pressure
within one or more compartments causes
massive compromise of circulation to the
area
• Pathophysiologic changes sometimes
referred to as ischemia-edema cycle
COMPARTMENT SYNDROME
Emergency Care - Acute Compartment
Syndrome
• Within 4 to 6 hr after the onset of acute
compartment syndrome, neuromuscular
damage is irreversible; the limb can become
useless within 24 to 48 hr.
Emergency Care (Continued)
• Fasciotomy may be performed to relieve
pressure.
• Pack and dress the wound after fasciotomy.
Fasciotomy
• Fascia:
• Connective tissue that
surrounds muscles,
groups of muscles,
blood vessels, and
nerves, binding some
structures together,
while permitting others
to slide smoothly over
each other.
Fat embolism syndrome
– serious complication resulting from a fracture;
Risk when fat globules are released from yellow
bone marrow into bloodstream w/in 1st week
after injury
– More common in fracture of pelvis or long bones,
especially if not well immobilized after injury
– Can travel to lungs and cause obstruction,
extensive inflammation, and respiratory distress
Fat emboli
Musculoskeletal Assessment
With few exceptions orthopedic
injuries are not life threatening.
Do not let drama of obvious or
grossly deformed fracture distract
you from more serious problems
involving ABC’s
Fractures—Treatment
• Immediate splinting and immobilization
• Reduction of bones to restore normal position
– Closed reduction: exerting pressure and traction
– Open reduction: requires surgery
• Pins, rods, plates, screws
• Immobilization
– Cast, splints, traction
• Traction
– Application of force or weight pulling on limb that is opposed by body
weight
– Force maintains alignment of bones, prevents muscle spasms, and
immobilizes the limb
SPLINTING INDICATIONS
• Prevention of further
injury
• Stabilize fracture or
dislocation
• Decrease pain
• Relieve impaired
neurological function or
muscle spasms
• Decrease swelling
• Reduce blood and fluid
loss into tissues
Casts
Casts
• Rigid device that immobilizes the affected
body part while allowing other body parts to
move
• Cast materials: plaster, fiberglass, polyestercotton
• Types of casts for various parts of the body:
arm, leg, brace, body
(Continued)
Cast, Splint, Braces, and Traction
Management Considerations
• Arm Casts
• Leg Casts
• Body or Spica Casts
• Splints and Braces
• External Fixator
• Traction
Spica Casts
Casts
Musculoskeletal
Nursing Care - Casts
• Cast (Leg, arm, body)
– Different materials-fiberglass,
plastic, plaster, stockinette
– Neurovascular
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Check color/capillary refill
Temperature
Pulse
Movement
Sensation
• Traction
– Buck’s
– Russell’s
– Skeletal
• Traction Nursing Care
– Weighs hang free
– Pin Site care
– Skin and neurovascular
check
Cast Care (continued)
• Elevate Extremity
• Exercises – to unaffected side; isometric exercises to
affected extremity
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Keep heel off mattress
Handle with palms of hands if cast wet
Turn every two hours till dry
Notify MD at once of wound drainage
Do not place items under cast.
Traction
• Application of a pulling force to the body to
provide reduction, alignment, and rest at that
site
• Types of traction: skin, skeletal, plaster,
brace, circumferential
(Continued)
Traction
–Manual
Nursing Management
• Positioning
• Strengthening Exercises
Musculoskeletal
Nursing Care
• Other External Immobilizations
– Halo Vest
– External Fixation with lag screws at tibia, pelvic,
ankle/foot
Halo Vest
Operative Procedures
• Open reduction with internal fixation
• External fixation
Surgical Treatment
External Fixation
Surgical Treatment
• Internal Fixation (ORIF)
Managing the Patient Undergoing Orthopedic
Surgery
• Joint Replacement
• Total Hip Replacement
• Total Knee Replacement
Acute Pain - Orthopedic Surgery
• Interventions include:
– Reduction and immobilization of fracture
– Assessment of pain
– Drug therapy: opioid and nonopioid drugs
(Continued)
Acute Pain (Continued)
Orthopedic Surgery
– Complementary and alternative therapies: ice,
heat, elevation of body part, massage, baths,
back rub, therapeutic touch, distraction, imagery,
music therapy, relaxation techniques
Pain Management
• Over-the-counter (OTC) pain relievers include:
• Acetaminophen (Tylenol, Aspirin Free Excedrin)
• Nonsteroidal anti-inflammatory drugs (NSAIDs;
aspirin, Motrin, and Aleve)
• Topical Corticosteroids (Cortaid and Cortizone)
• Both acetaminophen and NSAIDs reduce fever and relieve
pain caused by muscle aches and stiffness, but only NSAIDs
can also reduce inflammation (swelling and irritation).
Acetaminophen and NSAIDs also work differently. NSAIDs
relieve pain by reducing the production of prostaglandins,
which are hormone-like substances that causes pain.
Acetaminophen works on the parts of the brain that
receive the "pain messages."
Pain Management-Controlled
Substances (DEA Enforced)
• Definition of Controlled Substance Schedules
• The drugs and other substances that are considered
controlled substances under the CSA are divided into
five schedules. A listing of the substances and their
schedules is found in the DEA regulations, 21 C.F.R.
Sections 1308.11 through 1308.15. A controlled
substance is placed in its respective schedule based on
whether it has a currently accepted medical use in
treatment in the United States and its relative abuse
potential and likelihood of causing dependence. Some
examples of controlled substances in each schedule are
outlined below.
Controlled Substances
• These medications are locked up and require
them to be counted by two licensed people.
• They must never be left out and any waste the
medication must be witnessed by two
licensed people.
• Only physicians with DEA numbers can
prescribe these.
• It is illegal to give your friend one of these
drugs. IT IS CONSIDERED DRUG TRAFFICING.
• Schedule I Controlled Substances
• Substances in this schedule have a high potential
for abuse, have no currently accepted medical
use in treatment in the United States, and there is
a lack of accepted safety for use of the drug or
other substance under medical supervision.
• Some examples of substances listed in schedule I
are: heroin, lysergic acid diethylamide (LSD),
marijuana (cannabis).
• Schedule II Controlled Substances
• Substances in this schedule have a high potential for abuse
which may lead to severe psychological or physical
dependence.
• Examples of schedule II narcotics include morphine and
opium. Other schedule II narcotic substances and their
common name brand products include: Dilaudid,
methadone, meperidine (Demerol), oxycodone
(OxyContin), and fentanyl.
• Examples of schedule II stimulants include: Adderall,
methamphetamine, and methylphenidate (Ritalin). Other
schedule II substances include: cocaine, amobarbital, and
pentobarbital.
• Schedule III Controlled Substances
• Substances in this schedule have a potential for abuse
less than substances in schedules I or II and abuse may
lead to moderate or low physical dependence or high
psychological dependence.
• Examples of schedule III narcotics include combination
products containing less than 15 milligrams of
hydrocodone per dosage unit (Vicodin) and products
containing not more than 90 milligrams of codeine per
dosage unit (Tylenol with codeine). Example of
schedule III non-narcotics is ketamine.
• Schedule IV Controlled Substances
• Substances in this schedule have a low potential
for abuse relative to substances in schedule III.
• An example of a schedule IV narcotic is Darvocet.
• Other schedule IV substances include: Xanax,
clonazepam, diazepam (Valium), lorazepam
(Ativan), midazolam (Versed), temazepam
(Restoril), and triazolam (Halcion).
• Schedule V Controlled Substances
• Substances in this schedule have a low potential
for abuse relative to substances listed in schedule
IV and consist primarily of preparations
containing limited quantities of certain narcotics.
These are generally used for antitussive,
antidiarrheal, and analgesic purposes.
• Examples include cough preparations containing
not more than 200 milligrams of codeine per 100
milliliters or per 100 grams (Robitussin AC and
Phenergan with Codeine).
Impaired Physical Mobility
• Interventions include:
– Use of crutches to promote mobility
– Use of walkers and canes to promote mobility
Dislocations
• Separation of 2 bones at a joint
– Loss of contact between articulating bone surfaces
– Usually one bone out of position, other normal
– Ex: humerus displaced from glenoid fossa
• Subluxation
– Bone only partially displaced w/ partial loss of contact between surfaces
• Trauma (fall) usually cause
• Cause considerable soft tissue damage
– Also damage to ligaments, nerves, bv as bone pulled away from joint
– Inflammation and bleeding
• Severe pain, swelling, tenderness
• Diagnosis confirmed by X-ray
• Treatment
– Reduction to dislocated bone, immobilization, therapy to maintain joint
mobility
– Healing is slow if ligaments and soft tissue extensively damaged
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Amputation
Levels
Complications
Rehabilitation
Nursing Management
– relieving pain
– minimizing altered sensory perception
– promoting wound healing
– enhancing body image
– self-care
Amputations
Amputations
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Surgical amputation
Traumatic amputation
Levels of amputation
Complications of amputations: hemorrhage,
infection, phantom limb pain, problems
associated with immobility, neuroma, flexion
contracture
Phantom Limb Pain
• Phantom limb pain is a frequent
complication of amputation.
• Client complains of pain at the site of
the removed body part, most often
shortly after surgery.
• Pain is intense burning feeling, crushing
sensation or cramping.
• Some clients feel that the removed
body part is in a distorted position.
Prosthesis
Contusions, Strains, and Sprains
• Contusion is a soft tissue injury
• Strain is a pulled muscle from
overuse, overstretching, or excessive
stress
• Sprain is an injury to ligaments
surrounding a joint
Sprains
Strains
• Excessive stretching of a muscle or tendon
when it is weak or unstable
• Classified according to severity: first-,
second-, and third-degree strain
• Management: cold and heat applications,
exercise and activity limitations, antiinflammatory drugs, muscle relaxants, and
possible surgery
Sprains
• Excessive stretching of a ligament
• Treatment of sprains:
– first-degree: rest, ice for 24 to 48 hr, compression
bandage, and elevation
– second-degree: immobilization, partial weight
bearing as tear heals
– third-degree: immobilization for 4 to 6 weeks,
possible surgery