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Musculoskeletal
assessment
Presented by
Dr.Sheref Sayed Mohamed Nesnawy
Assistant lecturer of medical surgical nursing
‫مس...
Musculoskeletal assessment
•Mobiles off
•Share ideas
•Ask questions
•Listen actively
Introduction
The musculoskeletal system is the
supporting framework and collectively
the largest system in the body.
It is...
So it Consists of:
• A. Muscles (accounts for approximately
50% of the body weight):
• B. Bony structures and connective t...
1-Types
1. Skeletal muscles (voluntary
and striated),
2. Cardiac muscles
(involuntary and striated)
3. Smooth/visceral mus...
Skeletal muscles
Types of Muscle Contractions:
• 1-isometric contraction, the length of the
muscles remains constant but the force
generate...
.• NB: Many muscle movements are a
combination of isometric and isotonic
contraction. For example, during
walking, isotoni...
The function of muscles is
• Movement of body parts: by isotonic &
isometric contractions
• Maintenance of posture
• Produ...
SKELETAL FUNCTION
Movement
Support: protects the internal body organs
factory which produces red blood cells from the
b...
Consists of:
1. The Skeleton (bones)
2. Articular system (Joints)
3. Supportive connective tissues
(Cartilage, ligaments,...
1-The Skeleton(Bones):
Mobility and weight-bearing capacity are
directly related to the bone’s size and shape.
Bones: co...
Typs of bones cells:
• 1-Osteoblasts :function in bone
formation by secreting bone matrix.
• 2-Osteocytes are mature bone ...
Types of
bones:
 Long bones
Short bones
Flat bones
Irregular
bones
Osteogenesis:
• Ossification is the process by which the
bone matrix (collagen fibers and ground
substance) is formed and ...
regulating factors for Bone
Maintenance:
• 1-Local stress (weight bearing) acts to simulate
bone formation and remodeling....
.
• 4-Parathyroid hormone and calcitonin :
calcium homeostasis. demineralization of
bone, and the formation of bone cysts....
Anatomy of the Skeletal
System
Part I: Bones of the Cranium
Part II: Bones of the Appendicular
Skeleton
Bones of the Cranium
Frontal View
Frontal
Frontal View
Parietal
Frontal View
Temporal
Frontal View
Nasal
Frontal View
Vomer
Frontal View
Zygoma
Frontal View
Maxilla
Frontal View
Mandible
Frontal View
Frontal
Parietal
Temporal
Zygoma
Nasal
Vomer
Maxilla
Mandible
Frontal View
Lateral View
Frontal
Lateral View
Parietal
Lateral View
Temporal
Lateral View
Nasal
Lateral View
Zygoma
Lateral View
Maxilla
Lateral View
Mandible
Lateral View
Sphenoid
Lateral View
Occipital
Lateral View
Mastoid Process
Lateral View
External Auditory Meatus
Lateral View
Frontal
Nasal
Zygoma
Maxilla
Mandible
Parietal
Sphenoid
Temporal
Occipital
External Auditory Meatus
Mastoid Process
Latera...
Sutures
Sagittal
Sutures
Frontal
(Coronal)
Sutures
Squamous
Sutures
Lambdoid
Sutures
Frontal
(Coronal)
Sagittal
Squamous
Lambdoid
Sutures
Bones of the
Appendicular
Skeleton
Clavicle
Scapula
Costals (Ribs)
Sternum
Vertebra
Humerus
Ulna
Radius
Sternum
Clavicle
Scapula
Costals (Ribs)
Humerus
VertebraUlna
Radius
Sacrum
Ilium
Ischium
Pubis
Femur
Patella
Tibia
Fibula
Ilium
Ischium
Femur
Fibula
Sacrum
Pubis
Patella
Tibia
Bones of the Hand
Carpels
Bones of the Hand
Metacarpels
Carpels
Bones of the Hand
Phalanges
Metacarpels
Carpels
Bones of the Hand
Bones of the Foot
Bones of the Foot
Tarsals
Bones of the Foot
Metatarsals
Tarsals
Bones of the Foot
Phalanges
Metatarsals
Tarsals
2- Joints
Joint: the point at which two or more
bones meet. The synotide membrane lines
the joints. It secretes synovial ...
.
Bursa: disc shaped, fluid-filled synovial sacs that
develop at points of friction around joints, between
tendons, carti...
Classification of Joints
• (1) Synarthroses or fibrous
• (2) amphiarthroses or cartilaginous
• (3) diarthroses or synovial...
Movable joints
Joint motion produced by
muscle contraction - terms
• Flexion
• Extension
• Dorsiflexion
• Plantar flexion
• Adduction
• A...
3- Supportive connective tissue
(A)Cartilage : cushioning tissue within a joint
so that the bone ends do not rub together
...
(2)Ligaments
Is a small band of dense, white,
fibrous elastic tissue , connect
bones to each other at the joint
level to l...
(3)Tendons:
connect muscles to bones, When muscles
contract (shorten), tendons at each end of
the muscle cause the bone to...
ASSESMENT
OF THE
MUSCULO-
SKELETAL
SYSTEM
Aims of musculoskeletal assessment:
For the patient presenting with a musculoskeletal
problem his primary complaint is lik...
General aspects of musculoskeletal
assessment:
• two objective stages together ; inspection
and palpation. rather than ins...
General aspects of musculoskeletal
assessment:
• position for patient comfort
• Always compare each side.
• Organize your ...
Patient Preparation
Explain procedure
to patient
Use firm support,
gentle movement
Patient comfortable
Adequate Lighti...
stages of musculoskeletal assessment:
A-Subjective Data;
B-Objective Data;
(Inspection and Palpation) for system and its
f...
A-Subjective Data;
A-Subjective Data;
)1)Demographic data: Age, sex, Weight gain/loss
and Work………etc
(2) Present history musculoskeletal comp...
A-Subjective Data;
(3)PQRSTA: useful in gathering data about
any complaint/problem/symptom.
Provocative or Palliative
Wha...
Musculoskeletal assessment
Quality or Quantity
What is the character of the symptom i.e.
pain: is it crushing, piercing, ...
Musculoskeletal assessment
• Severity
How does the symptom rate on a severity scale of
1 to 10 with 10 being the most inte...
• Associated signs and symptoms of
the chief complaint
• Most common Chief complaint: pain,
weakness, and deformity, limit...
(4) Effects of presenting
musculoskeletal complaint on:
• activities of daily living: able to care for himself
(independen...
(5) Past Health History and
Concurrent health conditions:
(1)Certain illnesses can affect the musculoskeletal
system eithe...
• 2-History of trauma, surgery, period of
prolonged immobilization , Alcohol use
,Smoking, Family history of osteoporosis
...
4- Medications:
• for any possible side effects include antiseizure
drugs(osteomalacia),corticosteroids( vascular
necrosis...
Musculoskeletal Side Effects of
Medications/Substances
-Amphetamines : Muscle hyperactivity
-Anticoagulants: Bleeding into...
(B)Objective Data:
(B)Objective Data:(1) Inspection:
(1) Inspection:
• For a comprehensive assessment, inspection should be
carried out obser...
(B)Objective Data:(1) Inspection:
3-structural relationships:(Gait-involuntary
movements -Full Rom of all joints)
- Should...
In Gait…
Note ( joint and muscle symmetry - extremity
length and muscle deformity-Body alignment-
Use of Assistive devices...
wing scapula Varus (bow legs)
Valgus (knock-knees)
ganglion cyst
(2) Palpation
• • Palpate joints, bursal sites, bones and
surrounding muscles.
• • During Palpation: Assess the patient fo...
Palpation should assess for the
following:( TEC)2
• T: increased temperature (use the back of the hand
above, below and on...
During assessment
The part may has :
1. Muscles
2. Bones
3. Joints
4. Limb to be measured
so, those must be assessed
1-MUSCLE ASSESSMENT
A-Muscle mass
General view of muscle:
- Atrophy
- Hypertrophy
- Of normal
B-Muscle Measurement:
Muscle mass is measured
circumferentially at the largest
area of the muscle. When
recording measurem...
3-Muscle Strength:
• 1. Assess each group :Strong & Equal
2. Compare each side
3. Scale - 0-5
- It is considered a disabil...
Muscle strength scale
No detection of muscular contraction.
0
A barely detectable flicker or trace of contraction with obs...
4-Joint motion produced by muscle
contraction
• Flexion
• Extension
• Dorsiflexion
• Plantar flexion
• Adduction
• Abducti...
2-Bones
• Examine for:
1- Deformity 2- Tumors
3- Pain: is the pain focal (fracture/trauma,
infection, malignancy, Paget’s ...
3-Joint
1- Signs of inflammation, injury (swelling, redness, warmth)?
Deformity? Compare w/opposite side
2- activity and R...
Range of movement (ROM)
• Assess (Type: Active, Passive, Full, Limited,
Stiffness, contractures)
• If ROM is limited – det...
4-Limb measurement
• limbs are in the neutral
position.
• the patient is lying straight
• Full length upper limb –
measure...
• Special Tests
• Phalen’s Test –Ask the
patient to hold the wrist in
acute flexion for 60 seconds.
Numbness or burning
in...
• “Bulge sign” –assess
for small amount of
fluid on the knee.
Milk upward on the
medial side of the
knee then tap lateral
...
Diagnostic Studies Of
Musculoskeletal System
1-Radiological studies
2- Bone mineral density (BMD) measurements
3-NUCLEAR S...
1-Radiological studies
-X-rays provide information about bone
deformity, joint congruity, bone density,
and calcification in soft tissue.
-Fractu...
RELATED NURSING CARE
• Maintain privacy of patient
• patient is asked to remove some or all of his
clothes and to wear a g...
A-Fluoroscopy
Real-time x-ray images with digital detectors
X-ray source is underneath table and detector
above, thus sh...
B-Diskogram
• X-ray of cervical or lumbar intenvertebral disk
is done after injection of contrast media into
nucleus pulpo...
C-Computed Tomography
CT uses x-rays to produce cross
sectional images
• X-ray beam is used with a computer
to provide a ...
Computed Tomography
Computed Tomography
Principal musculoskeletal
indications
–Staging of complex fractures
–Detection of small intra-articul...
D-Magnetic Resonance
Imaging (MRI)
D-Magnetic Resonance
Imaging (MRI)
• Radio waves and magnetic field are used to
view soft tissue. Especially useful in the...
MRI
• RELATED NURSING CARE : Assess for metallic
implants or metal on clothing (metallic implants,
such as clips on aneury...
E-Myelogram with or without CT
• Involves injecting a radiographic
contrast medium: Into sac around
nerve roots. CT scan m...
.
2- Bone mineral density
(BMD) measurements
A-Quantitative ultrasound (QUS)
• Evaluates density,
elasticity, and strength
of bone using
ultrasound rather than
radiati...
B-Dual energy x-ray Absorptlomatry
(DEXA)
• Assesses bone density to diagnose
osteoporosis
• -Uses LOW dose radiation to m...
3-NUCLEAR STUDIES:
Imaging study with the use of a contrast radioactive
material
-Pre-test: Painless procedure, IV radioisotope is used,
no s...
.
3-Endoscopic Studies –
arthrocentesis,
arthroscopy
Arthroscopy
A direct visualization of the joint cavity
-Pre-test: consent, explanation of procedure, NPO
-Intra-test: Seda...
Arthrocentesis
-Done to obtain synovial fluid from a joint for
diagnosis (such as infections /hemorrhage)
or to remove exc...
.
(4)Laboratory
Urine Tests
• 24 hour creatine-creatinine ratio:- (Creatine
phosphate is the most important storage form of
high-energy ph...
Blood tests:
1-Rheumatoid Factor:
Importantly, RF is not a 'test for rheumatoid
arthritis'. It is therefore neither suffic...
Blood tests:
2-Antinuclear antibodies:
Mainly for diagnoses of SLE
- a negative ANA virtually excludes the diagnosis
- a p...
Calcium
Total
Ionized
8.6–10.3 mg/dl
4.4–5.1 mg/dl
2.2–2.74 mmol/L
1–1.3 mmol/L
Phosphorus 2.5–5 mg/dl 0.8–1.6 mmol/L
Phos...
CAUSES OF AN ELEVATED SERUM
CREATINE KINASE.
• Inflammatory myositis ± vasculitis
• Muscular dystrophy
• Motor neuron dise...
Invasive investigation
• Synovial fluid analysis
• Bone biopsies
• Musccle biopsies
SYNOVIAL FLUID ANALYSIS
• For: septic arthritis, crystal-associated arthritis and
intra-articular bleeding, and it should ...
• Turbid: joint inflammation, volume increases, the
total cell count and proportion of neutrophils
rise, and the viscosity...
Continue ..
• High concentrations of crystals: mainly urate or
cholesterol, can make SF appear white Non-
uniform blood-st...
Continue..
• A lipid layer floating: above blood-stained fluid is
diagnostic of intra-articular fracture with release of
l...
BONE BIOPSIES
• BONE BIOPSY:
in metabolic bone diseases
With patients who are
suspected of having
osteomalacia
Muscle biopsy
• For myopathy and myositis.
• Needle muscle biopsy of the
quadriceps or deltoid
• is preferred to open surg...
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Musculoskeletal assessment

  1. 1. Musculoskeletal assessment Presented by Dr.Sheref Sayed Mohamed Nesnawy Assistant lecturer of medical surgical nursing ‫مساعد‬ ‫مدرس‬/‫محمد‬ ‫يد‬‫س‬ ‫يف‬‫رش‬‫ناوي‬‫نس‬ Minia University 2015
  2. 2. Musculoskeletal assessment •Mobiles off •Share ideas •Ask questions •Listen actively
  3. 3. Introduction The musculoskeletal system is the supporting framework and collectively the largest system in the body. It is word of 2 syllables Muscle + Skeletal
  4. 4. So it Consists of: • A. Muscles (accounts for approximately 50% of the body weight): • B. Bony structures and connective tissue (accounts for approximately 25% of the body weight): – 1-The Skeleton – 2-Supportive connective tissues – 3-Articular system(Joints)
  5. 5. 1-Types 1. Skeletal muscles (voluntary and striated), 2. Cardiac muscles (involuntary and striated) 3. Smooth/visceral muscles (involuntary and non-striated)
  6. 6. Skeletal muscles
  7. 7. Types of Muscle Contractions: • 1-isometric contraction, the length of the muscles remains constant but the force generated by the muscles is increased; an example of this is when one pushes against an immovable wall. • 2- Isotonic contraction, is characterized by shortening of the muscle with no increase in tension within the muscle; an example of this is flexion of the forearm.
  8. 8. .• NB: Many muscle movements are a combination of isometric and isotonic contraction. For example, during walking, isotonic contraction results in shortening of the leg, and isometric contraction causes the stiff leg to push against the floor
  9. 9. The function of muscles is • Movement of body parts: by isotonic & isometric contractions • Maintenance of posture • Production of body heat
  10. 10. SKELETAL FUNCTION Movement Support: protects the internal body organs factory which produces red blood cells from the bone marrow of certain bones and white cells from the marrow of other bones  a storehouse for minerals - calcium, for example - which can be supplied to other parts of the body
  11. 11. Consists of: 1. The Skeleton (bones) 2. Articular system (Joints) 3. Supportive connective tissues (Cartilage, ligaments, tendons)
  12. 12. 1-The Skeleton(Bones): Mobility and weight-bearing capacity are directly related to the bone’s size and shape. Bones: composed of : cells, protein matrix, and mineral deposits.
  13. 13. Typs of bones cells: • 1-Osteoblasts :function in bone formation by secreting bone matrix. • 2-Osteocytes are mature bone cells involved in bone-maintenance functions. • 3-Osteoclasts: involved in destroying, resorbing, and remolding bone.
  14. 14. Types of bones:  Long bones Short bones Flat bones Irregular bones
  15. 15. Osteogenesis: • Ossification is the process by which the bone matrix (collagen fibers and ground substance) is formed and hardening minerals (eg, calcium salts) are deposited on the collagen fibers. The collagen fibers give tensile strength to the bone, and the calcium provides compressional strength.
  16. 16. regulating factors for Bone Maintenance: • 1-Local stress (weight bearing) acts to simulate bone formation and remodeling. prolonged bed rest? • 2- vitamin D: promoting absorption of calcium from the gastrointestinal tract. It also facilitates mineralization of osteoid tissue. • 3-Blood supply: With diminished blood supply or hyperemia (congestion), osteogenesis (bone formation) and bone density decrease
  17. 17. . • 4-Parathyroid hormone and calcitonin : calcium homeostasis. demineralization of bone, and the formation of bone cysts. Calcitonin, secreted by the thyroid gland in response to elevated blood calcium levels, inhibits bone resorption and increases the deposit of calcium in bone. • 5-Gerontologic Considerations: aged person become prone to fracture( vertebrae, hip, wrist), Weakness,Fatigue and Falls.
  18. 18. Anatomy of the Skeletal System Part I: Bones of the Cranium Part II: Bones of the Appendicular Skeleton
  19. 19. Bones of the Cranium
  20. 20. Frontal View
  21. 21. Frontal Frontal View
  22. 22. Parietal Frontal View
  23. 23. Temporal Frontal View
  24. 24. Nasal Frontal View
  25. 25. Vomer Frontal View
  26. 26. Zygoma Frontal View
  27. 27. Maxilla Frontal View
  28. 28. Mandible Frontal View
  29. 29. Frontal Parietal Temporal Zygoma Nasal Vomer Maxilla Mandible Frontal View
  30. 30. Lateral View
  31. 31. Frontal Lateral View
  32. 32. Parietal Lateral View
  33. 33. Temporal Lateral View
  34. 34. Nasal Lateral View
  35. 35. Zygoma Lateral View
  36. 36. Maxilla Lateral View
  37. 37. Mandible Lateral View
  38. 38. Sphenoid Lateral View
  39. 39. Occipital Lateral View
  40. 40. Mastoid Process Lateral View
  41. 41. External Auditory Meatus Lateral View
  42. 42. Frontal Nasal Zygoma Maxilla Mandible Parietal Sphenoid Temporal Occipital External Auditory Meatus Mastoid Process Lateral View
  43. 43. Sutures
  44. 44. Sagittal Sutures
  45. 45. Frontal (Coronal) Sutures
  46. 46. Squamous Sutures
  47. 47. Lambdoid Sutures
  48. 48. Frontal (Coronal) Sagittal Squamous Lambdoid Sutures
  49. 49. Bones of the Appendicular Skeleton
  50. 50. Clavicle
  51. 51. Scapula
  52. 52. Costals (Ribs)
  53. 53. Sternum
  54. 54. Vertebra
  55. 55. Humerus
  56. 56. Ulna
  57. 57. Radius
  58. 58. Sternum Clavicle Scapula Costals (Ribs) Humerus VertebraUlna Radius
  59. 59. Sacrum
  60. 60. Ilium
  61. 61. Ischium
  62. 62. Pubis
  63. 63. Femur
  64. 64. Patella
  65. 65. Tibia
  66. 66. Fibula
  67. 67. Ilium Ischium Femur Fibula Sacrum Pubis Patella Tibia
  68. 68. Bones of the Hand
  69. 69. Carpels Bones of the Hand
  70. 70. Metacarpels Carpels Bones of the Hand
  71. 71. Phalanges Metacarpels Carpels Bones of the Hand
  72. 72. Bones of the Foot
  73. 73. Bones of the Foot Tarsals
  74. 74. Bones of the Foot Metatarsals Tarsals
  75. 75. Bones of the Foot Phalanges Metatarsals Tarsals
  76. 76. 2- Joints Joint: the point at which two or more bones meet. The synotide membrane lines the joints. It secretes synovial fluid that acts as a lubricant so the joint can move smoothly Components: (Synovial fluid-Cartilage- Tendons-Ligaments-Bursa)
  77. 77. . Bursa: disc shaped, fluid-filled synovial sacs that develop at points of friction around joints, between tendons, cartilage & bonedecrease friction & promote ease of motion
  78. 78. Classification of Joints • (1) Synarthroses or fibrous • (2) amphiarthroses or cartilaginous • (3) diarthroses or synovial = movable joints
  79. 79. Movable joints
  80. 80. Joint motion produced by muscle contraction - terms • Flexion • Extension • Dorsiflexion • Plantar flexion • Adduction • Abduction • Inversion • Eversion • Internal rotation • External rotation • Pronation • Suppination
  81. 81. 3- Supportive connective tissue (A)Cartilage : cushioning tissue within a joint so that the bone ends do not rub together -Hyaline cartilages (trachea, nose and articular surface of bones) Elastic cartilage ( ear, epiglottis, and larynx) Fibrous cartilage (between the vertebral disks, between bones of the pelvic girdle, knee, and shoulder).
  82. 82. (2)Ligaments Is a small band of dense, white, fibrous elastic tissue , connect bones to each other at the joint level to limit dislocation and provide stability while permitting controlled movement at the joint. Also support many internal organs; including the uterus, the bladder, the liver, and the diaphragm and supporting the breasts.
  83. 83. (3)Tendons: connect muscles to bones, When muscles contract (shorten), tendons at each end of the muscle cause the bone to move
  84. 84. ASSESMENT OF THE MUSCULO- SKELETAL SYSTEM
  85. 85. Aims of musculoskeletal assessment: For the patient presenting with a musculoskeletal problem his primary complaint is likely to be that of pain or a decrease in functional ability. Thus, the aim of the musculoskeletal assessment is to determine the degree to which the patient’s activities of daily living are affected, through a systematic assessment.
  86. 86. General aspects of musculoskeletal assessment: • two objective stages together ; inspection and palpation. rather than inspecting all joints and then returning to palpate. • To discover you must uncover but ensure privacy and dignity. • Always ask whether the patient has any pain and if so, assess the pain-free side first.
  87. 87. General aspects of musculoskeletal assessment: • position for patient comfort • Always compare each side. • Organize your examination of the bones, muscles and joints in a head-to toe method. This will help avoid omissions. • Always start each part of the examination from the neutral position
  88. 88. Patient Preparation Explain procedure to patient Use firm support, gentle movement Patient comfortable Adequate Lighting
  89. 89. stages of musculoskeletal assessment: A-Subjective Data; B-Objective Data; (Inspection and Palpation) for system and its functions(ROM-limb measurement -Bones- Joints- Muscles) and Diagnostic Studies
  90. 90. A-Subjective Data;
  91. 91. A-Subjective Data; )1)Demographic data: Age, sex, Weight gain/loss and Work………etc (2) Present history musculoskeletal complaint: what’s functional limitation? -Symptoms in single vs multiple joints? -Acute vs slowly progressive? -If injurymechanism? -Prior problems w/area? -Systemic symptoms?
  92. 92. A-Subjective Data; (3)PQRSTA: useful in gathering data about any complaint/problem/symptom. Provocative or Palliative What causes the symptom? What makes is better or worse?  What have you done to get relief?
  93. 93. Musculoskeletal assessment Quality or Quantity What is the character of the symptom i.e. pain: is it crushing, piercing, dull, sharp? How much of it are you experiencing now? Region or Radiation Where is the symptom? Does it spread?
  94. 94. Musculoskeletal assessment • Severity How does the symptom rate on a severity scale of 1 to 10 with 10 being the most intense? • Timing &Time Timing:  When did the symptom begin? How long does it last (Identify 24 hour pattern of presenting complaint? • Time: How often does it occur? Is it sudden or gradual?
  95. 95. • Associated signs and symptoms of the chief complaint • Most common Chief complaint: pain, weakness, and deformity, limitation of movement, stiffness, and joint crepitating , changes in sensation or in the size of a muscle, discomfort , disturbed sleep pattern.. Musculoskeletal assessment
  96. 96. (4) Effects of presenting musculoskeletal complaint on: • activities of daily living: able to care for himself (independently-with assistance -complete dependence) • Activity-Exercise Pattern ,Nutritional-Metabolic Pattern, Elimination Pattern, Sleep Pattern, Role-Relationship Pattern
  97. 97. (5) Past Health History and Concurrent health conditions: (1)Certain illnesses can affect the musculoskeletal system either directly or indirectly :- • Tuberculosis, poliomyelitis, diabetes mellitus parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disabilities. • Arthritic and connective tissue diseases (e.g., gout, psoriatic arthritis, systemic lupus erythematosus)
  98. 98. • 2-History of trauma, surgery, period of prolonged immobilization , Alcohol use ,Smoking, Family history of osteoporosis • 3- Diet: Adequate amounts of vitamins C and D, calcium, and protein are essential for a healthy, intact musculoskeletal system.
  99. 99. 4- Medications: • for any possible side effects include antiseizure drugs(osteomalacia),corticosteroids( vascular necrosis, decrease bone and muscle mass) and potassium depleting diuretics( muscle cramps and weakness) • A history of medication use and response to pain medication aids in designing medication management regimens
  100. 100. Musculoskeletal Side Effects of Medications/Substances -Amphetamines : Muscle hyperactivity -Anticoagulants: Bleeding into the joints -Antipsychotics: Dystonic movements, altered gait -Caffeine: Muscle hyperactivity -Corticosteroids: Necrosis of femur head -Diuretics: Muscle weakness and cramping -Phenothiazines: Gait disturbances
  101. 101. (B)Objective Data:
  102. 102. (B)Objective Data:(1) Inspection: (1) Inspection: • For a comprehensive assessment, inspection should be carried out observing from anterior, posterior and lateral views. Inspection should assess for: 1-Shape: size , contour ,symmetry (Alike on both sides) 2- structure: • Normal or deviated from normal (Deformities ,fracture…) • muscle configuration: hypertrophy/atrophy (steroid use, malnutrition) • body build , posture and body alignment : (Standing ,Sitting and recumbent)
  103. 103. (B)Objective Data:(1) Inspection: 3-structural relationships:(Gait-involuntary movements -Full Rom of all joints) - Shoulders level, Scapulae level, Iliac crests level 4- skin condition • swelling/edema (effusions, hematoma) • discoloration (vascular insufficiency, bruising, hematoma) • pressure sores, necrosis, scarring scars indicating any previous surgery or trauma
  104. 104. In Gait… Note ( joint and muscle symmetry - extremity length and muscle deformity-Body alignment- Use of Assistive devices-Shoes) (type of gait:Unsteady–Shuffling–Limp–Steady)
  105. 105. wing scapula Varus (bow legs) Valgus (knock-knees) ganglion cyst
  106. 106. (2) Palpation • • Palpate joints, bursal sites, bones and surrounding muscles. • • During Palpation: Assess the patient for both verbal and non-verbal cues of pain, Ask the patient, ‘Does the pain radiate elsewhere from the initial region?’
  107. 107. Palpation should assess for the following:( TEC)2 • T: increased temperature (use the back of the hand above, below and on the joint and compare with the other side) • T:tenderness • E: edema/ swelling • E: enlargement (bone tumor) • C: crepitus (osteoarthritis, listen for crepitus as well as feeling) • C:Consistency and tone of muscle
  108. 108. During assessment The part may has : 1. Muscles 2. Bones 3. Joints 4. Limb to be measured so, those must be assessed
  109. 109. 1-MUSCLE ASSESSMENT
  110. 110. A-Muscle mass General view of muscle: - Atrophy - Hypertrophy - Of normal
  111. 111. B-Muscle Measurement: Muscle mass is measured circumferentially at the largest area of the muscle. When recording measurements, document the exact location at which the measurements were obtained (e.g., the quadriceps muscle is measured 15 cm above the patella). This informs the next examiner of the exact area to measure and ensures consistency during reassessment
  112. 112. 3-Muscle Strength: • 1. Assess each group :Strong & Equal 2. Compare each side 3. Scale - 0-5 - It is considered a disability is muscle strength is less than grade 3.
  113. 113. Muscle strength scale No detection of muscular contraction. 0 A barely detectable flicker or trace of contraction with observation 1 Active movement of body part with elimination of gravity 2 Active movement against gravity only and not against resistance 3 Active movement against gravity and some resistance 4 Active movements against full resistance without evident fatigue (normal muscle strength) 5
  114. 114. 4-Joint motion produced by muscle contraction • Flexion • Extension • Dorsiflexion • Plantar flexion • Adduction • Abduction • Inversion • Eversion • Internal rotation • External rotation • Pronation • Suppination
  115. 115. 2-Bones • Examine for: 1- Deformity 2- Tumors 3- Pain: is the pain focal (fracture/trauma, infection, malignancy, Paget’s disease, osteoid osteoma), or diffuse (malignancy, Paget’s disease, osteomalacia, osteoporosis, metabolic bone disease)?
  116. 116. 3-Joint 1- Signs of inflammation, injury (swelling, redness, warmth)? Deformity? Compare w/opposite side 2- activity and Range of motion–what can’t they do? Specific limitations? Discrete event (e.g. trauma)? Mechanism of injury? 3-Palpate joint  warmth? Point tenderness? Over what structure(s)? 4-Strength, neuro-vascular assessment. 5-If acute injury& pain  difficult to assess as patient
  117. 117. Range of movement (ROM) • Assess (Type: Active, Passive, Full, Limited, Stiffness, contractures) • If ROM is limited – determine the cause (excess fluid or any loose bodies in the joint e.g. cartilage, joint surface irregularity e.g. osteoarthritis, contracture of muscle, ligaments or capsule) • Range of motion assessed by: 1-goniometer, most accurate which measures the angle of the joint. 2- Symmetry
  118. 118. 4-Limb measurement • limbs are in the neutral position. • the patient is lying straight • Full length upper limb – measure from the acromion process to the end of the middle finger. • Full length lower limb – lower edge of the ileum to tibial malleolus.
  119. 119. • Special Tests • Phalen’s Test –Ask the patient to hold the wrist in acute flexion for 60 seconds. Numbness or burning indicate carpel tunnel syndrome.
  120. 120. • “Bulge sign” –assess for small amount of fluid on the knee. Milk upward on the medial side of the knee then tap lateral side of the patella. It indicated joint swelling
  121. 121. Diagnostic Studies Of Musculoskeletal System 1-Radiological studies 2- Bone mineral density (BMD) measurements 3-NUCLEAR STUDIES 4-Endoscopic Studies –arthrocentesis, arthroscopy 5-SYNOVIAL FLUID ANALYSIS 6-Muscle Biopsy 7-Laboratory
  122. 122. 1-Radiological studies
  123. 123. -X-rays provide information about bone deformity, joint congruity, bone density, and calcification in soft tissue. -Fracture diagnosis and management are the primary indications for x-ray. -but it is also useful in the evaluation of hereditary, developmental, infectious, inflammatory, neo-plastic, metabolic, and degenerative disorders
  124. 124. RELATED NURSING CARE • Maintain privacy of patient • patient is asked to remove some or all of his clothes and to wear a gown during the exam. • may also be asked to remove jewelry, removable dental appliances, eye glasses and any metal objects or clothing that might interfere with the x-ray images. • If contrast medium is used, assess for allergy to shellfish, iodine, or contrast medium used in previous tests. If allergy is present, test will not be performed.
  125. 125. A-Fluoroscopy Real-time x-ray images with digital detectors X-ray source is underneath table and detector above, thus shield needs to be placed underneath patient
  126. 126. B-Diskogram • X-ray of cervical or lumbar intenvertebral disk is done after injection of contrast media into nucleus pulpous. Permits visualization of intenvertebral disk abnormalities
  127. 127. C-Computed Tomography CT uses x-rays to produce cross sectional images • X-ray beam is used with a computer to provide a three-dimensional picture.
  128. 128. Computed Tomography
  129. 129. Computed Tomography Principal musculoskeletal indications –Staging of complex fractures –Detection of small intra-articular fragments –Fracture healing –Confirmation of plain film fractures –Bone tumor evaluation
  130. 130. D-Magnetic Resonance Imaging (MRI)
  131. 131. D-Magnetic Resonance Imaging (MRI) • Radio waves and magnetic field are used to view soft tissue. Especially useful in the diagnosis of a vascular necrosis, disk disease, tumors,; ligament tears, land cartilage tears. • Patient is placed inside scanning chamber. • Gadolinium may be injected IV to enhance visualization of structures
  132. 132. MRI • RELATED NURSING CARE : Assess for metallic implants or metal on clothing (metallic implants, such as clips on aneurysms, pacemakers, or shrapnel, will prohibit having an MRI) • Contraindicated in patient with eneurysm clips, metallic implants, pacemakers electronic devices, hearing aids, and shrapnel.
  133. 133. E-Myelogram with or without CT • Involves injecting a radiographic contrast medium: Into sac around nerve roots. CT scan may follow to show how the bone is affecting the nerve foots. Very sensitive test for nerve impingement and can detect very subtle lesions and injuries.
  134. 134. . 2- Bone mineral density (BMD) measurements
  135. 135. A-Quantitative ultrasound (QUS) • Evaluates density, elasticity, and strength of bone using ultrasound rather than radiation. Common area assessed is calcaneus's (heel).
  136. 136. B-Dual energy x-ray Absorptlomatry (DEXA) • Assesses bone density to diagnose osteoporosis • -Uses LOW dose radiation to measure bone density • - Painless procedure, non-invasive, no special preparation • -Advise to remove jewelry
  137. 137. 3-NUCLEAR STUDIES:
  138. 138. Imaging study with the use of a contrast radioactive material -Pre-test: Painless procedure, IV radioisotope is used, no special preparation, pregnancy is contraindicated -Intra-test: IV injection, Waiting period of 2 hours before X-ray, Fluids allowed, Supine position for scanning -Post-test: Increase fluid intake to flush out radioactive material BONE SCAN:
  139. 139. . 3-Endoscopic Studies – arthrocentesis, arthroscopy
  140. 140. Arthroscopy A direct visualization of the joint cavity -Pre-test: consent, explanation of procedure, NPO -Intra-test: Sedative, Anesthesia, incision will be made -Post-test: maintain dressing, ambulation as soon as awake, mild soreness of joint for 2 days, joint rest for a few days, ice application to relieve discomfort -NB: If general anesthesia is used, client is NPO after midnight. Following the procedure, assess for bleeding and swelling, apply ice to the area if prescribed, and teach client to avoid excessive use of the joint for 2 to 3 days.
  141. 141. Arthrocentesis -Done to obtain synovial fluid from a joint for diagnosis (such as infections /hemorrhage) or to remove excess fluid. A needle is inserted through the joint capsule and fluid is aspirated
  142. 142. . (4)Laboratory
  143. 143. Urine Tests • 24 hour creatine-creatinine ratio:- (Creatine phosphate is the most important storage form of high-energy phosphate; together with some other smaller sources, this energy reserve is sometimes called the creatine phosphate pool). • Urine Uric acid –24 hr specimen • Cancer of the bone has increased calcium levels • Urine deoxypyridino-line
  144. 144. Blood tests: 1-Rheumatoid Factor: Importantly, RF is not a 'test for rheumatoid arthritis'. It is therefore neither sufficient nor necessary for the diagnosis. Its principal use is as a prognostic marker; a high titre at presentation associates with a poorer prognosis. IgG RF has greater specificity for major rheumatic disease but the above caveats still remain.
  145. 145. Blood tests: 2-Antinuclear antibodies: Mainly for diagnoses of SLE - a negative ANA virtually excludes the diagnosis - a positive ANA :lupus is suspected. For lupus, ANA has high sensitivity (virtually 100%) However, the specificity is low (10-40%) so a positive result does not make the diagnosis -ANA directed against double-stranded DNA (anti-dsDNA) is highly specific for lupus.
  146. 146. Calcium Total Ionized 8.6–10.3 mg/dl 4.4–5.1 mg/dl 2.2–2.74 mmol/L 1–1.3 mmol/L Phosphorus 2.5–5 mg/dl 0.8–1.6 mmol/L Phosphatase (acid), total 0.13–0.63 IU/L 2.2–10.5 IU/L or 2.2–10.5 mckat/L Phosphatase alkaline2 20–130 IU/L 20–130 IU/L or 0.33–2.17 mckat/L Creatinine kinase 0–12 IU/L 0–0.2 mckat/L Hb 13.5-18 g/dl HCT 40%-55% TLC 5000-1000010ᶺ3/Cmm RBCs 4.5-6)×106Cmm
  147. 147. CAUSES OF AN ELEVATED SERUM CREATINE KINASE. • Inflammatory myositis ± vasculitis • Muscular dystrophy • Motor neuron disease • Alcohol, drugs • Trauma, strenuous exercise • Myocardial infarction* • Hypothyroidism, metabolic myopathy
  148. 148. Invasive investigation • Synovial fluid analysis • Bone biopsies • Musccle biopsies
  149. 149. SYNOVIAL FLUID ANALYSIS • For: septic arthritis, crystal-associated arthritis and intra-articular bleeding, and it should be performed in all patients with acute monoarthritis, especially with overlying erythema. • From: sample from most peripheral joints and for diagnostic purposes only a small volume is required • Normal SF: is present in small volume, contains very few cells, is clear and either colourless or pale yellow, and has high viscosity
  150. 150. • Turbid: joint inflammation, volume increases, the total cell count and proportion of neutrophils rise, and the viscosity lowers (due to enzymatic degradation of hyaluronan and aggrecan). However, because of considerable variation and overlap between arthropathies these features have little diagnostic value. • Frank pus or 'pyarthrosis‘: results from very high neutrophil counts and is not specific for sepsis. Continue..
  151. 151. Continue .. • High concentrations of crystals: mainly urate or cholesterol, can make SF appear white Non- uniform blood-staining of SF is common. • Florid: Uniform blood-staining-haemarthrosis- commonly accompanies florid synovitis but may also result from a bleeding diathesis, trauma or pigmented villonodular synovitis.
  152. 152. Continue.. • A lipid layer floating: above blood-stained fluid is diagnostic of intra-articular fracture with release of lipid from the bone marrow. • If sepsis is suspected, SF should be sent for urgent Gram stain and culture in a sterile universal container. If gonococcal sepsis or uncommon organisms are suspected, especially in immunocompromised patients, the microbiologist should be consulted to ensure that optimal cultures are established and that molecular techniques of antigen detection are used if appropriate
  153. 153. BONE BIOPSIES • BONE BIOPSY: in metabolic bone diseases With patients who are suspected of having osteomalacia
  154. 154. Muscle biopsy • For myopathy and myositis. • Needle muscle biopsy of the quadriceps or deltoid • is preferred to open surgical biopsy because it is a simple procedure which can be repeated for serial monitoring of treatment response
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