Module 8

Musculoskeletal
Kristen Eden, RN, BSN, MSN (c)
 Learning Outcomes
• 1.) Describe the elements of the musculoskeletal system and their function in the
body.
• 2.) Determine ways to assess and manage fractures.
• 3.) Assess abnormal findings related to diseases of the musculoskeletal system
including osteoporosis, osteomyelitis, and systemic lupus erythematosus.
• 4.) Compose a plan of care for patients with osteoporosis.
• 5.) Evaluate the clinical manifestations and treatment of patients with lupus
erythematosus.
 Composition of the musculoskeletal system

• Skeletal system
• Bones (206)
• Joints
• Muscular system
• Skeletal muscle
Assessment of the Musculoskeletal System
• Posture
• Gait
• Alignment
• Muscle tone
• Strength
• Range of Motion
 Diagnostic Testing

Radiography--Xray
• Bone density
• Alignment
• Swelling
• Condition of joints
 Diagnostic Testing
• Nuclear Scans (bone scan): Nucleotide test with radioactive material
• Tumors
• Arthritis
• Osteomyelitis
• Osteoporosis
• Hairline fractures
 Diagnostic Testing
• MRI: Magnetic Resonance Imaging
• Joints
• Soft tissues
• Bony tumors
 Diagnostic Testing
• Arthroscopy: Use of arthroscope (fiberoptic tube) inserted into the joint
• Direct visualization of the ligaments, menisci, and articular surfaces of the joint
 Question 1
• What type of diagnostic test is most often used to diagnose fractures?
• A. MRI
• B. Arthroscopy
• C. Xray
• D. Nuclear bone scan
 Question 1
• What type of diagnostic test is most often used to diagnose fractures?
• A. MRI
• B. Arthroscopy
• C. Xray
• D. Nuclear bone scan
 Fractures
• A break or disruption in the continuity of a bone that affects mobility and
sensory perception.
• Extent of bone involvement
• Extent of soft tissue involvement
 Classification of Fractures

Complete Fracture Incomplete Fracture

• Break is across entire bone • Break is through part of bone
 Description of Fractures

Open (Compound) Closed (Simple)

• Surface of skin is disrupted • Surface of skin is intact
 Treatment of Fractures
• Splinting: Immobilization of bone and joint
• Prevents further damage
• Reduces pain
• Increases circulation
 Treatment of Fractures
• Closed reduction: Realignment of the bone ends for proper healing
• https://youtu.be/jye9BWdq9R8
• Nursing interventions:
• Administer analgesia
• Monitor oxygen saturation
• Assess neurovascular status
• Provide emotional support
 Casts

Fiberglass Plaster
 ORIF
• Open Reduction Internal Fixation:
Surgical procedure whereby the
surgeon may visualize the fracture and
stabilize the bones with hardware
devises.
• Use of rods, screws, plates, wires or nails
to stabilize bone fragments
External
Fixation
• Use of pins or
wires inserted
through the skin
and bone and
connected to rigid
external frame
 Complications of Fractures
• Acute compartment syndrome
• Crush syndrome
• Hypovolemic shock
• Fat embolism syndrome
• Venous thromboembolism
• Infection
• Ischemic necrosis
• Osteomyelitis
• Delayed union
 Acute Compartment Syndrome
• Reduction of circulation due to increase in pressure within a compartment containing muscles,
blood vessels, and nerves enclosed in fascia.
• S/S:
• Pain with passive motion
• Pallor
• Edema
• Weakened pulses
• Numbness/tingling
• Paresthesia
• Necrosis
 Treatment for Acute Compartment Syndrome

• Fasciotomy: Surgical incision through the fascia to decrease internal pressure

• Nursing Interventions:
• Assess for signs of infection, improvement in perfusion
• Maintain wound dressing
• Administer pain medications
 Complications of Fractures
• Fat Embolism Syndrome: Leakage of fat globules into the bloodstream
from yellow bone marrow causing obstruction of the pulmonary vascular
bed.
• Nursing diagnosis: Decreased oxygenation r/t obstruction of pulmonary
microvasculature as evidenced by decreased PaO2 level, SOB, and DLOC
• Nursing Interventions:
• Administer oxygen, bedrest, hydration, possible steroid therapy, albumin infusion,
fracture immobilization
 Osteomyelitis
• Osteomyelitis: Infection of the bone
caused by bacteria, viruses, or fungi
that stimulate the inflammatory
response in bone tissue
• Inflammation
• Vessel thrombosis
• Exudate (puss) released
• Ischemia
• Bone necrosis (sequestrum formation)
• Bone abscess
• Superimposed infection
 Assessment Findings

Acute Osteomyelitis Chronic Osteomyelitis

• Pain: constant, localized, pulsating, • Ulceration
worse with movement • Localized pain
• Fever • Drainage
• Erythema
• Swelling
 Treatment and Nursing Interventions

Nonsurgical Surgical
• Administration of long-term • Sequestrectomy
antibiotics
• Bone grafts
• PICC line management
• Initiate contact precautions • Amputation
• Pain management • Frequent neurovascular assessment
• Coordinate hyperbaric oxygen therapy • Elevate extremity
 Question 2
• You are a nurse working on an orthopedic inpatient unit. You are assigned
four patients and must decide who to assess first. Which patient should you
recognize as needing immediate attention?
• A. The patient with an external fixator complaining of aching pain of 6/10
• B. The patient in a leg cast with cold, cyanotic toes
• C. The patient with a hip fracture complaining of shortness of breath
• D. The patient with a fasciotomy complaining of moderate drainage on his dressing
 Question 2
• You are a nurse working on an orthopedic inpatient unit. You are assigned
four patients and must decide who to assess first. Which patient should you
recognize as needing immediate attention?
• A. The patient with an external fixator complaining of aching pain of 6/10
• B. The patient in a leg cast with cold, cyanotic toes
• C. The patient with a hip fracture complaining of shortness of breath
• D. The patient with a fasciotomy complaining of moderate drainage on his dressing
 Osteoporosis

• Chronic metabolic disease in

which bone loss causes
decreased density and
possible fracture.
• Osteoclastic (bone
resportion)
activity>osteoblastic (bone
building) activity
• Decreased bone mineral
density (BMD)
• Primary and secondary
types
 Causes of Osteoporosis

Primary Secondary
• Postmenopausal women • Diabetes mellitus
• Hyperparathyroidism
• Family history
• Cushing’s syndrome
• Chronic low calcium and/or vit D intake
• Metabolic acidosis
• Smoking • Cirrhosis
• High alcohol intake • HIV/AIDS
• Lack of physical exercise • Chronic use of corticosteroids, barbiturates, loop
diuretics
 Diagnosis of Osteoporosis
• Dual x-ray absorptiometry (DEXA) scan
• Calculates T-score to compare patient’s bone mineral density to optimal peak bone
mineral density
• T-score of -1=normal
• T-score of -1 to -2.5=osteopenia
• T-score of less than -2.5=osteoporosis
 Nursing Assessment
• Pt complaint of sharp, shooting pain to back, hip, or wrist
• Pt states they are shorter than they used to be (compression fractures)
• Assess for swelling & signs of malalignment
• Psychosocial changes
• Dietary intake
• Fall risk
 Drug Therapy
• Calcium/vitamin D—Os-cal
• Biphosphates—alendronate (Fosamax), ibandronate (Boniva), and
risedronate (Actonel, Atelvia)
• Estrogen agonist/antagonist—raloxifene (Evista)
• Monoclonal antibodies—Prolia, Xgeva
 Question 3
• The nurse is assessing her patient’s understanding of her diagnosis of
osteoporosis. Which statement by the patient indicates a need for further
teaching?
• A. “I will need to increase my dietary intake of calcium and vitamin D.”
• B. “I will walk for 30 minutes each day to maintain my strength.”
• C. “I can continue to drink my favorite soda at every meal because it contains phosphorus.”
• D. “I need to make sure my home is clutter free and well lit.”
 Question 3
• The nurse is assessing her patient’s understanding of her diagnosis of
osteoporosis. Which statement by the patient indicates a need for further
teaching?
• A. “I will need to increase my dietary intake of calcium and vitamin D.”
• B. “I will walk for 30 minutes each day to maintain my strength.”
• C. “I can continue to drink my favorite soda at every meal because it contains
phosphorus.”
• D. “I need to make sure my home is clutter free and well lit.”
 Lupus Erythematosus
• Chronic, progressive, inflammatory connective tissue disorder
• Autoimmune disease
• Two types: discoid lupus erythematosus (DLE) & systemic lupus erythematosus (SLE)
• Antinuclear antibodies (ANAs) affect the DNA, RNA, and other components of the cell
nucleus
• Immune complexes form in the serum and organ tissues
• Inflammation, damage, and destruction of organs
• Vasculitis
• Spontaneous remissions and exacerbations
 Assessment Findings
• Discoid lesions/butterfly rash
• Polyarthritis
• Muscle atrophy/myalgia
• Fever
• Fatigue
• Pleural effusions
• Pericarditis
• Abdominal pain
• Neurologic manifestations
• Negative psychosocial effects
 Diagnostic Testing

• Laboratory tests:
• Rheumatoid factor
• Antinuclear antibody
• Erythrocyte sedimentation rate
• Serum protein electrophoresis
• Serum complement (C3, C4)
• Immunoglobulins
• Serum electrolyte levels
• Kidney function
• Cardiac & liver enzymes
• Clotting factors
 Drug Therapy
• Topical cortisone
• Tylenol & NSAIDS
• Hydroxychloroquine (Plaquenil)
• Methotrexate (Rheumatrex)
• Azathioprine (Imuran)
• Glucocorticoids (Prednisone)
• Belimumab (Benlysta)
 Patient and Family Education
• Infection prevention
• Skin care
• Monitoring of body temperature
• Coping mechanisms & support systems
• Pregnancy issues/contraception
 Question 4
• Which of the following statements should the nurse include when educating
her patient on their new diagnosis of lupus? Select all that apply.
• A. Lupus is an autoimmune disease that causes inflammation and damage to connective
tissues.
• B. Sun exposure can minimize the negative effects of lupus on the skin.
• C. You should avoid large crowds while taking steroids and immunosuppressants.
• D. Spiking a fever is the classic sign of an exacerbation of lupus.
• E. Lupus will not affect your ability to maintain a healthy pregnancy.
 Question 4
• Which of the following statements should the nurse include when educating her
patient on their new diagnosis of lupus? Select all that apply.
• A. Lupus is an autoimmune disease that causes inflammation and damage to
connective tissues.
• B. Sun exposure can minimize the negative effects of lupus on the skin.
• C. You should avoid large crowds while taking steroids and immunosuppressants.
• D. Spiking a fever is the classic sign of an exacerbation of lupus.
• E. Lupus will not affect your ability to maintain a healthy pregnancy.
 Question 5
• You are evaluating the laboratory values of your patient with systemic lupus
erythematosus. Which of the following values indicates organ damage due to
her disease?
• A. Potassium of 4.0 mmol/L
• B. Hemoglobin of 14g/dL
• C. Creatinine of 3.6 mg/dL
• D. White blood cell count of 7x10^9/L
 Question 5
• You are evaluating the laboratory values of your patient with systemic lupus
erythematosus. Which of the following values indicates organ damage due to
her disease?
• A. Potassium of 4.0 mmol/L
• B. Hemoglobin of 14g/dL
• C. Creatinine of 3.6 mg/dL
• D. White blood cell count of 7x10^9/L
 References
• Ignatavicious, D. & Workman, M. (2016). Medical-surgical nursing: Patient-centered
collaborative care (8th ed.). St. Louis, MO: Elsevier.
• Shaikh, N. (2009). Emergency management of fat embolism syndrome. Journal of
Emergencies, Trauma, and Shock, 2(1), 29-33. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700578/