1. Musculoskeletal System Day 1

2. What is the first step of the nursing process? A.Nursing Diagnosis B.Assessment C.Building a relationship of trust D.Empathy E.Teaching

3. Highly integrated system BONE JOINT LIGAMENT BURSAE MUSCLE TENDON

4. What is the leading cause of disability in the US? A.Motor Vehicle accidents B.Sports injuries C.Arthritis D.Diabetes E.Cardio-vascular impairment

5. Musculoskeletal System FUNCTION! Protection

6. Musculoskeletal System FUNCTION! Protection Framework Mobility – Move – Heat – Facilitates blood return

7. Musculoskeletal System FUNCTION! Protection Framework Mobility Reservoir – Blood cells – Essential minerals Ca Ph

8. Anatomy & Physiology SKELETAL SYSTEM How many bones are in the human body? A.206 B.1,245 C.847 D.145 E.666

9. Bone Types Long bones Short bones Flat bones Irregular bones

10. Bone components Compact Bone Dense Spongy bone Porous

11. Diaphysis – Shaft Epiphyses – End Epiphyseal plate – growth

12. Periosteum Covering Contains – Nerves – Blood vessels – Lymph tissue Function – Nourishment – Attachment

13. Which of the following are formed in the bone marrow? A.Red blood cells B.White blood cells C.Platelets D.Hemoglobin E.All of the above

14. Bone Marrow Red Locations – Flat bones Function – RBC – WBC – Platelets – Hgb Yellow Location – Long bones Fatty

15. Bone Cells Osteoblasts – Form matrix Osteocytes – Maintenance Osteoclasts – Dissolving & resorbing

16. Bone Maintenance Modeling – Childhood – Bones grow & form Remodeling – Adulthood – Resorption – Osteogenesis

17. Cool Fact! Complete skeletal turnover occurs every 10 years

18. Resorption / Osteogenesis Homeostasis a.Physical activity b.Nutrition c.Hormones

19. Physical Activity Weight-bearing stimulates bone formation & remodeling

20. What happens if… A person is on prolonged bed rest or physically disabled and they don't engage in regular weight bearing activities? –  bone resorption  – Calcium loss  – Osteopenic bones  – fractures

21. Nutrition Calcium – 1000 – 1200 mg / day – 16 – 24 oz. milk

22. What two endocrine hormones work in harmony to maintain normal serum Calcium levels? What? I need to give you multiple choice answers! NO way! Turn to your neighbor and tell them the answer to this question PTH Calcitonin

23. Hormones PTH Secreted by – Parathyroid Effect –  Serum Ca+ levels Action – Promotes movement of Ca + from bone to blood Calcitonin Secreted by – Thyroid Effect –  Serum Ca+ levels Action – Inhibits bone resorption &  deposits of Ca + in the bone

24. Hormones Hyperthyroidism  –  bone resorption –  bone formation Cushing’s syndrome  –  bone resorption –  bone formation

25. What is the name of the most common form of hyperthyroidism in the U.S.A? A.Hashimoto’s thyroiditis B.Graves disease C.Addison’s disease D.Cretinism E.Pheochromocytoma

26. Cushing’s Disease is caused by what hormonal imbalance? A.Steroid excess B.Steroid deficit C.Thyroid hormone excess D.Thyroid hormone deficit E.Excess ADH

27. Small Group Questions 1.What are the 4 main functions of the M/S system? 2.What & where is the periosteum? 3.What types of bone marrow are there? (location & function) 4.What are the 3 main types of bone cells and their main function? 5.Describe resorption and osteogenesis.

28. Articular System Joint – Junction of 2 or more bones

29. Joints Synarthrosis – immovable Amphiarthrosis – Limited motion – Joined by cartilage Diarthrosis – Freely movable

30. Types of diarthrosis joints Ball & Socket Hinge Saddle Pivot Gliding

31. Synovial Joints Bones covered with hyaline cartilage Form capsule Lined with synovium membrane Secretes lubricant

32. Do the bone surfaces of a normal functioning synovial joint come in direct contact with each other? A.Yes B.No Synovial fluid acts as a shock absorber

33. Ligaments, tendons, bursa Tendons – Bind muscle to bone

34. Ligaments, tendons, bursa Ligaments – Bind bone to bone

35. Ligaments, tendons, bursa  Bursa – Sac filled with synovial fluid Elbow Shoulder Hip Knee

36. Small Group Questions 1.Define synarthrosis, amphiarthrosis & diaarthrosis? 2.What is a synovial joint? 3.Define ligament, tendon & bursa. 4.What hormones are vital for Ca + and Ph + homeostasis?

37. Types of Muscles Skeletal Muscles – Voluntary movement Smooth muscles – Internal control – e.g. bladder, GI, bronchi Cardiac muscles – Heart

38. Muscle Cell Parallel cells encased – Fascia Contains – Myofibrils – Contain Sarcomeres Contracting unit

39. Contraction Cell contract in response to electrical stimulation  Ca+ ion enters sacromeres  Sacromeres contract  Ca+ rapidly removed  Sacromere relaxes Ca

40. Energy Source ATP – Adenosine triphosphate  – Glucose Metabolism Not all ATP is used with muscle contraction  excess energy  heat

41. Types of contractions Isometric – Length of muscle remains constant but   force Isotonic – Shortening of the muscle without increase in tension Combination

42. Muscle Tone State of readiness Flaccid: –  tone Spastic: –  tone Atonic: – No nerve impulse  no tone  atrophy

43. Muscle Action Contraction  movement! Exercise  – Function – Strength – Size Hypertrophy Over exercise  – Lactic acid – Fatigue

44. Gerontologic Considerations Aging vs… –  activity – Lifestyle – Pathophysiological factors

45. Aging Structural Changes Bones –  bone mass – Vertebrae collapse Muscles –  collagen – Atrophy –  elasticity Joints – Cartilage deteriorates Ligaments – Lax

46. Aging functional Changes Bones – Fragile, prone to fracture Muscles –  strength, weak, tired, stumble Joints – Stiff, pain Ligaments – Postural changes

47. Aging H&P findings  height Kyphosis Flexion of hips & knees Fractures Stiffness  strength

48. Assessment: Health History Common symptoms – Pain – Alt. sensation Past health Social history Family history

49. Small Group Question Mrs. Jones comes into the doctor’s office complaining of pain in her left knee. What questions will you ask her to assess her pain?

50. Did you ask the following questions? Characteristics Location Rating Onset Duration Manifestations Precipitating factors Effect of ADL’s Aggravations Diminishes Radiating Associated complaints Past injuries

51. Physical Examination Posture – What is this? – Kyphosis  curve of the thoracic spine

52. Physical Examination Posture – What is this? – Lordosis  Curve of the lumbar spine

53. Physical Examination Posture – What is this? – Scoliosis Lateral curve of the spine

54. Physical Examination Gait – Smooth – Steady

55. Physical Assessment Bone Integrity – Deformity? – Alignment – Symmetry

56. Physical Assessment Joint Function – ROM Range of Motion

57. ROM abduction Move away from midline adduction Move towards midline

58. ROM extension Straighten a limb flexion Bend a limb

59. ROM Dorsiflexion Bend ankle bringing toe upwards Plantar flexion Straighten ankle to point toes down

60. ROM Pronation Palm down Supination Palm up

61. ROM Eversion Turn out INversion Turn in

62. ROM Circumduction – Move in a circle

63. ROM Internal rotation / Medial rotation Move inward on a central axis External rotation / Lateral rotation Move outward on a central axis

64. Range of Motion Passive Total assist Active Independent

65. Range of Motion Never attempt to move a joint past its normal range of motion for the client or past the point at which pain is experienced.

66. Physical Assessment Joint Function – ROM – Deformity – Stability – Contracture Permanent shortening of the muscle – Crepitus – Effusion

67. Bulge Sign Position: supine Milk upward on the medial side of the knee Tap the lateral side of the patella Observe for a fluid bulge = effusion http://www.youtube.co m/watch?v=LsgutijmX7 U http://www.youtube.co m/watch?v=LsgutijmX7 U http://www.youtube.co m/watch?v=fNUGyNYV hqE http://www.youtube.co m/watch?v=fNUGyNYV hqE

68. Ballottement Apply downward pressure just above the knee Tap the patella Fluid will cause the patella to rebound http://www.youtube.co m/watch?v=PlgSsE8EvX E http://www.youtube.co m/watch?v=PlgSsE8EvX E

69. Balloon sign AKA – Water on the knee http://www.youtube.co m/watch?v=FfO4Nhu0u 3s http://www.youtube.co m/watch?v=FfO4Nhu0u 3s

70. Muscle Strength & Size GradeDescription 0No contraction, paralysis 1Contraction felt, no movement 2Passive ROM 3Full ROM against Gravity 4Full ROM against some resistance 5Full ROM against full resistance

71. Muscle Strength & Size Measure Girth – Max circumference – At rest

72. Skin Edema Temp Color

73. Neurovascular status CMS – Circulation Color Temp Cap. refill – Motion Weak / paralysis – Sensation Paresthesia Pain

74. Neurovascular status 5 – P’s – Pain – Pallor – Pulselessness – Paresthesia – Paralysis

75. Small group Questions 1.Define lordosis, scoliosis, kyphosis. 2.Differentiate between the different movement of ROM. 3.How are the bulge and ballottement signs assessed and what do they indicate? 4.How do you assess neurovascular status?

76. Diagnostic Tests Laboratory tests Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) Calcium Phosphate Uric Acid Diagnostic test X-ray CT-scan MRI Bone scan Densitometry Arthrocentesis Arthroscopy Electromyelogram

77. Erythrocyte Sedimentation Rate (ESR) What does an elevated ESR indicate? A.Bone cancer B.Osteoporosis C.Inflammation D.Anemia E.Auto-immune disease

78. C-reactive Protein What does an positive CRP indicate? A.Bone cancer B.Osteoporosis C.Inflammation D.Anemia E.Auto-immune disease

79. Calcium (Ca+) Location – Bone & teeth Vital for – Nerve impulse – Muscle contraction – Muscle relaxation – Blood clotting

80. Phosphate (Ph) ICF ion Important for energy  ATP Ca & Ph have an inverse relationship Ca Ph

81. Uric Acid End product of protein metabolism Excreted by kidneys Elevated levels  gout

82. Antinuclear antibodies (ANA) Found in auto-immune disorders

83. X-ray Purpose – Bone density, texture, erosion, placement Nrs. Considerations: – No prep – PG?

84. Computed Tomography (CT scan) Purpose –  detail - X-ray – Bone, tumor, soft tissue, ligaments, tendons Nrs. Considerations: – No prep – PG? – Contrast? allergies

85. Sagittal CT scan

86. Magnetic Resonance imaging (MRI) Purpose – Non-invasive – Soft Tissue Nrs. Considerations – No metal – No transdermal patches

87. Bone Scan Purpose – Bone seeking radioisotope injected IV – Scan Distribution Concentration Nrs considerations – Drink fluids Allergies PG

88. Bone densitometry Purpose – Bone mineral density – X-ray or ultrasound

89. Arthrocentesis Purpose – Remove fluid from the joint – Examination –  Pain d/t effusion Procedure – Needle inserted into joint – Aspirate fluid http://www.youtube.com/watch?v=f Z2dcZhoGP8 http://www.youtube.com/watch?v=f Z2dcZhoGP8

90. Arthrocentesis Nrs. Considerations – Sterile dressings – Risk of infection

91. Arthroscopy Purpose – Direct visualization of the joint Nrs. Considerations – Compression bandage – Ice – Elevate –  S&S of infection http://www.youtube.co m/watch?v=Yb2YsSbSdc k http://www.youtube.co m/watch?v=Yb2YsSbSdc k

92. Electromyelogram (EMG) Purpose – Electrical potential of a muscle – Differentiate muscle & nerve problem

93. Small Group Questions 1.What do the following tests measure? – ESR, CRP, Ca+, Ph+, Uric acid and ANA 2.How are the following diagnostic tests performed, what do they diagnose and what are the nursing considerations? – X-ray, Ctscan, MRI, Bone scan, Densitometry, Arthrocentesis, Arthroscopy, EMG