1. ALTERATIONS IN MOBILITY
Assessment of the Musculoskeletal System
And How Mobility can be Altered

2. Skeletal System Brief Overview of Anatomy
Bone types
Bone structure
Bone function
Bone growth and metabolism affected by calcium and phosphorus, calcitonin, vitamin D, parathyroid hormone, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin

3. Bone Structure

4. Joints Types include synarthrodial, amphiarthrodial, diarthrodial.
Structure synovial joint.
Subtyped by anatomic structure:
Ball-and-socket
Hinge
Condylar
Biaxial
Pivot

5. Structure Diarthrodial Joint

6. Muscular system assessment and how it can affect mobility.
Patient history
Nutritional history
Family history and genetic risk
General inspection:
Posture and gait

7. Muscular System Assessment (Cont.)

8. Specific Assessments Face and neck Spine Hand Hip Ankles, feet
Neurovascular assessment
Psychosocial assessment

9. Diagnostic Assessment
Laboratory tests—serum calcium and phosphorus, alkaline phosphatase, serum muscle enzymes
Radiographic examinations—standard radiography, bone density, tomography and xeroradiography, myelography, arthrography, and CT
Other diagnostic tests—bone and muscle biopsy

10. Question?
What is the patient at risk for developing during a CT scan with contrast material?
Claustrophobia
Renal failure
Allergic reaction to the contrast material
Panic attack
Answer: C
Rationale: The nurse or radiology technologist should ask the patient about iodine-based contrast allergies. Because current CT scanners are faster, claustrophobia is rarely an issue anymore.

11. Neuromuscular affects on mobility
The electromyography
EMG aids in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders; usually with nerve conduction studies.
Low electrical currents are passed through flat electrodes placed along the nerve.
If needles are used, inspect needle sites for hematoma formation.

13. Arthroscopy
Fiberoptic tube is inserted into a joint for direct visualization.
Patient must be able to flex the knee; exercises are prescribed for ROM.
Evaluate the neurovascular status of the affected limb frequently.
Analgesics are prescribed.
Monitor for complications.

14. Arthroscopy (Cont’d)

15. Other Tests Bone scan Gallium or thallium scan
Magnetic resonance imaging
Ultrasonography

16. Mobility can be affected by diseases
Exemplar: Osteoporosis
Chronic metabolic disease, in which bone loss causes decreased density and possible fracture
Osteopenia (low bone mass), which occurs when osteoclastic activity is greater than osteoblastic activity

18. Exemplar: Osteoporosis (Cont’d)

19. Exemplar: Osteoporosis (Cont’d)
Etiology and genetic risk
Genetic considerations
Incidence/prevalence
Cultural considerations

20. Classification of Osteoporosis
Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s.
Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility.
Regional osteoporosis occurs when a limb is immobilized.

21. Health Promotion/Illness Prevention
Teaching should begin with young women who begin to lose bone after 30 years of age.
The focus of osteoporosis prevention is to decrease modifiable risk factors.
Ensure adequate calcium intake.
Avoid sedentary lifestyle.
Continue program of weight-bearing exercises.

22. Assessment Physical assessment Psychosocial assessment
Laboratory assessment
Imaging assessment:
DXA
QCT
QUS

23. Nursing Interventions
Nutrition therapy
Exercise
Other lifestyle changes

24. Drug Therapy Calcium and vitamin D supplements
Estrogen or hormone therapy
Bisphosphonates
Selective estrogen receptor modulators
Calcitonin
Other agents used with varying results

25. Surgical Interventions
Vertebroplasty
Kyphoplasty

27. Cultural Consideration Question?
Which ethnic group typically has the least amount of
bone density of any group?
African-American women
Asian women
Caucasian women
American-Indian women
Answer: C
Rationale: Caucasian women tend to have the least amount of bone density of any group, which makes them more likely to have osteoporosis and fractures.

28. Diseases that affect mobility continued
Exemplar: Osteomalacia
Loss of bone related to vitamin D deficiency
Bone softens because of inadequate deposits of calcium and phosphorus in the bone matrix
Rickets

30. Collaborative Care Assessment
The major treatment for osteomalacia is vitamin D

31. Alterations in Mobility
Exemplar: Paget’s Disease
Chronic metabolic disorder in which bone is excessively broken down and reformed
Genetic considerations
Collaborative care:
Physical assessment
Diagnostic assessment

33. Nonsurgical Management
Analgesics
Decrease bone resorption
Selected bisphosphonates
Calcitonin
Plicamycin
Diet therapy
Nonpharmacologic pain-relief measures

34. Surgical Management Tibial osteotomy
Partial or total joint replacement
Surgical decompression and stabilization of the spine

35. Exemplar: Osteomylitis
Infection of the bone

36. Osteomyelitis of the tibia of a young child
Osteomyelitis of the tibia of a young child. See the numerous abscesses in the bone.

37. Collaborative Care Assessment Antibiotic therapy
Hyperbaric oxygen therapy
Surgical management:
Sequestrectomy
Microvascular bone transfers

38. Alterations in mobility
Exemplar: Benign bone tumors
Often asymptomatic and may be discovered on routine x-ray or as a cause of pathologic fracture:
Chrondrogenic tumors—from cartilage
Osteogenic tumors—from bone
Fibrogenic tumors—from fibrous tissue; most commonly found in children

40. Interventions Non-drug pain-relief measures
Drug therapy—analgesics, NSAIDs
Surgical therapy—curettage (simple excision of the tumor tissue), joint replacement, or arthrodesis

41. Alterations in mobility
Exemplar: Bone Cancer
Primary tumors
Metastatic lesions
Pathophysiology
Assessment
Nonsurgical management:
Drug therapy
Radiation therapy

42. Surgical Management Preoperative care Operative procedure
Postoperative care

43. Community-Based Care Home care management Health teaching
Health care resources

44. Disorders of the hand can affect a patient’s mobility
Exemplar:
Dupuytren's contracture—slowly progressive contracture of the palmar fascia resulting in flexion of the fourth or fifth digit of the hand

46. Alterations in mobility continued
Exemplar: Ganglion
Round, benign cyst often found on a wrist or foot joint or tendon

48. Disorders of the foot can affect a patient’s mobility
Exemplars:
Hallux valgus
Hammertoe
Morton’s neuroma
Tarsal tunnel syndrome
Plantar fasciitis
Other problems of the foot

49. Foot

50. Disorders of muscles and ligaments can alter mobility
Exemplar: Scoliosis
Changes in muscles and ligaments on the concave side of the spinal column

52.               
What problems other then mobility can you see with this patient?

53. Exemplar: Scoliosis (Cont’d)
Pathophysiology
History
Treatment of children
Treatment of adults

54. Diseases of the muscles can impair mobility
Exemplar: Progressive Muscular Dystrophies
Pathophysiology
Genetic considerations
Diagnosis
Management
Nursing interventions

56. Pediatric Differences
Primary ossification
Secondary ossification
Long bones
Muscles, Tendons, and Ligaments

57. References
Centers for Disease Control and Prevention, National Institutes of Health. (2009). Arthritis, osteoporosis, and chronic back conditions. Retrieved April 10, 2010, from Volume1/02Arthritis#_Toc
Chamley, C.A., Carson, P. Randoall, D, & Sandwell, M. (2005). Developmental anatomy and physiology of children. St. Louis, MO: Elsevier.
Harvey, C. (2005). Wound Healing. Orthopedic Nursing 24(2),

58. References Ignatavicius, D., & Workman, M.L. (Ed.). (2010).
Medical-Surgical Nursing Critical Thinking For
Collaborative Care. (6th Ed.) St. Louis: Elsevier
Saunders.

59. References
Kallmes DF, Comstock BA, Heagerty PJ, et al. (August, “A randomized trial of vertebroplasty for osteoporotic spinal fractures.” New England Journal of Medicine 361(6):
Medline Plus. (2010, July 22). Electromygraphy. Retrieved August
22, 2010, from:
MayoClinic.com (2010, July 22). Dupuytren’s Contracture.
Retrieved August 23, 2010, from:
contracture/DS00732

60. References: Potter, P. & Perry, A. (2009). Fundamentals of Nursing
(7th ed). St. Louis, Missouri: Mosby.
Vitale, M.G., Gross, J.M., Matsumoto, H., Roye, D.P. (2006). Epidemiology of pediatric spinal cord injury in the United States. Journal of Pediatric Orthopedics, 26(6),
Wikipedia. (2010, July 10). Ganglion . Retrieved Auguast 23, 2010, from:
Wikipedia. (2010, August 19). Scoliosis. Retrieved August 23,
2010, from: