Lecture Notes Part 2
Musculoskeletal Stressors
Musculoskeletal stressors:
Trauma: Includes fractures, sprains, strains, overuse injuries, amputations
Infection: Includes inflammatory conditions as osteomyelitis, arthritis
Altered metabolism: Includes cancer, osteoporosis, osteomalacia, rickets, and Paget's disease
For the person with a musculoskeletal condition:
List the effects on PERSON: (effects entire person; especially with long term immobilization)
P Psychosocial leads to depression, job change, altered body image, etc.
E Elimination, altered due to restricted body position, pain medications, altered diet, etc.
R
Rest, comfort, regulatory, altered due to pain control, sleep deficits due to pain and altered body position, limited movement due to casts, traction, braces, etc.
S Safety impaired due to altered gaits neurologic and sensory impairments.
O
N
Oxygenation, tissue perfusion deficits due to blood loss, complications of fat emboli, factors that compromise oxygenation
Nutrition impaired due to markedly increase metabolic needs. Bone healing requires increased protein, Vitamins C and D.
Most frequent nursing diagnosis for musculoskeletal
 Activity tolerance
 Disuse syndrome, high risk for
 Impaired adjustment
 Impaired skin integrity, high risk for
 Infection, high risk for
 Pain (acute)
 Pain (chronic)
 **Peripheral neurovascular dysfunction, high risk for (priority)
 Post-trauma response


Trauma, high risk for injury
*Alteration in tissue perfusion
 Knowledge deficit
 Anxiety
 Alteration in bowel elimination
 Fear
 Powerlessness
 Self-care deficit
* All complications of immobility apply depending upon particular dysfunction
Components of Assessment
Chief complaint:
Identify why care is sought.
Acute problem:
Identify what was injured; how it happened and what was the mechanism, force and direction of injury; when did it occur and what disability resulted; when did the swelling, redness, discoloration, and temperature change develop? What treatment was done? Any associated problems?
Chronic problem:
Identify when the symptoms began, how long, if continuous or intermittent; how did the symptoms begin if
1 of 5

Lecture Notes Part 2
Musculoskeletal Stressors spontaneous or a result of injury; why did the symptoms begin and the individual's perception of “why”; what helps or aggravates the problem; what treatment, home or otherwise?
History taking and significance:
Includes the biographical data such as age, sex, means of transportation, where he lives. Suggests problems.
Pain characteristics:
PQRST= P-provoking incident; Q= quantity; R= region and radiation and relief; S= severity
Location:
Poorly localized pain may be associated with blood vessels, joints, fascia, or the periosteum
Quality or character: throbbing is usually related to bone injury. Aches most often reflect muscular involvement. Sharp pain is associated with fractures, bone infection.
Radiation of pain, what makes it worse?
Pain involving tendons and bursa is usually worse at night. Pain on movement is typical of joint involvement.
Complications:
Pain on movement at the knee may indicate a tear to cartilage. Volkmann's ischemic contracture is reflected by increased pain with passive movement (compartment syndrome). Include assessment for
5 “Ps” which include evaluation of sensation and movement (pain, pulse, pallor, paresthesia, and paralysis).
Associated conditions to consider with musculoskeletal assessment:
Joint stiffness:
Swelling:
Which joints, how long does the pain last? Does heat decrease muscle spasm.
How long does the swelling last. When does it occur? Does rest relieve?
Deformity and immobility: Sudden, gradual, and limited. What effect on ADL? Any supportive equipment
Sensory/motor changes: Any loss of feeling, burning, tingling.
Case presentation of elderly person with cane arriving at health clinic with reports that “can no longer walk!”
 What questions to ask?
 How to conduct assessment? Follow principles of assessment.
-
Do normal first!
Proceed in orderly fashion with inspection, palpation, and percussion.
Inspection: standing, walking, sitting, general appearance. Bilateral comparison is very important. noting shape, size, contour, signs of inflammation, ecchymosis, , deformity.
-
Identify age-related changes: decreased muscle bulk, tone and strength
-
Consider nutritional status including overweight, underweight, etc.
Assess skin condition including turgor and texture. Papery skin may be associated with connective tissue disease and long term use of steroids. Thick, leathery patches over the forehead, hands, chest and face may indicate scleroderma.
Bruised tissue my indicate use of steroids.
-
Assess for evidence of impaired circulation, noting tissue atrophy, response to changes in temperature such as a white appearance indicating arteriolar spasm, to blue as occurs with venous compromise
Consider any inflammatory response such as erythema over a joint. Evaluate joints for effusion, (serous, purulent, or bloody). Inflamed synovium feels boggy and reflects a need to rest the joint.
2 of 5

Lecture Notes Part 2
Musculoskeletal Stressors
Specific Sites that should be assessed.
Hand and extremities: note tophaceous cysts (indicative of gout, swollen, firm to tough, painful) and are characterized as a hard translucent swelling over joints, especially the great toe and the cartilage of the ear; bony enlargement at ends of fingers
(Herberden’s nodules located at distal interphalangeal joints = DIP’s as with osteoarthritis or Bouchard’s nodules with swelling at proximal interphalangeal joints = PIPs as found in rheumatoid arthritis). May identify subcutaneous nodes along forearm which are present with rheumatoid arthritis; joint swelling due to synovial irritation and bursal swelling as found with rheumatoid arthritis.
Deformities:
Assess for any deformities such as ulnar drifts (away from midline) or, valgus deformity (toward midline), hypertrophy, presence of scoliosis, kyphosis, atrophy.
Assess for 5 P’s neurovascular integrity (CMS)
Evaluate sensory and motor function of radial, medial, ulnar, peroneal, and tibial nerves
Assessment of knee: evaluate for fluid in knee and stability of knee by checking for bulge sign and ballottment. In the knee joint note bogginess in suprapatellar pouch by palpating area with thumb and finger; check each site and note any tenderness, bogginess or boney changes. May reflect inflammation of synovial fluid or degenerative joint changes.
Bulge sign indicates fluid with the knee joint and can detect small amounts of fluid, but can be absent if large amount of fluid is present as the joint is extremely distended. To check for bulge sign:
(1) Milk fluid upward with the ball of the hand at the medial aspect of the knee to displace the fluid upward.
(2) Press or tap the knee below the lateral margin of the patella.
(3) Look for returning fluid in the hollow medial to the patella.
Ballottement checks for floating patella by eliciting a palpable tap that indicates fluid within the knee joint.
(1) Grasp the thigh just above the knee with one hand.
(2) Force fluid out of the superior portion of the joint space into the space between the patella and the femur.
(3) With the fingers of the hand, push the patella sharply back against the femur.
Knee Stability: Need to evaluate for stability of anterior cruciate ligament and the posterior cruciate ligament (Lachman and Anterior Drawer test); and medial and lateral collateral ligament. Need to also check the medial and lateral meniscus. http://www.scoi.com/arthros2.htm
The anterior and posterior cruciate ligaments connect the inner surfaces of the head of the femur with the head of the tibia. These ligaments cross each other, with the anterior ligament extending from the inside of the lateral condyle of the femur to the medial side of the tibial head, and the posterior ligament extending from the inside of the medial condyle of the femur to the lateral side of the tibial head.
The stability of the ligaments, which stabilize the knee joint, is evaluated as follows:
With the knee extended, fix the femur, grasp the ankle and adduct and abduct the leg. If there is mobility on adduction it indicates damage to the lateral collateral ligament. If there is mobility on adduction, it indicates damage to lateral collateral ligament. If there is mobility on abduction, it indicates damage to medial collateral ligament.
Lachman and anterior drawer test for stability of anterior and posterior cruciate ligament. With the patient lying down with knee at 90-degree flexion, the examiner stabilizes the foot, grasps the lower leg and pushes the lower leg forward and backward. Increased motion anteriorly indicates damage to the anterior cruciate ligament. Increased motion posterior indicates damage to the posterior cruciate ligament.
Meniscal injury is evaluated by checking for McMurray's sign. Flex the knee with the person in supine position with the foot near the buttocks. Place hand on the knee so that the thumb and index finger lies on
3 of 5

Lecture Notes Part 2
Musculoskeletal Stressors either side of the joint space. With other hand, grasp the heel and use both hands and forearm to rotate the foot and lower leg laterally. While maintaining the rotation, extend knee to a right angle. Feel and listen for a click. A palpable or audible click, resembles patient's symptoms suggests torn meniscus.
Diagnostic Tests/Procedures
 X-ray: Two planes required, anterior and posterior
 CT scan: For cross sectional slices, gives sharp distinct picture. Pt remove all jewelry and metal objects; motionless; maybe radiopaque solution; takes 10-60 minutes to complete.
 Bone scan: Bone matrix uptakes the radioactive isotope. Related to bone metabolism. Have to be supine for one hour, not harmful; uptake of technetium-99; "shows hot spots".
 Laminography: Specific planes
 Thermography: Measures heat and radiation as occurs with arthritis and inflammation
 MRI: Imagining modality, produces a cross sectional picture by interaction between magnetic fields radio waves, and atomic nuclei. Shows hydrogen density. The magnetic interaction differs in fat, muscle, bone and blood. Takes 30 to 90 minutes or longer. Cannot have any metal objects as prostheses. Cannot move; requires a consent form.
 Bone Marrow Biopsy or Aspiration
 Single-photon densimeter: Assesses bone density. Useful in recognizing early osteoporosis. Measures bone mineral content, mainly in forearm and wrist; looks mostly at cortical bone, which is affected by osteoporosis, but not as much as trabecular bone.
 Dual-Photon Absorptiometry: Measures total cortical and trabecular mineral contents of hip and spine; uses less radiation than conventional x-rays.
Arthrography, arthrocenthesis, arthroscope
Arthrogram is the radiographic exam of a joint, especially the knee, shoulder. Following injection or air or radiopaque contrast medium or both.
-
Outlines soft tissues not usually visualized by standard radiographs as the meniscus, cartilage, and ligaments of hip, knee, shoulder, elbow, ankle, and wrist.
-
Has 90-95% accuracy in detecting tears as outpatient under local.
-
Remove joint effusion first; don't dilute dye; use 3-15 ccs contrast fluid; then take joint through
ROM.
-
Complications include infection, allergy to dye; bleeding, soreness or pain, crepitus.
-
Prior to procedure: Check for allergies to iodine, seafood. Sign consent form.
-
Patient teaching to include what to expect a tingling or pressure in the area; seal site with colloid; will move joint through ROM during procedure.
-
Post-op complications rare; expect pain relief.
Post Operative: rest joint for 6-12 hours. If knee, wrap for 12 hours. If swelling, use ice.
Avoid strenuous exercise; mild analgesics, check joint for edema, color changes, heat, amount of pain. May hear cracking for "squishing" sound in joint for several days.
Arthrocenteses is the aspiration of synovial fluid. Use a sterile needle. Done under strict aseptic conditions. For patients with undiagnosed articular disease. Procedure relieves pain and distention. Means of administering a local and giving a steroid.
-
Joint fluid removed and analyzed. Normal joint fluid is clear, yellow, with high viscosity, a firm mucin clot, scant fluid, no debris, and 100 to 200 WBC's/MM3 and 10% polys.
Complications include joint infection and hemorrhage.
Patient teaching: includes no food, fluid restrictions; may have transient pain; consent form needs to be signed; If meds given check for sensitivity.
4 of 5

Lecture Notes Part 2
Musculoskeletal Stressors
Post-op care to include: Ice pack; expect increased swelling if large amount of fluid is removed. Use compression bandage. Observe for pain, increased temperature. Rest joint for
8-24 hours.
Arthroscopy
 http://www.scoi.com/arthros2.htm
 http://www.scoi.com/arthros1.htm
First performed in 1918 in Tokyo. In 1920 had the first arthroscope.
Allows concurrent diagnosis and surgery. Done under local or spinal. Have a cannula in the joint cavity and the arthroscope is positioned in it. Can obtain a visual record by attaching a camera to it. Surgery done by arthroscopy includes excision of meniscus, remove foreign bodies, synovectomy, drain septic joint, biopsy, ligament repair, smooth knee cartilage. Consider potential risks including vascular injury due to use of tourniquet; infection, bleeding. Post-op care determined by extent of repair. Ice and compression indicated; may need PCA pump.
Orthopedic Interventions: Management of musculoskeletal injury requires the use of various immobilization and therapeutic devices and interventions. Including traction, casts, external fixators, pins, plates, screws, CPM machines and crutch-walking devices. http://www.orthofix.com/ofprod/OFSite/P1000000.htm
Traction: Recall principles of traction http://www2.austin.cc.tx.us/cmorse/2410/traction/traction.htm
Crutch-walking: http://www.postgradmed.com/issues/1998/08_98/pn_cane.htm http://www.mayohealth.org/mayo/9902/htm/canes.htm
Usual move involved limb at same time or immediately after advance of device; uninvolved last. Canes held in hand opposite of involved extremity
1.
2 point: some weight both legs; right leg and left crutch move together; then left leg and right crutch
2.
3 point; no weight bearing to partial on affected leg
3.
4 point; weight bearing on both legs; crutches and feet move alternately; like natural walking
4.
4 point: slower version of 2 point; advance each point separately
5.
Swing to: advance both crutches together and lift lower limbs to same place
6.
Swing through: like above, client swings body past crutches. No weight bearing on affected leg.
Keys: Stand up straight using crutches with 2 fingers between your armpit and top of crutches
 Elbow should bend
 Avoid pressure at brachial plexus
 Up with good, down with bad
Safety tips:
 Small steps
 Avoid waxy place
 Shoes with low heel
 Good crutch tips
5 of 5