Ch23 Musculoskeletal System

Obesity increases risk for arthritis in weight-bearing joints, therefore the nurse encourages the client to continue to watch her weight. The nurse should encourage the client to continue a regular exercise program according to age and ability to maintain or improve musculoskeletal function.

Muscle strength is rated on a 0-5 scale (no muscle contraction-normal muscle strength). A rating of 5/5 is considered normal muscle strength, meaning that the client has full range of motion against gravity with full resistance.

2/5 muscle strength is full range of motion without gravity (passive motion).

A rating of 3/5 muscle strength is considered fair and means the client has full range of motion with gravity, but not against resistance.

4/5 muscle strength is documented if the client has full range of motion against gravity with moderate resistance.

As the pregnancy progresses, lordosis (an inward curvature of the lower spine-sway back) compensates for the enlarging fetus. The center of gravity shifts forward, which strains the lower spine, causing lower back pain.

Weakened abdominal muscles are not the cause of the lordosis.

The development of back pain is common; however, the nurse should not dismiss the client's concern by stating that "there is nothing to worry about."

A previous history of back pain may aggravate the situation; however, this woman does not have a previous history of back pain.

Recommend regular exercise according to age and ability to maintain or improve musculoskeletal function. Sedentary lifestyles increase the risk for musculoskeletal complications.

A normal degenerative change associated with aging, osteoarthritis can contribute to decreased physical activity. A well-balanced diet and regular exercise help to slow the progression of this change.

The disorder is not related to genetics.

Calcium supplementation will not prevent the development of the disorder.

Over-the-counter analgesics will help with the pain associated with the disease, but will not prevent the progression of the disease.

Allis' sign is used to detect unequal leg length, which could indicate congenital hip dislocation and should be assessed at every office visit until one year of age. The nurse is positioned at the infant's feet. With the infant supine, the nurse flexes the infant's knees, keeping the femurs aligned, and compares the height of the knees. An uneven height indicates unequal leg length.

Tibial torsion is a curving of the tibias.

Genu valgum (knock knees) is found typically after the age of four and identified when the child walks.

Genu varum (bowlegs) is identified in infants before they learn to walk.

Kyphosis is an exaggeration of the normal convex curve of the thoracic spine. It may result from congenital abnormality, rheumatic conditions, compression fractures, or other disease processes including syphilis, tuberculosis, and rickets.

Scoliosis is a lateral curvature of the spine.

Lordosis is an exaggeration of the normal lumbar curve of the spine.

Osteoporosis occurs because of decreased bone density. The nurse is not able to observe this during an assessment.

Abduction is movement of a limb away from the midline or median plane of the body, along the frontal plane.

Adduction is movement of a limb toward the midline. Pronation and supination refer only to the movements of the radius around the ulna.

In pronation, the palm moves to face downward.

Flexion is a bending movement that decreases the angle of the joint and brings the articulating bones closer together.

Weight-bearing activities may increase the pain if the client has a degenerative disease of the hip, knees, or vertebrae.

Sensations of burning, tingling, or prickling (paraesthesia) may accompany compression of nerves and blood vessels in a particular body region.

Shoulder pain may be the result of referred pain such as a hiatal hernia or cardiac, gallbladder, and pleural conditions.

Lumbosacral nerve root irritation may cause pain to be felt in the leg.

Hallux valgus (bunion): The great toe deviates laterally from the midline, crowding the other toes. The metatarsophalangeal joint and bursa become enlarged and inflamed, causing a bunion.

Hammertoe occurs when there is flexion of the proximal interphalangeal joint of a toe, while the distal metatarsophalangeal joint hyperextends. A callus or corn frequently occurs on the surface of the flexed joint from external pressure.

Pes planus (flatfoot) occurs when the arch of the foot is flattened.

Genu varum is the term for bowlegs.

If the client complains of sharp pain that begins in the lower back and radiates down the leg during the straight-leg-raise test, the nurse should record the distribution and severity of the pain and the degree of leg elevation at the time the pain occurs. Pain along the course of the sciatic nerve with the straight-leg-raise test may indicate a herniated disk.

Arthritis of the lumbar spine would not cause symptoms related to pressure on the sciatic nerve.

Inflammation of the hip joint, arthritis, causes localized pain at the hip and does not radiate down the leg.

Synovitis is an effusion within the synovium of the knee resulting in distention of the suprapatellar area and lateral aspects of the knee.

A positive Tinel's sign is present if there is numbness, tingling, and pain along the median nerve when percussing lightly over the median nerve in each wrist. A positive Tinel's sign is often seen with carpal tunnel syndrome.

A positive Phalen's test is performed in individuals with carpal tunnel syndrome. The wrists are bent downward, pressing the backs of both hands together causing the flexion of the wrists to 90 degrees. Normally clients experience no symptoms with this maneuver. In individuals with carpal tunnel syndrome, this maneuver produces pain, tingling, and numbness that radiates to the arm, shoulder, or neck.

Dupuytren's contracture is not associated with carpal tunnel syndrome. With Dupuytren's contracture, the fourth and fifth fingers are flexed. This is a progressive, painless, inherited disorder that causes severe flexion in the affected fingers, is usually bilateral, and is more common in middle-aged and older males.

Atrophy of the thenar eminence is a common finding with carpal tunnel syndrome; however, it does not cause numbness and tingling.

Osteomyelitis, an infection of the bone, frequently recurs in clients with a history of previous infections.

Individuals with osteomalacia (adult vitamin D deficiency) are more prone to develop multiple fractures of the bone.

The development of osteoarthritis is not related to osteomyelitis.

A previous history of osteomyelitis is not a risk factor for the development of fractures.

Fibromyalgia, classified as a rheumatic disease, is characterized by pain in the muscles and soft tissues that support and surround joints. Pain is experienced in tender points of the head, neck, shoulders, and hips.

With osteoarthritis, the joint cartilage erodes, resulting in pain and stiffness primarily in the spine, knees, and hips.

Systemic lupus erythematosus (SLE) is an autoimmune disease that causes inflammation in joints and other body organs.

Gout is a type of arthritis caused by uric acid crystal deposits in the joints. The deposits cause inflammation, pain, and swelling in the joints, especially the great toe.

In rotator cuff tears, the client is unable to perform abduction without lifting or shrugging the shoulder. This sign is accompanied by pain, tenderness, and muscle atrophy.

Olecranon bursitis occurs over the olecranon process of the elbow. It s caused by swelling of the bursa and results in swelling of the elbow.

A dislocation of a joint would result in obvious deformity of the area and an inability to move the joint.

Osteoarthritis of the joint causes generalized pain and stiffness of the area.

With osteoarthritis the joint cartilage erodes and typically affects the spine, hips, and knees. Bones joined by cartilage, such as the vertebrae, are called cartilaginous joints.

Bones joined by fibrous tissue, such as the sutures joining the bones of the skull, are called fibrous joints.

Bones separated by a fluid-filled joint cavity are called synovial joints.
Synovial joints are reinforced and strengthened by ligaments. Ligaments are protected by small, synovial fluid-filled sacs called bursae.

Cervical bones do not have bursae.

Increasing the client’s awareness about her disease process will allow her to be able to cope with her disease with an understanding of of her symptoms.

This is probably not the most realistic goal for the client, considering how much pain she has been experiencing.

The nurse should set realistic goals for the client. Because the client has been experiencing a great deal of pain in the past few weeks, the nurse should use goals that are more realistic until she feels better.

According to Healthy People 2010, arthritis affects more than 20% of the adult population, instead of more than 40%.