NCLEX: Musculoskeletal disorders

Musculoskeletal disorders: Diagnostic tests

Focus Topic: Musculoskeletal disorders

Diagnostic tests help to confirm the diagnosis and identify the underlying cause of musculoskeletal problems. Common procedures include aspiration tests, endoscopic tests, and radiographic and imaging studies.

Musculoskeletal disorders: Aspiration tests

Focus Topic: Musculoskeletal disorders

The doctor may aspirate a specimen from the joint capsule (arthro centesis) or from the bone marrow to detect various disorders.

Arthrocentesis
Arthrocentesis is a joint puncture that’s used to collect fluid for analysis to identify the cause of pain and swelling, to assess for infection, and to distinguish forms of arthritis, such as pseudogout and infectious arthritis. The doctor will probably choose the knee for this procedure, but he may tap synovial fluid from the wrist, ankle, elbow, or first metatarsophalangeal joint.

Telltale findings

In joint infection, for example, synovial fluid looks cloudy and contains more white blood cells (WBCs) and less glucose than normal. When trauma causes bleeding into a joint, synovial fluid contains RBCs. In specific types of arthritis, crystals can confirm the diagnosis — for instance, urate crystals indicate gout.

Doing double duty

Arthrocentesis also has therapeutic value. For example, in symptomatic joint effusion, removing excess synovial fluid relieves pain.

Nursing considerations
• Describe the procedure to the patient. Explain that he’ll be asked to assume a certain position, depending on the joint being aspirated, and that he’ll need to remain still.
• After the test, the practitioner may ask you to apply ice or cold packs to the joint to reduce pain and swelling.
• If the doctor removed a large amount of fluid, tell the patient that he may need to wear an elastic bandage.
• Advise him not to use the joint excessively for 24 hours after the test to avoid joint pain, swelling, and stiffness.
• Instruct him to report these signs of infection: fever and increased pain, tenderness, swelling, warmth, or redness.

Bone marrow aspiration
In bone marrow aspiration, a doctor removes a small amount of fluid from the bone marrow using a special needle. This procedure can be used to diagnose many abnormalities, including rheumatoid arthritis, TB, amyloidosis, syphilis, bacterial or viral infection, parasitic infestation, tumors, and hematologic problems.

Suck it up

Bone marrow is usually aspirated from the sternum or iliac crests. The site is prepared as for any minor surgical procedure and then is infiltrated with a local anesthetic such as lidocaine. The doctor inserts the marrow needle, with stylet in place, through the cortex into the marrow cavity. Marrow cavity penetration causes the patient to feel a collapsing sensation. Then the doctor removes the stylet, attaches a syringe to the needle hub, and aspirates 0.2 to 0.5 ml of fluid.

Nursing considerations
• Tell the patient that he’ll be sedated and that he’ll receive a local anesthetic before needle insertion.

• Explain that the test takes about 10 minutes.
• Warn the patient that he’ll feel pressure as the doctor inserts the needle and that aspiration may hurt briefly.
• Watch for signs of infection after the procedure.
• Make sure bleeding stops, particularly if the patient has a clotting disorder.

Musculoskeletal disorders: Endoscopic tests

Focus Topic: Musculoskeletal disorders

Endoscopic studies allow direct visualization of joint problems. Arthroscopy is a common endoscopic procedure.

Arthroscopy
Arthroscopy is usually used to evaluate the knee. It helps the doctor assess joint problems, plan surgical approaches, and document pathology.

Needling the knee

After inserting a large-bore needle into the suprapatellar pouch, the surgeon injects sterile saline solution to distend the joint. Then he passes a fiber-optic scope through puncture sites lateral or medial to the tibial plateau, allowing direct visualization. With a large scope, he can remove articular debris and small, loose bodies or repair a torn meniscus.

Nursing considerations
• Tell the patient that he can’t eat or drink after midnight before the test.
• Explain that, if ordered, he’ll receive a sedative immediately before the test, and that the area around the joint will be prepped.
• If the test will be performed under local anesthesia, check the patient history for hypersensitivity to local anesthetics. Warn the patient that he may feel transient discomfort during injection of the anesthetic.
• Explain that the surgeon will make a small incision and insert the arthroscope into the joint cavity.
• Tell the patient that he’ll be allowed to walk as soon as he’s fully awake. He’ll experience mild soreness and a slight grinding sensation in his knee for 1 to 2 days.
• Instruct him to notify the practitioner if he feels severe or persistent pain or develops a fever with signs of local inflammation.
• Advise against excessive use of the joint for a few days after the test. Tell the patient that he may resume his normal diet.

• Ask the surgeon about specific leg exercises, ice application, and dressing changes that are necessary after the procedure and at home.
• Assess the patient for signs of complications, such as infection, hemarthrosis (blood accumulation in the joint), or a synovial cyst.
• Teach the patient proper crutch walking technique if crutches are ordered, and ask him to perform a return demonstration.

Musculoskeletal disorders: Radiographic and imaging studies

Focus Topic: Musculoskeletal disorders

Radiographic and imaging studies include bone scans, computed tomography (CT) scans, dual energy X-ray absorptiometry (DEXA), magnetic resonance imaging (MRI), and X-rays.

Bone scan
A bone scan helps detect bony metastasis, benign disease, fractures, avascular necrosis, and infection.

Scintillating study

After I.V. introduction of a radioactive material, such as the radioisotope technetium polyphosphate, the isotope collects in areas of increased bone activity or active bone formation. A scintillation counter detects the gamma rays, indicating abnormal areas of increased uptake (positive findings). The radioisotope has a short half-life and soon passes from the patient’s body.

Nursing considerations
• Explain to the patient how this painless test commonly detects bone abnormalities earlier than conventional X-rays.
• Tell him that he can eat and drink as usual before the test.
• Describe how the doctor applies a tourniquet on the patient’s arm and then injects a small dose of a radioactive isotope. Assure the patient that the isotope emits less radiation than a standard X-ray machine.
• Explain that after the isotope is injected, there’s a 2- to 3-hour waiting period before the scan is done. During this time, the patient must drink four to six glasses of fluid.
• Explain that when it’s time for the scan, he’ll lie supine on a table within the scanner. The scanner moves back and forth slowly, recording images for about 1 hour. Instruct the patient to lie as still as possible and to expect to assume various positions.

CT scan
A CT scan aids diagnosis of bone tumors and other abnormalities. It helps assess questionable cervical or spinal fractures, fracture fragments, bone lesions, and intra-articular loose bodies.

Beam me up, Scotty

Multiple X-ray beams from a computerized body scanner are directed at the body from different angles. The beams pass through the body and strike radiation detectors, producing electrical impulses. A computer then converts these impulses into digital information, which is displayed as a three-dimensional image on a video monitor.

Nursing considerations
• If the patient is scheduled to receive a contrast medium, inform him that he must not eat for 4 hours before the test. Check his records to make sure he isn’t hypersensitive to any contrast media. If he is hypersensitive, he may need preprocedure medication.
• Tell the patient that he needs to put on a hospital gown, remove all jewelry, and empty his bladder before the test.
• Instruct him to remain still during the test. Although he’ll be alone in the room, assure him that he can communicate with the technician through an intercom system.
• If the patient received a contrast medium by mouth, encourage him to drink plenty of fluids after the test to help flush the contrast medium from his body.

DEXA
DEXA can be used to assess the bone density of the entire body or just the hip or spine. It’s used to help diagnose osteoporosis, especially before a fracture occurs. This noninvasive technique involves using a radiography tube to measure bone mineral density and exposes the patient to only minimal radiation.

Alternative approaches

Several other machines can also be used to measure bone density.

Nursing considerations
• Reassure the patient that this test is painless and noninvasive and usually takes less than 15 minutes.
• Have the patient remove all jewelry from the area that will be examined.

Musculoskeletal disorders

MRI
MRI can show irregularities of the spinal cord and is especially useful for diagnosing disk herniation.

Must be animal magnetism

The MRI scanner uses a powerful magnetic field and radiofrequency energy to produce images based on the hydrogen content of body tissues. The computer processes signals and displays the resulting high-resolution image on a video monitor. The patient can’t feel the magnetic fields.

Nursing considerations
• Explain to the patient that he’ll be positioned on a narrow bed that slides into a large cylinder housing the MRI magnets.
• Tell him that he’ll be asked to put on a hospital gown and to remove all metal objects, including bobby pins, jewelry, watches, eyeglasses, hearing aids, and dental appliances. He should also remove clothes with metal zippers, buckles, or buttons as well as credit, bank, and parking cards, because the scan could erase the magnetic codes. He will also need to remove any medication patches.
• Ask the patient if he has any implanted metal, such as a pacemaker, plate, screws, or an artificial joint. If the patient has implanted metal, an MRI may not be possible.
• Tell the patient he’ll hear soft thumping noises during the test. Ask if claustrophobia has ever been a problem for him. If so, sedation may help him tolerate the scan.
• Instruct him to remain still during the test. Although he’ll be alone in the room, assure him that he can communicate with the technician through an intercom system.

X-rays
Anteroposterior, posteroanterior, and lateral X-rays allow threedimensional visualization. They help diagnose:
• traumatic disorders, such as fractures and dislocations
• bone disease, including solitary lesions, multiple focal lesions in one bone, or generalized lesions involving all bones
• joint disease, such as arthritis, infection, degenerative changes, synoviosarcoma, osteochondromatosis, avascular necrosis, slipped femoral epiphysis, and inflamed tendons and bursae around a joint
• masses and calcifications.

If the practitioner needs further clarification of standard X-rays, he may order a CT scan or MRI.

Nursing considerations
• Make sure the patient removes all jewelry from the area to be X-rayed.
• Verify that the X-ray order includes pertinent recent history, such as trauma, and identifies the point tenderness site. It should also include past fractures, dislocations, or surgery involving the affected area.

Musculoskeletal disorders: Treatments

Focus Topic: Musculoskeletal disorders

Pain and impaired mobility provide good motivation for obtaining medical care. Consequently, most patients with musculoskeletal problems eagerly seek treatment.

Get up and go again

To restore a patient’s mobility, several treatments are used alone or in combination:
• a balanced program of exercise and rest
• a splint, brace, or other device to support a weakened or injured limb or joint
• drug therapy to control pain, inflammation, or muscle spasticity
• nonsurgical treatments, including closed reduction or immobilization
• surgery with subsequent immobilization with a cast, brace, or other device.

Musculoskeletal disorders: Drug therapy

Focus Topic: Musculoskeletal disorders

Salicylates are the first line of defense against arthropathies. Other drug therapy includes analgesics, nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, and skeletal muscle relaxants.

Musculoskeletal disorders: Nonsurgical treatments

Focus Topic: Musculoskeletal disorders

Some patients with musculoskeletal disorders require nonsurgical treatment. Such treatment may include closed reduction of a fracture or immobilization.

Closed reduction
Closed reduction involves external manipulation of fracture fragments or dislocated joints to restore their normal position and alignment. It may be done under local, regional, or general anesthesia or monitored sedation.

Patient preparation
Prepare the patient for reduction by taking these steps:
• If he’ll be receiving a general anesthetic, instruct him not to eat after midnight. Tell him he’ll receive a sedative before the procedure.
• If appropriate, explain how traction can reduce pain, relieve muscle spasms, and maintain alignment while he awaits the procedure.

Monitoring and aftercare
After the procedure, take these steps:
• Assess for pain and provide pain management, as needed.
• Be prepared to care for a bandage, sling, splint, or cast after the procedure. These devices immobilize the fracture or dislocation.
• Tell the patient that he’ll have an X-ray to evaluate the closed reduction.

Home care instructions
Before discharge, take these steps:
• Teach the patient how to apply (if appropriate) and care for the immobilization device. Tell him to regularly check his skin under and around the device for irritation and breakdown.
• Stress the importance of following prescribed exercises.

Immobilization
Immobilization devices are commonly used to maintain proper alignment and limit movement. They also relieve pressure and pain.

Don’t move a muscle!

Immobilization devices include:
• plaster and synthetic casts applied after closed or open reduction of fractures or after other severe injuries
• splints to immobilize fractures, dislocations, or subluxations
• slings to support and immobilize an injured arm, wrist, or hand, or to support the weight of a splint or hold dressings in place
• skin or skeletal traction, using a system of weights and pulleys to reduce fractures, treat dislocations, correct deformities, or decrease muscle spasms

• braces to support weakened or deformed joints
• cervical collars to immobilize the cervical spine, decrease muscle spasms, and possibly relieve pain.

Patient preparation
Before the procedure, prepare the patient for immobilization by taking these steps:
• Explain the purpose of the immobilization device. If possible, show the patient the device before application and demonstrate how it works. Reinforce to the patient approximately how long the device will remain in place.
• Explain that he’ll have discomfort initially, but reassure him that this will resolve as he becomes accustomed to the device. If the patient is in pain, give analgesics and muscle relaxants as ordered.

Monitoring and aftercare
After the procedure, take these steps:
• Take precautions to help prevent complications of immobility, especially if the patient is in traction or requires long-term bed rest. For example, reposition him frequently to enhance comfort and prevent pressure ulcers.
• As ordered, assist with active or passive ROM exercises to maintain muscle tone and prevent contractures.
• Encourage regular coughing and deep breathing to prevent pulmonary complications.
• Stress adequate fluid intake to prevent urinary stasis and constipation.
• Encourage the bedridden patient to engage in hobbies or other activities to relieve boredom. This also helps maintain the positive mental outlook that’s important to recovery.
• Encourage ambulation, if appropriate, and provide assistance as necessary.
• Provide analgesics as ordered. If you’re administering opioid analgesics, watch for signs of toxicity or over-sedation.
• Provide regular pin care for the patient in skeletal traction to help minimize the risk of infection.

Musculoskeletal disorders

Home care instructions
Before discharge, give the patient these instructions:
• Tell him to promptly report signs of complications, including increased pain, drainage, or swelling in the involved area.
• Stress the need for strict compliance with activity restrictions while the immobilization device is in place.
• If the patient has been given crutches to use with a leg or ankle cast, splint, or knee immobilizer, make sure he understands how to use them. If the patient has a removable device, such as a knee immobilizer, make sure he knows how to apply it correctly.
• Advise the patient to keep scheduled medical appointments to evaluate healing.

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