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Nutrition for Nurses

19.1 Assess and Analyze the Impact of Nutrition on the Musculoskeletal and Integumentary Systems

Nutrition for Nurses19.1 Assess and Analyze the Impact of Nutrition on the Musculoskeletal and Integumentary Systems

Learning Outcomes

By the end of this section, you should be able to:

  • 19.1.1 Recognize the normal function of the musculoskeletal and integumentary systems.
  • 19.1.2 Recognize cues of nutritional impact on the musculoskeletal and integumentary systems.
  • 19.1.3 Analyze cues of nutritional impact on the musculoskeletal and integumentary systems.

Normal Function of the Neurological System

The impact of nutrition on the musculoskeletal and integumentary systems cannot be explained without first reviewing the normal function of the neurological system. The neurological system and the musculoskeletal system relate to one another in that the brain and nerves tell the voluntary muscles what to do. In response to the messages sent to the brain through the nerve pathways, muscle fibers become tense and cause the muscles to contract.

The brain is the most complex organ in the body. The brain is divided into lobes each having a specific function in the neurological system. The frontal lobes are responsible for imagination, memory, and reasoning. Damage to a frontal lobe is often manifested in memory loss and poor judgment and often follows a cerebrovascular accident (CVA). When this lobe is not functioning properly, secondary issues related to the musculoskeletal and integumentary systems emerge. For example, after injury to the frontal lobe, a client may not recognize the importance of mobility and skin care. Therefore, damage to this area of the brain may have detrimental secondary consequences on the musculoskeletal and integumentary systems (National Institute of Neurological Disorders and Stroke, 2023; National Library of Medicine, 2022).

Important structures in the inner brain that play a part in musculoskeletal and integumentary function, like the basal ganglia, initiate and coordinate movements. Diseases of the cells leading into the basal ganglia, such as Parkinson’s disease, result in disturbance of movement as seen with tremors. The other important structures in the inner brain include the hypothalamus, thalamus, and hippocampus, which do not directly affect the musculoskeletal or integumentary systems (National Institute of Neurological Disorders and Stroke, 2023, National Library of Medicine, 2022).

Assessment of Nutrition and the Function of the Musculoskeletal and Integumentary Systems

Nutrition plays a key role in the development of a healthy musculoskeletal and integumentary system. Nurses are taught to holistically view the client during the initial and ongoing assessment to reveal and relay any problems with the client that may help the health care provider in diagnosing and treating the client. Delays in diagnosing and treating the client with nutritional deficiencies can lead to muscle wasting, bone fractures, skin ulcerations, and so much more. Many of the complications of inadequate nutrition are irreversible and even life threatening as related to the musculoskeletal and integumentary systems. After surgery and at other times of stress on the body, the importance of an accurate nutritional assessment cannot be underestimated.

The benefits of eating properly for the musculoskeletal and integumentary systems include healthy skin, muscles, bones, and teeth, as well as maintaining a healthy weight which, in turn, affects the cardiovascular system, the endocrine system, and so on. Maintaining a proper body weight through good nutrition leads to healthier joints, muscles, tendons, and bones because there is less stress on the musculoskeletal system. Musculoskeletal and joint problems such as osteoarthritis are often worse for people who are overweight (Centers for Disease Control and Prevention, 2022). Maintaining a healthy weight lowers the risk of heart disease, hypertension, stroke, and type 2 diabetes, breathing problems and sleep apnea, anxiety, and other conditions in other body systems.

With all the problems associated with inadequate nutritional intake on the musculoskeletal and integumentary systems, the nurse has a priority of completing a full intake history of the client and proper follow-up assessment. From there, the nurse can develop a plan of care for the client. This ensures that the client is assisted in maintaining physiological and psychological integrity throughout the course of their treatment.

The health history should focus on past surgical history, including possible complications of previous surgeries and a family medical history as many of the musculoskeletal and integumentary disorders have heredity tendencies. Some of the most important medical history to obtain in these system categories include history of rheumatoid arthritis or other autoimmune disorders (when the body’s immune system attacks and destroys healthy body tissue). Osteoarthritis, osteoporosis, osteopenia, scleroderma, systemic lupus erythematous (SLE), and eczema are just some of the genetically inherited diseases of the musculoskeletal and integumentary systems (Orthopedic Oncology, 2023).

Normal Function of the Musculoskeletal and Integumentary Systems

Bones, muscles, tendons, ligaments, joints, and connective tissue hold the body together. The main function of the musculoskeletal system is to support the body. This system also allows for movement of the body as well as providing protection for internal organs. The bones that comprise the skeletal system store calcium and phosphorus—minerals important to body function—blood components, and certain fats. The skeletal muscles attached to bones are empowered by nerves with electrical current from the central nervous system. These nerves located throughout the muscles allow for the contraction of the muscles. Only two types of muscles, the skeletal muscles and the smooth muscles, are considered a part of the musculoskeletal system. The skeletal muscles provide for the movement of the body and the smooth muscles are found in intestinal and vessel walls. Ligaments and tendons help with body movement by connecting bones together to form joints (LibreTexts Medicine, 2019).

Aging influences the musculoskeletal system. As a person ages, height decreases because calcium, phosphorus, and other minerals are lost. Fluid decreases between the disks in the vertebrae of the spine, which can cause pain and deformity. Joints tend to lose cartilage contributing to stiff joints and joint pain. This contributes to osteoarthritis and worsens its symptoms associated. Working to maintain a healthy musculoskeletal system is important throughout the lifespan (Academic Senate for California Community Colleges (ASCCC) Open Educational Resources Initiative, 2021).

The integumentary system is made up of the skin and accessory structures—such as hair, nails, sweat glands, and sebaceous glands—and is the largest organ system in the human body. The function of the integumentary system is to protect the body from invading microorganisms, chemicals, and other environmental irritants. The skin helps to control temperature and regulate electrolytes by preventing dehydration. The skin and its structures play a role in storing fats and synthesizing vitamin D. The integumentary system is susceptible to diseases and injuries, many of which are life threatening. Maintaining a healthy integumentary system is vital for maintaining good health. Musculoskeletal tissue is especially vulnerable to injury (ASCCC Open Educational Resources Initiative, 2021).

Assessment of the Musculoskeletal and Integumentary Systems

Nursing assessment of the musculoskeletal system involves the collection of subjective and objective data. Subjective data is gathered through a thorough interview of the client’s past medical and surgical history, family medical history, current medical problems, lifestyle history, and nutritional history. The following interview questions are good examples that focus on the musculoskeletal system:

  • Are you experiencing any pain, weakness, swelling, or stiffness in any of your bones/joints?
  • Have you ever been told that you have a long-term musculoskeletal disease such as osteoarthritis or rheumatoid arthritis?
  • Have you ever been diagnosed with nerve pain that affects the muscles of any of your extremities?
  • Have you ever had any fractures, sprains, or strains that required medical treatment?
  • Have you ever been told you had tendonitis or bursitis?
  • Have you ever had any orthopedic surgeries?
  • Have you ever had to undergo physical therapy for pain management?
  • What is the list of your current medications including herbs and supplements?

Objective data is gathered as the nurse observes or inspects the client’s posture, movements, gait, deformities, muscle tone, and range of motion. Range of motion reflects the client’s ability to move their joints actively or passively.

General objective findings within the healthy musculoskeletal system are muscles with no wasting, no edema noted over bones and joints, and skin color appropriate for skin tone over bones, joints, ligaments, and muscles. Assessment findings should include posture that is well balanced with the head positioned over the shoulders, a slight curve in the lower back, and a level pelvis. The knees are symmetrical, the toes face forward when standing, and the shoulders and extremities are all symmetrical.

In healthy individuals, the movement of the musculoskeletal system is not restricted. There is full range of motion (ROM), which is defined as the movement potential of the joints using flexion and extension. Movement is fluid and smooth with no sounds heard from joints upon movement. There is full symmetrical muscle strength in all extremities. The gait is balanced with no shuffling or limping. A center of gravity is maintained when standing—there is no leaning or swaying, dragging feet, or waddling. Full ROM is evidenced by no pain.

The healthy musculoskeletal system is strong and symmetrical. Strong active movement is noted against gravity and resistance. Muscle tone is a measure of a muscle’s resistance to stretching while at rest. Even when at rest, muscle fibers are at least partially contracted, so muscle tone should have no flaccidity.

Musculoskeletal System

Nursing.com and Jon Haws, RN, provide a video review of how to perform a musculoskeletal assessment of the spine and upper and lower extremities.

Nursing assessment of the integumentary system can often be done simultaneously with the musculoskeletal system. If fact, observing for redness and swelling in the joints as already described relates both to the musculoskeletal and integumentary systems. This is why these systems are grouped together. One system influences the other and abnormal findings are typically related to both systems. Another example is for the sprain and strain mentioned earlier—the skin will reflect bruising (ecchymosis) and swelling.

General objective findings within the healthy integumentary system includes normal skin, hair, and nails. Skin should be distributed over the body in three tissue layers, all intact without any breaks in the skin. Healthy skin is free of lesions, ulcers, irritations, skin tears, blisters, and sores. The color is appropriate for race with no disturbances in pigmentation. Birthmarks and moles are smooth and consistent in color. Skin is warm and dry or appropriate for present environmental factors. Skin temperature does not vary from one site on the body to another. Normal moisture level is indicated by good skin turgor, with no tenting. To measure skin turgor, pinch up skin on the back of the hand and observe for tenting (when the skin stands up like a tent).

The hair of a healthy integumentary system is equally distributed in places where hair should be growing. There is no hair loss or hair growing where it does not belong. Texture is within normal limits for client per genetics, hormones, and chemical use. There are sufficient oils to prevent breakage. No parasite infestation is noted, and there is no fungus on the scalp.

The nails are translucent with pinkish tone. The base of the nail is about 160 degrees with normal sized fingertips. There is no clubbing and no spoon-shaped nails. The nails should be smooth and firm. The nails are clean, with no material growing under the nails. The cuticles are intact, and the surrounding skin is intact with no redness or edema (Figure 19.2).

A hand with healthy fingernails. The nail beds are pink with white crescents at the bottom of the nail bed.
Figure 19.2 An assessment includes nail color and shape. (credit: “Fingernails, about 2 mm long, just the right length” by Kommissar/Wikimedia Commons, Public Domain)

Tests Used in the Assessment of the Musculoskeletal and Integumentary Systems

During the assessment, nurses and providers use screening tests to determine objective findings in the musculoskeletal and integumentary systems. The provider uses this information to determine the diagnostic tests needed. The provider combines subjective data with these objective findings to help make a diagnosis. Refer to Table 19.1 for screening and diagnostic tests used for the musculoskeletal system.

Screening Tests for Musculoskeletal System Diagnostic Tests for Musculoskeletal System
  • Neuropathy impairment score (NIS)
  • Active and passive ROM
  • Bilateral hand grip test
  • Bilateral foot push test
  • Morse, or other, fall risk assessment
  • Swollen joint count
  • Auscultation for crepitus
  • Gait assessment
  • Use of ambulatory device
  • Use of prosthesis
  • Radiology and nerve studies
    • X-ray
    • Computerized tomography (CT) scan
    • Magnetic resonance imaging (MRI)
    • Ultrasound
    • Arthroscopy
    • Electromyography (EMG)
    • Bone scan
    • Dual-energy x-ray absorptiometry (DXA)
    • Ultrasound
  • Labs
    • Creatinine kinase
    • Creatine Phosphokinase (CPK)
    • Anti-cyclic citrullinated peptide (anti-CCP) antibody
    • Erythrocyte sedimentation rate (ESR)
    • Antinuclear antibody (ANA)
    • Complete blood count (CBC)
    • Serum calcium
    • Rheumatoid factor
    • C-reactive protein (CRP)
    • Tissue biopsy
Table 19.1 Screening and Diagnostic Musculoskeletal Tests (sources: LibreTexts Musculoskeletal Assessment; 2022; Pagana & Pagana, 2023)

The nurse’s assessment of the integumentary system includes the skin, hair, and nails. Abnormalities found in this system often reflect a dysfunction in other body systems. See Table 19.2 for screening tests and diagnostic tests for the integumentary system.

Screening Tests for Integumentary System Diagnostic Tests for Integumentary System
  • Capillary refill
  • Skin turgor test
  • Grading of edema test (pitting test seen in Figure 19.3)
  • Staging of pressure ulcers
  • Braden Scale (assessment tool using six categories to determine risk for pressure injury)
  • Burn classification
  • Patch testing (a skin test for allergies)
  • Biopsy
  • Scraping (a test for obtaining superficial dead skin for testing)
  • Diascopy (a test for determining blanchability of the skin)
  • Wood light test (a black light test used to diagnose lesions)
  • Tzanck testing (a test used to diagnose viral disease with active vesicles)
  • Culture and sensitivity
Table 19.2 Screening and Diagnostic Integumentary Tests (sources: Bendetti, 2021; Mazzasette, 2021)
The calf portion of a leg that is swollen.  Near the ankle it is especially swollen, with a discolored, ball shaped protrusion.
Figure 19.3 A recurrent erysipelas is evident on an edematous leg. (credit: “Recurrent erysipelas on edematous leg” by Mikael Häggström/Wikimedia Commons, Public Domain)

Unfolding Case Study

Part A

Read the following clinical scenario and then answer the questions that follow. This case study will evolve throughout the chapter.

Anne Wilson, a 70-year-old Black woman is referred by the primary care provider to a rheumatologist for complaints of pain and swelling in bilateral knees. Anne states that the ibuprofen that was earlier prescribed is no longer treating the pain. The nurse at the rheumatologist’s office notices that Anne appears anxious with a facial grimace. Anne states that she is having 8 out of 10 pain in both knees and that she only got a few hours of sleep last night due to the pain. Anne reports that she exercises daily by walking, but she admits that her nutritional plan (meal plan) could improve.

The provider enters the examination room to see Anne. On assessment, both knees are swollen with no redness or discoloration noted. The client denies injury to the knees or legs and has no history of falls. The client is taking short, tentative steps on observance of ambulation. The client admits that legs are stiff. No pain in both feet is reported. Anne said her primary doctor thinks she has arthritis and needs to see a rheumatologist. Client vitals are listed in the following table.

Vital Signs
Temperature: 98.4°F
Blood pressure: 142/88 mm Hg
Heart rate: 82 beats/min
Respiratory rate: 20 breaths/min
Table 19.3
1.
Based on these findings and client history, what screening tests should the nurse perform?
  1. Morse fall risk assessment
  2. NIS
  3. Passive and active ROM
  4. Braden scale
2.
What diagnostic testing would the nurse expect the rheumatology provider to order?
  1. X-ray of both knees
  2. Vitamin D level
  3. Tissue biopsy
  4. Serum electrolyte panel

After x-rays, C-reactive protein, ESR, client history, and physical examination, the client was diagnosed with osteoarthritis in both knees.

Anne is treated with ibuprofen 600 mg, 3 times daily, and instructed to follow up with the provider in 6 weeks for re-evaluation to determine if the prescribed nonsteroidal anti-inflammatory drug (NSAID) is working. Anne is also referred to physical therapy for strengthening and gait training. The nurse plans to provide nutritional education before discharging the client.

Analysis of Nutrition and the Musculoskeletal and Integumentary Systems

A complete health history—including client dietary habits—is essential to any nursing assessment of the musculoskeletal and integumentary systems. A person’s diet impacts how the body remains in a state of homeostasis, how it heals, and how it helps to fight off diseases.

See Table 19.4 for abnormal objective assessment findings for the musculoskeletal system and nutritional factors that are related to the abnormal assessment findings. Nutritional factors related to musculoskeletal disorders are shown in Table 19.5.

Abnormal Objective Findings in the Musculoskeletal System
  • Posture
    • Kyphosis (an excessive outward curvature of the spine)
    • Lordosis (an excessive inward curvature of the spine)
    • Scoliosis (a sideways curvature of the spine)
    • Intoeing (foot turned inward)
    • Genu varum (bowing of legs)
  • Asymmetry of shoulders and extremities
  • Movement
    • Limited ROM
    • Crepitus (a grating sound produced by friction between bone and cartilage or bone and bone)
    • Popping
    • Limited muscle strength
    • Balance disturbance
    • Gait disturbance, including limping, leaning, falling or near falls, shuffling the feet, dragging the feet, waddling, swaying
    • Pain with movement
  • Rheumatoid arthritis
  • Osteoarthritis (a degenerative joint disease resulting in chronic pain and often edema)
  • Scleroderma
  • Psoriatic arthritis (a long-term inflammatory disease of the joints)
  • SLE
  • Inflammatory joint disease
  • Cellulitis
  • Sprains and strains
  • Muscle soreness
  • Strength
    • Alterations in muscle tone
    • Muscle atrophy, flaccid muscles
    • Asymmetry of strength in extremities
    • Fractures
    • Osteoporosis
    • Osteopenia
    • Paget’s disease
  • Observation
    • Pressure injuries
    • Skin tear
    • Muscle tear
Table 19.4 Nutritional Relationship to Musculoskeletal Abnormalities (sources: Bendetti, 2021; Nursing Skills, 2023; Saeg, 2021)
Disorder Foods and Nutrients
Inflammation Anti-inflammatory foods:
  • Tomatoes
  • Olive oil
  • Leafy green vegetables
  • Nuts
  • Fatty fish
  • Fruits
    • Pineapple (contains a a group of enyzmes called bromelain)
Muscle and tissue damage Foods that aid in the repair of muscle and tissue:
  • Protein-rich foods
    • Lean turkey, chicken
    • Fish
    • Beans
    • Peas
    • Lentils
    • Tofu
    • Yogurt
    • Eggs
    • Cottage cheese
  • Fiber-rich foods
    • Fruits
    • Vegetables
    • Legumes
    • Whole grains
  • Vitamin C
    • Citrus fruits
    • Orange juice
  • Omega-3 fatty acids
    • Fatty fish (salmon, tuna)
  • Zinc-rich foods
    • Meat
    • Poultry
    • Seafood
    • Liver
Bone disorders Foods that aid in bone growth and repair:
  • Calcium-rich foods
    • Milk
    • Cheese
    • Kale
    • Yogurt
  • Vitamin D
    • Egg yolk
    • Fatty fish
    • Milk
Table 19.5 Nutritional and Musculoskeletal Relationship (sources: Bendetti, 2021; Meacham 2022; Saeg, 2021)

Pressure injuries must be treated with optimal nutrition for tissue healing. Using the guidelines from Johns Hopkins Medicine (2023), pressure injury assessment and classification includes:

  • Stage 1: A red, blue, or purplish area appears on the skin. This area, which looks like a bruise, may be warm to the touch, burn, or itch.
  • Stage 2: The area becomes an open sore that looks like an abrasion or blister and can be painful. The skin around the wound may be discolored.
  • Stage 3: The wound deepens, with a crater-like appearance, and often has dark patches of skin around its edges.
  • Stage 4: The wound extends even deeper to the muscle, bone, or joints. This can cause osteomyelitis, which is a serious bone infection. It may also lead to sepsis (a life-threatening inflammatory response to a massive infection).

An analysis of nutritional effects on abnormal findings within the integumentary system is listed in Table 19.6. The nurse should understand the relationship between nutrition and abnormal findings in the integumentary system so that the client can receive appropriate nutritional education.

Abnormal Objective Findings in the Integumentary System Related Nutritional Factors Associated Foods
Hair
  • Alopecia (hair loss)
  • Hirsutism (an abundance of hair in places where hair is normally scarce or absent)
  • Coarse texture
  • Fine texture
  • Breakage of hair
Overall hair health:
biotin
  • Liver, egg yolk, salmon, sweet potatoes, cauliflower
Vitamin B12 (cobalamin)
  • Liver, salmon, tuna, yogurt, eggs
Folate
  • Asparagus, oranges, white beans
Iron
  • Liver, beef, chicken, lamb, ham
Hair – Parasite Infections
  • Lice, nits, scabies
  • Scalp ringworm
No related nutritional factors for parasite infestations
Skin – Temperature
  • Hot or warm, cold, or cool with variations in temperature
No related nutritional factors for skin temperature
Skin – Color
  • Skin discoloration: blue, gray, red, white, yellow, darkened
  • Presence of pigmentation disturbance (vitiligo)
  • Moles or birthmarks
Pigmentation: vitamin C
  • Citrus fruits, strawberries, broccoli
Skin – Moisture Level
  • Dry, cracked skin
  • Diaphoretic
  • Clammy
  • Leathery
Zinc
  • Eggs, meat and poultry, seafood, beans and lentils, whole grains, liver, potato with skin
Iron
  • Liver, beef, chicken, lamb, ham
Niacin
  • Liver, chicken, turkey, ground beef
Vitamin D
  • Egg yolks, fatty fish, milk
Vitamin A
  • Carrots, sweet potatoes, spinach
Skin – Tenting
  • Tenting (when the skin remains raised when pinched on the back of the hand)
Dehydration
  • Water and other liquids
Skin – Integrity
  • Lesions (pustules, vesicles, hives, wheals, cyst)
  • Irritations
  • Broken skin
  • Pressure injuries
  • Skin ulcers
  • Skin tears
  • Blisters
Vitamin A
  • Carrots, sweet potatoes
  • Spinach
Vitamin B1 (thiamin)
  • Barley
Vitamin B6 (pyridoxine)
  • Fish, organ meats, potatoes
Vitamin B9 (folate)
  • Asparagus, beans, peas
Vitamin B12 (cobalamin)
  • Liver, salmon, tuna, yogurt, eggs
Vitamin C
  • Citrus fruits, orange juice
Vitamin D
  • Egg yolks, fatty fish, milk
Vitamin E
  • Olive oil, almonds, peanuts
Zinc
  • Eggs, meat and poultry, seafood
  • Beans and lentils
Calcium
  • Cheese, milk, yogurt
Copper
  • Liver, oysters, nuts, seeds
Magnesium
  • Bananas, nuts, avocado, legumes
Selenium
  • Seafood, meat
Protein
  • Lean chicken, turkey, fish
  • Beans, peas, lentils, tofu
  • Nuts, peanut butter, seeds
  • Cheese, yogurt, cottage cheese, eggs
  • Milk or fortified soy
Nails
Overall nail health: biotin
  • Liver, egg yolk, salmon, sweet potatoes, cauliflower
Nails – Discoloration
  • Yellowing, blue, darkening, greenish black, white, reddish brown
Vitamin B12 deficiency causes blue/black nails
  • Liver, salmon, tuna, yogurt, eggs
Folate deficiency causes pigmentation to change in nails
  • Asparagus, oranges, white beans
Iron deficiency causes pale nails
  • Liver, beef, chicken, lamb, ham
Nails – Shape
  • Clubbing
Low oxygen levels
  • Spoon-shaped
Iron deficiency
  • Liver, chicken, ham, lamb
Vitamin B deficiency
  • Legumes, nuts, dairy, fish, lean meats
Nails – Texture
  • Brittle
  • Coarse
  • Notched
  • Pitting
  • Ridges
  • Capillary refill: prolonged (more than 3 seconds)
  • Brittle: vitamin A deficiency
  • Ridges: vitamin B12 deficiency
  • Sweet potatoes, pumpkin, carrots
  • Liver, salmon, tuna, yogurt, eggs
Nails – Condition
  • Fungus, dirt, lack grooming
No related nutritional factors
Table 19.6 Nutritional Relationship to Integumentary (sources: Marriott et al., 2020; White, 2022)

Special Considerations

Vitiligo

Vitiligo—a skin condition where the skin loses its pigmentation—physically affects all races and sexes equally, about 1% of the population globally; however, the psychological impact on clients with darker skin tones is much greater. Because this skin disease is more visible in darker skin tones, many clients struggle with self-esteem and confidence after developing vitiligo (Cleveland Clinic, 2022). The nurse works to offer emotional support by recommending support groups for their clients with vitiligo.

Vitamin B12 has been shown to be useful for repigmentation in clients with vitiligo. Meat, eggs, and dairy products are good sources of Vitamin B12. Folic acid has also been proven to treat vitiligo. Although Vitamin D is thought to play a role in vitiligo, there is insufficient evidence to indicate that a low Vitamin D could cause vitiligo. Zinc is thought to inhibit melanocyte destruction and may be a useful mineral in the treatment of vitiligo.

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