302- Musculoskeletal Assessment

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KristaDavis
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171722
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302- Musculoskeletal Assessment
Updated:
2012-09-18 14:48:30
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302 Musculoskeletal Assessment
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Exam 2
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  1. —The degree of movement of a joint is called the range of motion.  Diarthrotic, or freely movable, joints are the only joints that have one or more ranges of motion.
    ROM (range of movement)
  2. Is the bending forward of the joint to decrease the angle between the bones that it connects.
    Flexion
  3. Is the straightening of a limb to increase the joint angle.
    Extension
  4. Is the movement of the limb away from the midline of the body
    Abduction
  5. Is the movement of the limb toward the central axis of the body.
    Adduction
  6. Is the turning of the body part inward toward the central axis of the body.
    Internal Rotation
  7. Is the turning of the body part away from the midline
    External Rotation
  8. Health History assessment musculoskeletal:
    • —History of trauma, arthritis, or neurologic disorders
    • —History of swelling in the joints
    • —History of pain or swelling in the muscles or joints
    • —Frequency and type of usual exercise
    • —Dietary intake of calcium
    • —History of smoking
    • —History of alcohol intake
  9. Subjective Data of the Musculoskeletal Health History:
    • *For any symptom the person has you should ask about:
    • 1.Location
    • 2.Quality
    • 3.Quantity
    • 4.Timing
    • 5.Aggravating Factors
    • 6.Relieving Factors
    • 7.Associated Symptoms
    • 8.Effects on ADLs
  10. Physical Assessment --- GAIT
    • —Assess movement
    • (Quick and sure or slow and deliberate)

    • —Assess gait
    • —5-6 steps
    • —Arms swing freely
    • Alternating with legs

    • —Swing – stance gait
    • —Tandem walking
    • —Tip toes*
    • —Heels*

    —Assess Romberg
  11. Physical Assessment --- Alignment
    • —*Lying, sitting, or standing
    • *—Maintain correct alignment independently
    • —*Correct alignment when standing occurs when:
    • --—Head is held erect
    • —--Face is in the forward position, in the same direction as the feet
    • —--The chest is held upward and forward
    • —--The spinal column is upright, and the curves of the spine are within normal limits
    • —--The abdominal muscles are held upward and the buttocks downward
    • —--The knees are extended
    • --The feet are at right angles to the lower legs
    • --—The line of gravity goes through the center of the knees and in front of the ankle joints
    • --The base of support is on the soles of the feet and weight is distributed through the soles and heels

    • Posture:  The client/patient posture is upright with good alignment of the head, shoulders, and hips
  12. Physical Assessment --- Spine
    • *—Begin with patient standing
    • *—Inspect spinal curves
    • *Inspect from the back- posterior view
    • *—Inspect from the side- lateral view
    • *—Palpate vertebral column
    • *—Palpate the area around spine for tenderness
    • *—Next have the patient lean forward (touch toes)
    • *—Inspect spinal curves
    • *—Hips and shoulder should be level
    • *—Palpate spine
  13. Exaggerated concave curvature of the lumbar spine
    Lordosis (swayback)
  14. Excessively convex (backward curvature of the thoracic spine).
    Kyposis (hunchback)
  15. Abnormal lateral curvature of the spine. Best detected when a person bends at the waist.
    Scoliosis
  16. Physical Assessment ---Muscles
    • —*Inspect and palpate the muscles
    • *—Observe bilaterally
    •    —Size
    •    Symmetry
    •    —Tone
    • *—Palpate for tenderness
    • Normally they are symmetric and non-tender
    • *—Assess muscle tone and strength
    • *—Tone is usually tested by passive ROM
    • *—Muscle strength (see guidelines 25-10) against resistance

    • Muscle strength is tested against resistance of the examiner.
    • Grade // Description
    • 5--Full ROM against gravity with extreme resistance
    • 4--Full Rom against gravity with some resistance
    • 3--Full ROM against gravity with no resistance
    • 2--Full Rom with gravity eliminated
    • 1--Slight contraction visible
    • 0--No contraction
  17. Abnormal Findings in Musculoskeletal Assessment:
    • —Atrophy of muscle mass
    • —Tremors
    • —Flaccidity of muscles
    • —Loss of strength and tone
    • —Decreased ROM
    • —Uncoordinated movements
    • —Swelling
    • —Pain
  18. Palpate Bones for:
    • —Contour
    • —Prominence
    • Bilaterally symmetry
  19. Abnormal Findings in BONES
    • —Pain
    • —Enlargement
    • —Asymmetry
    • —Changes in contour
  20. Physical Assessment ---JOINTS
    • *—Inspect and palpate the joints
    • *—Assess Symmetry
    • —*Assess degree of movement of each joint (ROM)
    • — Flexion
    • — Extension
    • — Hyperextension
    • — Abduction
    • — Adduction
    • — Supination
    •  —Pronation
    • —*Normally each joint has full ROM, is non-tender, and moves smoothly.
    • *You may palpate each joint during ROM to assess for crepitus.

    —
  21. ROM GUIDELINES
    • 1.   —Wash hands
    • —2.   Explain/teach
    • —3.   Use proper body mechanics
    • —4.   Provide privacy
    • —5.  ROM‑ Support joint and limb
    • —6   Move smoothly, slowly, rhythmically
    • —7.   Move to resistance (not pain)
    • —8.   Return joint to neutral alignment
    • —9.   Perform 2‑3 times per day
    • —10. Assess client
    • —11. Document
  22. Abnormal Findings in JOINTS
    • —Pain
    • —Swelling
    • —Nodules
    • —Crepitation
  23. Swelling often seen with peripheral vascular insuffiency.
    Edema
  24. When assessing ENDURANCE
    • —Evaluate the patient’s ability to turn in bed
    • —Maintain correct body alignment when sitting or standing
    • —Ambulation
    • —Perform self care activities
  25. Physical Assessment -- Endurance
    • *—Indications that a person has reach exercise tolerance
    • —Noticeable increase
    • —   Pulse
    • —   Respirations
    • —   Blood pressure
    • —Shortness of breath
    • —Dyspnea
    • —Weakness
    • —Pallor
    • —Confusion
    • —Vertigo
  26. Example Documentation of Musculoskeletal Assessment:
    Muscles developed without atrophy/ hypertrophy.  Arms and legs symmetrical.  No edema, varicosity’s, or tenderness.  Joints non-tender, without swelling, and with full ROM.  Muscle tone and strength 5/5 bilaterally.  Spine has full Rom and is without tenderness or deformities.
  27. Suggested Order for Performing ROM
    • 1. —Wash hands
    • —2.  Explain ROM
    • —3.  Raise bed (body mechanics)
    • —4.  Position client close to side of bed
    • —5.  Neck‑ flexion, extension, rotation,   hyperextension
    • —6.  Shoulder‑ flexion, extension,   hyperextension, abduction, adduction, external rotation, internal rotation, circumduction —Elbow‑ flexion, extension
    • —8.  Forearm‑ supination, pronation
    • —9.  Wrist‑ flexion, extension, hyperextension, radial deviation, ulnar deviation
    • —10.  Hands/fingers‑ flexion, extension, hyperextension, abduction, adduction
    • —11. Thumb‑ flexion, extension, abduction, adduction, opposition —Hip‑flexion, -extension, abduction, adduction, external rotation, internal rotation, circumduction, hyperextension
    • —13.  Knee‑ flexion, extension
    • —14.  Ankle‑ dorsiflexion, plantar flexion
    • —15.  Foot‑ inversion, eversion
    • —16.  Toes‑ flexion, extension, abduction, adduction
    • —17.  Documentation
    • —18.  Nursing diagnosis‑ Impaired Mobility

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