302- Musculoskeletal Assessment

ROM (range of movement)

Flexion

Extension

Abduction

Adduction

Internal Rotation

External Rotation

• —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

• *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

• —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

• —*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

• *—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

Lordosis (swayback)

Kyposis (hunchback)

Scoliosis

• —*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

• —Atrophy of muscle mass
• —Tremors
• —Flaccidity of muscles
• —Loss of strength and tone
• —Decreased ROM
• —Uncoordinated movements
• —Swelling
• —Pain

• —Contour
• —Prominence
• Bilaterally symmetry

• —Pain
• —Enlargement
• —Asymmetry
• —Changes in contour

• *—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.

—

• 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

• —Pain
• —Swelling
• —Nodules
• —Crepitation

Edema

• —Evaluate the patient’s ability to turn in bed
• —Maintain correct body alignment when sitting or standing
• —Ambulation
• —Perform self care activities

• *—Indications that a person has reach exercise tolerance
• —Noticeable increase
• —   Pulse
• —   Respirations
• —   Blood pressure
• —Shortness of breath
• —Dyspnea
• —Weakness
• —Pallor
• —Confusion
• —Vertigo

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.

• 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