Ch.30 Genitourinary, Musculoskeletal

•How do they go to the bathroom?

–Foley cath can describe during initial assessment

–If voids have to wait to describe-each time

•Urine - color, amt.,odor, clarity – with every void

•Voiding Patterns/problems

•Genitalia with advanced, just look to see if “normal” and clean

• •Normal tissues are
• examined before injured, inflamed, or otherwise involved

• •Bilateral observations
• are made and compared

• •Palpation is gently
• performed while observing facial or other reactions to note tenderness or
• sensitivity within the tissues

• •Movements are assessed
• within norms for ROM of all joints from head to foot

•Watch (for speed and coordination of movement) as rise from chair or bed

•“Get up and go"

• •Climb in and out of bed
• table

• –Watch
• for coordination

• –Note
• speed of movement

• •Ask if use any assistive
• devices

• •Ask if ADLs can be done
• alone, with assistance, or not at all

• kyphosis- hunchback, affects breathing
• scoliosis- S spine

•Inspect and palpate

–Swelling

–Deformity

–Masses

–Movement

–Tenderness

Crepitations- snap, crackle, pop

• •Joint movement should be
• smooth and painless

• •Ask that joint be moved
• through full range of movement

• •Rationale for assessing
• ROM before strength

• •Nurse does for the client - Carried out by nurse without
• assistance from client

•Maintain join mobility only

•Body part not to be moved beyond its existing ROM

•Move relaxed joint through limits of movement

•Inspect and Palpate

–Size

–Bilateral Symmetry

–Tone

–Strength

- Muscle wasting

Increased muscle mass

Muscle shortening

tingling, numbness

•Temperature

–Infection

–inflammation?

•Sensation

–Parasthesia


•Edema

•Crepitus


•Nodules

•Strength

• –0-5
• scale

• –Compare
• the two extremities

•Expect dominant side to be stronger

•Tone

Tension at rest