Health Assessment: Musculoskeletal System

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Health Assessment in Nursing (4th Ed.) - J. Weber, J. Kelley: Chapter 26

Bones, function of

provide structure, give protection, serve as levers, store calcium, and produce blood cells

Axial Skeleton

head and trunk

Appendicular Skeleton

extremities, shoulders, and hips

Bones, composed of

osseous tissue

Bones, two types

compact bone and spongy bone

Compact Bone

hard and dense;
makes up the shaft and outer layers

Spongy Bone

contains numerous spaces;
makes up the ends and centers of bones

Osteoblasts

active cells that form bone tissue

Osteoclasts

cells that break down bone tissue

Periosteum

covers the bones;
contains osteoblasts and blood vessels that promote nourishment and formation of new bone tissues

Bone Shapes

short bones (e.g., carpals);
long bones (e.g., humerus, femur);
flat bones (e.g., sternum, ribs);
irregular shaped bones (e.g., hip, vertebrae)

M/S System is made up of 650 _____ _____

skeletal (voluntary) muscles

Skeletal (Voluntary) Muscles

650 muscles of the M/S system that are under conscious control

Tendons

strong, fibrous cords that attach skeletal muscles to bones

Skeletal Muscles, function of

assist with posture, produce body heat, and allow the body to move

Abduction

moving away from midline of the body

Adduction

moving toward midline of the body

Circumduction

circular motion

Inversion

moving inward

Eversion

moving outward

Extension

straightening the extremity at the joint and increasing the angle of the joint

Hyperextension

joint bends > 180 degrees

Flexion

bending the extremity at the joint and decreasing the angle of the joint

Dorsiflexion

toes draw upward to ankle

Plantar Flexion

toes point away from ankle

Pronation

turning or facing downward

Supination

turning or facing upward

Protraction

moving forward

Retraction

moving backward

Rotation

turning of a bone on its own long axis

Internal Rotation

turning of a bone toward the center of the body

External Rotation

turning of a bone away from the center of the body

Joint

AKA articulation;
place where two or more bones meet

Joint, classification

fibrous, cartilaginous, or synovial

Bursa*

fluid filled sac that reduces stress and promotes movement

Structure of the Bones*

- 206 bones
- axial and appendicular skeleton
- compact and spongy bones
- osteoblasts, osteoclasts

Osteoblasts*

cells that form active bone tissue

Structure of Skeletal Muscles*

3 types: skeletal, smooth, cardiac

Movements: abduction, adduction, circumduction, inversion, eversion, extension, flexion, pronation, supination, protraction, retraction, rotation

Protraction*

skeletal muscle movement that means "to move forward"

Collection of Subjective Data*

- history of present health concern
- past health history
- family history
- lifestyle and health practices

Subjective Data - Health Hx Questions*

Do you have any problem(s) with your joints?
[pain; stiffness; swelling, heat, and
redness]

Do you have a problem with your muscles?
[pain (cramps); weakness]

Have you had a bone injury or problem?
[pain; deformity; trauma (fractures,
sprains, dislocations]

Functional assessment (ADL)

Self-care behaviors

What is a Functional Assessment?*

Ask patient if he can complete the following (ADLs):
- washing your face
- putting on clothes, shoes
- getting out of bed
- walking to the bathroom and
independently using the toilet

Functional Assessment*

Ask patient if she can perform IADLs (Independent Activities of Daily Living):
- walking up and down stairs
- going shopping for food
- preparing food
(Who prepares the meals?)
- cleaning the house
(Who takes care of the home?)

Objective Data - Physical Exam:
Preparation*

- screening musculoskeletal examination
- complete musculoskeletal examination

Objective Data - Physical Exam:
Equipment Needed*

- tape measure
- skin marking pen

Objective Data - Physical Exam:
Order of Examination*

- inspection:
> size and contour of joint
> skin and tissues over joint
- palpation:
> skin temperature
> muscles, bony articulations, area of
joint capsule
- range of motion
- muscle tension:
> apply opposing force
> grading muscle strength

Strength Grading Scale*

0 = no contraction
1 = slight contraction
2 = full ROM w/ passive ROM
3 = full ROM w/ gravity (weak)
4 = full ROM w/ some resistance (good)
5 = full ROM w/ full resistance (normal)

Tendon*

fibrous cord that connects muscle to bone

Objective Data - Physical Exam: Temporomandibular Joint*

Inspect joint area
Palpate as person opens mouth
Motion and expected range:
> open mouth maximally
> protrude lower jaw and
move side-to-side
> stick out lower jaw
Palpate muscles of mastication

TMJ - Physical Exam*

Palpate muscles as patient opens mouth against resistance. Normal - no swelling

Objective Data - Physical Exam: Cervical Spine*

Inspect alignment of head and neck
Palpate spinous processes and muscles
Motion and expected range
> chin to chest
> lift chin
> each ear to shoulder
> turn chin to each shoulder

Type of Joint in the Shoulder*

Ball & Socket

Objective Data - Physical Exam: Shoulders*

- Palpate both shoulders
- Note joint, scapula, humerus, joints
- Palpate axillae
- Have patient perform range of motion
(ROM)

Objective Data - Physical Exam: Elbow*

- Inspect joint in flexed and extended
positions
- Palpate joint and bony prominences
- Motion and expected range:
> bend and straighten elbow
> pronate and supinate hand
- Test ROM of elbow

Objective Data - Physical Exam: Wrist*

- Inspect joints on dorsal and palmar sides
- Palpate each joint
- Motion and expected range:
> bend hand up, down
> bend fingers up, down
> turn hands out, in
> spread fingers, make fist
> touch thumb to each finger

What is Carpal Tunnel Syndrome?*

Compression (pressure) on the median nerve, resulting in numbness and/or pain

Median Nerve Compression*

Positive: patient feels pain, numbness, or tingling upon flexing wrists (Phalen's Test) or percussing lightly on median nerve (Tinel's Sign)

Negative: no pain, numbness, or tingling

Objective Data - Physical Exam: Hip*

Inspect as person stands
Palpate w/ person supine
Motion and expected range:
> raise leg
> knee to chest
> flex knee and hip; swing foot out, in
> swing leg laterally, medially
> stand and swing leg back

Objective Data - Physical Exam: Knee*

Inspect joint and muscle
Palpate
Bulge sign
Ballottement of patella
Motion and expected range:
> bend knee
> extend knee
> check knee while client is walking

McMurray's Test*

Flex knee
Place hand on knee
Hold hand on foot
Rotate leg toward you
Straighten leg and assess for clicks and pain

Bulge Sign*

Detects small amount of fluid in knee
Stroke medial side of knee upward
Tap on lateral side and look for bulge on medial side

Ballottement*

Detects large amounts of fluid in knee
Hold knee firmly
Push patella towards femur
Patella should stay firm and not move
Positive - click

Objective Data - Physical Exam: Ankle and Foot*

Inspect w/ person sitting, standing, and walking
Palpate joints
Motion and expected range:
> point toes down, up
> turn soles out, in
> flex and straighten toes

Cervical & Lumbar*

Normal adult concave curves of the spine

Objective Data - Physical Exam: Posterior Spine*

Inspect while person stands
Palpate spinous processes
Motion and expected range:
> bend sideways, backward
> twist shoulders to each side
Straight leg raising
Measure leg length discrepancy

Straight Leg Raising for Herniated Nucleus Pulposus*

Client lies supine
Raise leg
If pain occurs:
> dorsiflex foot
> note degree of elevation of pain occurrence

Adams or Forward Bend Test*

Check for scoliosis
Client bends forward and touches knees
Check for uneven shoulder height
Check for uneven spine

Osteoporosis - Uncontrollable Risk Factors*

Gender
Age
Body size
Ethnicity
Bone fractures

Osteoporosis - Modifiable Risk Factors*

Lack of exercise
Low calcium
Anorexia nervosa
Low estrogen levels
Smoking
Caffeine
Alcohol
Medication intake

Osteoporosis - Risk Reduction*

Increase physical activity
Increase calcium & vitamin D intake
Avoid excessive caffeine, alcohol, steroids, smoking
Estrogen replacement therapy
Prevent falls

Osteoporosis - Sex, Ethnicity*

Men have denser bones than women
Blacks have denser bones than whites
Bone density of Chinese, Japanese, and Eskimo individuals below that of Caucasians

Osteoporosis and Menopause*

Decreased estrogen levels in postmenopausal increase the risk of osteoporosis due to decreased bone mass density

Calluses vs. Corns*

Calluses - painless, thickened skin; occur at pressure points

Corns - painful thickening of the skin that occur over bony prominences and pressure points

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