Focal Musculoskeletal Assessment

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(WEEK 3)Wednesday 2/3/10 Material included: Musculoskeletal Assessment Lecture (from the H2T series) Safety and Patient Transfer Lab in class room (material comes from online modules)

PQRST Questions

PQRST Questions:
(Proactive or Palliative - Quality or Quantity - Region and Radiation - Severity - Timing)
*Proactive or Palliative: What provokes or worsens you pain? What relieves or causes the pain to subside?
*Quality or Quantity: What does the pain feel like? Is it aching, intense, burning, knifelike, cramping? Are you in pain right now? Is it more or less severe than usual? To what degree does the pain affect your normal activities? Other symptoms with the pain such as nausea or vomiting?
*Region and Radiation Severity : Where is the pain? Does the pain radiate to other parts of your body?
*Severity: How severe is your pain? How would you rate it on a scale of 1-10? How would you describe the intensity of your pain?
*Timing: When did the pain begin? At what time of day is your pain best/worst? Is the onset sudden or gradual? Is the pain constant or intermittent?
Recently casted? (could = atrophy)

Health History Questions

-Present Health Status: What brings you in today? When did it start? What has changed? Is it effecting ADL's? Pain on scale of 1-10?"
-Past Medical History: Questions related to: Past injuries, surgery, Trauma, Fractures, Dislocations, Sprains, Age, Congenital defects?
-Family History: Questions related to: Cancer, MS, Back problems
- System Analysis: Use the PQRST - Questions related to: Muscle Pain (Could = Vascular issue). Sudden onset of pain (Could = Gout, acid buildup, difficulty moving - caused by too much protein/ = Arthritis - Rheumatoid - wakes up w/ pain - Osteoarthritis - develops pain throughout day). Deep pain? (could = bone). Does pain move from one area to another? What makes pain worse/better? What have you done previously for pain? Seen any specialists? Do you stretch before exercise? How limited are your ADLs?

Objective Data Types

OBJECTIVE DATA
*Examination (should include...)
- Inspection - For body strength & symmetry
- Palpation - For muscle tone, pain, heat or edema
- Muscle Strength - Body ROM, strength & resistance

Objective Data Collecting - Inspection Exam

- INSPECTION: Check for deformities or obvious injuries; Body shape and symmetry; Posture; Alignment; Gait; Balance; Movement; Coordination
TESTS INCLUDE: Heel 2 Toe walk; Romberg Test (Arms at side, feet together, eyes closed, Check for balance for 20 seconds); Heel of one foot down the shin of another.

Objective Data Collecting - Palpation & Strength Exams

- PALPATION & STRENGTH: Symmetry of muscles & joints (will be slightly stronger on dominant side); Tone, Pain, Heat(Use Dorsal side of hand to feel for heat), Edema (No redness or swelling)
- Muscle Strength & resistance; ROM (range of movement)
TESTS INCLUDE STRENGTH & RESISTANCE & ROM: Palpations (starting at shoulders using palms of hands to check for symmetry, joint swelling and pain when squeezed); Pushes & Pulls (for muscle strength symmetry) - Place hands on shoulders as patient shrugs, have patient squeeze your thumbs; SPINE CURVATURE (Have patient bend over as far as comfortable and run hands up spine for curvature and alignment); Alignment of iliac crest and scapula; Free motion (pain or crepitus - popping of joints during movement); TMJ (jaw); Strength in feet
*IF THERE IS ROM RESISTENCE OR PAIN - STOP THE ASSESSMENT!

Assessment of an OrthoPatient

COMPARE SIDE TO SIDE, NORMAL TO AFFECTED. CMS = Cirulation, Motion and Sensation *CIRCULATION: Check distal extremities for circulation (Pulse,Capillary refill should be less than 3 sec., Color may be red or pink, Temperature-Heat or cool) EVERY HOUR directly after Surgery/Procedure.
*MOTION: Movement of affected extremity; Foot - Dorsi & Plantar flexion; Hand - bend & spread fingers
*SENSATION: Ask about numbness & Tingling (Collect subjective & objective data)

Musculoskeletal - Age Related Changes (Older Adults)

* Decrease in bone mass
* Muscle Weakness
* Atrophy of muscle for disuse
* Decreased ROM (will affect ADL's)

Musculoskeletal Assessment - Nursing Diagnosis

*Use ADPIE to formulate (Assessment, Diagnosis, Plan, Implement, Evaluate)
*Use NANDA Nursing Diagnosis
*Goal/Outcome (3 critera) - 1 SAFETY GOAL & 1 SPIRITUAL, etc.
* 4 Nursing Interventions (Implement)
*Evaluation of Interventions
*DIAGNOSIS SHOULD BE MORE THAN "related to pain", try..."Transfer risk", "Social Isolation"

Musculoskeletal - A&P Terms

Anatomy and Physiology
- provides support and protection
- 206 bones
*Skeletal Muscles- attached to bones to facilitate movement
*Joints - articulations where two or more bones are joined, allow for ROM, hold bones firmly together while allowing movement.
*Ligaments - flexible bands of connective tissue that hold bones to bonesTendons - attach muscle to bones
*Cartilage - gel like tissue over bones that provides a smooth surface for movement, absorbs weight and stress

Musculoskeletal - Health History Guidelines

SUBJECTIVE DATA should include answers related to questions about...
*Present health status - chronic diseases, cancer, arthritis, loss of bone density or osteoporosis? Medications? Changes in ADL's?, Muscle strength? Exercise, sports, tobacco or ETOH.
*Past health history - accidents, trauma, congenital bone problems
*Family Medical History - curvature of the spine, back problems, arthritis, osteoarthritis or gout
*System Analysis - Problem Based History - Pain, limitation of movement, limitation on self care behaviors.

Muscle Strength - Face and Neck

- palpate TMJ (front of each ear) for movement, sounds and tenderness: move jaw from side to side; palpate Head and neck strength
- check resistance against nurses hand, side to side and back and front - ear to shoulder

Muscle Strength - Arms

have client hold arms out while your try to push them down - have client put arms in fight position the push and pull on nurse - palpate for crepitus, pain, heat, tenderness and edema

Muscle Strength - Shoulders and Spine

Inspect shoulders and spine for alignment and symmetry- have client touch toes - have client bend and waist, side to side and back to front - palpate spine for tenderness or displacement - have client shrug shoulders while nurse attempts to push down

Muscle Strength - Wrist, Hand & Fingers

palpate for heat, tenderness, edema, pain - ROM exams include: WRIST: (Hyperextension)Bring dorsal surface of hand back as far as possible (Flexion) Move palm toward inner aspect of forearm, (Extension) Move fingers and hand posterior to midline. (Abduction) Place hand w/ palm down and extend wrist laterally toward fifth finger (Adduction) Place hand w/ palm down and extend wrist medially toward thumb. FINGERS: (Flexion) Make fist (Hyperextension) Bend fingers back as far as possible. (Abduction) Spread fingers apart and bring together. THUMB: (Flexion) Move thumb across palmar surface of hand. (Extension) Move thumb straight away from hand. (Adduction) Move thumb back toward hand (Opposition) touch thumb to each finger of same hand.

Muscle Strength - Hips

palpate for tenderness, edema *HIPS: (Flexion)Move leg forward and up (Extension) Move back beside other leg (Hyperextension)Move leg behind body. (Abduction) Move leg laterally away from body (Adduction) Move leg back toward medial position and beyond if possible (Internal Rotation) Turn foot and leg toward other leg (External Rotation)Turn foot and leg away fromn other leg .(Circumduciton) Move leg in a circle

Muslce Strength - Knees, Ankle, Foot & Toes

palpate for tenderness, edema KNEES: (Flexion)Bring heel back toward back of thigh (Extension)Return leg to floor, ANKLE: (Dorsal Flexion) Move foot so that toes are pointed upwards, (Plantar Flexion) Move foot so that toes are pointed downward. FOOT: (Inversion) Turn sole of foot medially, (Eversion) Turn sole of foot laterally. TOES: (Flexion) Curl toes downward, (Extension) Straighten toes (Abduction) Spread toes apart (Adduction) Bring toes together.

Kyphosis

Hunchback: An exageration of the posterior curvature of teh thoracic spine. This postural abnormality is common in the older adult.

Lordosis

Swayback: An increased lumbar curvature.

Scoliosis

Lateral spinal curvature

Osteoperosis

Metabolic bone disease taht causes a decrease in quality and quantity of bone. First sign is loss of height as verebral fracture and collapse. Women are mainly afflicted.

Goniometer

Measures the precise degree of motion in a particular joint and is mainly for clients who have a suspected reduction in joint movement. Instruments have two arms with a 180-degree protractor in the center. Frequently used by physical and occupational therapists.

Hypertonicity

A muscle with increased tone. Considerable resistance w/ any sudden passive movement of a joint.

Hypotonicity

A muscle with little tone and feels flabby. The involved extremity hangs loosely in a position determined by gravity.

Flexion

Movement decreasing angle between 2 adjoining bones; bending of limb.

Extension

Movement increasing angle between 2 adjoining bones.

Hyperextension

Movement of body part beyond its normal resting extended position

Pronation

Movement of body part so that front or ventral surface faces downward.

Supination

Movement of body part so that th front or ventral surface faces upward.

Abduction

Movement of extremity away from midline of body

Adduction

Movement of extremity toward midline of body

Internal Rotation

Rotation of joint inward

External Rotation

Rotation of joint outward

Eversion

Turning of body part away from midline

Inversion

Turning of body part toward midline

Dorsiflexion

Flexion of toes and foot upward

Plantar Flexion

Bending of toes and foot downward

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