Musculoskeletal Assessment

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Musculoskeletal System

Consists of BONES, SKELETAL MUSCLES and JOINTS

Joints

Articulation of two or more bones

Functions of the Musculoskeletal System

~Provides structure, support and movement for the body
~Allows the body to maintain posture and position
~Supports and protects organs and soft tissues
~Guards entrances and exits to digestive and urinary systems
~Produces red blood cells- hematopoiesis
~Stores fat and minerals
~Generates heat

Skeleton

Is composed of 206 BONES; Provides support for the soft tissue and organs of the body
Types of Bones:
~Long (femur)
~Short (tarsals)
~Flat (sternum)
~Irregular (skull)
~Ligaments

Ligaments

Connect BONE to BONE

Skeletal Muscles

Composed of fibers and tendons

Tendons

Connect BONE to MUSCLE

Non-synovial joints

Non-movable or slightly movable joints
Ex: Sutures of skull and vertebrae

Synovial joints

Movable joint lubricated by synovial fluid

Flexion

Bending a limb at the joint

Extension

Straightening a limb at a joint

Rotation

Moving the head around a central axis

Circumduction

Moving the arm or leg in a circle around the shoulder or hip

Elevation

Raising a part of the body

Depression

Lowering a part of the body

Protraction

Moving a body part foward and parallel to the ground (FROWNING)

Retraction

Moving a body part backward and parallel to the ground (SMILING)

ABduction

Moving a limb AWAY from the body

ADduction

Moving a limb TOWARD the body

Pronation

Turning the forearm so that the palm is DOWN

Supination

Turning the forearm so that the palm is UP

Inversion

Moving the plantar surface(sole) of the foot INWARD at the ankle

Eversion

Moving the plantar surface (sole) of the foot OUTWARD at the ankle

Need for FULL MS Assessment

If patient has COMPLAINTS, DISEASE or difficulty ADLs

Screening/Mini Assessment

~Inspection/palpations of major joints and muscles
~Functional ROM
~Muscle strength in arms and legs

Objective Data

~Ensure patient is comfortable
~Use a CEPHALOCAUDAL approach (Head to Toe)
~Always COMPARE WITH THE OPPOSITE SIDE (unaffected side)
~Assess painful areas LAST

Inspection

~Size
~Contour
~Color
~Swelling (Edema)
~Masses
~Deformities

Palpation

~Temperature
~Swelling (Edema)
~Tenderness
~Masses
~ROM
~Strength

Swelling Grade Scale

0 = none
1 = mild
2 = moderate
3 = marked
4 = maximum

Range of Motion (ROM)

Measured in degrees with a GONIOMETER
Active = patient does on own
Passive = nurse helps patient perform - is usually greater than active
~Describe limitations in a narrative note
~May also complain of pain and stiffness

Muscle Strength

Graded on scale 0-5

(Muscle Strength Scale) 0

No muscle contraction

(Muscle Strength Scale) 1

Palpable muscle contraction, but no movement

(Muscle Strength Scale) 2

Full ROM without gravity (passive ROM)

(Muscle Strength Scale) 3

Full ROM with gravity

(Muscle Strength Scale) 4

Full ROM with moderate resistance

(Muscle Strength Scale) 5

Full ROM with full resistance

Joints/Muscles to be assessed

~Cervical Spine
~Shoulders
~Elbows
~Wrist/Hands
~Spine
~Hips/Knees
~Ankles/Feet

Cervical Spine

I: Observe alignment of head
P: Spinous processes, muscles
ROM: flexion, neutral (extension), hypertension, lateral bend, rotation

Torticollis

A shortening or twisting in one sternomastoid muscle - probably injured by intrauterine malposition

Abnormality: Cervical Spine

Shoulders

I: Shape, size, symmetry
P: Sternoclavicular joint to clavicle to acromioclavicular joint, check for crepitus
ROM: flexion, neutral (extension), hypertension, internal/external rotation, ABduction, ADduction, circumduction, elevation, depression

Rotator cuff tears, DJD, strains/sprains

Pain without palpation or movement; Referred pain from increased intra-abdominal pressure, cardiac ischemia, hiatal hernias, or GI disease
Abnormalities: Shoulders

Elbows

I: Symmetrical
P: Grooves on sides of olecranon process for pain, tenderness, swelling or crepitus
ROM: Flexion, hyperextension, extension (neutral), pronation, supination
Muscle strength

Lateral or Medial Epicondylitis (Tennis Elbow)/ Rheumatoid Arthritis

Abnormalities: Elbows

Wrist/Hands/Fingers

I: Symmetry, swelling, color, deformity
P: Temperature, dorsum of hand and interphalangeal joints (1 at a time)
ROM: Flexion and extension of wrist and fingers, hyperextension of wrist, ulnar/radial deviation, ABduction, ADduction, opposition
Muscle strength

Carpel Tunnel Syndrome

Compression of the medial nerve leading to decreased motor function of thenar eminence; Pain, numbess

Abnormality: Wrist/Hands/Fingers

Carpel Tunnel Syndrome Test: Phalen's sign

Bend wrists downward and press backs of hands together; Symptoms within 60 seconds test is +

Carpel Tunnel Syndrome: Tinel's sign

MORE predictive than Phalen's
Percuss lightly over the median nerve in each wrist; Pain, numbess or tingling with percussion is +

Dupuytren's Contracture

Flexion contracture of the fingers; Impaired ROM
May be inherited or occur with diabetes or cirrhosis r/t alcoholism or caused by compartment syndrome of forearm

Abnormality: Wrist/Hand/Finger

Rheumatoid Arthritis

WORST of arthritises
Ulnar deviation; Swelling in the joints
Flexion contractures
Swan-Neck Deformity
Boutonniere Deformity

Abnormality: Wrist/Hand/Finger

Swan-Neck Deformity

Proximal interphalangeal (PIP) joints hyperextend while distal flex

Abnormality: Wrist/Hand/Finger

Boutonniere Deformity

PIP joint is flexed with the distal joint hyperextended

Abnormality: Wrist/Hand/Finger

Syndactyly

Webbed fingers

Abnormality: Wrist/Hand/Finger

Polydactyly

Extra digits

Abnormality: Wrist/Hand/Finger

Bouchard's and Heberden's Nodes

Occurs with osteoarthritis; Hard nodules over the proximal interphalangeal joint (PIP) = Bouchard's & distal interphalangeal joint (DIP) = Heberden's

Abnormality: Wrist/Hand/Fingers

Spine

I: Curvature, symmetrical, midline
P: vertebral processes
ROM: flexion, extension (neutral), hyperextension, lateral blend, rotation
Muscle strength

Kyphosis

Exaggerated thoracic curve

Abnormality: Spine

Lordosis

Exaggerated LUMBAR curve

Abnormality: Spine

Scoliosis

Curves to right or left causing an exaggerated thoracic convex curve

Straight Leg Raise or LaSegue's Test

Checks for HNP or herniated nucleus pulposus (herniated disk)

Special Test: Spine

Forward Bending Test

Screening for scoliosis

Special Test: Spine

Hips

I: Symmetry
P: Stability, pain, crepitus
ROM: Flexion, hyperextension, internal/external rotation, abduction, adduction, circumduction
Muscle strength

Special Consideration: Hip replacements

Patrick's Test

Assessing for hip joint or sacral injuries/pathologies

Special Test: Hip

Hip Replacement Consideration

~Should not flex hip past 90 degrees
~Should not internally rotate hip
~Should not allow hip to ADduct acorss midline of body (use ABduction pillow)

Knees

I: Symmetry, location
P: crepitus, pain, tenderness, stability
ROM: flexion, extension
Muscle Strength

Bursitis

Bursa of the knee is inflammed

Abnormality: Knee

Bowleg (genu varus)

Abnormality: Knee

Knock knees (genu valgus)

Abnormality: Knee

Ligament instability or tears

Abnormality: Knee

Meniscus tears

Abnormality: Knee

Bulge sign (detect small effusions) Ballotment Test (increased fluid)

Tests for fluid on the knee

Special Test: Knee

Drawer Test

Tests the Instability of the knee

Special Test: Knee

McMurray Test

Test for torn meniscus

Special Test: Knee

Ankles/Feet/Toes

I: Color, symmetry, alignment
P: one at a time, medial and lateral aspects, crepitus
ROM: plantar flexion, dorsiflexion, invert, evert, move toes
Muscle strength

Gout

Inflammation in joints as a result of ALTERED PURINE metabolism; Pain, edema, erthyema
Generally starts in the GREAT TOE
Abnormality: Ankles/Feet/Toes

Bunions

Abnormality: Ankles/Feet/Toes

Hammertoe

Abnormality: Ankles/Feet/Toes

Ganglia

Prevalent on the wrist; Painless mass from tendon sheaths (Fluid filled)

Subluxation

Partial dislocation

Crepitus

Dry crackling sound or sensation due to grating of ends of damaged bones

Ankylosis

Immobility, consolidation and fixation of a joint d/t disease, injury or surgery; Most often d/t chronic rheumatoid arthritis

Neurovascular Assessment

Assess and COMPARE bilateral extremities
Inspection
~Color
~Edema
~Alignment of limb in relationship to body
~Prescence of deformity
~Ability to move fingers/toes or wrist/ankles (PROM)
~Ask patient if there is any numbness or tingling

Palpation
~Most distal pulses
~Most distal corresponding pulses
~Temperature
~Capillary Refill or blanching
~Assess for sensation
~Have pt close eyes and ask if he/she can feel you touching his hand or foot and where you are touching

Homan's sign

Very unreliable but gives a way to assess for blood clot in the lower extremity

Assessment for Deep Vein Thrombosis (DVT) - the most common in the leg

Lifespan Consideration: Newborns

~Flat feet
~Bowlegged
~Check spine
~Physician or Nurse Practitioner assess hips for congenital hip dislocation until age 1- Ortolani's maneuver

Lifespan Considerations: Children

~Ligaments are stronger than bones
~Age 4 changes to knock knees and usually resolves in late childhood or early adolescence
~Screening (Scoliosis) - starts in middle school (age 11 or 12)

Lifespan Considerations: Pregnant Female

~Softened cartilage in the pelvis and increased mobility of the joints
~Lordosis (common)
~Shift in center of gravity
~Waddle

Lifespan Considerations: Older adults

~Decreased muscle mass, tone, strength
~Decrease cartilage
~Decreased bone density
~Changes in mobility and endurance

Men vs Women Considerations

~Men muscles are bigger, bones are more dense
~Women are more flexible, bone is less dense

Psychosocial Considerations

Mental health problems may promote inactivity or isolation; Health probelms may trigger mental health issues
Abuse

Cultural Considerations

African Americans have higher bone density than Europeans; Europeans have higher bone density than Asians

Risk Factor Considerations for MS Disease

~Family History (Congenital Abnormalities)
~Arthritis (Rheumatoid or Osteoarthritis)
~Activity (Lifestyle, tobacco, chronic illness and medication therapy)
~Nutrition (Diet, Weight)

Nursing Diagnosis R/T MS Disorders

~Impaired physical mobility
~Risk for potential for impaired neurovascular assessment
~Activity intolerance
~Acute or chronic pain
~Self-care deficit
~Risk for injury
~Impaired elimination pattern

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