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    Musculoskeletal Assessment

    Uploaded by

    blckblwhtpnk
    Nursing Health Assessment

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Musculoskeletal Assessment

    Uploaded by

    blckblwhtpnk
    5 views4 pages
    Nursing Health Assessment

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    Nursing Health Assessment

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    5 views4 pages

    Musculoskeletal Assessment

    Uploaded by

    blckblwhtpnk
    Nursing Health Assessment

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    MUSCULOSKELETAL ASSESSMENT

    ◾ (indicates normal ndings)


    # (indicates abnormal ndings)

    Posture
    163. Instructs the client to stand then inspects posture from Front, Back, and Side
    ◾ Posture is erect and comfortable for age.
    # Spinal deformities include:
    # Kyphosis: Accentuated thoracic curve. I Scoliosis: Lateral “S” spinal deviation.

    165. Inspects for spine curve and deformities from the client’s back such as Scoliosis by having
    the client bend forward from the waist with arms relaxed.
    ◾ Cervical and lumbar spines are concave; thoracic spine is convex.
    # Spinal deformities include:
    # Kyphosis: Accentuated thoracic curve. I Scoliosis: Lateral “S” spinal deviation.

    166. Lordosis
    Have the patient stand against a wall and atten her back against it while I slide my hand
    through the lumbar curve.
    ◾ Lumbar spines are concave.
    # Spinal deformities include:
    # Kyphosis: Accentuated thoracic curve. I Scoliosis: Lateral “S” spinal deviation.

    Alternative method
    With patient supine and knees slightly exed, instruct patient to atten back against mattress
    while I slide my hand through the lumbar curve.
    ◾ Lumbar spines are concave.
    # Spinal deformities include:
    # Kyphosis: Accentuated thoracic curve. I Scoliosis: Lateral “S” spinal deviation.

    Gait
    167. Instructs the client to walk and observe while she is walking
    ◾ Posture erect and arms swing in opposition.
    # Scissors gait (legs cross over): Disorders of motor cortex or corticospinal tracts, such as
    bilateral spastic paresis.
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    Cerebellar Function
    169. Balance
    Instructs the client to perform the balance tests

    - Tandem walk
    - Heel-and-Toe walk
    - Deep Knee Bend
    - Hop in Place
    - Romberg Test Coordination
    ◾ Balance intact. Patient can tandem walk, heel-and-toe walk, perform deep knee bend, and
    hop in place. Negative Romberg test.
    # Balance problems: Cerebellar disorder

    170. Coordination
    Determine the client’s dominant side.
    Instructs the client to perform the coordination tests
    - Rapid alternating movements RAMs
    Have patient perform RAMS by patting thigh with one hand, alternating with supination and
    pronation.
    - Finger thumb opposition
    - Toe tapping
    - Heel down shin
    ◾ Positive RAM, nger-thumb opposition, toe tapping, and heel down shin.
    # Balance problems: Cerebellar disorder
    # Inaccurate movements: Cerebellar disorder.

    171. Accuracy of Movements


    Have patient perform Point-to-point localization
    Stand in front of patient, hold your nger about 12 inches in front and instruct patient to touch
    your nger and then touches her own nose.
    ◾ Movements accurate.
    # Balance problems: Cerebellar disorder
    # Inaccurate movements: Cerebellar disorder.

    Measurements
    172. Arm lengths
    Measures arm length from acromion process to tip of middle nger
    
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    ◾
    # Leg length discrepancies can cause back and hip pain, gait problems, and pseudoscoliosis, or
    apparent scoliosis.
    # Circumference differences " 1 cm may re ect muscular atrophy or hypertrophy.

    173. Arm circumference


    Measures midpoint of extremity and then measures arm circumference.
    ◾
    # Leg length discrepancies can cause back and hip pain, gait problems, and pseudoscoliosis, or
    apparent scoliosis.
    # Circumference differences " 1 cm may re ect muscular atrophy or hypertrophy.

    174. Leg lengths


    Measures leg from anterior iliac crest, crossing over knee to the medial malleolus
    ◾
    # Leg length discrepancies can cause back and hip pain, gait problems, and pseudoscoliosis, or
    apparent scoliosis.
    # Circumference differences " 1 cm may re ect muscular atrophy or hypertrophy.

    175. Leg circumference


    Measures midpoint of extremity then measures leg circumference.
    ◾
    # Leg length discrepancies can cause back and hip pain, gait problems, and pseudoscoliosis, or
    apparent scoliosis.
    # Circumference differences " 1 cm may re ect muscular atrophy or hypertrophy.

    Muscles
    176. Muscle Tone
    Palpate muscles of upper and lower extremities in relaxed and contracted state
    ◾ Muscles soft, pliable, and nontender in relaxed state; rm and nontender in contracted state.
    # Atrophy (muscle wasting), unexplained hypertrophy (excessive muscle size), accidity (atony),
    weakness (hypotonicity), fasciculations (involuntary twitching of muscle bers), or tremors
    (involuntary contraction of muscles).

    177. Muscle Strength


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    Upper extremities
    Cross index and middle ngers and ask patient to squeeze.
    ◾ Muscles nontender and no abnormal movements.
    # Atrophy (muscle wasting), unexplained hypertrophy (excessive muscle size), accidity (atony),
    weakness (hypotonicity), fasciculations (involuntary twitching of muscle bers), or tremors
    (involuntary contraction of muscles).

    Lower Extremity
    Have patient raise leg against your hand as you apply resistance.
    ◾ Muscles nontender and no abnormal movements.
    # Atrophy (muscle wasting), unexplained hypertrophy (excessive muscle size), accidity (atony),
    weakness (hypotonicity), fasciculations (involuntary twitching of muscle bers), or tremors
    (involuntary contraction of muscles).

    Joints and Comprehensive muscle strength


    Test ROM of joints and palpate, then note condition of skin, erythema, edema, heat, deformity,
    crepitus, tenderness, and stability of all joints.
    Demonstrate movement of each joint and have patient return movement.
    To test muscle strength, repeat against resistance.
    🔸 Temporomandibular joints
    🔸 Cervical spine
    🔸 Thoracic and Lumbar spine
    🔸 Shoulders
    🔸 Upper arm and elbow
    🔸 Wrist
    🔸 Hands and Fingers
    🔸 Hips
    🔸 Knees
    🔸 Ankle and feet

    ◾ Uniform skin color, no redness or swelling; nontender; without deformities. ROM performed
    without dif culty, grade strength 5 and that is normal.
    # Decreased ROM, tenderness, swelling, crepitus: Arthritis.
    # Pain, swelling, popping, clicking, or grating sounds: TMJ dysfunction.
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