Assessing the Musculoskeletal System PDF

Assessing Health the Assessment Musculoskel Property of Susan L. Arnold, RN, MSN, ACUE etal System Functions of the Musculoskeletal System  The musculoskeletal system is a complex system that provides  Structure  Support  Pro...

Assessing Health the Assessment Musculoskel Property of Susan L. Arnold, RN, MSN, ACUE etal System Functions of the Musculoskeletal System  The musculoskeletal system is a complex system that provides  Structure  Support  Protection  Ability of the human body to move in many directions  The skeletal system also provides the attachment points for ligaments and tendons  Controlled and innervated by the nervous system Musculoskeletal System Movement  Movement occurs within the musculoskeletal system when the muscles contract, or shorten, in response to a neurological stimulus from the neurological system.  Movement within the musculoskeletal system is generally voluntary. However, at times, movement will be involuntary such as a response to remove a hand from hot items, or a reflex.  The neurological system is responsible for coordinating the functions of the skeleton and muscles. Diagnostics  Blood test---Creatine Phosphokinase (CPK) increases when muscle tissue is injured.  X-ray assesses bones and bony structures.  Magnetic resonance imaging (MRI) assesses soft tissue. Assesses injury to tendons, ligaments, bones, and soft tissues. (see safety alert below)  Computed tomography (CT scan) assesses bones, ligaments, joints and the axial skeleton.  May be used when an MRI is not possible due to metal in the region of injury.  Strain - when a tendon is injured  Sprain – when a ligament is injured  Dual-energy X-ray absorptiometry (DEXA) scan is used to assess bone mineral density. Health History  Assessment of the musculoskeletal system helps to evaluate the client’s level of functioning with activities of daily living (ADLs); this system affects the entire body and greatly influences what physical activities the client will or will not be able to do.  Proper functioning of the musculoskeletal system is important for the performance of activities of daily living (ADLs).  Use the COLDSPA mnemonic to identify attributes of a symptom. Health History Family history Medical history Genetic or familial  Chronic diseases May predispose patient  Arthritis to a MSK disorder Muscular dystrophies  Myopathy Genetic disorder that  Rheumatoid arthritis results in muscle weakness  Osteoarthritis  Osteoporosis  Gout Surgical history Injury Repair Overuse Chronic Disorders Over 100 types of arthritis; osteoarthritis is the most common type of joint disorder in the U.S. Osteoarthritis (OA) – is a progressive disease where the protective cartilage at the ends of the bones wears down; “wear & tear arthritis” Heberden nodes on the distal interphalangeal joints. Usually Rheumatoid painless. arthritis (RA) – is a progressive, inflammatory, autoimmune disorder that destroys joints and causes joint deformity. Symptoms include tender, painful, swollen, stiff joints Osteoporosis – is a progressive disease where the bone matrix is not being replaced by new bone; bone mass and density decrease. Myopathy – is a disease of the muscle tissue that may cause muscular dysfunction/weakness. Often seen in long term patient hospitalization d/t being bedridden. Health History  Nutrition – weight loss or weight gain (planned/unplanned)  Pain assessment (Use COLDSPA mnemonic)  Ask patient to point to the greatest area of pain or stiffness  Myalgia – muscle pain  Numbness or Tingling – nerve or vascular  Temperature changes  Signs of inflammation/swelling  Skin color changes  Bruising - injury  Erythema – redness (inflammation/infection)  Pale/Cool – decreased circulation  Scars – repair or injury Health History  Risk factors:  Gender - Women more likely to develop rheumatoid arthritis (RA) and Osteoarthritis (OA) than men  Age (40-60 years)  Smoking, Alcohol, Caffeine  Diabetes  Sickle cell anemia  Lupus  Family history of - Osteoporosis, Rheumatoid Arthritis (RA), or Gout  Injuries; aftereffects?  Decreased activity levels, exercise, occupation  Sunlight exposure – lack of vitamin D  Diet and weight; poor diet & obesity  Contact sports participation Health History  Lifestyle and Health practices:  Difficulty performing ADLs  MSK problems interfering with social activities  Posture  Contact sports (injury)  Increased stress due to MSK problems  Bone density screening (women at 65 unless increased risk factors)   “Five Ps” will help you to focus on specific musculoskeletal symptoms or injuries.  Pain The Five  Paralysis “Ps”  Paresthesia  Pallor  Pulselessness Sequence of Assessment Inspection Palpation Assessing range of motion Assessing strength Nurse Assessment  General Routine Screening:  The nurse observes the client’s posture, gait, movements, and ADLs  Inspect: (symmetry, color, and mobility)  Spine – Cervical, Thoracic, and Lumbar region  Shoulders, arms, elbows, wrists, hands, and fingers  Hips, knees, ankles, and feet  Palpate: (tenderness, heat, swelling, and nodules)  Spine – Cervical, Thoracic, and Lumbar region  Shoulders, arms, elbows, wrists, hands, and fingers  Hips, knees, ankles, and feet Inspecting Posture & Gait  Purpose: To assess posture and the ability to ambulate noting any limitations with ambulation  Safety considerations are important.  Patient may have an assistive device.  Patient may need a support to steady themselves.  Patient may not be able to ambulate due to injury.  Ask the patient about the presence of pain.  Observe client posture while standing with feet together, noting alignment of the head, trunk, pelvis, and extremities. Observe client posture while sitting. Inspecting Gait  Have the patient walk away from you first and then back towards you. This allows you to observe anterior and posterior gait  Inspect any differences in leg swing and arm swing (contralateral)  Assess the patient’s ability or inability to control any joints  Assess if the patient uses any assistive devices Inspecting Gait Normal Findings: Equal leg and arm swing; Arm swing contralateral Stride with smooth, even pattern; length appropriate No assistive devices Maintains balance easily Base of support and stability No limp Expected motion Inspecting Gait  Abnormal Findings:  Limping  Alterations in motion; limited or increased  Ataxia – unsteady gait  Scissors (Cerebral Palsy)  Shuffling (Parkinson's)  Foot drop – weakness or paralysis of lower leg muscles  Unequal arm/leg swing; not contralateral  Pattern not smooth or even  Use of assistive device  Unable to maintain balance Inspecting Posture  Purpose: To assess alignment of muscle and joints  If the patient is unable to perform activities in a standing position safely, have the patient sit.  Ask the patient about the presence of pain.   Inspect the patient’s posture while the patient is walking.  Isthe head centered on the axial skeleton? Inspecti  Is there an alteration ng in balance, ability to ambulate, or stand? Posture  Have patient sit in a chair and get up from a chair; note any difficulties in lowering or raising his or her body.   Assess position of shoulders and head.  Ask patient to rotate (turn) the head to the right and then to the Inspecti left ng  Ask patient to tip the head to the right and Posture then to the left  Ask patient to flex and extend the neck  Inspectin g Posture  Assess patient’s ability to stand and sit.  Ask the patient to bend forward at the waist; inspect the spinal curvature  Ask patient to bend at the waist to the right and left, forwards and backwards. Inspecting Posture Normal Findings:  Head centered on  No pain or alteration axial skeleton of sensation  Balance unaltered  Shoulders level, even  Able to stand  Head centered on axial skeleton  Able to ambulate  without assistive No limitations in all devices motion  Able to rise from chair  Weight evenly without difficulty distributed on feet Inspecting Posture Abnormal Findings:  Head not centered on  Presence of pain, axial skeleton altered sensation  Unable to maintain  Shoulders not level, balance even  Unable to stand  Head not centered on  Unable to ambulate axial skeleton without assistive  Motion limited devices  Weight unevenly  Unable to rise from distributed on feet chair without difficulty  Wide-based gait  Shuffles  Limps Inspecting and Palpating the Vertebral Column  Purpose: To assess for abnormalities in the structure of the vertebral column.  Have patient stand.  Inspect alignment of vertebral column.  Using two or three finger pads, starting at the top of the vertebral column, palpate the vertebral column for tenderness, deviations, or protrusions. Inspecting and Palpating Vertebral Column Normal Findings Abnormal Findings  No pain or alteration  Presence of pain, of sensation altered sensation  No deformities found  Deformities found  Scoliosis  Kyphosis  Lordosis (A) Scoliosis (B) Kyphosis (C) Lordosis Inspecting and Palpating Upper Extremities  Purpose: To determine if there are any abnormalities within the upper extremities  Always compare the right with the left side for symmetry  Assess  Shoulder  Elbow  Wrist  Hand/fingers Inspecting and Palpating Upper Extremities  Using two or three finger pads, gently palpate the upper extremity on the right side.  Assess for:  Size & shape; symmetry  Color  Deformities  Redness or swelling  Tenderness  Depressions  Bulges  Changes in temperature  Repeat on the left side and compare sides. Inspecting and Palpating Upper Extremities Normal Findings:  No forward rounding of shoulders  Upper arms straight  Slight bend at elbow  Wrists in alignment with lower arm  Color consistent  No redness or swelling  No pain, tenderness, or alteration of sensation  No nodules or deformities found  Full range of motion  Symmetry between right and left Inspecting and Palpating Upper Extremities Abnormal Findings:  Presence of pain,  Forwardrounding of tenderness, or altered shoulders sensation  Upper arms not  Deformities found straight  Limited range of  No,or excessive bend motion at elbow  No symmetry between  Wrists not in right and left alignment with lower  Bouchard’s or arm Heberden’s nodes  Redness and swelling Protrusions: A. Bouchard’s nodes – bony enlargements on proximal interphalangeal joints; often seen in osteoarthritis and rheumatoid arthritis. B. Heberden’s nodes – bony enlargements on distal interphalangeal joints; often seen in osteoarthritis. Assessing ROM of Upper Extremities  Purpose: To assess limitations in range of motion (ROM) in the upper extremities.  Ask the patient to perform specific motions independently Assessing ROM of Upper Extremities Normal Abnormal Findings: Findings:  Symmetric ROM  Asymmetric ROM from from right to left right to left  Absence of pain or  Presence of pain or altered sensation altered sensation Inspecting and Palpating Lower Extremities  Purpose: To assess for any abnormalities within the lower extremity.  Ask patient to perform specific motions independently.  Ask patient to perform ROM activities of the right and left lower extremity.  Inspect each extremity and compare the right side with the left side. Inspecting and Palpating Lower Extremities Assess the presence of:  Size, shape, symmetry  Hip  Deformities  Knee  Alignment  Ankle  Tenderness  Foot  Depressions  Toes  Bulges  Temperature change  Redness or swelling  ROM Inspecting and Palpating Lower Extremities Normal Findings:  Weight placed on  No pain or alteration both legs evenly of sensation  Hipsin neutral  No deformities found position  Full ROM  Slight bend at  Symmetry between knee, pointed right and left forward  Ankleis perpendicular to lower leg  Foot straight Inspecting and Palpating Lower Abnormal Extremities Findings:  Presence of pain,  Weight unevenly altered sensation, distributed to one side temperature change  Hipsnot in neutral  Deformities found position  Limited range of  No,or excessive bend motion at knee  No symmetry  Ankle not between right and perpendicular to lower left leg Assessing ROM and Strength of Lower Extremities  Purpose: To assess strength and limitations in ROM in the lower extremities.  Assess any differences in symmetry of motion and the fluid nature of the motion.  Compare one side with the other side. Assessing ROM and Strength of Lower Extremities Normal Findings Abnormal Findings  Symmetric ROM  Asymmetric ROM from right to left from right to left  Absence of pain  Presence of pain or or altered altered sensation sensation Healthy People 2030  Goal: Prevent illness and disability related to arthritis and other rheumatic conditions, osteoporosis, and chronic back conditions.  Work-related musculoskeletal disorders including those of the neck, upper extremities, and low back are one of the leading causes of lost workday injury and illness. Question  Identify each spinal abnormality (from left to right)   Scoliosis Answer  Kyphosis  Lordosis   What type of arthritis is a progressive, inflammatory, autoimmune disorder? Questio A. Osteoarthritis (OA) n B. Rheumatoid arthritis (RA) C. Arthritis D. Osteoporosis   Correct answer: B Answer   Which diagnostic tool is contraindicated for someone with an implanted insulin pump? Questio A. CT Scan n B. DEXA Scan C. MRI D. CPK   Correct answer C  The MRI uses a strong magnetic field and pulses of radio wave energy to create images of the body. Answer  The insulin pump may be affected by the magnetic field.  Images are distorted by any metal in the area of the images.   The patient complains of muscle weakness after spending a week in the hospital. What is this Question called? A. Arthritis B. Myalgia C. Myopathy D. Muscular dystrophy   Correct answer: C  Myopathy may be focal or Answer diffuse muscular dysfunction and weakness.