Health Assessment of Musculoskeletal System PDF

HEALTH ASSESSMENT ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM OBJECTIVES: 2. Cancellous bone o Understand the basic anatomy of the musculoskeletal ‒ Trabecular bones and Spongy bone system...

HEALTH ASSESSMENT ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM OBJECTIVES: 2. Cancellous bone o Understand the basic anatomy of the musculoskeletal ‒ Trabecular bones and Spongy bone system ‒ Contains numerous spaces and makes up the o Perform proper assessment of the musculoskeletal ends and centers (interior) of the bones. system o Identify normal and abnormal findings o Recognize cardinal signs of musculoskeletal disease o Differentiate abnormalities in the: 1. Spinal Curvature 2. Wrists, Hands, Fingers 3. Feet, Toes FUNCTIONS OF THE MUSCULOSKELETAL SYSTEM 1. Support organs and for mobility in conjunction with muscle; serves as levers 2. Movement 3. Protect inner organs 4. Produce red blood cells BONE CELLS 5. Reservoir of essential minerals (calcium) 1. Osteoblasts COMPONENTS OF THE MUSCULOSKELETAL SYSTEM ‒ Bone firming cells A. BONES 2. Osteoclasts ‒ A total of 206 bones make up the human body; including ‒ Resorb or breakdown bone the axial skeleton (head and trunk) and the appendicular 3. Osteocytes skeleton. ‒ Matured bone cells ‒ An organ made up of bone tissue, bone marrow, blood vessels, epithelium, and nerves ‒ Bones contain red marrow that produces blood cells and yellow marrow composed mostly of fat. ‒ The periosteum covers the bones; it contains osteoblasts and blood vessels that promote nourishment and formation of new bone tissues. BONE SHAPES B. MUSCLES ‒ Bone shapes vary and include: ‒ Provide strength, balance, posture, movement and heat short bones (e.g., carpals) for the body to keep warm long bones (e.g., humerus, femur) ‒ The primary job is to move the bones of the skeleton flat bones (e.g., sternum, ribs) ‒ Enable the heart to beat and constitute the walls of other bones with an irregular shape (e.g., hips, vertebrae). important hollow organs THREE TYPES OF MUSCLES 1. Skeletal ‒ Creates movement in the body ‒ More than 600 skeletal muscles ‒ Makes up about 40% of a person’s body weight ‒ The musculoskeletal system is made up of 650 skeletal (voluntary) muscles, which are under conscious control. ‒ Made up of long muscle fibers (fasciculi) that are arranged together in bundles and joined by connective tissue ‒ skeletal muscles attach to bones by way of strong, fibrous cords called tendons. ‒ Skeletal muscles assist with posture, produce body heat, and allow the body to move. 2. Cardiac BONE TISSUES ‒ Makes up the walls of the heart and creates the ‒ Bones are composed of osseous tissue or bone tissue, steady, rhythmic pulsing that pumps blood a type of dense connective tissue; through the body from signals from the brain ‒ bone tissue is formed by active cells called osteoblasts ‒ Creates electrical impulses that produces the and broken down by cells referred to as osteoclasts. heart’s contraction ‒ Bone tissues can be divided into two types: 1. Cortical bone ‒ Compact bone ‒ Hard and dense and makes up the shaft and outer layers (exterior)  3. Smooth SKELETAL MUSCLE MOVEMENT ‒ Makes up the walls of hollow organs, respiratory passageway and blood vessels. Abduction Moving away from midline of the body ‒ Contracts in response to stimuli and nerve Adduction Moving toward midline of the body impulses Circumduction Circular motion Inversion Moving inward TYPES OF MUSCLE CONTRACTION Eversion Moving outward 1. Isometric Extension Straightening the extremity at the joint ‒ Generate force without changing the length of the and increasing the angle of the joint muscle Hyperextension Joint bends greater than 180 degrees ‒ Common in the muscles of the hand and forearm Flexion Bending the extremity at the joint and responsible for grip decreasing the angle of the joint 2. Isotonic Dorsiflexion Toes draw upward to ankle ‒ Maintain constant tension in the muscle as the Plantar flexion Toes point away from ankle muscle changes length Pronation Turning or facing downward ‒ 2 Types: Supination Turning or facing upward 1. Eccentric Protraction Moving forward – Results in the elongation of a muscle while Retraction Moving backward the muscle is still generating force; in effect, Rotation Turning of a bone on its own long axis resistance is greater than force generated; Internal rotation Turning of a bone toward the center of – can be voluntary and involuntary the body Voluntary Eccentric – controlled External Turning of a bone away from the center lowering of the heavy weight raised rotation of the body during the concentric contraction Involuntary Eccentric – occur when weight is too great for a muscle to bear and so it is slowly lowered while under tension 2. Concentric ‒ A type of muscle contraction in which the muscles shorten while generating force, overcoming resistance. ‒ Example: Lifting heavy weight, a concentric contraction of the biceps causes the arm to bend at the elbow, lifting weight towards the shoulder. Isometric – iso=same; metric=length: same length Isotonic – iso=same; tonic=tension: same tension PROPERTIES OF MUSCLE TISSUES 1. Electrical excitability ‒ is the ability to respond to certain stimuli by producing electrical signals called action potentials 2. Contractility – is the ability of muscular tissue to contract forcefully when stimulated by an action potential 3. Extensibility ‒ is the ability of muscular tissue to stretch without being damaged 4. Elasticity ‒ is the ability of muscular tissue to return to its original length and shape after contraction or extension  ‒ TYPES OF SYNOVIAL JOINTS: 1. Ball-and-Socket Joint - possess a rounded, ball-like end of one bone fitting into a cup-like socket of another bone. This organization allows the greatest range of motion, as all movement types are possible in all directions. Examples of ball-and-socket joints are the shoulder and hip joints. 2. Hinge Joint - the slightly-rounded end of one bone fits into the slightly-hollow end of the other bone. In this way, one bone moves while the other remains stationary, similar to the hinge of a door. The elbow is an example of a hinge joint. The knee is sometimes classified as a modified hinge joint. 3. Pivot Joint - consist of the rounded end of one bone fitting into a ring formed by the other bone. This structure allows rotational movement, as the rounded bone moves around its own axis. An example of a pivot joint is the joint of the first and second vertebrae of the neck that allows the head to move back and forth. The joint of the wrist that allows the palm of the hand to be turned up and down is also a pivot joint. 4. Ellipsoidal Joint (Condyloid joints) - consist of an oval-shaped end of one bone fitting into a similarly oval-shaped hollow of another bone. This is also sometimes called an ellipsoidal joint. This type of joint allows angular movement along two axes, as seen in the joints of the wrist and fingers, which can move both side to side and up and down. FUNCTIONAL CLASSIFICATION 1. Synarthrosis ‒ An immobile or nearly immobile joint. ‒ The immobile nature of these joints provides for a C. JOINTS strong union between the articulating bones. ‒ The joint (or articulation) is the connection made ‒ This is important at locations where the bones between bones in the body which link the skeletal system provide protection for internal organs. into a functional whole; the place where two or more ‒ Examples include sutures, the fibrous joints bones meet. between the bones of the skull that surround and ‒ Constructed to allow different degrees and types of protect the brain, and the manubriosternal joint, movement the cartilaginous joint that unites the manubrium and ‒ Joints provide a variety of ranges of motion (ROM) for the body of the sternum for protection of the heart. body parts. 2. Amphiarthrosis ‒ Classified both structurally and functionality ‒ An amphiarthrosis is a joint that has limited mobility. ‒ An example of this type of joint is the cartilaginous STRUCTURAL CLASSIFICATION joint that unites the bodies of adjacent vertebrae. 1. Fibrous Joint ‒ Another example of an amphiarthrosis is the pubic ‒ adjacent bones are joined by fibrous connective symphysis of the pelvis. This is a cartilaginous joint tissue and are immovable in which the pubic regions of the right and left hip ‒ e.g., sutures between skull bones bones are strongly anchored to each other by 2. Cartilaginous Joint fibrocartilage. ‒ Bones are joined by hyaline cartilage or fibrocartilage 3. Diarthrosis ‒ e.g., joints between vertebrae ‒ A freely mobile joint 3. Synovial Joint ‒ These types of joints include all synovial joints of ‒ Articulating surfaces are not directly connected, but the body, which provide the majority of body instead come into contact with each other within a movements. joint cavity ‒ Most diarthrotic joints are found in the appendicular ‒ e.g., shoulders, wrists, hips, knees, ankles skeleton and thus give the limbs a wide range of ‒ contain a space between the bones that is filled with motion. synovial fluid, a lubricant that promotes a sliding movement of the ends of the bones. Range of Motion is the capability of a joint to go through ‒ Bones in synovial joints are joined by ligaments, its complete spectrum of movements; it can be passive or which are strong, dense bands of fibrous connective active. tissue. ‒ Synovial joints are enclosed by a fibrous capsule made of connective tissue and connected to the periosteum of the bone.  JOINTS ARE CONSISTS OF THE FOLLOWING Cartilage TaMa Ba? = Tendons, muscle to bone ‒ This is a type of tissue that covers the surface of a Luh BoBo = Ligaments, bone to bone bone at a joint. ‒ helps reduce the friction of movement within a joint. Bursa/Bursae Synovial membrane ‒ Fluid-filled sacs, called bursas, between bones, ‒ A tissue that lines the joint and seals it into a joint ligaments, or other nearby structures. They help capsule. cushion the friction in a joint. ‒ The synovial membrane secretes a clear, sticky Synovial fluid fluid (synovial fluid) around the joint to lubricate it. ‒ A clear, sticky fluid secreted by the synovial Ligaments membrane. ‒ Strong ligaments (tough, elastic bands of connective Meniscus tissue) surround the joint to give support and limit the ‒ This is a curved part of cartilage in the knees and joint's movement. other joints. ‒ Ligaments connect bones together (bone to bone). Tendons ‒ Tendons (another type of tough connective tissue) on each side of a joint attach to muscles that control movement of the joint. ‒ Tendons connect muscles to bones. ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM A. Collecting Subjective Data ✓ 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, from head to toe, and greatly influences what physical activities a client can and cannot do. ✓ Only the client can give you data regarding pain, stiffness, and levels of movement and how ADLs are affected. ✓ In addition, information regarding the client’s nutrition, activities, and exercise is a significant part of the musculoskeletal assessment. ✓ Pain or stiffness is often a chief concern with musculoskeletal problems; therefore, a pain assessment may also be needed. ✓ It is very important to remember to investigate signs and symptoms reported by the client. ✓ Assessment of the musculoskeletal system will provide the nurse with information about the client’s daily activity and exercise patterns that promote either healthy or unhealthy functioning of the musculoskeletal system. ✓ Client teaching regarding exercise, diet, positioning, posture, and safety habits to promote health thus becomes an essential part of this examination. UNDERSTANDING MAJOR JOINTS JOINT MOTION FUNCTION Temporomandibular Opens and closes mouth ‒ Articulation between the temporal bone and Projects and retracts jaw mandible Moves jaw from side to side Sternoclavicular No obvious movement ‒ Junction between the manubrium of the sternum and the clavicle Elbow Flexion and extension of the forearm ‒ Articulation between the ulna and radius of Supination and pronation of the forearm the lower arm and contains synovial membrane and several bursae Shoulder Flexion and extension ‒ Articulation of the head of the humerus in the Abduction and adduction glenoid cavity of the scapula. Circumduction ‒ The acromioclavicular joint includes the External and internal rotation clavicle and acromion process. ‒ It contains the subacromial and subcapsular bursae. Wrist, fingers, thumb Wrist: flexion, extension, hyperextension, ‒ Articulation between the distal radius, ulnar adduction, radial and ulnar deviation bone, carpals, and metacarpals. Fingers: flexion, extension, hyperextension, ‒ Contains ligaments and is lined with a abduction, circumduction synovial membrane. Thumb: flexion, extension, opposition Vertebrae Flexion ‒ Thirty-three bones: Hyperextension o 7 concave-shaped cervical (C) Lateral bending o 12 convex-shaped thoracic (T) Rotation o 5 concave-shaped lumbar (L) o 5 sacral (S) o 3-4 coccygeal  ‒ Bones are cushioned by elastic fibrocartilaginous plates that provide flexibility and posture to spine ‒ Paravertebral muscles positioned on both sides of vertebrae Hip Flexion with knee flexed and extended ‒ Articulation between the head of the femur Extension and hyperextension and the acetabulum Circumduction ‒ Contains a fibrous capsule Rotation (Internal and external) Abduction Adduction Knees Flexion ‒ Articulation of the femur, tibia, patella Extension ‒ Contains fibrocartilaginous discs and many bursae Ankle and Foot Ankle: plantar flexion and dorsiflexion ‒ Articulation between the talus, tibia, fibula Foot: inversion and eversion ‒ The talus articulates with the navicular Toes: flexion, extension, abduction, bones adduction ‒ The heel is connected to the tibia and fibula by ligaments B. Collecting Objective Data ✓ Physical assessment of the musculoskeletal system provides data regarding the client’s posture, gait, bone structure, muscle strength, and joint mobility, as well as the client’s ability to perform ADLs. ✓ The physical assessment includes inspecting and palpating the joints, muscles, and bones, testing ROM, and assessing muscle strength. I Preparing the Client Provide adequate draping to avoid unnecessary exposure Explain that the patient will be frequently asked to change position and move various body parts against resistance and gravity Demonstrate to the client how to move the various body parts and providing verbal directions facilitate examination ASSESSING MUSCLE AND JOINTS Joints 1. Inspect size, shape, color, symmetry. Note any masses, deformities or muscle atrophy. Compare bilateral joint findings. 2. Palpate for edema, heat, tenderness, pain, nodules, or crepitus. Compare bilateral joint findings. 3. Test each joint’s ROM. Demonstrate how to move each joint through normal ROM, then ask client to actively move joint through same motion. Compare bilateral joint findings. *If there is limitation with ROM, measure with goniometer Muscles 1. Test muscle strength by asking the client to move each extremity through full ROM against resistance. Compare bilateral joint findings. 2. Rate muscle strength. *Scale 5 Active motion against full resistance Normal 4 Active motion against some resistance Slight weakness 3 Active motion against gravity Average weakness Passive ROM (gravity removed and assisted by 2 Poor ROM examiner) 1 Slight flicker of contraction Severe weakness 0 No muscular contraction Paralysis OLDER ADULT CONSIDERATION: Older clients usually have slower movements, reduced flexibility, and decreased muscle strength because of age-related muscle fiber and joint degeneration, reduced elasticity of the tendons, and joint capsule calcification. Ankylosis is the fixation of a joint, often in an abnormal position; seen frequently with rheumatoid arthritis.  ASSESSMENT FINDINGS Always begin with Inspection, Palpation, Range of Motion. REMEMBER: LOOK, FEEL, MOVE NORMAL FINDINGS ABNORMAL FINDINGS Gait ✓ Evenly distributed weight ✓ Uneven weight bearing is evident Inspection ✓ Client able to stand on heels and toes ✓ Client cannot stand on heels or toes ✓ Toes point straight ahead ✓ Toes point in and out Gait is simple the ✓ Equal on both sides ✓ Client limps, shuffles, propel forward, or has ability to walk of ✓ Posture erect, movements coordinated and wide-based gait. the client; it is use rhythmic ✓ Falling backward easily to check ✓ Arms swing in position, stride length appropriate stability/balance ✓ Client does not fall backward of the client to know for risk for falls TMJ ✓ Snapping and clicking may be heard ✓ Decreased ROM, swelling, tenderness or Inspection ✓ Mouth opens 1-2inches crepitus Palpation ✓ The client’s mouth opens and closes smoothly ✓ Decreased muscle strength with muscle and ✓ Jaw moves laterally 1-2cm joint disease ✓ Jaw protrudes and relaxes easily ✓ Clicking, popping, or grating sound may be noted Crepitus is a dry crackling sound or sensation heard or felt as a joint is moved through ROM; it is a palpable or audible grating or crunching sensation produced by motion. Sternoclavicular ✓ There is no visible overgrowth, swelling, or ✓ Swollen, red, or enlarged joint Joint redness ✓ Tender and painful joint Inspection ✓ Joint is nontender Palpation Cervical, Thoracic, ✓ Cervical and lumbar spine concave ✓ Flattened lumbar curvature seen with Lumbar spine ✓ Thoracic spine is convex herniated lumbar disc or ankylosing Inspection ✓ Spine is straight spondylitis Palpation ✓ Lateral curvature of thoracic spine with increased convexity on the curved side seen with scoliosis ✓ Exaggerated lumbar curve (lordosis) ✓ Unequal height of hips ✓ Unequal leg length ✓ Pain and tenderness (seen in compression fracture and lumbosacral muscle strain) ✓ Neck pain with limited ROM Shoulder, Arms ✓ Shoulders are symmetrically round ✓ Flat, hollow, less-rounded shoulders (seen Inspection ✓ No redness, swelling, deformity, heat, with dislocation) Palpation tenderness ✓ Muscle atrophy (Seen with nerve or muscle ✓ Muscles are fully developed damage or lack of use) ✓ Clavicles and scapula are even and symmetric ✓ Tenderness, swelling, heat ✓ Extent of: ✓ Painful and limited abduction o Forward flexion should be 180 degrees; ✓ Client has sharp pain when bringing hands o Hyperextension at 50 degrees; overhead (seen with rotator cuff tendinitis) o Adduction at 50 degrees; ✓ Chronic pain and severe limitation of all o Abduction at 180 degrees shoulder motions (seen with calcified ✓ Extent of internal and external rotation should be tendinitis) at 90 degrees ✓ Inability to shrug shoulders against resistance ✓ The client can flex, extend, adduct, abduct, ✓ Decreased muscle strength rotate, shrug shoulders, against resistance Elbows ✓ Elbows symmetric, without deformities, redness, ✓ Redness, heat, swelling (seen with bursitis) Inspection swelling ✓ Firm, nontender, subcutaneous nodules (in Palpation ✓ Nontender; without nodules Rheumatoid arthritis or rheumatic fever) ✓ Full ROM against resistance ✓ Tenderness or pain over the epicondyles ✓ Normal ROM are: (epicondylitis) o Flexion: 160 degrees ✓ Decreased ROM against resistance o Extension: 180 degrees o Pronation: 90 degrees Bursitis is a painful condition that affects the o Supination: 90 degrees bursae; occurs when bursae become inflamed. o Some clients lack 5-10 degrees or have hyperextension Common locations: shoulder, elboew, and hip Wrists ✓ Symmetric, without redness and swelling ✓ Swelling Inspection ✓ Nontender and free of nodules ✓ Tenderness and nodules Palpation ✓ Normal ROM: ✓ Snuffbox tenderness o Flexion: 90 degrees ✓ Wrist fracture: o Hyperextension: 70 degrees o Pain o Ulnar deviation: 55 degrees o Tenderness o Radial deviation: 20 degrees o Swelling ✓ No tingling, numbness, pain o Inability to hold grip ✓ No shocking sensation o Pain goes away and returns as deep ✓ Client will not shake or flick wrist o Dull ache ✓ Client can raise thumb up from the plane and ✓ Motion that resembles shaking of thermometer stretch the thumb finger pad to the little finger ✓ Cannot raise thumb pad Hands, Fingers ✓ Symmetric, nontender and without nodules ✓ Pain, tenderness, swelling, shortened fingers, Inspection ✓ No swelling or deformities depressed knuckle Palpation ✓ Rounded protuberance ✓ Swollen, stiff, tender joints ✓ Normal ranges: ✓ Hard, painless nodules o Abduction: 20 degrees ✓ Inability to extend the ring and little finger o Adduction: 20 degrees (seen with Dupuytren’s contracture) o Flexion: 90 degrees ✓ Painful extension of a finger o Hyperextension: 30 degrees ✓ Decreased muscle strength Hips ✓ Buttocks are equally sized ✓ Instability and inability to stand Inspection ✓ Iliac crests are symmetric in height ✓ Tenderness, edema, decreased ROM, Palpation ✓ Hips are stable, nontender, without crepitus crepitus ✓ Full ROM against resistance ✓ Pain ✓ Normal ROM: ✓ Decrease hip rotation o Abduction: 45-50 degrees o Adduction: 20-30 degrees o Internal hip rotation: 40 degrees o External hip rotation: 45 degrees o Hyperextension: 15 degrees Knees ✓ Symmetric, hollows on both patella ✓ Knees turn in with knock knees and turn out Inspection ✓ No swelling or deformity with bowed legs Palpation ✓ No bulge of fluid on medial side of knee ✓ Tenderness and warmth ✓ No movement of patella is noted ✓ Fluid wave or click palpated, with joint effusion ✓ No pain or clicking ✓ Normal ROM: o Flexion: 120-130 degrees o Extension: 0 degrees o Hyperextension: 15 degrees Ankles, feet ✓ Toes point forward and lie flat ✓ Tenderness, pain, redness, warmth Inspection ✓ No pain, heat, swelling or nodules Palpation ✓ Normal ROM: o Dorsiflexion: 20 degrees o Plantarflexion: 45 degrees o Eversion: 20 degrees o Inversion: 30 degrees o Abduction: 10 degrees o Adduction: 20 degrees o Flexion: 40 degrees o Extension: 40 degrees  flexion = decreasing the angle extension = increasing the angle ABNORMAL SPINAL CURVATURES Flattening of the Lumbar Curve Flattening of the lumbar curvature in herniated lumbar disc or ankylosing spondylitis Kyphosis A rounded thoracic convexity Lumbar Lordosis An exaggerated lumbar curve Scoliosis A lateral curvature of the spine with an increase in convexity on the side that is curved ABNORMALITIES AFFECTING THE WRISTS, HANDS, FINGERS Acute rheumatoid arthritis Tender, painful, swollen, stiff joints Chronic rheumatoid arthritis Chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints, limited ROM, and finger deviation toward the ulnar side Boutonnière and Swan-Neck Flexion of the proximal interphalangeal Deformities joint and hyperextension of the distal interphalangeal joint (boutonnière deformity) and hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint (swan-neck deformity) are also common in chronic rheumatoid arthritis. Ganglion Nontender, round, enlarged, swollen, fluid-filled cyst (ganglion) is commonly seen at the dorsum of the wrist. Osteoarthritis (Degenerative Nodules on the dorsolateral aspects of Joint Disease) the distal interphalangeal joints (Heberden’s nodes) are due to the bony overgrowth of osteoarthritis. Usually hard and painless, they may affect middle-age or older adults and often, although not always, are associated with arthritic changes in other joints. Flexion and deviation deformities may develop. Tenosynovitis Painful extension of a finger may be seen in acute tenosynovitis (infection of the flexor tendon sheaths). Thenar atrophy Atrophy of the thenar prominence due to pressure on the median nerve is seen in carpal tunnel syndrome.  ABNORMALITIES OF THE FEET AND TOES Acute gouty arthritis In gouty arthritis, the metatarsophalangeal joint of the great toe is tender, painful, reddened, hot, and swollen. Flat feet (Pes planus) Has no arch and may cause pain and swelling of the foot surface. Callus Calluses are nonpainful, thickened skin that occur at pressure points. Corn Are painful thickenings of the skin that occur over bony prominences and at pressure points. The circular, central, translucent core resembles a kernel of corn. Hammer toe Hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint (hammer toe) commonly occurs with the second toe. Plantar wart Plantar warts are painful warts (verruca vulgaris) that often occur under a callus, appearing as tiny dark spots. Hallux valgus Hallux valgus is an abnormality in which the great toe is deviated laterally and may overlap the second toe. An enlarged, painful, inflamed bursa (bunion) may form on the medial side. Clonus is the involuntary, rhythmic, muscular contractions and relaxations in response to an abruptly applied stretch stimulus; spasmodic alternation of muscular contraction and relaxation Clonus Sustained Ill-sustained (>6 beats) (≤6 beats) Involvement of Pyramidal Tens people/ after straining/ Tract (UMN lesion) frightening experience Myalgia or muscle pain/tenderness, is a sign of an injury, infection, disease or other health problem. Causes: ✓ Autoimmune diseases ✓ Infections ✓ Injuries ✓ Medications ✓ Neuromuscular disorders Rigidity – involuntary increase in muscle tone present throughout the range of movement; can be tested through passive ROM. Cogwheel - Type of rigidity characterized by jerky movements when the muscle is passively stretched Lead-Pipe – if rigidity is smooth and consistent Fasciculation is an involuntary firing of a single motor neuron and all its innervated muscle fibers; the localized uncoordinated twitching of a single muscle group  CARDINAL SIGNS OF MUSCULOSKELETAL DISEASE 1. PAIN 4. INCREASED WARMTH 2. REDNESS 5. DEFORMITY 6. LOSS OF 3. SWELLING FUNCTION References o Weber,J.R.,&Kelley,J.H.(2013).Healthassessmentinnursing.LippincottWilliams&Wilkins.  Health Assessment Neurologic Assessment 6. Provide client Maintains client dignity and Learning Objectives: privacy. shows respect. o Identify subjective and objective data 7. Gather client’s Enhances focused related to the assessment of neurologic pertinent health assessment and integrates system. history. physical assessment o Discuss the importance of assessing the findings. neurologic system o Identify normal and abnormal findings in MENTAL STATUS and LEVEL of CONSCIOUSNESS the assessment of the neurologic system STEP NORMAL ABNORMAL o Demonstrate proper assessment of the neurologic system  A. Inspection: Observe the level client is ALERT, lethargic NEUROLOGIC ASSESSMENT of AWAKE Components  Mental Status and Level of Consciousness CONSCIOUSNESS 1. Call client’s  eyes open obtunded (LOC) name and note and looks at  Cranial Nerve Assessment response. examiner stupor  Motor and Cerebellar functions 2. If client does  Reflexes Subjective Data: not respond, call name  client responds comatose  Headache (unusually frequent or severe) louder and appropriately - You may use coldspa in assessing headache shake gently.  Head injury 3. If still no  Dizziness 4. response,  Seizures apply painful - In assessing seizures, you should ask what does stimuli. the patient feel before having this seizure and usually the patients with having a seizure they kept a diary or log book of their seizure like the  ALERT – opens eyes spontaneously, timing and what’s the last activities they did oriented and awake before the seizures. Some patients may - Orientation can be assessing by asking questions experience cold aura, before they experience such as name, place and time. seizure.  LETHARGY – opens eyes to verbal stimuli,  Tremors answers questions, and falls back to sleep  Weakness or in coordination  OBTUNDED – opens eyes to loud voice,  Numbness or tingling sensation responds slowly with confusion, seems  Difficulty swallowing unaware of environment  Difficulty speaking  STUPOR – awakens to vigorous shake or  Neurologic past history – stroke, spinal cord painful stimuli but returns to unresponsive injury, meningitis, encephalitis, congenital sleep defect  COMATOSE – remains unresponsive to ALL STEPS RATIONALE stimuli; eyes remain closed - However, in using this words it’s better the 1. Introduce self to Establishes rapport. description in documentation rather than in use the client. single words. 2. Identify the Establishes correct client The GLASGOW COMA SCALE client using two identity.  it is a useful tool for rating one’s response to (2) identifiers. stimuli 3. Establishes Enhances client  it is used in high dependency areas to correct client cooperation/participation. determine the client’s level of consciousness identity. Promotes psychological - High dependency areas are areas like ICU’s, they preparedness. are intensiveness units. 4. Perform hand Promotes infection control.  Scoring is based on the client’s: hygiene (hand o EYE OPENING response wash or apply o most appropriate VERBAL alcohol-based response rub). o MOTOR response (arm) 5. Assemble Organizes and facilitates  A score of 15 – indicates optimal level of equipment systematic assessment. consciousness needed.  A score of 8 - 10 – needs emergency attention   A score of 7 or lower – considered a state of STEP NORMAL ABNORMAL  - coma There are 3 components, the low score that on B. Inspection: Observe client appears ▪ slumped health care practitioner can give to a patient is 1, POSTURE & relaxed postpos the low score of 3 and the highest is 15. The BODY e higher the number, the sum of this 3 components the better condition of your client. However, in MOVEMENT S ▪ bowed head practice and in recent updates we don’t usually add these 3 components because they are ▪ no eye independent to each other and it gives up a better contact picture of the client.  C. Inspection: Skin is clean ▪ poor Observe hygiene dress,  Nails are GROOMING and neat and trim ▪ inappro priate HYGIENE dressing - These 2  Clothes ap components, propriate Posture and for Grooming are occasion also and psychological weather assessment. STEP NORMAL ABNORMAL  D. Inspection: Observe good eye contact ▪ poor eye FACIAL contact - EXPRESSIONS Note eye  smiles, frowns ▪ extreme facial contact and appropriat expressio affect ely ns (happines s, sadness) E. Inspection: Observe SPEECH - Listen to tone,  speech is ▪ slow, clarity and in a repetitive pace of speech moderate speech - ask the client to name tone, clear and with ▪ loud, rapid speech objects in the moderate - In practice we really use the 3 component separately or to document it separately or we room pace ▪ stammerin - Ask the client g and referred to the doctor using the (e.g. the patient to read from stuttering has the GCS of 15.) instead using the GCS 15 printed we tell to the doctor or colleagues, E4, E5, M6 it’s material a more detailed picture of a client. appropriate for his or her MENTAL STATUS and LEVEL of educational CONSCIOUSNESS level - Ask the client inquiring to read a about client’s sentence. perceptions - In example if expressed. you are talking to your patient, - use you don’t need statement to assess this such as” tell because you me more can conclude what you they have a said or” tell good speech me more while they are about what talking to you. you just said or “Tell me with what STEP NORMAL ABNORMAL your  understandin F.Inspection: Observe cooperati ve and ▪ negative g is of the MOOD, friendly gloomy, current FEELINGS and  expresse despairin situation of EXPRESSIONS s g your health.” - ask the client appropria feelings “how are you today? And te feelings ▪ elation - Identify possibly and “what are to grandiosi destructive or your plans situations ty suicidal for the tendencies future?” ▪ excessiv by asking - Assessing e worry “How do you the mental feel about status and the future?’ level of of “Have you consciousne ss should be  client expresse ▪ illogical ever had thoughts of thoughts hurting conversation s free between with flowing ▪ rapid yourself” or “How do your patient. thoughts flight of In stabling ideas others feel rapport, it’s  expresse about you? not just s realistic ▪ illusion establishing perceptio rapport but ns H. Inspection: you also Observe assessing COGNITIVE already the ABILITIES mental status - Orientation or your Ask the client’s  appropria  inability patient. name te and to recall - Concentration congruen past and - Memory t recent G. Inspection: (Recent & response events Observe Remote) s  impairm THOUGHT - Abstract ent in PROCESSE Reasoning judgmen S and - Judgment t PERCEPTIO - NS Visual Perceptual - observe for and clarity, Constructional content, and ability perception by Mini-Mental State Examination (MMSE) We are going to do a test. Get a pen and a sheet of paper BH Close your eyes. CRANIAL NERVE ASSESSMENT  Have the client sit in comfortable position.  Inform the client that position may need to be changed during the assessment.  Explain that examination may take a considerable amount of time. Rest periods may be necessary especially for weak and elderly patients.  Prepare all equipment needed. STEP NORMAL ABNORMAL Test CN I:  Client Inability to Olfactory correctly smell identifies (nuerogenic 1. Have client scent anosmia) or sit presented identify the comfortably. to each correct smell nostril may indicate www.me /i /toolsM Hxvx 2. Have client olfactory to clear the tract lesion nose to  some or tumor or remove any elderly lesion on the mucus clients may frontal lobe. have a decreased 3. Ask client to sense of close eyes. smell 4. Occlude one nostril and let client  identify the A. VISUAL is scented ACUITY 20/20  If vision is object (The poorer than presented. 5. Record numerator 20/30, refer to the result indicates an - Usually use using the the ophthalmologi coffee, numeric distance st or vinegar or fraction at the patient optometrist perfume. the end is standing of the last from the 5. Repeat successf chart and procedure ul line the in other read. denominato nostril. r gives the 6. Indicate distance at whether which the STEP NORMAL ABNORMAL any normal eye Test CN II: letters can read a Optic were particular missed line A. VISUAL and ACUITY whether 1. Position corrective the  client can  hesitancy lenses patient see and  squinting were exactly correctly leaning worn. 20 feet deciphers  forward from the letters,  misreading Snellen images or letters STEP NORMAL ABNORMAL or “E” position of Test CN II: Optic chart. letter “E” B. PERIPHERAL VISION 2. If the (Confrontation test) person wears 1. Position self glasses approximately 2 or contact ft. away from lenses, patient at eye leave level. them on. 2. Have the patient cover his left eye 3. Shield while you cover one eye your right eye. at a time 3. Look directly at during each other with the test. your uncovered eyes. 4. Ask the patient to STEPS NORMAL ABNORMAL read the chart to B. PERIPHER  The  delayed AL patient or absent the VISION shoud perceptio smallest (…continued) see the n of the line of examiner examiner letters 4. Fully extend ’s finger ’s finger possible. left arm at at the indicates midline and same reduced STEP NORMAL ABNORMAL slowly move time the periphera Test CN II:  Normal  the larger the one finger examiner l vision Optic Visual denominator, (or pencil) sees it. acuity the poorer the from the vision periphery in  several directions (upward, downward, temporally and nasally) STEP NORMAL ABNORMAL until the Test CN III  Unequal patient sees (Oculomotor), or no the finger or CN respons pencil. IV (Trochlear) & e to CN V light. 5. Ask the (Abducens) patient to say “now” as B. PUPILLAR the finger or Y LIGHT pencil is first REFLEX seen. 1. Darken the room 6. Repeat test 2. Ask patient  constriction for other eye to gaze into of the the same-sided distance. pupil (direct light reflex) STEPS NORMAL ABNORMAL 3. Advance a light in from  Siultaneou Test CN III  eye  failure of (Oculomotor), the eyes to the side of s movem CN follow one eye constriction ent IV (Trochlear) & movement and note of the other should CN V symmetric response. pupil be (Abducens) ally (consensua smooth A. EXTRAOCU 4. Repeat on l light and LAR other eye. reflex) symmet MOVEMEN ric T through out all 6 STEP NORMAL ABNORMAL 1. Instruct the client to directio Test CN III  pupillary  absence focus on an object ns (Oculomotor), CN constricti of you are holding IV (Trochlear) & on constricti approximately 12 CN V  converge on or inches from the (Abducens) nce of converge patient’s face. the eyes nce C. PUPILLARY 2. Move the object ACCOMODAT through the 6 cardinal  asymmet ION positions of gaze in a ric clockwise direction.  parallel  NYSTAGM 1. Ask the response tracking US- ans patient to 3. Observe the patient’s of the accilating focus on a eye movement. object or shaking distant object. with moverone 2. Have patient both of the eye. shift the gaze eyes to a near object such as a finger or pencil about 3 inches from the nose. 3. Note pupillary response.  A. Test frowns, asked motor wrinkles along with function forehead, paralysis STEP NORMAL ABNORMAL 1. Ask client shows of the Test CN V: to: teeth, lower part Trigeminal - smile puffs out of the face - frown and cheeks, is seen A. Test motor wrinkle purse lips with Bell’s function  temporal  unilateral forehead and raises palsy and weakness - Bell’ palsy, - show eyebrows 1. Ask client massete indicate CN is teeth to clench r V abnormal - puff out teeth while muscles (trigeminal) paralysis cheeks palpating contract lesion of the face - purse lips the bilaterall due - raise temporal y affectaion eyebrows and of cranial masseter nerve 7 B. Test muscles sensory  cleint for function correctly contractio 1. Touch identifies  inability to n. anterior flavors identify 2/3 correct B. Test portion of flavor in sensory tongue anterior function with a 2/3 of the cotton tongue 1. Instruct  the  inability to applicator suggests client to client feel and dipped in impairment close eyes correctly correctly salt, of the and that identifie identify sugar, or facial you are s sharp facial stimuli lemon nerve going to and dull occurs with juice. touch the stimuli lesions of 2. Ask client forehead, and light trigeminal to identify cheeks touch on nerve or the flavor. and chin forehea spinothalami with safety d, c tract pin or cheeks paper clip. and chin STEP NORMAL ABNORMAL 2. Ask client Test CN VIII: to tell Acoustic or whether Vestibulocochle he/she ar feels  the patient  unable to sharp & A. WHISPER repeats hear dull TEST each word whispere sensation. after the d words 3. Repeat 1. Test one examiner with a are at a says it wisp of time. cotton. 2. Mask  it is hearing on normal for the other old people ear by to pressing on experienc the tragus. e some STEP NORMAL ABNORMAL 3. Shield your hearing Test CN VII: lips. Facial loss 4. With a (PRESBY distance of  client  inability to CUSIS) 1-2 feet smiles, do what is  from the 2. Ask him/her mastoid conductio head of to signal process) n with a patient, when the conductiv whisper sound goes  positive e loss slowly away. Rinne some 3. Quickly Test: 2syllable invert the - “AC > BC” words fork so the (Tuesday, vibrating baseball, end is near etc..) the ear canal. 4. Ask the STEP NORMAL ABNORMAL patient if he/she still B. WEBER hears a TEST sound. 5. Repeat with 1. Strike a  patient  sound other ear. tuning hears the lateralizes in fork tone by or heard only softly bone in one ear SHAPE NORMAL ABNORMAL with the conduction Test CN IX back of through  CONDUCTIVE (Glossopharynge  uvula and  soft your the skull HEARING al) soft palate palate hand. LOSS- sound & CN X (Vagus) rise does 2. Place it  sound is is hear on the bilaterally not rise in the equally “poor” ear A. Gag Reflex and center of loud in 1. Ask client to symmetric the both ears  SENSORI- open mouth ally patient’s NEURAL wide and head or HEARING say “ah”. forehead. LOSS- sound 2. Use tongue 3. Ask the is heard in the depressor patient if “good” ear on client’s the tone tongue. sounds 3. Touch the same posterior in both pharynx with ears or tongue better in depressor & one. note response. B. Check STEP NORMAL ABNORMAL Ability to Test CN VIII: Swallow Acoustic or  absent Vestibulocochlea 1. Give the gag r client water  gag reflex reflex to drink. present C. RINNE  the  the ratio  dyspha TEST sound is of AC to 2. Note gia heard BC is swallowing  client noted 1. Place the twice as altered reflex. swallows stem of a long by with without vibrating AC (near hearing difficulty tuning fork the ear loss on the canal) patient’s compare  sound is mastoid d to BC heard STEP NORMAL ABNORM process. (through longer by AL the bone  Test CN XI: Note: older motor (Spinal  asym adult may neurons or Accessory) metric have reduced muscle muscl muscle mass disorder 1. Ask client to e from shrug the contra degeneration shoulders  there is ction of muscle against symmetric, or fiber resistance to strong droopi assess the contraction ng of trapezius of the should muscle. trapezius ers  Assess the Relaxed Flaccid, muscle due to strength and muscles spastic and 2. Ask client to neck tone of all contract rigid turn head  there is injury muscle voluntarily against strong or groups and show resistance, contraction torticol mild, smooth first on the of lis resistance to left and then sternocleido (stiff passive to the right, mastoid neck) movement all to assess muscle on muscle group side are strong the opposite the sternocleido mastoid turned face  Note any unusual No Presence of muscle. fasciculation, fasciculation, involuntary movements tics, or tics, or STEP NORMAL ABNORMAL such as tremors tremors Test CN XII: fasciculation, (Hypoglossal)  tongue  atrophy of tics, or 1. Ask client movement the tongue tremors to is is seen protrude symmetric with the and peripheral tongue. smooth nerve STEP NORMAL ABNORMAL and disease A. Evaluate 2. Ask client bilateral BALANCE to move it strength is  deviation to each observed of the 1. Assess the  gait is  stiff, side tongue to gait ask steady immobile against one side client to  opposite posture the of the walk arms  lack of resistance mouth is naturally swing arm swing of a sometimes across the  walks on or rigid tongue seen after room. heels and arms depressor. stroke 2. Note toes with 