Assessment of Neurological and Musculoskeletal Systems PDF

Assessment of the Neurological and Musculoskeletal Systems Lakeland Community College NURS 1090 Course Outcomes Discuss use of physical Describe components assessment techniques of basic neurological of inspection, and musculoskeletal palpation, percussion, and...

Assessment of the Neurological and Musculoskeletal Systems Lakeland Community College NURS 1090 Course Outcomes Discuss use of physical Describe components assessment techniques of basic neurological of inspection, and musculoskeletal palpation, percussion, and auscultation. assessments. Demonstrate the ability to assess Identify physical the neurological and assessment changes musculoskeletal system in the older adult.. Concepts Assessment Sensory perception Cognition Metabolism Perfusion Oxygenation  Getting Started Examinations of the Neurological and Musculoskeletal (M/S) systems are often performed together Health history, inspection and palpation Evaluation of cognitive (thinking), sensory (feeling) and motor (moving) or all three Getting Started (continued) The nervous system exam may include testing of reflexes, the senses, and motor skills Examination of the musculoskeletal system may also include observation of range of motion, movement and gait, and palpation of the joints and muscles. Supplies: penlight, reflex hammer, something for sharp and dull discrimination Health History  Pain  Headache, back pain, muscle/joint pain  Fainting or syncope  Seizure activity  Focal, grand mal  Changes in vision, hearing, or smelling  Change in balance and coordination Health History (continued) History of Weakness, Changes in neurological numbness, memory illness tremors or tingling How do symptoms Gait changes or Use of assistive interfere with limitation of devices or activities of daily movement prostheses living (ADL) Health History (continued) History of orthopedic injuries, trauma or surgery Work and home environment Lifestyle – Describe physical activity for past 24 hours – Employment Does job require lifting, bending, twisting – Use of alcohol, tobacco, recreational drugs General Survey Observe the patient’s overall presentation: hygiene, posture, body movements, and affect. Observe for evidence of: – Pain – Visible deformities or amputation – Limited or uncontrolled movements General Survey (continued) Emotional response – affect: a person’s feelings as he or she appears to others Described as: Appropriate, abnormal, flat Quality of Speech Is the patient verbal or non-verbal Aphasia: defective or absent language function Receptive, expressive, global Voice quality: clear, hoarse, slurred General Survey (continued) Memory – Recent and remote – Vocabulary: Does it seem appropriate for age and educational background Memory: Remembering a group of words Mental Status Assessment Level of Consciousness (LOC) – Alert, lethargic, stuporous, comatose – LOC is most sensitive indicator of neurological status Orientation – Time: what year is it? – Place: where are you now? – Person: what is your name? – Situation: What is happening now? Describe responses  Glasgow Coma Scale Method to provide an objective measure of a person’s LOC Assesses three parameters: eye opening, verbal response, motor response Numerical score assigned to each parameter Total score: 3 (worst) to 15 (best) A Glasgow score of 15 does not necessarily mean that there is no neurological injury Glasgow Coma Scale Quick Quiz: Glasgow Coma Scale An older adult male is hospitalized patient with a fractured hip. It is unknown if the patient hit his head. During the nursing assessment, the patient is lethargic and opens his eyes only when called by name. The patient follows commands but provides incorrect answers to questions regarding time and place. Assess the patient’s Glasgow Coma Score. Pupil Assessment Observe pupils for color, size, equality, shape, reaction to light, and accommodation Normal: black, round, regular, and equal in size. Pupillary reaction – you need a dimly lit room – Shine a penlight from the side of the patient’s face towards the bridge of the nose PERRLA – Pupils: black – Equal: equal vs unequal Measure in mm; 2-5 mm (Pearson, Vol 3, skill 1.14) – Round: surgeries may alter shape – Reactive: Fixed vs. reactive – Light – Accommodation Pupil sizes Pupillary reflex to light L = light Direct response Consensual response: opposite eye also responds Pupillary Accommodation A = accommodation: the ability of the eye to change its focus to maintain a clear image as the distance to an object changes – Have the patient look at a distant object so the pupils dilate – Then have the patient focus on an object approximately 4 inches from bridge of nose – Pupils converge and accommodate by constricting to focus on close objects. – Cannot assess accommodation in unresponsive patient - just note PERRL Pupillary Accommodation Studyblue.com Sensory Function Different sensations are carried by different nerve pathways May be described as intact, absent, diminished, numb, tingling, painful Ask patient to close eyes when assessing for sensory function. Always compare side to side---look for symmetry Compare proximal and distal areas Vary the pace of the assessment so the patient does not ‘anticipate’ the next stimulus Sensory Function: Light Touch – Use a cotton wisp – Touch lightly on all 4 extremities – Start distal to proximal – Vary the site, rate and rhythm – Have patient say ‘now’ or ‘yes’ when stimulus is felt and identify area Sensory Function: Pain Sensation – Use a sharp object (opened paper clip or end of cotton swab); do not break the skin – Alternate sharp and dull ends – Ask patient to identify location and state ‘sharp’ or ‘dull’ or ‘don’t know’ – Agnosia – failure to recognize a sensory stimulus Motor Function: General Survey Muscle tone: flaccid, rigid Do all extremities move? Can the patient bear their own weight? Involuntary motor movements: – tremors (fine or coarse) rhythmic motion – twitches: localized Assess for pain Motor Function: Inspection Extremities: bones and alignment – Arms and hands Deformities of fingers such as ulnar deviation How well can the patient use their hands for activities of daily living?  Ulnar deviation Motor Function: Inspection Legs Straight? Are the contours of the muscle hidden by edema? Feet Deformities of toes Inspect Spine – Observe patient from side and while facing patient, arms at sides – Normal: head erect and both shoulders and both hips at same height bilaterally – Abnormal spine curvatures: Lordosis Kyphosis Scoliosis Limb length: Lower extremities Lower extremities: anterior superior iliac spine, across the top of the leg, to the medial malleolus (inner ankle) Each side should be within 1 cm  Limb circumference and length – Assess upper and lower limbs for symmetry – Use tape measure and compare side to side Note any atrophy or asymmetry Leg circumference and length Motor Function: Palpation Gently palpate major muscles with pads of fingers during contraction and relaxation. – Note the tone of the muscle (firm/soft) – Compare side-to side for symmetry of muscle mass and shape Motor Function: Palpation Joints: Gently palpate during movement – Note any swelling, warmth, or nodules – Look for redness or deformity – Appearance of pain with movement – Deviations in alignment – Motion should feel smooth and without any sense of grating or popping. Range of Motion Active vs. Passive Assess each major joint with active and/or passive ROM – Assess patient’s ability to perform active ROM – Note symmetry – Note if ROM is full or decreased --Note any associated pain with movement  Goniometer Device that measures angle of each joint in degrees Goniometric measurement varies with each joint Example: knee www.study.com – 0 to 150 degrees Muscle Strength Assess muscles for symmetrical development and strength Strength may be rated on a 0 to 5 scale 0 = no contraction noted 5 = full movement against gravity and full resistance May also be described as strong, moderate, weak, absent Upper Extremity Strength Arms: Push down/pull up – Place your hands on outstretched arms and apply resistance as patient pushes down and pulls up Hand grasp: – Patient to grip examiner hands and release – Also demonstrates ability to follow commands Lower Extremity Strength Feet pushes/pulls “push on the gas pedal” or “push down” (plantar flexion) Pull up against resistance (dorsiflexion) Legs: place hands on legs and ask patient to raise legs against resistance Motor Function: Gait Normal Gait – Ask patient to walk across the room and back – Upright posture – Steady gait with opposing arm swing – Walks unaided – Describe characteristics: steady or unsteady, jerky, shuffling, abnormally slow Balance and Coordination: Heel-Toe Walking – walk heel to toe in a straight line with arms at side – should not need arms out for balance – look for persistent unsteadiness www.ahrq.gov Balance and Coordination: Romberg’s Test – stand with feet close together and arms at sides – first with eyes open then with eyes closed – should not have excessive sway with eyes closed – keep hands on patient for safety  Balance and Coordination Finger to nose: – Extend arms and rapidly touch his finger to his nose – Alternate hand with eyes open then closed – movements should be smooth and coordinated – look for tremors or missing the target Reflexes Evaluates: – motor neurons and fibers at the spinal cord level Deep Tendon Reflex (DTR) – By striking tendon, sensory nerve impulses activated and motor reflex results – Compare side to side – Reflexes can be graded on a scale of 0 to +4 – Typically performed by advanced practitioner  Babinski Reflex Plantar or Babinski: stroke lateral side of foot from heel to ball to medial side (upside down “J”) For an adult ****Plantar flexing of toes (in and down) is normal (negative Babinski) – Fanning toes or dorsiflexed great toe is abnormal ( positive Babinski response) in an adult  Normal Neurological Changes in the Older Adult Decrease in size/weight of cerebral cortex Decreased number of brain cells Diminished cerebral blood flow Decreased peripheral nerve function What is the significance of these changes? Normal Neurological Changes in the Older Adult Assessment findings: – Decreased short-term memory – Decreased reflexes – Slower reaction time – Impaired coordination – Diminished sensation to light touch, pain, and joint position (proprioception) – Increased tremors in upper extremities – What problems can occur as a result of these changes? Normal Musculoskeletal Changes in the Older Adult: Postural alterations – Kyphosis – Decrease in height – Difficulty maintaining balance Postural sway Normal Musculoskeletal Changes in the Older Adult: Decreased muscle mass, decreased blood supply to muscles, decreased tissue elasticity – Sarcopenia : low muscle mass and low muscle function – Lower extremities atrophy earlier than upper extremities – Decreased endurance, coordination, and strength – Decreased flexibility – Decreased ROM