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Musculoskeletal Assessment

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MUSCULOSKELETAL WEEK 4
Provide privacy, wash hands, introduce self, and check ID vital signs
HISTORY:
-Reason for the visit, PQRSTU
-if there isn’t one: so, from my understanding we are going to be doing an assessment on your muscles, joints, and bones/ ROM and muscles strength do I have that correct?
-Do you have any pain, stiffness, weakness, swelling, twitching in your joins or muscles? Any redness, heat limited ROM you have noticed?
-Any PHx of injury to your arms/ legs/ bones, muscles, joints (broken bones, strain, fractures)?
-Is there any physical problems that limit your ADL?
-Do you exercise or participate in sports on a regular basis? (how much, how often)
-Women: Calcium and Vit. D supplements?
-FHx of scoliosis, osteoporosis, osteoarthritis, rheumatoid arthritis?
-Medication (OTC, herbal, prn), Allergies, Alcohol, Smoking/Tobacco, Street Drugs
ORDER OF THE EXAM: 1. Inspection: symmetry of structures and function (ROM), size, contour, skin for color, swelling, masses, atrophy, deformities, nodules. 2. Palpation: Joint and skin for temp, muscles, articulations. Notice heat, tenderness, swelling (inflammation), atrophy, masses, hard muscles, muscles spasms 3. ROM: No tenderness, pain, or crepitation 4. Muscle Testing: Prime mover, “I’m going to push, don’t let me push, I’m going to pull, don’t let me pull” resistance. Equal, bilaterally, and fully resist my opposing force
-Full or limited ROM- use goniometer to measure angle
-Strength: 5 pt. scale 5=Full ROM and Full resistance 100% 4=Full ROM and some resistance 75% 3=Full ROM 50% 2=Passive Motion 25% 1=Slight Contraction 10% 0=No contraction
CERVICAL SPINE:
-Inspect: alignment of spine and processes, shoulders, scapula,
-Palpate: spinous process, sternomastoid, trapezius, paravertebral muscles- firm, no spasm or tenderness
-ROM: Chin to chest, look up, ear to shoulder (lateral bending), and look over shoulder (rotation)
-Strength CN XI Spinal Accessory: Repeat all motions, W/Resistance
UPPER EXTREMITIES
Shoulders:
-Inspect: Posteriorly and anteriorly, equality of bony landmarks
-ROM: Arms straight up (flexion), behind (hyperextension), clap overhead (abduction/ adduction), internal (getting arrested) and external rotation (getting an itch o your shoulder blade), across the body
-Strength CN XI spinal accessory: Shoulder Shrug and one w/resistance
Elbow:
-Inspect: joints
-Palpate: Olecranon process and bursa, epicondyles of the humorous hollow spaces
-ROM: flexion, pronation, supination
-Strength: Push and pull
Wrist and Hand:
-Inspect: Dorsal and Palmar sides, fingers in same axis as forearm, knuckle wrinkles
-Palpate: EVERY joint
-ROM: fingers towards celling (hyperextension), towards floor (flexion), point fingers in and out (ulnar and radial deviation), spread fingers apart (abduction), touch thumb to each finger
-Strength: Squeeze my fingers as tight as you can, hold at finger tips and have them bring wrist towards them
LOWER EXTREMITIES
HIP: Laying down
-Inspect: symmetry of gluteal folds, iliac crest, equally sized buttock
-Palpate: push down on hips (pain=hip problems)
-ROM: Raise each leg (flexion), over body, adduction and abduction bend knee to chest (flexion/ opposite hip on table), internal and external rotation, slide heal down shin -limited abd, add, and internal and external rotation suggest hip disease
KNEE:
-Inspect: swelling
-Palpate: tibia turbosity, medial and later condyles of tibia and epicondyles or femur, hollow, fullness, check atopy of quad
-Strength: Push and pull
ANKLE and FOOT
-Inspect: foot aligned/ same axis as lower leg, toes pointing straight, calluses, bursal
-Palpate: tibiotalar joint, malleolus, toe joints, pitting edema
-ROM: Point toes down (plantar flexion), toes up (dorsiflexion), soles of feet in and out (eversion/ inversion), curl and straighten toes -Strength: Push and pull -Pedial pulse: (3+ full/ bounding, 2+normal, 1+weak, 0 absent)
SPINE: Pt stands
-Inspect: alignment of spine and processes, shoulders, scapula, iliac crest, gluteal folds
-Palpate: hips
-Scoliosis screening: pt. touch toes. Im BEHIND pt. to feel down spine (Pull shirt up)
-ROM: Bend backwards (hyperextension), bend to the side (later bending/ herniated nucleus pulposus), rotation
-Trendelenburg’s Test: Stand on one leg, note symmetry of iliac crest, shoulders, and scapula -if not: weakness in the opposite gluteal muscles

ASSESS GAIT
-Pt. should walk
-Heal to toe

TEACHING:
-Healthy weight
-Proper body mechanics when lifting
-Osteoporosis: low bone mineral density, increases risk for fractures
-Calcium intake and vitamin D intake (salmon, sardines)
-leafy green vegies, spinach, kale, broccoli
-limit caffeine, smoking, alcohol intake
-Weight-bearing exercise, 30 min, 3x/day

KEY TERMINOLOGY
-Rheumatoid Arthritis: chronic autoimmune disease causing inflammation of synovial tissues, causes fibrosis/ thickening and scaring of the CT and bone destruction
-Osteoarthritis: stiffening in joints, deterioration of cartilage which keeps your bones from touching/ cushions. Hands, hip, knees, vertebra. Osteophytes-bone spurs. Pain worse later in the day, nodes in hands, fluid in knee, limited ROM.
EXAMPLE DOCUMENTAION
S: Ptn denies Hx of musculoskeletal problems, any discomfort, weakness, or stiffness in spine bones, or joints. Reports no musculoskeletal difficulties with work, hobbies, or ADLs. No Family Hx; Denies taking Medications, NKA. Denies having ever smoked.
O: B/P-114/78; P-68, R-16; 32 year old male nursing student, stands erect with even gate, head midline, shoulder, hips, scapulae, and Iliac crest level. Spinous processes straight and non-tender. Extremities & muscles symmetrical, proportional and non-tender bilaterally. Muscle strength of head, neck, chin, shoulders, forearms, hands, calf, and feet is 5/5 for all. Gross ROM full for all of head/neck, cervical spine, shoulders, hands, hip, and ankle. No pitting edema, no tenderness or pain on palpation. Negative Trendelenburg & Babinski.
A: (1) Healthy musculoskeletal function.
(2) At risk for back injury as evidenced by being a nursing student.…...

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