Muskuloskeletal assessment
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Health History Physical Assessment Inspection Palpation Range of Motion Muscular Strength. Muskuloskeletal Assessment. Rachel S. Natividad, RN, MSN. Cervical spine Shoulders Elbows Wrists/hands Hips Knees Ankles/feet Spine. Functional assessment. Physical Assessment- Cont.

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Muskuloskeletal Assessment

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Health History

Physical Assessment

Inspection

Palpation

Range of Motion

Muscular Strength

Muskuloskeletal Assessment

Rachel S. Natividad, RN, MSN


Cervical spine

Shoulders

Elbows

Wrists/hands

Hips

Knees

Ankles/feet

Spine

Functional assessment

Physical Assessment- Cont.


Inspection/Palpation

  • Note size and symmetry color, swelling, masses & deformities of joints, limbs and body regions

  • Palpate for temperature, pain, tenderness,


Spine


Have the pt perform active ROM

If unable to, use passive ROM

ROM’s


Strength against gravity, full resistance

note as 0/5-5/5

“5/5” = normal

Assessing Muscles


Chronic, systemic, inflammatory disease that attacks the joints, and surrounding tissues, hand, knees, hips, and feet

Rheumatoid arthritis


Deformitiesof RA

Ulnar Shift

Boutinniere Deformity

Swan neck deformity


A chronic degeneration of joint cartilage caused by aging or trauma

Osteoarthritis


Osteoarthritis

  • Heberden’s nodes on distal interphalangeal joints (DIP’s )

  • Bouchards nodes on proximal interphalangeal joints (PIPs) as disease progresses


A decrease in bone mass, porous, brittle, and prone to fracture

Osteoporosis


Contractures


Assessment Guide: Activity & Rest

  • Objective Data

  • Activity Level and Tolerance:

    • ambulates with walker independently/ with minimal assistance; bedrest; up in wheelchair


Assessment Guide: Activity & Rest Muscles and joints

  • Description: fair muscle tone, no atrophy; atrophy to RLE. No stiffness or contractures; R wrist contracted

  • Movement: limited ROM to RUE; FROM all extremities

  • Strength: strong UE, LE; weak RUE & RLE

  • Coordination: able to perform most ADLs; can comb hair and reach for water glass


Assessment Guide: Activity & Rest

  • Posture/Gait

    • Slumped, kyphosis, erect; gait unsteady, shuffling, ataxia


Assessment Guide: Activity & Rest

  • Circulation, Sensation, and Movement

    • Describe:

      • CSM intact;

      • no sensation to R big toe and second toe;

      • numbness and tingling to LEs;

      • Decreased ROM to LUE due to contractures


Assessment Guide: Activity & Rest

  • Rest/Sleep Patterns

    • Sleeps most of the day

    • Takes midday naps


Assessment Guide: Activity & Rest

Interventions in use:

  • Assistive device, equipment

    • Cast, trapeze, foot cradle,

    • Special beds

      • Air bed, eggcrate mattress

    • Med List:

      • Glucosamine, Allopurinol, NSAIDS, etc.


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