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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
Health History

Physical Assessment

Inspection

Palpation

Range of Motion

Muscular Strength

Muskuloskeletal Assessment

Rachel S. Natividad, RN, MSN

physical assessment cont
Cervical spine

Shoulders

Elbows

Wrists/hands

Hips

Knees

Ankles/feet

Spine

Functional assessment

Physical Assessment- Cont.
inspection palpation
Inspection/Palpation
  • Note size and symmetry color, swelling, masses & deformities of joints, limbs and body regions
  • Palpate for temperature, pain, tenderness,
rom s
Have the pt perform active ROM

If unable to, use passive ROM

ROM’s
rheumatoid arthritis
Chronic, systemic, inflammatory disease that attacks the joints, and surrounding tissues, hand, knees, hips, and feetRheumatoid arthritis
deformities of ra
Deformitiesof RA

Ulnar Shift

Boutinniere Deformity

Swan neck deformity

osteoarthritis1
Osteoarthritis
  • Heberden’s nodes on distal interphalangeal joints (DIP’s )
  • Bouchards nodes on proximal interphalangeal joints (PIPs) as disease progresses
assessment guide activity rest
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
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 rest1
Assessment Guide: Activity & Rest
  • Posture/Gait
    • Slumped, kyphosis, erect; gait unsteady, shuffling, ataxia
assessment guide activity rest2
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 rest3
Assessment Guide: Activity & Rest
  • Rest/Sleep Patterns
    • Sleeps most of the day
    • Takes midday naps
assessment guide activity rest4
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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