Islamic University of Gaza Faculty of Nursing Chapter

Islamic University of Gaza Faculty of Nursing Chapter (10) Assessment of musculo-skeletal system 1

*Subjective data: ask about: • Pain: at rest, with exercise, changes in shape or size of an extremity, changes in mobility to carry out activities of daily living, sports, and works. • Stiffness: time of day, relation to weight, " bearing or exercise". • Decreased or altered or absent sensations. • Redness or swelling of joints. • History of fractures and orthopedic surgery. • Occupational history. 2

• Assessment of musculo-skeletal system done firstly when the client walks, moves in bed or performs any type of physical activity. • Determine range of motion, muscle strength and tone, joint and muscle condition. • N. B: muscle problems commonly are manifestations of neurological disease, so you must do neurological assessment simultaneously. • Joints vary in their degree of mobility, range from freely movable e. g. knee, to slightly movable joints e. g. the spinal vertebra. 3

• During assessment of muscle groups: assess muscle weakness, or swelling, and size, then compare between sides. Joints should not be forced into painful positions. • Observe gait and posture as client walks into room. • Normally the client walks with arms swinging freely at sides and the head and the face leading the body. 4

• Loss of height is frequently the first clinical sign of osteoporosis. • Small amount of height loss expected with aging. • Ask client to put each joint through its full range of motion, if there is weakness, gently supporting & moving extremities through their range of motion, to assess abnormalities. • Normal joints are non tender, without swelling and move freely. **Elderly joints often become swollen & stiff, with reduced range of motion, resulting from cartilage erosion and fibrosis of synovial membranes. 5

Assessment of Neurological system • You can assess this system when doing physical examination e. g. cranial nerve function can be testing during the survey of the head and neck. • The neurological assessment consists of six parts: (mental status, cranial nerves, sensory functions, motor function, cerebellar function, reflexes). 6

*Subjective data: ask about: • Loss of consciousness, dizziness, and fainting. • Headache: precipitating factors and duration. • Numbness and tingling or paralysis or neuralgia. • Loss of memory, confusion, visual loss, blurring, and pain. • Facial pain, weakness, twitching, speech problems e. g. aphasia. • Swallowing problems and drooling. • Neck weakness or spasm. 7

• Mental and emotional status is observed as the nursing history is collected, and by simply interacting with client, e. g. “Nursing care plan” • Level of consciousness, which ranges from full awakening, “alertness” to unresponsiveness to any form of external stimuli. • Alert client responds to questions spontaneously. • You can assess Level of consciousness by using Glasgow coma scale. 8

Glasgow coma scale Action Response Score Open eyes Spontaneous 4 To speech 3 To pain 2 None 1 Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Obeys commands 6 Localized pain 5 Flexion withdrawal 4 Abnormal flexion 3 Abnormal extension 2 Flaccid 1 Best verbal response Best motor response Total score 15 9

*Assessment of behavior and appearance • Behavior, mood, hygiene, grooming and choice of dress reveal pertinent information about client’s mental status. • Appearance reflects how a client feels about the self. • Personal hygiene such as unkempt hair, a dirty body, or broken, dirty fingernails should be noted. *Language: Assess ability of individual to understand spoken or written words & how he/she speaks or writes. 10

• Assess intellectual function, which includes: memory “recent, immediate, past”, knowledge, abstract thinking, association and judgment. * Assess for sensory function: - Assess sensitivity to light touch “cotton” - Assess sensitivity to pain “pinprick” - Assess sensitivity to vibrations “tuning fork” - Assess sensitivity to positions. **Don’t forget comparing both sides of body 11

Assessment of the breast Subjective data: ask about: • Tenderness, pain, swelling, or change in size of breasts. • Change in position of nipple or nipple discharge. • Presence of cysts, lumps, and lesions. • History of prior breast surgery. 12

*Female breast: *Inspection: • With the client sitting, arms relaxed at sides. Inspect Areola and nipples for position, pigmentation, inversion, discharge, crusting & masses. • Examine the breast tissue for size, shape, color, symmetry, surface, contour, skin characteristics. • Assess level of breasts, notes any retractions or dimpling of the skin. • Ask client to elevate her hands over head, repeat the observation. • Ask client to press her hands to her hips and repeat observation. 13

*Palpation: • Best done in recumbent position: -Raise the arm of client on the side of the breast being palpated above clients head. -Palpate the breast from less painful or less diseased area -Use on palpation palmer aspects of the fingers in a rotating motion, compressing the breast tissue against the chest wall, this is done quadrant by until the entire breast has been palpated. 14

-Note skin texture, moisture, temperature, or masses. -Gently squeeze the nipple and note any expressible discharge (Normally not present in non lactating women). -Repeat examination on the opposite breast & compare findings. **N. B: If mass is palpated, its location, size, shape, consistency, mobility and associated tenderness are reported. 15

*Male Breast: • Examination of male breast can be brief and should never be omitted. • Observe nipple & Palpate Areola for ulceration, nodules, swelling or discharge (Normally not present). *Genitourinary and reproductive assessment • You must focus your questions on the following: -Any bulges or pain when straining or lifting heavy objects. -Unusual drainage. -Pain with urination or incontinence. -Lower abdominal pain. 16