Musculoskeletal Assessment Spring 14 Musculoskeletal System Provides support

Musculoskeletal Assessment Spring 14

Musculoskeletal System Provides support for the body Protection for the internal organs Mobility to engage in physical activities Production of red blood cells Storage of minerals

Musculoskeletal System Bones muscles Ligaments Tendons Cartilage joints MRI of the shoulder

Musculoskeletal System Neurological assessment important in Musculoskeletal assessment CNS coordinates muscle and bone function Disorders can affect the individual at any age

Musculoskeletal System M/S concerns vary at different ages Children and young adults Injuries Middle-aged and Older adults Inflammatory Degenerative Rheumatic conditions

Purpose of Assessment Perform a systematic functional assessment Activities of daily living Detection of common dysfunctions

Assessment Correct diagnosis depends on an accurate patient history and thorough examination Can be made on a specific body part or part of a general physical examination Accidents often result in trauma to the musculoskeletal system and require a thorough assessment

Complaints that should alert the nurse to obtain subjective and objective data related to the M/S system is: JOINT OR MUSCLE PAIN JOINT SWELLING DECREASING STRENGTH OR FUNCTION CHANGE IN SIZE OF AN EXTREMITY OR MUSCLE DEFORMITY SPASM CREPITATION CHANGES IN SENSATION STIFFNESS CHANGES IN GAIT

Health Perception Health Management Describe your usual daily activities Do you experience any difficulties performing these activities? Describe what you do when you experience difficulty in dressing, feeding yourself, performing basic hygiene, or maintaining your home.

Health Perception Health Management Do you use any mechanical assistive devices? Do you have to lift heavy objects? If so, describe how you do this. Describe any specialized equipment you use or wear when you work or exercise that helps protect you from injury. What type of safety precautions do you take?

Health Perception Health Management Do you take any medications to manage your musculoskeletal problem? If so, what is/are the name(s) of the medication? When did you have your last tetanus and polio immunization? When were you last tested for tuberculosis?

Health Perception Health Management A 3 - generation family history should be obtained related to rheumatoid arthritis, degenerative joint disease, gout, osteoporosis, and scoliosis

Nutrition-Metabolic Pattern Give a 24 hour diet recall Do you take supplemental vitamins or minerals? Ask specifically about calcium and vitamin D supplements What is your weight? Have you had recent change in your weight? If yes, describe.

Nutrition-Metabolic Pattern Obesity predisposes to ligamentous instability (especially in the back) Adequate amounts of vitamins C and D, calcium, and protein essential for healthy, intact musculoskeletal system Evaluate patient’s tolerance to milk products

Elimination Pattern Does your musculoskeletal problem make it difficult for you to reach the toilet in time? Do you experience constipation related to immobility? Do you need any assistive devices or equipment to achieve satisfactory toileting?

Elimination Pattern Ability to ambulate and reach toilet can affect bowel and bladder health Constipation and incontinence can be caused by immobility Grab bars or elevated toilet seat

Activity-Exercise Pattern Do you have any limitations in your activities of daily living because of your musculoskeletal problem? Describe your usual exercise pattern. Do you experience symptoms related to your musculoskeletal system before, during, or after exercising?

Activity-Exercise Pattern Are you able to move all your joints comfortably through full range of motion? Describe any limitations in mobility. Do you require assistance in moving or in doing activities of daily living? Do you use any prosthetic or orthotic devices?

Activity-Exercise Pattern Extremes of activity related to occupation can affect the musculoskeletal system Tile layer Heavy lifting Laborer Sedentary lifestyle does not allow for muscle flexibility and strength

Sleep-Rest Pattern Do you experience any difficulty sleeping because of a musculoskeletal problem? Do you require frequent position changes at night? Why? Do you wake up at night because of musculoskeletal pain?

Sleep-Rest Pattern Musculoskeletal disorders might require frequent position changes Discomfort, therefore, would interfere with restful sleep Type of bedding, pillows used Sleeping partner Sleeping positions

Cognitive-Perceptual Pattern Describe any musculoskeletal pain you experience. How do you mange your pain? Swelling, decreased strength, changes in sensation cause problems

Self Perception- Self Concept Pattern Describe how changes in your musculoskeletal system (posture, walking, muscle strength) or the ability to do certain things have affected how you feel about yourself. How have these changes affected your lifestyle?

Role- Relationship Pattern Do you live alone? Describe how your family or others assist you with your musculoskeletal problems. Describe the effect of your musculoskeletal problem on your work and on your social relationships.

Sexuality-Reproduction Pattern Describe the effect of your musculoskeletal problem on your sexual activity. How do you feel about this? Pain, movement, and positioning may cause problems

Coping-Stress Tolerance Pattern Describe how you deal with the problems such as pain or immobility that have resulted from your musculoskeletal problem. Serious stressors- acute or chronic pain Pain is exhausting!! Physically and emotionally

Value-Belief Pattern Describe any cultural or religious beliefs that may influence the treatment of your musculoskeletal problem.

Pain Assessment Character Precipitating or alleviating factors Onset Location Timing Referred pain

Specific Complaints Character: which joint(s) affected, number of joints involved, pain, ache, stiffness or limitation of movement, redness, increased warmth, or swelling, pain associated with particular movement or weight bearing Onset: specific date of first episode (or age when occurred), sudden, gradual

Specific Complaints Duration: length of episode Frequency: change in pattern, similar episodes in past Precipitating factors: specific movements, prolonged activity, rest, injury, weather, time of day, specific foods, medications (diuretics) alcohol intake

Specific Complaints Alleviating factors: rest, movement Associated symptoms: fever, weight loss, fatigue, malaise, rash, chronic diarrhea Efforts to treat and their effectiveness: medications, heat and/or ice, exercise, weight reduction, splints, home remedies

Injury Complaint Mechanism of Injury: what happened-direct trauma, overuse, overstretching, fall Character: location of pain; any noise with injury (popping, click, tearing) numbness; tingling; loss of sensation, strength, or mobility; warmth or coldness, swelling (immediate or gradual)

Injury Complaint Duration: length of episode Frequency: similar episodes in the past Precipitating factors: sudden movement, repetitive movement, stress

Injury Complaint Alleviating factors: rest, position of comfort Associated symptoms or conditions: loss of consciousness, other injuries Efforts to treat and their effectiveness: medications, heat and/or ice, splints, immobilization, home remedies

Objective Data Primary methods used in the physical examination of the musculoskeletal system Inspection Palpation Clues received from health history

Inspection Observe for any asymmetry Sitting and standing posture General body build Configuration of muscles Limitations in patient’s ability to perform normal activities (dressing, toileting, eating)

Inspection Condition of the skin General color Scars Overt signs of previous injury or operations Head – toe Avoids missing anything Joint motion Asymmetry of movement

Inspection Swelling Deformity Masses Evidence of limb-length or muscle-size discrepancies Opposite body part used for comparison when abnormality is suspected

Palpation Any area that has aroused concern should be carefully palpated Hands should be warm to prevent spasm Palpation of soft tissues (including muscles and joints) enables examiner to evaluate skin temperature, local tenderness, swelling, and crepitation Establish relationship of adjacent structures

Palpation Evaluate general contour Evaluate abnormal prominences Evaluate local landmarks Both superficial and deep palpation are performed Evaluate passive and active range of joint motion Passive- someone else doing the moving Be careful not to overextend patient’s limitations Manipulation must cease immediately if this occurs

Palpation Active- patient moves own joints through their normal ROM Functional- assessed by asking patient to go about doing own ADLs (eating, bathing, etc) Patient may require assistive device to perform functional Joint motion most accurately measured by goniometer

Palpation Measures amount of bending or angles of joints Not usually measured unless a musculoskeletal problem has been identified Less accurate but valuable method is to compare ROM of one extremity with the corresponding opposite one!

Measurement Limb length When gait disorders are detected Measured and compared between 2 bony prominences Circumferential measurement Muscle mass

Muscle-strength testing Individual muscle or muscle groups Graded in performance Applied resistance

Gait Assess by walking across the room Observe Stance-and-Swing Phase Musculoskeletal and neurologic problems can result in gait abnormalities

Other Assessment of reflexes

Movement of Synovial Joints Flexion Bending of joint that decreases angle between two bones Shortening of muscle length Extension Bending of joint that increases angle between two bones Hyperextension Extension in which angle exceeds 180 degrees

Movement of Synovial Joints Abduction Movement of part away from midline Adduction Movement of part toward midline Pronation Turning of palm downward or sole outward Supination Turning of palm upward or sole inward

Movement of Synovial Joints Circumduction Combination of flexion, extension, abduction, and adduction Resulting in circular motion of body part Rotation Movement about longitudinal axis Inversion Turning of sole inward toward midline Eversion Turning of sole outward away from midline

Common Assessment Abnormalities Ankylosis Scarring within a joint leading to stiffness or fixation Chronic joint inflammation

Common Assessment Abnormalities Atrophy Wasting of muscle Characterized by decrease in circumference and flabby appearance Resulting in decrease in function and muscle tone Prolonged disuse Contracture Immobilization Muscle denervation

Common Assessment Abnormalities Contracture Resistance to movement of muscle or joint A result of fibrosis of supporting soft tissues Shortening of muscle or ligament structure Tightness of soft tissue Immobilization Incorrect positioning

Common Assessment Abnormalities Crepitation Crackling sound or grating sensation as result of friction between bones Fracture Chronic inflammation Dislocation

Common Assessment Abnormalities Effusion Fluid in joint possibly with swelling and pain Trauma Especially to knee

Common Assessment Abnormalities Felon Abscess occurring in pulp space (tissue mass) of distal phalanx of finger Result of infection Minor hand injury Puncture wound laceration

Common Assessment Abnormalities Ganglion Small, fluid-filled synovial cyst Usually dorsal surface of wrist and foot Degeneration of connective tissue close to tendons and joints Leading to formation of small cysts

Common Assessment Abnormalities Hypertrophy Increase in size of muscle Result of enlargement of existing cells Exercise Increased andogens Increased stimulation or use

Common Assessment Abnormalities Kyphosis (round back) Anterioposterior or forward bending of spine with convexity of curve in posterior direction Common at thoracic and sacral levels Poor posture Tuberculosis Chronic arthritis Growth disturbance of vertebral epiphysis osteoporosis

Common Assessment Abnormalities Lordosis Deformity of spine Results in anterioposterior curvature with concavity in posterior direction Common in lumbar spine Secondary to other deformities of the spine Muscular dystrophy Obesity Flexion contracture of hip Congenital dislocation of hip

Common Assessment Abnormalities Pes planus Flatfoot Congenital condition Muscle paralysis Mild cerebral palsy Early muscular dystrophy

Common Assessment Abnormalities Scoliosis Deformity resulting in lateral curvature of spine Idiopathic or congenital condition Fracture or dislocation Oseomalacia Functional condition

Common Assessment Abnormalities Subluxation Partial dislocation of joint Instability of joint capsule and supporting ligaments (trauma, arthritis)

Common Assessment Abnormalities Valgus Angulation of bone away from midline Alteration in gait Pain Abnormal erosion of articular cartilage

Common Assessment Abnormalities Varus Angulation of bone toward midline Alteration in gait Pain Abnormal erosion of articular cartilage

Normal Physical Assessment of the Musculoskeletal System Full ROM of all joints No joint swelling, deformity, or crepitation Normal spinal curvatures No tenderness on palpation of spine No muscle atrophy or asymmetry Muscle strength of 5 draining wound) Study visualizes course of sinus and tissues involved Same nursing responsibilities as arthogram