FAR EASTERN UNIVERSITY
Institute of Nursing
PATIENT DOCUMENTATION: CERES ARVILLE C. ROLDAN
HEALTH ASSESSMENT OF MUSCULOSKELETAL
Name : Ceegi Arville C. Roldan
Sec/Grp: 107-Group 4
ASSESSMENT PROCEDURES
MUSCLES, BONES, & JOINTS
1. Inspect the muscles for size.
Compare each muscle on one
side of the body to the same
muscle on the other side.
2. Inspect the muscles and
tendons for contractures.
3. Inspect the muscles for
tremors.
4. Palpate muscles at rest to
determine muscle tonicity.
5. Palpate muscles at while the
client is active and passive
for flaccidity, spasticity, and
smoothness of movement.
6. Test muscle strength of the
head& shoulders.
7. Test muscle strength upper
extremities
Score:
Date: May 21, 2020
Normal Findings Deviation from Normal
   
The size of the muscles on both The right and left side of the
sides of the body are body differ in size.
symmetrical.
*There are no abnormal
findings.*
No presence of contractures. Presence of contractures.
*There are no abnormal
findings.*
No presence of fasciculation or There is presence of
tremors fasciculation in the left calve.
The muscles are normally firm. *There are no abnormal
findings.*
Client tolerates test without There is presence of sudden
extreme pain. involuntary muscle contraction
and pain.
*There are no abnormal
findings.*
Jaw: has full ROM against Temporal mandibular joint:
resistance. Decreased muscle strength with
Shoulders: the client can flex, muscle and joint disease.
extend, adduct, abduct, rotate,
and shrug shoulders against *There are no abnormal
resistance. findings.*
Shoulders: The client can flex, Decreased strength against
extend, adduct, abduct, rotate, resistance is a common in
and shrug shoulders against muscle and joint disease.
resistance.
Elbows: the client can flex, *There are no abnormal
extend, adduct, abduct, and findings.*

8. Test muscle strength of
lower extremities.
9. Inspect the skeleton for
normal structure and
deformities.
10. Palpate the bones to locate
any areas of edema or
tenderness.
11. Inspect the joint for swelling.
ASSESMENT PROCEDURES
12. Assess joint range of motion
of the head.
rotate against resistance. Client
should have full ROM against
resistance.
Wrists: Client should have full
ROM against resistance.
Client tolerates test without
extreme pain.
Client should have full ROM Decreased strength against
against resistance. resistance is a common in
muscle and joint disease.
*There are no abnormal
findings.*
Posture: erect and comfortable There is presence of
for age misalignment of bones. Visible
Elbows: Symmetric without excessive inward angulation of
deformaties the legs.
Hands: Round protuberance
noted next to the thumb over
the thenar prominence. Smaller
protuberance seen adjacent to
the small finger.
Fingers: lie in straight line.
Cervical/Lumbar spine: Concave
Thoracic spine: Convex
Knees: Symmetric.
Lower leg: in alignment w/
upper leg
No presence of edema or There are presence of edema or
tenderness palpated. tenderness.
*There are no abnormal
findings.*
No swelling or deformities. There are presence of swelling.
*There are no abnormal
findings.*
   
Mouth opens 1-2 in distance Decreased ROM against
between upper and lower resistance is a common in
teeth). The client’s mouth muscle and joint disease.
opens and closes smoothly. Jaw
moves laterally 1-2 cm and it *There are no abnormal
protrudes and retracts easily. findings.*
Client tolerates test without
 extreme pain.

13. Assess joint range of motion Normal range: Cervical Decreased ROM against
of body trunk. o Left side: 40⁰ resistance is a common in
 Cervical o Right side: 40⁰ muscle and joint disease.
 Thoracic o Rotation: about 70⁰
 Lumbar spine *There are no abnormal
Normal range: Thoracic findings.*
o Lateral bending capacity:
35⁰
o Hyperextensions: 30⁰
o Rotation: 30⁰
Normal range: Lumbar spine
o Flexion: 75-90⁰
o Lateral bending capacity:
35⁰
o Hyperextensions: 30⁰
o Rotation: 30⁰
*w/ smooth movement, lumbar
concavity flattens out, and the
spinal process are in alignment.

Client tolerates test without

extreme pain.

14. Assess joint range of motion Normal range: Shoulders
of upper extremities. o Forward flexion: 180⁰
 Shoulders o Hyperextension: 50⁰
 Elbows o Adduction: 50⁰
o Abduction: 180⁰
o Ex/Internal rotation: 90⁰
respectively
Decreased ROM against
resistance is a common in
muscle and joint disease.
*There are no abnormal
findings.*

Normal range: Elbows

o Flexion: 160⁰
o Extension: 180
o Pronation: 90⁰
o Supination: 90⁰
*Some clients may lack 5-10
degrees or have
hyperextension.

Client should have full ROM

against resistance.
 Wrists Normal range: Wrist
 Fingers o Flexion: 90⁰
o Hyperextension: 70⁰
o Ulnar deviation: 55⁰
o Radial deviation: 20⁰

Normal range: Fingers

o Abduction: 20⁰
o Full Adduction: 20⁰
(touching)
o Flexion: 90⁰
o Hyperextension: 30⁰
*Thumb should easily move
away from other fingers and
50⁰ of thumb flexion of thumb
is normal

Client should have full ROM

15. Assess joint range of motion
of lower extremities.
 Hips and Buttocks
 Knees
 Feet
against resistance.
Normal ROM: Hips and Decreased ROM against
Buttocks resistance is a common in
- 90 degrees of hip flexion muscle and joint disease.
with the knee straight and
120 degrees of hip flexion *There are no abnormal
with the knee bent and the findings.*
other leg remaining
straight.
o Abduction: 45-50⁰
o Adduction: 20-30⁰
o Internal hip rotation: 40⁰
o External hip rotation: 45⁰
o Hip hyperextension: 15⁰

Normal ranges: Knees

- 120-130 degrees of flexion
- 0 degrees of extension to
15 degrees of
hyperextension

Normal ranges: Feet

- 20 degrees dorsiflexion of
ankle and foot and 45
degrees plantarflexion of
angle and foot.
- 20 degrees of eversion and
30 degrees of inversion.
- 10 degrees of abduction
and 20 degrees of
 adduction.
- 40 degrees of flexion and
40 degrees of extension.
Client should have full ROM
against resistance.
16. Document findings. Aside from the two abnormal Involuntary muscle contraction
findings, there are no or fasciculation is present on the
contractures, tenderness, left calve of the patient. There is
edema and swelling noted or also a present bone
present. The size, movements, misalignment of the client’s legs
muscle strength, and range of (excessive inward angulation).
motions of the client’s
musculoskeletal system are
normal.