EUFREIN NIÑA RADOC

ASSESSING MUSCULOSKELETAL SYSTEM

Assemble Equipment:
 Goniometer
R: It is used to measure
joint angle
 Tape measure
PROCEDURES NORMAL ABNORMAL
1. Introduce yourself and verify
the client’s identity.
R: To promote the clients
cooperation and to ensure that
the right assessment is given
to the right client.

Explain to the client what you are

going to do, why it is necessary,
and how the client can cooperate.
R: To ensure that the client is
aware on the procedure
2. Perform hand hygiene and
observe other appropriate
infection control procedures.
R: To prevent cross
contamination between the
patients.
3. Provide client privacy.
R: To maximize cooperation
and reduce anxiety of the
client.
4. Inquire if client has any
history of the following:
 Muscle pain: onset, location,
character, associated
phenomena and
aggravating and
 alleviating factors
 Any limitations to movement
or inability to perform
activities of daily living.
 Previous sports injuries
 Any loss of action without
 EUFREIN NIÑA RADOC

pain
MUSCLES
5. Inspect the muscles for size. Equal size on both Atrophy (a decrease in
 Compare each muscle on sides of body size) or hypertrophy
one side of the body to the (an increase in size),
same muscle on the other asymmetry
side. For any apparent
discrepancies, measure the
muscles with tape.
6. Inspect the muscles and No contractures Malposition of body
tendons for contractures. part, e.g., foot drop
(foot flexed downward)
7. Inspect the muscles for No tremors Presence of tremor
tremors.
 Inspect any tremors of the
hands and arms by having
the client hold arms out in
front of the body.
8. Palpate muscles at rest to Normally firm A tonic (lacking tone)
determine muscle tonicity.

9. Palpate muscles while the No deformities Bones misaligned

client is active and passive for
flaccidity, spasticity, and
smoothness of movement.
10. Test muscle strength. Equal strength on each Grading Muscle
Compare the right side with left body side Strength
side. 0: 0% of normal
strength; complete
Sternocleidomastoid: Client paralysis
turns the head to one side against 1: 10% of normal
the resistance of your hand. strength; no movement,
Repeat with the other side. contraction of muscle is
palpable or visible
Trapezius: 2: 25% of normal
Client shrugs the shoulders strength; full muscle
against the resistance of your movement against
hands. gravity, with support
3: 50% of normal
Deltoid: strength; normal
Client holds arm up and resists movement against
while you try to push it down. gravity
 EUFREIN NIÑA RADOC

4: 75% of normal
Biceps: strength; normal full
Client fully extends each arm and movement against
tries to flex it while you attempt to gravity and against
hold arm in extension. minimal resistance
5: 100% of normal
Triceps: strength; normal full
Client flexes each arm and then movement against
tries to extend it against your gravity and against full
attempt to keep arm in flexion. resistance

Wrist and finger muscles:

Client spreads the fingers and
resists as you attempt to push the
fingers together.

Grip strength:
Client grasps your index and
middle fingers while you try to pull
the fingers out.

Hip muscles:
Client is supine, both legs
extended; client raises one leg at
a time while you attempt to hold it
down.

Hip abduction:
Client is supine, both legs
extended. Place your hands on
the lateral surface of each knee;
client spreads the legs apart
against your resistance.

Hip adduction:
Client is in same position as for
hip abduction. Place your hands
between the knees; client brings
the legs together against your
resistance.

Hamstrings:
Client is supine, both knees bent.
 EUFREIN NIÑA RADOC

Client resists while you attempt to

straighten the legs.

Quadriceps:
Client is supine, knee partially
extended; client resists while you
attempt to flex the knee.

Muscles of the ankles and feet:

Client resists while you attempt to
dorsiflex the foot and again resists
while you attempt to flex the foot.

11. Inspect the skeleton for No deformities Bones misaligned

normal structure and
deformities.

12. Palpate the bones to locate No tenderness or Presence of tenderness

any areas of edema or swelling or swelling
tenderness. (may indicate fracture,
neoplasms, or
osteoporosis)

13. Inspect the joint for No swelling One or more swollen

swelling.
 Palpate each joint for
tenderness, smoothness of
movement, swelling,
crepitation, and presence of
nodules.
No tenderness, joints
swelling, crepitation, or Presence of
nodules tenderness, swelling,
Joints move smoothly crepitation, or nodules

14. Assess joint range of Varies to some degree Limited range of motion
motion. in accordance with in one or more
 Ask the client to move person’s genetic joints
selected body parts. If makeup and degree of
available, use a goniometer physical activity
to measure the angle of the
joint in degrees.
15. Document findings in the
client record.
R: To serve as evidence or
record of what I did or assess
 EUFREIN NIÑA RADOC

ASSESSING NEUROLOGICAL SYSTEM

Assemble Equipment:
∙ Sugar, salt, lemon juice,
quinine flavors
∙ Percussion hammer
∙ Tongue depressors (one
broken diagonally, for testing
pain sensation)
∙ Wisps of cotton, to assess light
touch sensation
∙ Test tubes of hot and cold
water, for skin temperature
assessment (optional)
∙ Pins or needles for tactile
discrimination
PROCEDURES NORMAL ABNORMAL
1. Introduce yourself and verify
the client’s identity.
R: To promote the clients
cooperation and to ensure
that the right assessment is
given to the right client.

Explain to the client what you

are going to do, why it is
necessary, and how the client
can cooperate.
R: To ensure that the client is
aware on the procedure
2. Perform hand hygiene and
observe other appropriate
infection control procedures.
R: To prevent cross
contamination between the
patients.
3. Provide for client privacy.
R: To maximize cooperation
and reduce anxiety of the
client.
4. Inquire if the client has any
history of the following:
∙ Presence of pain in the head,
 EUFREIN NIÑA RADOC

back, or extremities as well as

onset and aggravating and
alleviating factors.
∙Disorientation to time, place or
person
∙Speech disorders
∙Any history of loss
consciousness, fainting,
convulsions, trauma, tingling or
numbness, tremors or tics,
limping, paralysis, uncontrolled
muscle
movements, loss of memory or
mood swings
∙Problems with smell, vision,
taste, touch or hearing

LANGUAGE
5. If the client displays
difficulty speaking:

∙ Point to common objects, and

ask the client to name them.
∙ Ask the client to read some
words and to match the printed
and written words with pictures.
Ask the client to respond to
simple verbal and written
commands – e.g., “Point to your
toes” or “Raise your left arm.”

ORIENTATION
6. Determine the client’s
orientation to time, place, and
person by tactful questioning.

∙ Ask the client the city and state

of residence, time of day, date,
day of the week, duration of
illness, and names of family
members.
 EUFREIN NIÑA RADOC

∙ More direct questioning might

be necessary for some people –
e.g., “Where are you now?”
“What day is it today?”
MEMORY
7. Listen for lapses in
memory.
∙ Ask the client about difficulty
with memory. If problems are
apparent, three categories of
memory are tested: Immediate
recall, recent memory, and
remote memory.

⮚ To assess immediate recall:

▪ Ask the client to repeat a series
of three digits – e.g., 7—4—3 –
spoken slowly.
▪ Gradually increase the number
of digits –e.g., 7—4—3—5, 7—4
—3— 5—6 , and 7—4—3—5—6
—7—2—until the client fails to
repeat the series correctly.
▪ Start again with a series of
three digits, but this time ask the
client to repeat them backward.
▪ The average person can repeat
a series of 5-8 digits in
sequence, and 4-6 digits in
reverse order.

⮚ To assess recent memory:

▪ Ask the client to recall the
recent events of the day, such
as how he got to the clinic. This
information must be validated,
however.
▪ Ask the client to recall
information given early in the
interview—e.g., the name of a
doctor.
▪ Provide the client with three
facts to recall—e.g., a color, an
 EUFREIN NIÑA RADOC

object, an address or a three

digit number – and ask the client
to repeat all three. Later in the
interview, ask the client to repeat
all three items.

⮚ To assess remote memory.

▪ Ask the client to describe a
previous illness or surgery.
ATTENTION SPAN AND
CALCULATION
8. Test the ability to . Normally, an adult can
concentrate or attention span complete the serial
by asking the client to recite the sevens test in about 90
alphabet or to count backward seconds with three or
from 100. Test the ability to fewer errors.
calculate by asking the client to
subtract 7 or 3 progressively
from 100 (i.e., 100, 93, 86, 79, or
100, 97, 94. , 91), a task that is
referred to as serial sevens or
serial threes.
LEVEL OF CONSCIOUSNESS
9. Apply the Glasgow Coma
Scale: An assessment totaling A comatose client scores
∙ Eye response, motor response, 15 points indicates the 7 or less.
verbal response client is alert and
completely oriented.
CRANIAL NERVES  One can not test smell
10. Test the cranial nerves. when upper respiratory
infection or with sinusitis
Cranial Nerve I – Olfactory decreases or loss of
▪ Ask the client to close eyes and smell with tobacco
identify different mild aromas, smoking or cocaine use
such as coffee and vanilla

Cranial Nerve II – Optic

▪ Ask the client to read Snellen’s
chart; check visual fields by
confrontation, and conduct an
opthalmoscopic examination.

Cranial Nerve III – Oculomotor

 EUFREIN NIÑA RADOC

▪ Assess six ocular movements

and pupil reaction.

Cranial Nerve IV – Trochlear

▪ Assess six ocular movements.
unilateral decrease or
Cranial Nerve V – Trigeminal Sensations should be loss of sensation may be
▪ While client looks upward, symmetric; caused by CN V lesion
lightly touch the lateral sclera of
the eye to elicit the blink reflex.
To test light sensation, have the
client close eyes, and wipe a
wisp of cotton over client’s
forehead and paranasal sinuses.
To test deep sensation, use
alternating blunt and sharp ends
of a safety pin over same area.
Cranial Nerve VI – Abducens
▪ Assess directions of gaze.

Cranial Nerve VII – Facial Expressions should be Bell’s palsy causes

▪ Ask the client to smile, raise symmetric; drooping of upper and
the eyebrows, frown, puff out lower face; CVA causes
cheeks, and close eyes tightly. asymmetry.
Ask the client to identify various
taste placed on the tip and sides
of tongue—sugar, salt—and to
identify areas of taste.

Cranial Nerve VIII – Auditory

▪ Assess the client’s ability to
hear the spoken word and the
vibrations of a tuning fork.

Cranial Nerve IX –
Glossopharyngeal
▪ Apply tastes on the posterior
tongue for identification. Ask the
client to move tongue from side
to side and up and down.

Cranial Nerve X – Vagus

▪ Assess with CN IX; Assess the
 EUFREIN NIÑA RADOC

client’s speech for hoarseness.

Cranial Nerve XI – Accessory

▪ Ask the client to shrug
shoulders against resistance
from your hands and to turn
head to the side against
resistance from your hand.
Repeat for the other side.

Cranial Nerve XII –

Hypoglossal
▪ Ask the client to protrude
tongue at midline, then move it
side to side.

REFLEXES
11. Test reflexes using a
percussion hammer,
comparing one side of the
body with the other to
evaluate the symmetry of
response.

Biceps Reflex  Normal response is Hyperreflexia is defined

The biceps reflex test the spinal contraction of the as overactive or
cord level C-5, C-6. biceps muscle and overresponsive reflexes
∙ Partially flex the client’s arm at flexion of the forearm
the elbow, and rest the forearm
over the thighs, placing the palm
of the hand down. Hyporeflexia refers to a
∙ Place the thumb of your condition in which your
nondominant hand horizontally muscles are less
over the biceps tendon. responsive to stimuli.
∙ Deliver a blow (slight downward
thrust) with the percussion
hammer to your thumb.
∙ Observe the normal slight
flexion of the elbow, and feel the
biceps’ contraction through your
thumb.
 EUFREIN NIÑA RADOC

Triceps Reflex  Normal response is

The triceps reflex test the spinal extension of the forearm
cord level C-7, C-8.
∙ Flex the client’s arm at the
elbow, and support it in the palm
of your nondominant hand.
∙ Palpate the triceps tendon
about 2-5 cm (1-2 inches) above
the elbow.
∙ Deliver a blow with the
percussion hammer directly to
the tendon.
∙ Observe for the normal slight
extension of the elbow.

Brachioradialis Reflex Normal response is

The brachioradialis reflex test flexion and supination of
the spinal cord level C-3, C-6. the forearm
∙ Rest the client’s arm in a
relaxed position on your forearm
or on the client’s own leg.
∙ Deliver a blow with the
percussion hammer directly on
the radius 2-5 cm (1-2 inches)
above the wrist or the styloid
process, the bony prominence
on the thumb side of the wrist.
∙ Observe the normal flexion and
supination of the forearm. The
fingers of the hand might also
extend slightly.
Patellar Reflex
The patellar reflex tests the
spinal cord level L-2, L-3, L-4.
∙ Ask the client to sit on the edge
of the examining table so that
legs hang freely.
∙ Locate the patellar tendon
directly below the patella.
∙ Deliver a blow with the
percussion hammer directly to
the tendon.
∙ Observe the normal extension
 EUFREIN NIÑA RADOC

or kicking out of the leg as the

quadriceps muscle contracts.
∙ If no response occurs, and you
suspect the client is not relaxed,
ask the client to interlock fingers
and pull.
Achilles Reflex Normal response is the
The Achilles reflex tests the foot planter flexes
spinal cord level S-1, S-2. against your hand
∙ With the client in the same
position as for the patellar reflex
test, slightly dorsiflex the client’s
ankle by supporting the foot
lightly in your hand.
∙ Deliver a blow with the
percussion hammer directly to
the Achilles tendon just above
the heel.
∙ Observe and feel the normal
plantar flexion (downward jerk)
of the foot.

Plantar (Babinski’s) Reflex

The plantar or Babinski’s reflex Normally, all five toes
is superficial. It might be absent bend
in adults without pathology or downward; this reaction In an abnormal (positive)
overridden by voluntary control. is negative Babinski Babinski response, the
∙ Use a moderately sharp object, toes spread outward and
such as the handle of the the big toe moves
percussion hammer, a key, or upward.
the dull end of a pipn or
applicator stick.
∙ Stroke the lateral border of the
sole of the client’s foot, starting
at the heel, continuing to the ball
of the foot, and then proceeding
across the ball of the foot toward
the big toe.
∙ Observe the response.

MOTOR FUNCTION
12. Gross Motor and Balance
Tests

∙ Walking Gait
Ask the client to walk across the
room and back, and assess the
client’s gait.
∙ Romberg’s Test
Ask the client to stand with feet
together and arms resting at the
sides, first with eyes open, then
closed.
Stand close during this test.
R: This prevents the client
from falling.
∙ Standing On One Foot With
Eyes Closed
Ask the client to close eyes and
stand on one foot, then the
other. Stand close to the client
during test.
∙ Heel—Toe Walking
Ask the client to walk a straight
line, placing the heel of one foot
directly in front of the toes of the
other foot.
∙ Toe or Heel Walking
EUFREIN NIÑA RADOC
Has upright posture and Has poor posture and
steady gait with unsteady, irregular,
opposing arm swing; staggering gait with wide
walks unaided, stance; bends legs only
maintaining balance from hips; has rigid or no
arm
movements
Negative Romberg: may Positive Romberg:
sway slightly but cannot maintain foot
is able to maintain stance; moves the feet
upright posture and foot apart to maintain stance
stance If client cannot maintain
balance with the eyes
shut, client may have
sensory ataxia (lack of
coordination of the
voluntary muscles)
If balance cannot be
maintained whether the
eyes are open or shut,
client may have
Cerebellar ataxia.
Maintains stance for at Cannot maintain stance
least 5 seconds for 5 seconds
Maintains heel-toe Assumes a wider foot
walking along a straight gait to stay upright
line
Able to walk several Cannot maintain balance
 EUFREIN NIÑA RADOC

Ask the client to walk several steps on toes or heels on toes and heels
steps on the toes and then on
the heels.
13. Fine Motor Test for the
Upper Extremities

∙ Finger-to- Nose Test Repeatedly and Misses the nose or gives

Ask the client to abduct and rhythmically touches the slow response
extend arms at shoulder height Nose
and rapidly touch nose
alternately with one index finger
and then the other. Have the
client repeat the test with eyes
closed if the test is performed
easily.

∙ Alternating Supination and Performs with

Pronation of Hands on Knees coordination and
Ask the client to pat both knees rapidity
with the palms of both hands
and then with the backs of the
hands, alternately, at an ever-
increasing rate.

∙ Finger to Nose and to the Performs with accuracy Misses the finger and
Nurse’s Finger and rapidity moves slowly
Ask the client to touch nose and
then your index finger, held at a
distance at about 45 cm (18
inches), at a rapid and
increasing rate.

∙ Fingers to Fingers
Ask the client to spread arms Moves slowly and is
broadly at shoulder height and Rapidly touches each unable to touch fingers
then bring fingers together at the finger to thumb with consistently
midline, first with eyes open and each hand
then closed, first slowly and then
rapidly.

∙ Fingers to Thumb (Same Cannot coordinate this

Hand) fine discrete movement
Ask the client to touch each with either one or both
 EUFREIN NIÑA RADOC

finger of one hand to the thumb hands

of the same hand as rapidly as
possible.

14. Fine Motor Test for the

Lower Extremities
Ask the client to lie supine and
to perform these tests:

∙ Heel Down Opposite Shin Demonstrates bilateral Has tremors or is

Ask the client to place the heel equal coordination awkward; heel moves off
of one foot just below the shin
opposite knee and run the heel
down the shin to foot. Repeat
with the other foot. The client
may also use a sitting position
for this test. Moves smoothly, with Misses your finger;
coordination cannot coordinate
∙ Toe or Ball of Foot to the movement
Nurse’s Finger
Ask the client to touch your
finger with the large toe of each
foot.

15. Light-Touch Sensation

∙ Compare the light-touch

sensation of symmetric areas of Light tickling or touch Anesthesia,
the body. sensation hyperesthesia,
R: Sensitivity to touch varies hypoesthesia,
among different skin areas. or paresthesia
∙ Ask the client to close eyes and
to respond by saying “yes” or
“now” whenever the client feels
the cotton wisp touching skin.
∙ With a wisp of cotton, lightly
touch one specific spot and then
the same spot on the other side
of the body.
∙ Test areas on the forehead,
cheek, hand, lower arm,
abdomen, foot, and lower leg.
Check a distal area of the limb
 EUFREIN NIÑA RADOC

first.
R: The sensory nerve may be
assumed to be intact if
sensation is felt at its most
distal part.
∙ Ask the client to point to the
spot where the touch was felt.
∙ If the areas of sensory
dysfunction are found, determine
the boundaries of sensation by
testing responses approximately
every 2.5 cm (1 inch) in the area.
Make a sketch of the sensory
loss area for recording purposes.

16. Pain Sensation

Assess pain sensation as Able to discriminate Areas of reduced,
follows: “sharp” and “dull” heightened, or absent
sensations sensation (map them out
∙ Ask the client to close his eyes for recording
and to say “sharp”, “dull”, or purposes)
“don’t know” when the sharp or
dull end of the broken tongue
depressor is felt.
∙ Alternately, use the sharp and
dull end of the sterile pin or
needle to lightly prick designated
anatomic areas at random. The
face is not tested in this manner.
∙ Allow at least 2 seconds
between each test.
17. Temperature Sensation

∙ Touch skin areas with test

tubes filled with hot or cold
water.
∙ Have the client respond saying
“hot”, “cold”, or “I don’t know”.
18. Position or Kinesthetic Can readily determine Unable to determine the
Sensation the position of fingers position of one or more
and toes fingers or toes
∙ Commonly, the middle fingers
and the large toes are tested for
 EUFREIN NIÑA RADOC

the kinesthetic sensation.

∙ To test the fingers, support the
client’s arm with one hand and
hold the client’s palm in the
other. To test the toes, place the
client’s heels on the examining
table.
∙ Ask the client to close his eyes.
∙ Grasp a middle finger or a big
toe firmly between your thumb
and index finger, and exert the
same pressure on both sides of
the finger or toe while moving it.
∙ Move the finger or toe until it is
up, down, or straight out, and
ask the client to identify the
position.
∙ Use a series of brisk up-and-
down movements before
bringing the finger or toe
suddenly to rest in one of the
three positions.

19. Tactile Discrimination

For all tests, the client’s eyes
need to be close:

∙ One-and Two-Point
Discrimination
Alternately stimulate the skin
with two pins simultaneously and
then with one pin. Ask whether
the client feels one or two
pinpricks.

∙ Stereognosis
Place familiar objects- such as Normal client can  Inability to identify
key, paper clip, or coin- in the identify the familiar object correctly,
client’s hand, and ask the client object especially in brain stroke
to identify them.
If the client has a motor
impairment of the hand and is
unable to manipulate an object,
 EUFREIN NIÑA RADOC

write a number or letter on the

client’s palm, using a blunt
instrument and ask the client to
identify it.

∙ Extinction Phenomenon
Simultaneously stimulate two
symmetric areas of the body,
such as the thighs, the cheeks,
or the hands.

20. Document findings in the

client record. R: To serve as
evidence or record of what I
did or assess

ASSESSING THE FEMALE GENITALS AND INGUINAL AREA

Equipment
• Clean gloves
• Drape
• Supplemental lighting, if
needed
PROCEDURES NORMAL ABNORMAL
1. Introduce yourself and
verify the client’s identity.
R: To promote the clients
cooperation and to ensure
that the right assessment is
given to the right client.

Explain to the client what

you are going to do, why it
is necessary, and how the
client can cooperate.
 EUFREIN NIÑA RADOC

R: To ensure that the

client is aware on the
procedure
2. Perform hand hygiene
and observe other
appropriate infection
control procedures.
R: To prevent cross
contamination between the
patients.
3. Provide client privacy.
R: To maximize
cooperation and reduce
anxiety of the client.
4. Inquire about the
following:
• Age of onset of
menstruation, last menstrual
period (LMP), regularity of
cycle, duration, amount of
daily
flow, and whether
menstruation is painful
• Incidence of pain during
intercourse
• Vaginal discharge
• Number of pregnancies,
number of live births, labor
or delivery complications
• Urgency and frequency of
urination at night; blood in
urine, painful urination,
incontinence
• History of sexually
 EUFREIN NIÑA RADOC

transmitted infection, past

and present.

5. Cover the pelvic area

with a sheet or drape at all
times when the client is not
actually being examined.
Position the client supine.
6. Inspect the distribution, There are wide Scant pubic hair
amount, and characteristics variations; generally (may indicate
of pubic hair kinky in the hormonal
menstruating adult, problem)
thinner and
straighter
after menopause
Distributed in the
shape of an inverse Hair growth should
triangle not extend over the
abdomen
7. Inspect the skin of the Pubic skin intact, no Lice, lesions, scars,
pubic area for parasites, lesions. fissures, swelling,
inflammation, swelling, and Skin of vulva area erythema,
lesions. To assess pubic slightly darker than excoriations,
skin adequately, separate the rest of the body. varicosities, or
the labia majora and labia Labia round, full, leukoplakia
minora. and relatively
symmetric in
adult females
8. Inspect the clitoris, Clitoris does not Presence of lesions
urethral orifice, and vaginal exceed 1 cm (0.4
orifice when separating the in.) in width and 2
labia minora. cm (0.8 in.) in
length.
 EUFREIN NIÑA RADOC

Urethral orifice
appears as a small
slit and is the same
color as surrounding
tissues.
No inflammation, Presence of
swelling, or inflammation,
discharge swelling, or
discharge
9. Palpate the inguinal No enlargement or Enlargement and
lymph nodes. Use the pads tenderness tenderness
of the fingers in a rotary
motion, noting any
enlargement or tenderness.
10. Remove and discard
gloves. Perform hand
hygiene
Rationale: to prevent spread
of microorganisms
11. Document findings in
the client record using
printed or electronic forms
or checklists supplemented
by narrative notes when
appropriate.
Rationale: To serve as
evidence or record of what
we did or assess.