PERIPHERAL AND MUSCULOSKELETAL SYSTEM

STEPS 5 4 3 2 1

Preparatory Phase
1 Reassess client's previous medical records if available.
To obtain accurate history of the client’s abdomen. To have significant
implications in preventing medical errors

2 Determine the scope of assessment needed. Prepare necessary equipment.

It is to gather relevant information why patient seeks medical health care

3 Perform hand washing and donned gloves (if deemed necessary).

Reduces transfer of microorganisms

4 Assemble equipment & supplies needed

For organized work place and easy access of the equipment needed

5 Introduce self and verify the client's identity.

Ensures the right patient receives the right assessments. Introducing oneself
eases client anxiety

6 Explain the procedure to the client.

Patient understanding facilitates cooperation. So for this assessment we are going
to assess your peripheral and musculoskeletal areas. Here, I'm going to inspect first,
then auscultate, percuss, and palpate on the assessment area to see if there are
abnormalities present.

7 Position patient comfortably and provides privacy.

To provide comfort and helps build and develop trust

Assessment Phase
ASSESSING PERIPHERAL PERFUSION

Arteries are the blood vessels that carry oxygenated, nutrientrich blood from the heart to the capillaries

The brachial artery is the major artery that supplies the arm. The brachial pulse can be palpated medial to
the biceps tendon in and above the bend of the elbow. The brachial artery divides near the elbow to become
the radial artery (extending down the thumb side of the arm) and the ulnar artery (extending down the little-
finger side of the arm)

Veins are the blood vessels that carry deoxygenated, nutrientdepleted, waste-laden blood from the tissues
back to the heart.

A. ARMS

8 Observe arm size, venous pattern, coloration and edema.

IPA SHOW IYAHA ARMS
Arms are bilaterally symmetric with minimal variation in size and shape.
No edema or prominent venous pattern

Lymphedema results from blocked lymphatic circulation, which may be caused

by breast surgery. Color varies depending on the client’s skin tone, although
color should be the same bilaterally

Raynaud’s disorder is sometimes referred to as a disease, syndrome, or

phenomenon. It is a vascular disorder caused by vasoconstriction or
vasospasm of the fingers or toes, characterized by rapid changes of color
(pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning,
throbbing, and coldness. Raynaud’s affects about 5% of the population and can
often be controlled with minor lifestyle changes.
9 Palpate the client’s fingers, hands, and arms, and note the temperature.

A cool extremity may be a sign of arterial insufficiency. Cold fingers and hands,
for example, are common findings with Raynaud’s

10 Palpate to assess capillary refill time

Compress the nail bed until it blanches then release the pressure and calculate the time it
takes for color to return

Capillary beds refill (and, therefore, color returns) in 2 seconds or less

Capillary refill time exceeding 2 seconds may indicate vasoconstriction,
decreased cardiac output, shock, arterial occlusion, or hypothermia.

11 Palpate the radial pulse.

Gently press the radial artery against the radius and note for elasticity and strength.

Radial pulses are bilaterally strong (2+). Artery walls have a resilient quality (bounce).

Increased radial pulse volume indicates a hyperkinetic state (3+ or bounding pulse).
Diminished (1+) or absent (0) pulse suggests partial or complete arterial occlusion
(which is more common in the legs than the arms).
The pulse could also be decreased from Buerger’s disease or scleroderma

12 Palpate the ulnar pulses.

Apply pressure with your first three fingertips to the medial aspects of the inner wrists.

Obliteration of the pulse may result from compression by external sources, as in

compartment syndrome

13 Palpate the brachial pulses.

Place the first three fingertips of each hand at the client’s right and left medial ante-cubital creases.

Brachial pulses have equal strength bilaterally. Brachial pulses are increased,
diminished, or absent.
14 Perform the Allen test. For blood circulation in the hand.. This determines the ulnar and
radial artery with a healthy blood streaming back to the hand s quickly,

Ask the patient to open and close tha hand several times asap the squeeze the hand
tightly. Then compress the radius and the ulnar arteries with the tumbs. Hold it quicly and
ask the patient to open the hand and release the radial artetry. We can see how the blood
is treaming back into the hand quickly.

Repeat the process and release the ulnar artery.

Pink coloration returns to the palms within 3–5 seconds if the ulnar artery is
patent. Pink coloration returns within 3–5 seconds if the radial artery is patent

B. LEGS
The femoral artery is the major supplier of blood to the legs. Its pulse can be
palpated just under the inguinal ligament.

There are three types of veins: deep veins, superficial veins, and perforator
(or communicator) veins. The two deep veins in the leg are the femoral vein in
the upper thigh and the popliteal vein located behind the knee.

15 Ask the client to lie supine.

16 Drape the groin area and place a pillow under the patient’s head for comfort.

17 Inspect for skin color, hair distribution and lesions or ulcers

Legs are free of lesions or ulcerations.

Pink color for lighter-skinned clients and pink or red tones visible under darker-
pigmented skin. There should be no changes in pigmentation

Pallor, especially when elevated, and rubor, when dependent, suggests arterial
 insufficiency. Cyanosis when dependent suggests venous insufficiency. A rusty or
brownish pigmentation around the ankles indicates venous insufficiency

18 Inspect and palpate for edema and note for veins, tendons, and bony
prominences. If appears asymmetric, use a centimetre tape to measure in four different
areas: mid-thigh, calf, ankle and forefoot.

Identical size and shape bilaterally; no swelling or atrophy. Bilateral

edema may be detected by the absence of visible veins, tendons, or bony
prominence.

Unilateral edema is characterized by a 1-cm difference in measurement at

the ankles or a 2-cm difference at the calf, and a swollen extremity. It is
usually caused by venous stasis due to insufficiency or an obstruction. It
may also be caused by lymphedema

Pitting edema is associated with systemic problems, such as congestive

heart failure or hepatic cirrhosis, and local causes such as venous stasis
due to insufficiency or obstruction or prolonged standing or sitting
(orthostatic edema

19 Palpate bilaterally for temperature of the feet and legs.

Generalized coolness in one leg or change in temperature from warm to cool as

you move down the leg suggests arterial insufficiency. Increased warmth in the
leg may be caused by superficial thrombophlebitis resulting from a secondary
inflammation in the tissue around the vein

20 Palpate the superficial inguinal lymph nodes.

Nontender, movable lymph nodes up to 1 or even 2 cm are commonly palpated.

Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy)
may be from a local infection or generalized lymphadenopathy. Fixed nodes may
indicate malignancy

21 Palpate the femoral pulses.

Ask patient to bend the knee and move it out to the side.

Femoral pulses strong and equal bilaterally. Weak or absent femoral pulses
indicate partial or complete arterial occlusion.
22 Auscultate the femoral pulses.
If arterial occlusion is suspected in the femoral pulse, position the stethoscope over the femoral artery and
listen for bruits.

Bruits over one or both femoral arteries suggest partial obstruction of the vessel
and diminished blood flow to the lower extremities.

23 Palpate the popliteal pulses.

Ask the patient to raise (flex) the knee partially and place your thumbs on the knee while
positioning your fingers deep in the bend of the knee.

It is not unusual for the popliteal pulse to be difficult or impossible to detect,

and an absent pulse may also be the result of an occluded artery. No
sounds auscultated over the femoral arteries.

24 Palpate the dorsalis pedis pulses.

Dorsiflex the client’s foot and apply light pressure lateral to and along the side of the extensor
tendon of the big toe.

Dorsalis pedis pulses are bilaterally strong. This pulse is congenitally absent in
5%–10% of the population. A weak or absent pulse may indicate impaired
arterial circulation. Further circulatory assessments (temperature and color) are
warranted to determine the significance of an absent pulse

STEPS 5 4 3 2 1

25 Palpate the posterior tibial pulses.

Palpate behind and just below the medial malleolus.

The posterior tibial pulses should be strong bilaterally. However, in about 15%
of healthy clients, the posterior tibial pulses are absent

A weak or absent pulse indicates partial or complete arterial occlusion.

26 Inspect for varicosities and thrombophlebitis
Ask the patient to stand because varicose veins may not be visible when the patient is supine and sitting.

Varicose veins may appear as distended, nodular, bulging, and tortuous,

depending on severity. Varicosities are common in the anterior lateral thigh and
lower leg, the posterior lateral calf, or anus (known as hemorrhoids).

Superficial vein thrombophlebitis is marked by redness, thickening, and

tenderness along the vein. Aching or cramping may occur with walking. Swelling
and inflammation are often noted

ASSESSING ARTERIAL INSUFFICIENCY

27 Perform Position Change Test

Place one forearm under both of the client’s ankles and the other forearm
underneath the knees. Raise the legs about 12 inches above the level of the
heart. As you support the client’s legs, ask the client to pump the feet up and
down for about a minute to drain the legs of venous blood, leaving only arterial
blood to color the legs

28 Perform Manual Compression Test

If the client has varicose veins, perform manual compression to assess the
competence of the vein’s valves. Ask the client to stand. Firmly compress the
lower portion of the varicose vein with one hand. Place your other hand 6–8
inches above your first hand (Fig. 22-26). Feel for a pulsation to your fingers in
the upper hand. Repeat this test in the other leg if varicosities are present

29 Perform Trendelenburg Test

 No pulsation is palpated if the client has competent valves. Abnormally, You will feel a
pulsation with your upper fingers if the valves in the veins are incompetent.

Saphenous vein fills from below in 30 seconds. If valves are competent, there will be
no rapid filling of the varicose veins from above (retrograde filling) after removal of
tourniquet

MUSCULOSKELETAL SYSTEM

The musculoskeletal system is made up of 650 skeletal (voluntary) muscles, which are under conscious
control

30 Assess patient’s gait (base of support, foot position, stride and length, arm swing and posture)

We have scissrors gait, ■ Knees adduct and meet or cross like scissors
Spatic gait- ■ Unilaterally stiff, dragging leg from leg, muscle hypertonicity
Waddling gait- ■ Ducklike walk with wide base of support
Steppage gaut- Foot drop with external rotation of hip and hip and knee flexio

Stand straight, bend at waist, let the patient walk, romborg testing. Let the patient stand straight
and close eyes. Patt the thigh and supinate the hand and pronation of hands., toe tapping,
running heel down shin, finger thumb opposition

Evenly distributed weight. Client able to stand on heels and toes. Toes point straight
ahead. Equal on both sides. Posture erect, movements coordinated and rhythmic,
arms swing in opposition, stride length appropriate.

A. Upper Extremities

31 Inspect, palpate and test ROM - TMJ.

. Inspect size, shape, color, and symmetry. Note any masses, deformities, or muscle
atrophy. Palpate for edema, heat, tenderness, pain, nodules, or crepitus..
Ask the client to open the mouth as widely as possible
Snapping and clicking may be felt and heard in the normal client.

Mouth opens 1–2 inches (distance between upper and lower teeth). The client’s mouth
opens and closes smoothly. Jaw moves laterally 1–2 cm. Jaw protrudes and retracts
easily.

(B) Move the jaw from side to side.

(C) Protrude (push out) and retract (pull in) jaw

Test ROM. Ask the client to open the mouth and move the jaw laterally against
resistance. Next, as the client clenches the teeth, feel for the contraction of the
temporal and masseter muscles to test the integrity of cranial nerve V (trigeminal
nerve).
 Decreased ROM, and a clicking, popping, or grating sound may be noted with TMJ
dysfunction.

32 Inspect, palpate and test ROM - Sternoclavicular Joint.

inspect the sternoclavicular joint for location in midline, color, swelling, and masses.
Then palpate for tenderness or pain.

There is no visible bony overgrowth, swelling, or redness; joint is nontender.

So if the patient with restricted end range of elevation may have altered mechanics of
SC joint that need to be restricted

33 Inspect, palpate and test ROM - Cervical Spine.

Cervical and lumbar spines are concave; thoracic spine is convex. Spine is straight
(when observed from behind).

A flattened lumbar curvature may be seen with a herniated lumbar disc or ankylosing
spondylitis..
. Test ROM of the cervical spine by asking the client to touch the chin to the chest
(flexion) and to look up at the ceiling (hyperextension)
Maam, I wil be doing some muscle movements please repeat after me. Can you turn
your head up down, side to the other side on your shoulder please..

Flexion of the cervical spine is 45 degrees. Extension of the cervical spine is 45

degrees.

Cervical strain is the most common cause of neck pain

Impaired ROM and neck pain associated with fever, chills, and headache could be
indicative of a serious infection such as meningitis
34 Inspect, palpate and test ROM - Thoracic Spine.

Test ROM of the thoracic and lumbar spine. Ask the client to bend forward and touch
the toes

tabilize the client’s pelvis with your hands, and ask the client to bend sideways (lateral
bending), bend backward toward you (hyperextension), and twist the shoulders one
way then the other (rotation).

Flexion of 75–90 degrees, smooth movement, lumbar concavity flattens out, and the
spinal processes are in alignment.

Lateral curvature of the thoracic spine with an increase in the convexity on the curved
side is seen in scoliosis
An exaggerated thoracic curve (kyphosis) is common with aging.

36 Inspect, palpate and test ROM - Lumbar Spine.

An exaggerated lumbar curve (lordosis) is often seen in pregnancy or obesity

36 Inspect, palpate and test ROM - Shoulders.

75 to 90 degrees of flexion, smooth movement. ■ 30 degrees of hyperextension. ■ 35

degrees of left and right lateral bending. ■ 30 degrees of left and right rotation.

Palpate for tenderness, swelling, or heat. Anteriorly palpate the clavicle,

acromioclavicular joint, subacromial area, and the biceps. Posteriorly palpate the
glenohumeral joint, coracoid area, trapezius muscle, and the scapular area.
37 Inspect, palpate and test ROM - Arms.

38 Inspect, palpate and test ROM - Elbows. With the elbow relaxed and flexed about 70
degrees, use your thumb and middle fingers to palpate the olecranon process and
epicondyles.
38 Inspect, palpate and test ROM – Wrists S
igns of a wrist fracture include pain, tenderness, swelling, and inability to hold a grip;
as well as pain that goes away and then returns as a deep, dull ache

Palpate the anatomic snuffbox (the hollow area on the back of the wrist at the base of
the fully extended thumb

40 Inspect, palpate and test ROM – Hands and Fingers

20 degrees of abduction. ■ Adduction of fingers. ■ 90 degrees of flexion. ■ 30 degrees
of hyperextension. ■ Easily moves away from other fingers, palmar abduction. ■ 50
degrees of flexion, palmar adduction. ■ Full ROM against resistance. ■
5 muscle strength

TESTS FOR CARPAL TUNNEL SYNDROME

41 Perform Phalen’s test

Ask the client to rest elbows on a table and place the backs of both hands against
each other while flexing the wrists 90 degrees with fingers pointed downward and
wrists dangling. Have the client hold this position for 60 seconds.

If symptoms develop within a minute with Phalen’s test, carpel tunnel syndrome is
suspected

42 Perform Test for Tinel’s sign

Use your finger to percuss lightly over the median nerve

Tingling or shocking sensation experienced with test for Tinel’s sign

43 Perform Test for thumb weakness
Ask the patient to raise thumb up from the plane of the palm and stretch the thumb
so that its pad rests on the pad of the little finger pad.

AN abnormal finding of this is the client cannot raise the thumb up from the plane and
stretch the thumb pad to the little finger pad. This indicates thumb weakness in
carpal tunnel syndrome

B. Lower Extremities
44 Inspect, palpate and test ROM – Hips

Buttocks are equally sized; iliac crests are symmetric in height. Hips are stable,
nontender, and without crepitus. Tenderness, edema, decreased ROM, and crepitus
are seen in hip inflammation and DJD.

45 Inspect, palpate and test ROM – Knees

 Swelling above or next to the patella may indicate fluid in the knee joint or thickening
of the synovial membrane Tenderness and warmth with a boggy consistency may be
symptoms of synovitis. Asymmetric muscular development in the quadriceps may
indicate atrophy.

46 Inspect, palpate and test ROM – Ankles and Feet

Tender, painful, reddened, hot, and swollen metatarsophalangeal joint of the great toe
is seen in gouty arthritis. Nodules of the posterior ankle may be palpated with
rheumatoid arthritis

Assess the metatarsophalangeal joints by squeezing the foot from each side with your
thumb and fingers. Palpate each metatarsal, noting swelling or tenderness. Palpate
the plantar area (bottom) of the foot, noting pain or swelling

Point toes upward (dorsiflexion) and then downward (plantarflexion, Fig. 24-31A). •
Turn soles outward (eversion) and then inward (inversion, Fig. 24-31B). • Rotate foot
outward (abduction) and then inward (adduction, Fig. 24-31C). • Turn toes under foot
(flexion) and then upward (extension).

Hyperextension of the metatarsophalangeal joint and flexion of the proximal

interphalangeal joint is apparent in hammer toe

TEST FOR SWELLING

47 Perform the Bulge Test. Performing the “bulge” knee test:

This is done due to accumulation of fluid or soft-tissue swelling, , use the ball of your
hand firmly to stroke the medial side of the knee upward, three to four times, to displace
any accumulated fluid
 (A) stroking the knee; (B) observing the medial side for bulging.

48 Perform the Ballottement Test.

This test helps to detect large amounts of fluid in the knee. With the client in a supine
position, firmly press your nondominant thumb and index finger on each side of the
patella. Then with your dominant fingers, push the patella down on the femur

A positive ballottement test may be present with meniscal tears

Bend each knee up (flexion) toward buttocks or back. • Straighten the knee
(extension/hyperextension)

TEST FOR PAIN AND INJURY

49 Perform McMurray’s Test

 Then place your thumb and index finger of one hand on either side of the knee. Use
your other hand to hold the heel of the foot up. Rotate the lower leg and foot laterally.
Slowly extend the knee, noting pain or clicking. Repeat, rotating lower leg and foot
medially. Again, note pain or clicking

Pain or clicking is indicative of a torn meniscus of the knee

Termination Phase
50 Review the information obtained during the assessment phase and discussed findings to the
client. Present to the client possible plans to resolve health concern, if present.
Assessment is the first and most critical step of nursing process.
Accuracy of assessment data affects all other phases of the nursing
process.
51 Measure client's understanding of the plan and the need for further teaching. Provide the client
the opportunity to clarify, ask or raise any concern
To know the effectiveness of the plan to the client and also to further assess
the client's knowledge and understanding of the plan.

52 End the interview politely.

To ensure the collaboration of the patient with the continuity of care and
shows respect.

53 Do after care. Fix the equipment used and arrange it properly.

Provides patient comfort and promotes organization of equipment

54 Perform hand washing.

Hand hygiene reduces transmission of microorganisms

55 Document the findings in the client’s record.

Provides information to the health care provider and promotes continuity of care.

TOTAL

References:
Dillon, P. (2006). Nursing Health Assessment: A Critical Thinking, Case Studies Approach, 2nd Ed. Philadelphia: F A
Davis. Weber, Janet R. (2014). Health Assessment in Nursing, 5th Edition. Philadelphia: Lippincott Williams & Wilkins.
Weber, Janet R. (2018). Health Assessment in Nursing, 6th Edition. Philadelphia: Lippincott Williams & Wilkins.