Musculoskeletal Assessment

Overview
 A&P
 Developmental
 Musculoskeletal Assessment
 Nursing Diagnoses
 Plan and Implement nursing care
 Teaching

Anatomy & Physiology

Musculoskeletal system provides

 support for body

 protection of internal organs
 mobility to engage in physical activities
 production of RBCs
 storage of minerals

 For proper functioning, must be integration between neurologic and

musculoskeletal systems
 M-S system provides mobility and stability through the integration of
muscles, bones and joints which are assessed together

A&P
Structures of the MS System

 Bones - how many ?

 Muscles - myo

voluntary/striated
involuntary/smooth

 joints - arthro

held together by ligaments

  tendons - join muscle to bone
 ligaments and muscles give joint stability
 cartilage - pads joints during weight bearing

A&P
Structures of the MS System

Joint is the functional unit of the MS system

Skeletal muscles attach to each of 2 bones

flexor
extensor

Which is stronger ?

ROM is maximum possible joint movement

Synovial joint motion/ ROM

(freely movable)

 Flexion  Bending a joint; decreases <

 Extension  straightening joint; >
 Hyperextension  moving past extension
 Abduction  moving away from midline
 Adduction  moving toward the midline
 Int. rotation  rotating toward midline
 Ext. rotation  rotating away from midline
 Circumduction  rotating in complete circle

Developmental Considerations
Infants birth - 

Apgar (muscle tone assessed)

Hips- congenital dislocation

walk 12 - 14 mos
wide gait
lack coordination
bowlegged NL > 18 mos

School age 
check for spinal deformities/scoliosis
degree sports participation/injuries

Adolescents injuries, Osgood-Schlatter

Young adults injuries

(check pulses with Fx)

Adult (degenerative)

 degenerative joint disease (DJD)

non-inflammatory
weight bearing joints

 osteoarthritis

inflammation of the joint

 rheumatoid arthritis

systemic disease
chronic inflammation leads to erosion/destruction of joint

 osteoporosis

loss of bone mass; more common after menopause

calcium, exercise

Elderly 

Assess for falls, injuries

changes 20 decreased muscle mass
changes in bone
        collapse of intervertebral discs
        decreased stature
        kyphosis
        barrel chest (increased AP diameter)

Decreased mobility decreased endurance

20 decreased  muscle strength
decreased fear of falling
decreased CV disease
decreased vision
decreased bone mass
 fear falling, death
loss of independence

Musculoskeletal Assessment
 Current concerns
 General health
 Life style/ADL/functional status
o employment (repetitive motions)
o activity level
o recent or past injuries

Generally assess (screen):

o joint inspection/ROM
o muscle strength
o ADL/functional abilities
o activity tolerance

Further assessment based on findings in history and physical exam

History
 Previous occurrences of the problem
 Past history of trauma to bones, joints, nerves, soft tissue
 Orthopedic surgery
 Congential deformities
 Chronic illness
 Pain Assessment
o Frequently the reason for seeking care
o Character
o Intensity
o Precipitating events
o Onset
o Location
o Timing
o Referred pain
o Aggravating factors
o Alleviating factors
 Arthritis
 o osteoarthritis
o rheumatoid
 Gout
 Ankylosing spondylitis
 Congenital Disorders
o hip
o foot
 Scoliosis or back problems

Family History
 Arthritis
 osteoarthritis-disintegration of cartilage that covers ends of bones
 rheumatoid- inflammatory changes in connective tissue
 gout- excessive uric acid production
 ankylosing spondylitis- spine

Risk Factors
 Osteoarthritis
o age > 50
o Family history
o Obesity
o Joint abnormality
o History of trauma, RA, or other degenerative process

 Osteoporosis
o age
o gender
o family history
o estrogen deficiency
o small stature
o race
o Northern European descent
o Heavy cigarette and/or ETOH use
o Poor diet with low Ca intake
o Periods of immobilization
o Use of steroids
o Sedentary lifestyle
Musculoskeletal Assessment
Begins with the meet and greet

 Watch as rise from seat

("get up and go")

 climb onto examining table

 Watch for coordination
 Note speed of movement

Assess muscles, bones and joints of:

spine, shoulder,
posterior iliac crest 
head, neck, thorax
upper extremities
lower extremities

Inspection
Inspect for:

position, deformity
surrounding tissue
swelling
atrophy
ROM

Inspect gait and stance

o gait -characteristic pattern of walk

o stance - posture
o spinal curves

Range of Motion - 
Assessment and Exercises
 Active (isotonic)
 Active-assistive
 Passive
  Static (isometric)
 Resistive

Range of Motion Exercises

 Active (isotonic)  Ask pt to do
 Active-assistive  help pt (or self-help)
 Passive  do for pt
 Static (isometric)  tense muscle without moving joint
 Resistive  builds strength

Range of Motion
Active

 joint movement should be smooth and painless

 ask that joint be moved through full range of movement
 less muscle tension and joint compression is seen with active ROM
compared to movement against resistance
 Rationale for assessing ROM before strength

Passive-

 move relaxed joint through limits of movement

 if ROM is limited try to determine if:
o excess fluid in joint
o loose bodies are present
o joint surface irregularity or contracture of muscle

Palpation
During active or passive ROM, palpate bones, muscles and joints.

Palpate temperature infection, inflammation?

sensation  paresthesia?
edema
crepitus
nodules
strength 0-5 scale, active/resistive
COMPARE, expect dominant side to be
stronger
tone
 tension at rest and passive ROM

Terms related to muscle assessment

 muscle wasting
 Atrophy
 increased muscle mass
 Hypertrophy
 muscle shortening
 Contracture
 involuntary muscle
 Fasciculation
movement

Nursing Diagnoses
 Impaired physical mobility
 Risk for injury
 Pain Chronic Pain
 Activity intolerance
 Risk for disuse syndrome
 Fatigue

 
Range of Motion Exercises
 Nursing order - Frequently encouraged for the bed ridden, immobile
 Frequently incorporated into care
o bathing
o getting OOB
 Support joints
 Avoid pain, overexertion, over extension
 Move joint to point of resistance- not pain

Range of Motion Exercises

Active-Assistive
Active Passive
Independent Some support Full support
       muscle mass        muscle mass        jt mobility

       muscle tone        muscle tone

        muscle    strength        some strength  

       jt mobility jt mobility

 

Musculoskeletal injuries
 Check for fracture
 If fracture check pulses

 Rest
 Ice (20’ on/20’ off) 24 hours
 Compression
 Elevation

Teaching Opportunities
 Risk factors for injury, trauma
 Prevention of injuries
 Risk for osteoporosis
 Benefits of exercise

Musculoskeletal findings
Upright posture, good alignment, no evidence of abnormal spinal curvature.

Symmetrical musculature, equal strength bilaterally. No atrophy, hypertrophy or masses

noted.

Symmetrical joints, full ROM head, neck, spine, upper and lower extremities. No
swelling, tenderness or crepitation. Bones symmetrical, aligned. No tenderness, masses.

Case Study
KA, a 17-yr-old high school gymnast, fell and fractured his L femur several weeks ago.
He has been on bedrest in skeletal traction since then. Because of painful muscle spasms,
he often refuses to be turned or to move voluntarily.

Nursing Diagnosis?
Goals/Expected Outcomes?
Nursing Orders?