1.

MUSCULO-SKELETAL SYSTEM

Performance

a. Prior to performing the procedure, introduce self and verify the client’s identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can
participate. Discuss how the results will be used in planning further care or treatments

b. Perform hand hygiene and observe other appropriate infection prevention procedures.

c. Provide for client privacy.

d. Inquire if the client has any history of the following: muscle pain: onset, location, character,
associated phenomena (e.g., redness and swelling of joints), and aggravating and alleviating factors;
limitations to movement or inability to perform activities of daily living; previous sports injuries; loss of
function without pain.

MUSCLES

Assessment Normal Findings Deviations from Normal

Inspect the muscles for size. Equal size on both sides of Atrophy (a decrease in size) or
Compare the muscles on one side of body hypertrophy (an increase in
the body (e.g., of the arm, thigh, and size), asymmetry
calf) to the same muscle on the
other side. For any discrepancies,
measure the muscles with tape.
6. Inspect the muscles and tendons No contractures Malposition of body part, e.g.,
for contractures (shortening). foot drop (foot flexed
downward
7. Inspect the muscles for tremors, No tremors Presence of tremor
for
Example by having the client hold
the arms out in front of the body.
8. Test muscle strength. Compare Equal strength on each body Grading Muscle Strength
the right side with the left side. side 0: 0% of normal strength;
Sternocleidomastoid: Client turns complete
the paralysis
head to one side against the 1: 10% of normal strength; no
resistance of your hand. Repeat with movement,
the other side. contraction of muscle is
Trapezius: Client shrugs the palpable or visible
shoulders against the resistance of 2: 25% of normal strength; full
your hands. muscle
Deltoid: Client holds arm up and movement against gravity,
resists while you try to push it down. with support
Biceps: Client fully extends each arm 3: 50% of normal strength;
and tries to flex it while you attempt normal
to hold arm in extension. movement
against gravity
Triceps: Client flexes each arm and 4: 75% of normal strength;
then tries to extend it against your normal full
attempt to keep arm in flexion. movement against gravity and
Wrist and finger muscles: Client against
spreads the fingers and resists as minimal
you attempt to push the fingers resistance
together. 5: 100% of normal strength;
Grip strength: Client grasps your normal full
index and middle fingers while you movement against gravity and
try to pull the fingers out. against full
Hip muscles: Client is supine, both resistance
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. 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.
BONES No deformities Bones misaligned
9. Inspect the skeleton for structure.
10. Palpate the bones to locate any No tenderness or swelling Presence of tenderness or
areas of edema or tenderness. swelling
(may indicate fracture,
neoplasms, or
osteoporosis)
JOINTS No swelling One or more swollen joints
11. Inspect the joint for swelling. No tenderness, swelling, Presence of tenderness,
Palpate each joint for tenderness, crepitation, or nodules Joints swelling,
smoothness of movement, swelling, move smoothly crepitation, or nodules
crepitation, and presence of
nodules.
 12.Assess joint range of motion. Varies to some degree in Limited range of motion in
• Ask the client to move selected accordance with a person’s one or more joints
body parts. genetic makeup and degree
• The amount of joint movement of physical activity
can be measured by a goniometer, a
device that measures the angle of a
joint in degrees.
13. Document findings in the client
record using printed or electronic
forms or checklists supplemented by
narrative notes when appropriate.

1. FEMALE GENITALS AND INGUINAL AREA

The examination of the genitals and reproductive tract of women includes assessment of the inguinal
lymph nodes and inspection and palpation of the external genitals. Completeness of the assessment of
the genitals and reproductive tract depends on the needs and problems of the individual client. In most
practice settings, generalist nurses perform only inspection of the external genitals and palpation of the
inguinal lymph nodes.

For sexually active adolescent and adult women, a Papanicolaou test (Pap test) is used to detect cancer
of the cervix. If there is an increased or abnormal vaginal discharge, specimens should be taken to check
for a sexually transmitted infection. Examination of the genitals usually creates uncertainty and
apprehension in women, and the lithotomy position required for an internal examination can cause
embarrassment. The nurse must explain each part of the examination in advance and perform the
examination in an objective, supportive, and efficient manner. Not all agencies permit male practitioners
to examine the female genitals.

Performance

1. Prior to performing the procedure, introduce self and verify the client’s identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how she can
participate. Discuss how the results will be used in planning further care or treatments.

2. Perform hand hygiene, apply gloves, and observe other appropriate infection prevention
procedures.

3. Provide for client privacy. Request the presence of another health care provider if desired,
required by agency policy, or requested by 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 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 in supine

ASSESSMENT NORMAL FINDINGS DEVIATION FROM NORMAL

6.Inspect the distribution, amount,
and characteristics of pubic hair.
7.Inspect the skin of the pubic area
for parasites, inflammation,
swelling, and lesions.
To assess pubic skin adequately,
separate the labia majora and labia
minora
8.Inspect the clitoris, urethral
orifice, and vaginal orifice when
separating the labia
minora.
There are wide variations, Scant pubic hair
generally kinky in the
menstruating adult, thinner Hair growth should not extend
and straighter after over the abdomen
menopause.
Distributed in the shape of an
inverse triangle
Pubic skin intact, no lesions Lice, lesions, scars, fissures,
swelling, erythema,
Skin of vulva area slightly excoriations, varicosities, or
darker than the rest of the leukoplakia
body
Labia round, full, and
relatively symmetric in adult
females
Clitoris does not exceed 1 cm Presence of lesions
(0.4 in.) in width and 2 cm
(0.8 in.) in length Presence of inflammation,
swelling, or discharge
Urethral orifice appears as a
small slit and is the same
color as surrounding tissues

No inflammation, swelling, or
discharge
9.Palpate the inguinal lymph nodes. No enlargement or Enlargement and tenderness
Use the pads of the fingers tenderness
in a rotary motion, noting
any enlargement or
tenderness
10.Remove and discard gloves.
Perform hand hygiene
2. MALE GENITALIA and RECTUM (Anus, rectum, and prostate): Bowel habits, pain with defecation,
hemorrhoids, blood in stool, constipation, diarrhea

ANUS

Assessment Normal Findings Deviations from Normal

Palpate the anus. Inform the client Client’s sphincter relaxes, Sphincter tightens, making
that you are going to perform the permitting entry. further examination
internal examination at this point. unrealistic.
Explain that it may feel like his or
her bowels are going to move but Examination finger cannot
that this will not happen. Lubricate enter the anus.
your gloved index finger; ask the If severe pain prevents your
client to bear down. As the client entrance to the anus, do not
bears down, place the pad of your force the examination.
index finger on the anal opening
and apply slight pressure; this will
cause relaxation of the sphincter
Never use your fingertip—this
causes the sphincter to tighten
and, if forced into the rectum, may
cause pain.
When you feel the sphincter relax, Examination finger enters Po poor sphincter tone may be
insert your finger gently with the anus. the result of a spinal cord
pad facing down injury, previous surgery,
trauma, or a prolapsed
rectum. Tightened sphincter
tone may indicate anxiety,
scarring, or inflammation.
If the sphincter does not relax and
the client reports severe pain,
spread the gluteal folds with your
hands in close approximation to
the anus and attempt to visualize a
lesion that may be causing pain. If
tension is maintained on the
gluteal folds for 60 seconds, the
anus will dilate normally.

Ask the client to tighten the The client can normally close
external sphincter; note the tone. the sphincter around the

Rotate finger to examine the
muscular anal ring. Palpate for
tenderness, nodules, and hardness.
gloved finger.
The anus is normally smooth,
nontender, and free of
nodules and hardness.
Tenderness may indicate
hemorrhoids, fistula, or
fissure. Nodules may indicate
polyps or cancer. Hardness
may indicate scarring or
cancer.

RECTUM

Assessment Normal Findings Deviations from Normal

Palpate the rectum. Insert your This area is normally smooth Hardness and irregularities
finger further into the rectum as and nontender. may be from scarring or
far as possible. Next, turn your cancer. Nodules may indicate
hand clockwise then polyps or cancer.
counterclockwise. This allows
palpation of as much rectal surface
as possible. Note tenderness,
irregularities, nodules, and
hardness.
Palpate the peritoneal cavity. This A peritoneal protrusion into
area may be palpated in men the rectum, called a rectal
above the prostate gland in the shelf, may indicate a
area of the seminal vesicles on the cancerous lesion or peritoneal
anterior surface of the rectum. In metastasis. Tenderness may
women, this area may be palpated indicate peritoneal
on the anterior rectal surface in the inflammation.
area of the recto-uterine pouch
(behind the cervix and the uterus).
Note tenderness or nodules.

3. NEUROLOGICAL ASSESSMENT

Three major considerations determine the extent of a neurologic exam:

1. the client’s chief complaints,

2. the client’s physical condition (i.e., level of consciousness and ability to ambulate) because many parts
of the examination require movement and coordination of the extremities,

3. The client’s willingness to participate and cooperate.

Examination of the neurologic system includes assessment of:

a. mental status including level of consciousness,

b. the cranial nerves,

c. reflexes,

d. motor function,

e. sensory function.

Performance

1. Prior to performing the procedure, introduce self and verify the client’s identity. Explain to the
client what you are going to do, why it is necessary, and how he or she can participate.

2. Perform hand hygiene and observe other appropriate infection prevention procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following: presence of pain in the head, back, or
extremities, as well as onset and aggravating and alleviating factors; disorientation to time, place, or
person; speech disorder; loss of consciousness, fainting, convulsions, trauma, tingling or numbness,
tremors or tics, limping, paralysis, uncontrolled muscle movements, loss of memory, mood swings; or
problems with smell, vision, taste, touch, or hearing.

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”).

6. 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.

affect calculating ability, this test may be inappropriate for

some people.

7. Apply the Glasgow Coma Scale: eye response, motor response, and verbal response.
Assessment Normal Findings Deviation from Normal
Gross Motor and Balance Tests
Generally, the Romberg test
and one other gross motor
function and balance tests are
used.
WALKING GAIT
Ask the client to walk across the Has upright posture and steady Has poor posture and unsteady,
room and back, and assess the gait with opposing arm swing; irregular, staggering gait with
client’s gait. walks unaided, maintaining wide stance; bends legs only
balance from hips; has rigid or no arm
movement
HEEL-TOE WALKING
Ask the client to walk a straight Maintains heel-toe walking Assumes a wider foot gait to
line, placing the heel of one foot along a straight line stay upright
directly in front of the toes of
the other foot
TOE OR HEEL WALKING
Ask the client to walk several Able to walk several steps on Cannot maintain balance on
steps on the toes and then on toes or heels toes and heels
the heels.
FINGER-TO-NOSE TEST
Ask the client to abduct and Repeatedly and rhythmically Misses the nose or gives slow
extend the arms touches the response
at shoulder height and then nose
rapidly touch the nose
alternately with one index
finger and then the other. The
client repeats the test with the
eyes closed if the test is
performed easily.
FINGER-TO-NOSE AND TO
THE NURSE’S FINGER Performs with coordination and Rapidity misses the finger and
Ask the client to touch the nose rapidity moves slowly
and then your
index finger, held at a distance
of about 45 cm
(18 in.), at a rapid and
increasing rate.
FINGERS-TO-FINGERS
Ask the client to spread the Performs with accuracy and Moves slowly and is unable to
arms broadly at shoulder height rapidity touch fingers
and then bring the fingers consistently
together at the midline, first
with the eyes open and then
closed, first slowly and then
rapidly.
FINGERS-TO-THUMB (SAME
HAND) Rapidly touches each finger to Cannot coordinate this fine
Ask the client to touch each thumb with discrete movement
finger of one hand to the thumb each hand with either one or both hands
of the same hand as rapidly
as possible.
HEEL DOWN OPPOSITE SHIN
Ask the client to place the heel Demonstrates bilateral equal Has tremors or is awkward; heel
of one foot just below the coordination moves
opposite knee and run the heel off shin
down the shin to the foot.
Repeat with the other foot. The
client may also use a sitting
position for this test.
TOE OR BALL OF FOOT TO
THE NURSE’S FINGER Moves smoothly, with Misses your finger; cannot
Ask the client to touch your coordination coordinate
finger with the movement
large toe of each foot.
Light-Touch Sensation
Compare the light-touch
sensation of symmetric areas of Light tickling or touch sensation Anesthesia, hyperesthesia,
the body. hypoesthesia, or paresthesia
Pain Sensation
Assess pain sensation as
follows: Able to discriminate “sharp” Areas of reduced, heightened,
• Ask the client to close the and “dull” or absent sensation
eyes and to say “sharp,” sensations
“dull,” or “don’t know” when
the sharp or dull end of a
safety pin is felt.
• Alternately, use the sharp and
dull end to lightly prick
designated anatomic areas at
random (e.g., hand, forearm,
foot, lower leg, abdomen).
• Allow at least 2 seconds
between each test to prevent
summation effects of stimuli
Position or Kinesthetic
Sensation
Commonly, the middle fingers Can readily determine the Unable to determine the
and the large toes are tested for position of fingers position of one or
the kin aesthetic sensation and toes more fingers or toes
(sense of position).
• To test the fingers, support
the client’s arm and hand with
one hand. To test the toes,
place the client’s heels on
the examining table.
• Ask the client to close the
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.