Health Assessment (Lecture)

STUDENT ACTIVITY SHEET BS NURSING / FIRST YEAR

Session # 20

LESSON TITLE: The Musculoskeletal System (Part 2)

LEARNING OUTCOMES:
Materials:
Upon completion of this lesson, the nursing student can:
Book, pen and notebook, index card/class list
1. Inspect and palpate the joints, bones, and muscles;
2. Describe the range of motion of the major joints; 3. Assess muscle
strength using the muscle strength grading

scale;
4. Correctly document the findings of the musculoskeletal References: Bates’ Nursing Guide to Physical
assessment; Examination and History Taking (Second Edition)
5. Discuss risk factors for osteoporosis and falls; by Beth Hogan-Quigley, Mary Louise Palm, and 6. Discuss
risk reduction and health promotion strategies to Lynn Bickley. reduce musculoskeletal injuries and disease

MAIN LESSON (60 minutes)

The students will study and read Chapter 18 of their book about this lesson:

EXAMINATION OF JOINTS: ANATOMY AND PHYSIOLOGY AND PHYSICAL EXAMINATION

Important Areas of Examination for Each of the Major Joints:

• Inspection for joint symmetry, alignment, bony deformities
• Inspection and palpation of surrounding tissues for skin changes, nodules, muscle atrophy, crepitus
• Range of motion and maneuvers to test joint function and stability, and integrity of ligaments, tendons, bursae,
especially if pain or trauma
• Assessment of inflammation or arthritis, especially swelling, warmth, tenderness, redness
• Assessment of muscle strength

Tips for Successful Examination of the Musculoskeletal System:

• During inspection, look for symmetry of involvement. Is there a symmetric change in joints on both sides of the
body, or is the change only in one or two joints?
o Acute involvement of only one joint suggests trauma, septic arthritis, gout. Rheumatoid arthritis typically
involves several joints, symmetrically distributed.
• Use inspection and palpation to assess the surrounding tissues, noting skin changes, subcutaneous nodules, and
muscle atrophy. Note any crepitus, an audible or palpable crunching during movement of tendons or ligaments
over bone. This may occur in normal joints but is more significant when associated with symptoms or signs.
o Subcutaneous nodules in rheumatoid arthritis or rheumatic fever; effusions in trauma; crepitus over
inflamed joints, in osteoarthritis, or in inflamed tendon sheaths
• Test range of motion and maneuvers (described for each joint) to demonstrate limitations in range of motion or
joint instability from excess mobility of joint ligaments, called ligamentous laxity.
o Decreased range of motion in arthritis, inflammation of tissues around a joint, fibrosis in or around a joint,
or bony fixation (ankylosis). Ligamentous laxity of the anterior cruciate ligament (ACL) in knee trauma.
• Finally, test muscle strength to aid in the assessment of joint function. Be especially alert to signs of inflammation
and arthritis.

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 o Muscle atrophy or weakness in rheumatoid arthritis.
• Swelling. Palpable swelling may involve (1) the synovial membrane, which can feel boggy or doughy; (2) effusion
from excess synovial fluid within the joint space; or (3) soft-tissue structures such as bursae, tendons, and tendon
sheaths.
o Palpable bogginess or doughiness of the synovial membrane indicates synovitis, which is often
accompanied by effusion. Palpable joint fluid in effusion, tenderness over the tendon sheaths in tendinitis
• Warmth. Use the backs of your fingers to compare the involved joint with its unaffected contralateral joint, or with
nearby tissues if both joints are involved. (Felt in arthritis, tendinitis, bursitis, and osteomyelitis)
• Tenderness. Try to identify the specific anatomic structure that is tender. Trauma may also cause tenderness. o
Tenderness and warmth over a thickened synovium suggest arthritis or infection.
• Redness. Redness of the overlying o Redness over a tender joint suggests septic or gouty arthritis, or possible
rheumatoid arthritis.

Muscle Bulk

• Begin the exam by inspecting the size and contours of muscles. Do the muscles look flat or concave, suggesting
atrophy? If so, is the process unilateral or bilateral? Is it proximal or distal?
o Muscular atrophy refers to a loss of muscle bulk, or wasting. It results from diseases of the peripheral
nervous system such as diabetic neuropathy, as well as diseases of the muscles themselves.
Hypertrophy is an increase in bulk with proportionate strength, whereas increased bulk with diminished
strength is called pseudohypertrophy (seen in the Duchenne form of musculardystrophy).
• When looking for atrophy, pay particular attention to the hands, shoulders, and thighs. The thenar and hypothenar
eminences should be full and convex, and the spaces between the metacarpals, where the dorsal interosseous
muscles lie, should be full or only slightly depressed. Atrophy of hand muscles may occur with normal aging,
however, as shown on the right below. Be alert for fasciculations in atrophic muscles. If absent tap on the muscle
with a reflex hammer to stimulate them.
o Flattening of the thenar and hypothenar eminences and furrowing between the metacarpals suggest
atrophy. Localized atrophy of the thenar and hypothenar eminences in median and ulnar nerve damage,
respectively.
o Other causes of muscular atrophy include motor neuron diseases, any disease that affects the peripheral
motor system projecting from the spinal cord, rheumatoid arthritis, and protein-calorie malnutrition.

Muscle Tone.

• When a normal muscle with an intact nerve supply is relaxed voluntarily, it maintains a slight residual tension
known as muscle tone. This can be assessed best by feeling the muscle’s resistance to passive stretch. Persuade
the patient to relax. Take one hand with yours and, while supporting the elbow, flex and extend the patient’s
fingers, wrist, and elbow, and put the shoulder through a moderate range of motion. With practice, these actions
can be combined into a single smooth movement. On each side, note muscle tone—the resistance offered to your
movements. Tense patients may show increased resistance. The feel of normal resistance is learned with
repeated practice.
o Decreased resistance suggests disease of the peripheral nervous system, cerebellar disease, or the
acute stages of spinal cord injury.
• If you suspect decreased resistance, hold the forearm and shake the hand loosely back and forth. Normally the
hand moves back and forth freely but is not completely floppy.
o Marked floppiness indicates muscle hypotonia or flaccidity, usually from a disorder of the peripheral motor
system.
• If resistance is increased, determine whether it varies as you move the limb or whether it persists throughout the
range of movement and in both directions, for example, during both flexion and extension. Feel for any jerkiness
in the resistance.
o Spasticity is increased resistance that worsens at the extremes of range. Spasticity, seen in central
corticospinal tract diseases, is rate dependent, increasing with rapid movement. Rigidity is increased
resistance throughout the range of movement and in both directions (not rate dependent).  To
assess muscle tone in the legs, support the patient’s thigh with one hand, grasp the foot with the other,
and

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 flex and extend the patient’s knee and ankle on each side. Note the resistance to your movements.

Muscle Strength.
• People vary widely in their strength, and the assessment should allow for such variables as age, sex, and
muscular training. A person’s dominant side is usually slightly stronger than the other side. Keep this difference in
mind when comparing sides.
o Impaired strength is called weakness, or paresis. Absence of strength is called paralysis, or plegia.
Hemiparesis refers to weakness of one half of the body; hemiplegia to paralysis of one half of the body.
Paraplegia means paralysis of the legs; quadriplegia, paralysis of all four limbs.
• Test muscle strength by asking the patient to move actively against your resistance or to resist your movement.
Remember that a muscle is strongest when shortest, and weakest when longest.
• If the muscles are too weak to overcome resistance, test them against gravity alone or with gravity eliminated.
When the forearm rests in a pronated position, for example, dorsiflexion at the wrist can be tested against gravity
alone. When the forearm is midway between pronation and supination, extension at the wrist can be tested with
gravity eliminated. Finally, if the patient fails to move the body part, watch or feel for weak muscular contraction.

CHECK FOR UNDERSTANDING (10 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 20 minutes for this activity:

Multiple Choice

1. Which of the following types of arthritis usually has high uric acid serum levels in the blood?
a. Gouty arthritis
b. Rheumatoid arthritis
c. Osteoarthritis
d. Any of the above

ANSWER: A

RATIONALE: Uric acid builds up in the joints and tissues of patients with this illness, causing pain, swelling, and
discoloration. The toe joints, ankles, and knees are the most typically affected by gout.

2. Which of the following is the cause of rheumatoid arthritis in a patient?

a. Overweight or obese body
b. Increased intake of purine rich foods
c. Recent infection
d. Unknown

ANSWER: C

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RATIONALE: Recent infection is the cause of rheumatoid arthritis in a patient, which such infection with certain
viruses and bacteria that may trigger the disease.

3. Tenderness or warmth above a thickened synovium is indicative of which of the following?

a. Arthritis
b. Infection
c. Tendinitis
d. Both a and b

ANSWER: D

RATIONALE: Both arthritis and infection indicate the tenderness or warmth above a thickened synovium.

4. Which of the following conditions have progressive loss of cartilage within the joints causing damage to underlying
bone, and formation of new bone at the margins of the cartilage?
a. Rheumatoid arthritis
b. Osteoarthritis
c. Gouty arthritis
d. Fibromyalgia syndrome

ANSWER: B

RATIONALE: Osteoarthritis is sometimes referred to as a wear-and-tear condition. However, osteoarthritis affects

the entire joint, not only the cartilage. It causes bone changes and the connective tissues that hold the joint
together and connect muscle to bone to deteriorate. Inflammation of the joint lining is also a side effect.

5. Which of the following joints are affected in osteoarthritis?

a. Knees
b. Hips
c. Cervical and lumbar spine
d. All of the above

ANSWER: D

RATIONALE: Osteoarthritis most commonly affects joints in your hands, knees, hips and spine.

6. Which of the following best describes the “swan neck” deformity seen in patients with rheumatoid arthritis?
a. Hyperextension of the proximal interphalangeal joints with fixed flexion of the distal
interphalangeal joints.
b. Persistent flexion of the proximal interphalangeal joint with hyperextension of the distal
interphalangeal joint.
c. Knobby swellings around the joints ulcerate and contains discharges of white chalk-like
urates.
d. It is a thickened plaque overlying the flexor tendon of the ring finger and possibly the little
finger at the level of the distal palmar crease.

ANSWER: A

RATIONALE: Swan neck deformity is characterized by proximal interphalangeal joint hyperextension and flexion
of the distal interphalangeal joint.

7. Which of the following finger abnormalities are seen in patients who have osteoarthritis or degenerative joint
disease?
a. Heberden’s nodes
b. Boutonniere deformity
c. Bouchard’s nodes

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 d. Both a and c

ANSWER: D

RATIONALE: Bouchard's nodes and Heberden's nodes are signs of hand osteoarthritis.

8. Quadriplegia can occur due to injury to the

a. Cervical spine
b. Thoracic spine
c. Lumbar spine
d. Sacral spine

ANSWER: C

RATIONALE: Quadriplegia can result from a lumbar spine injury.

9. When assessing for the muscle strength of a post-stroke patient, the nurse has noticed paralysis in the right half
of the body. The nurse must note this on her chart as
a. Paraplegia
b. Quadriplegia
c. Hemiplegia
d. Hemiparesis

ANSWER: C

RATIONALE: The nurse must note hemiplegia on the chart, because damage to the neurological system causes
hemiplegia, which affects the muscles on the right side of the body.

10. The nurse is assessing the muscle strength of a patient who is post-stroke. The nurse has noticed a barely
detectable flicker or trace of contraction from the muscle. She must grade the patient’s muscle strength as
a. 0

b. 1

c. 2

d. 3

ANSWER: B

RATIONALE: The nurse must grade the patient’s muscle strength as 1, since it barely detectable flicker or trace of
contraction from the muscle.

LESSON WRAP-UP (10 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

Wrapping Up-Student Reflection

1. This time you are going to write 3 important things you learned from today’s session.

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 -In this lesson I have learned all about joints.
- I have learned the scale for grading the muscle strength.
- I have also learned the causes of paraplegia, quadriplegia, hemiplegia, and hemiparesis.

2. After you have completed the task, I will call 3-5 students to share and read out loud the things you have learned from
the session.

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