ASSESSING THE MUSCULOSKELETAL SYSTEM

For the ASSESSMENT, assemble equipment like goniometer. Explain to client

what you are going to do. Perform hand hygiene
For PLANNING, Provide client privacy
Determine client history of the following like: history or presence of muscle pain,
limitations to movement related to ADL.
Sports injuries or loss of functions without pain.
For IMPLEMENTATION,
Inspect muscle for size. Compare each muscle on one side of the body to same
muscle on other side.
Inspect muscle and tendons for contractures. Inspect muscles for fasciculations
or tremors.
Inspect any tremors on hands and arms by holding arms out in front of body.
Test muscle strength. Compare right with left side.
Inspect skeleton for normal structures and deformities. Palpate bones to locate
areas of edema or tenderness.
Inspect joint for swelling. Palpate each joint for tenderness, smoothness,
movement, swelling, crepitation and nodules.
Assess joint range of motion. Ask client to move selected body parts. Use
goniometer to measure angle of joint in degrees.
For EVALUATION, Document findings in client record
 ASSESSING THE NEUROLOGICAL SYSTEM
For ASSESSMENT, Assemble equipment and supplies: Percussion hammer, Tongue depressors
(one broken diagonally, for testing pain sensation)
Wisps of cotton, Test tubes of hot and cold water,
Explain to the client what you are going to do, why it is necessary, perform hand hygiene.
For PLANNING, Provide for client privacy. Determine client's history of the following.
Presence of pain in the head, back or extremities, Disorientation to time, place or person
Speech disorders, Any history of loss of consciousness, Alterations in smell, vision, taste, touch, or
hearing
For IMPLEMENTATION
QUALITY LANGUAGE - 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,
Orientation - Determine the client's orientation to time, place, and person, Ask the client the city and
sate of residence, time of day, date, day of the week, duration of illness, and names of family
members.
MEMORY - Listen for lapses in memory. Ask the client about difficulty with memory.
To assess immediate recall: Ask the client to repeat a series of three digits .Gradually increase the
number of digits
Start again with a series of three digits, but this time ask the client to repeat them backward.
To assess recent memory, Ask the client to recall the recent events of the day,
To assess remote memory: Ask the client to describe a previous illness or surgery.
ATTENTION SPAN AND CALCULATION -
Test the ability to concentrate or attention span by asking the client to recite the alphabet or to count
backward from 100-2.Test the ability to calculate by asking the client to subtract 7 or 3 progressively
from 100
LEVEL OF CONCIOUSNESS - Apply the Glasgow Coma Scale. And Cranial Nerves
Test Cranial Nerves
1. Cranial Nerve I – Olfactory - Ask client to close eyes and identify different mild aromas, such as
coffee, vanilla
2. Cranial Nerve II – Optic. Ask client to read Snellen's Chart, check visual fields by confrontation,
and conduct an ophthalmoscopic examination.
3. Cranial Nerve III – Oculomotor - Assess six ocular movements and pupil reaction.
4. Cranial Nerve IV – Trochlear - Assess six ocular movements.
5. Cranial Nerve V – Trigeminal - Sensory Function With the person's eyes closed, test light touch
sensation by touching a cotton wisp to these designated areas on person's face: forehead and chin.
6. Corneal Function - Omit this test, unless the person has abnormal facial sensation or
abnormalities of facial movement
7. Motor Function - Assess the muscles of mastication by palpating the tomporal and masseter
muscles as the person clenches the leth. Next, try to separate the jaws by pushing down on the chin;
normally you cannot
8. Cranial Nerve VI – Abducens - Assess directions of gaze.
9.Cranial Nerve VII – Facial Motor function - Ask client to smile, raise the eyebrows, frown, puff out
his cheeks, close his eyes tightly.
10. Sensory function - Ask client to identify various tastes place on tip and sides of tongue - sugar,
salt - and identify areas of taste.
11.Cranial Nerve VIII – Auditory - Assess client's ability to hear spoken word and vibrations of tuning
fork.
12.Cranial Nerve IX – Glossopharyngeal - Apply tastes on posterior tongue for identification Ask
client to move tongue from side to side and up and down.
13.Cranial Nerve X – Vagus Assessed with CN IX; assess client's speech for hoarseness.
14.Cranial Nerve XI – Accessory Ask client to shrug shoulders against resistance from your hands
and to turn his head to side against resistance from your hand.
15.Cranial Nerve XII – Hypoglossal - Ask client to protrude his tongue at midline, then move it side to
side.
REFLEXES - Test reflexes using a percussion hammer, comparing one side of the body with the
other to evaluate the symmetry of response.
Biceps Reflex
• Partially flex the client's arm at the elbow, and rest the forearm over the thighs, placing the
palm of the hand down
• Place the thumb of your nondominant hand horizontally over the biceps tendon.
• Deliver a blow (slight downward thrust) with the percussion hammer to your thumb.
• Observe the normal slight flexion of the elbow and fell the bicep's contraction through your
thumb.
Triceps Reflex
• Flex 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 in) 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
• 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 in) 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
Patellar Reflex
• Ask the client to sit on the edge of the examining table so that his legs hang freely.
• Locate the patellar tendon. Deliver a blow with the percussion hammer directly to the tendon.
• Observe the normal extension 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 the
fingers and pull.
Achilles Reflex
• slightly dorsiflex the client's ankle by supporting the foot lightly in the hand. Deliver a blow
with the percussion hammer direcily to the Achilles tendon just above the heel.
• Observe and feel the normal plantar flexion (downward jerk) of the foot.
Plantar (Babinski) Reflex
• 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. Normally, all five toes bend downward; this reaction is negative
Babinski's. in an abnormal Babinski response, the toes spread outward and the big toe
moves upward.
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.
Standing on one foot with eyes closed - Ask the client to close his eyes and stand on one foot,
then the other.
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 - Ask the client to walk several steps on the toes and then on the heels.
Finger to Nose Test - Ask the client to abduct and extend the arms at shoulder height and rapidly
touch the nose alternately with one index finger and then the other.
Alternating Supination and Pronation of Hands on Knees - Ask the client to pat both knees 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 nurse's finger - Ask the client to touch the nose and then your index
finger, held at a distance of about 45 cm (18 in), at a rapid and increasing rate.
Fingers to Finger - Ask the client to spread the arms broadly at shoulder height and then bring the
fingers together at the midline, first with the eyes open and then closed, first slowly and then rapidly.
Fingers to Thumb (Same Hand) - Ask the client to touch each finger of one hand to the thumb of the
same hand as rapidly as possible
Ask the client to lie supine and to perform these tests:
Heel Down Opposite Shin - Ask the client to place the heel of one foot iust below the opposite knee
and run the heel down the shin to the foot. Repeat with the other foot.
.Toe or Ball of Foot to the Nurse's Finger - Ask the client to touch your finger with the large toe of
each foot.
Light - Touch Sensation.
1. Compare the light touch sensation of symmetrical body areas.
2. Instruct the client to close their eyes and indicate when they feel a cotton wisp on their skin by
saying "yes" or "now."
3. Gently touch a specific spot on one side of the body, then the same spot on the other side,
using a cotton wisp.
4. Test areas on the forehead, cheek, hand, lower arm, abdomen, foot, and lower leg, starting
with a specific area of the limb.
5. Ask the client to point to where they felt the touch.
6. If any sensory dysfunction is detected, determine the sensation boundaries by testing
responses approximately every 2.5 cm (1 in) in the area.
PAIN SENSATION
1. 1.Ask the client to close his eyes and to say "sharp.» "full," or "don't know" when the sharp or
dull end of the broken tongue depressor is felt.
2. Alternately, use the sharp and dull end of the sterile pin or needle to lightly prick designated
anatomic
3. Allow at least 2 seconds between each test.
Temperature Sensation
1. Touch skin areas with test tubes filled with hot or cold water.
2. Have the client respond say saying "hot,» "cold," or "don't know"
Position or Kinesthetic Sensation
1. 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' heels on the examining table.
2. Ask the client to close his eyes.
3. Grasp a middle finger or a big toes firmly between your thumb and index finger, and exert the
same pressure on both sides of the finger or toe while moving it.
4. Move the finger or toe until it is up, down, or straight out, and ask the client to identify the
position.
5. Use a series of brisk up and down movements before bringing the finger or toe suddenly to
rest in one of the three positions.
Tactile Discrimination
1. For all tests, the client's eyes need to be closed: One- and Two- Point Discrimination one or
two pinpricks.
2. Stereognosis Alternately stimulate the skin with two pins simultaneously and then with one
pin. Ask whether the client feels
1. Place familiar objects - such as a key, paper clip, or coin - in the client's hand, and ask the
client to identify them.
2. If the client has a motor impairment of the hand and is unable to manipulate an object, write a
number or letter on the client's palm, using a blunt instrument, and ask the client to identify it.
EXTINCTION PHENOMENON
3. Simultaneously stimulate two symmetric areas of the body, such as the thighs, the cheeks, or
the hands.
EVALUATION
1. Document the findings in the client record
 ASSESSING THE FEMALE GENITALIA AND INGUINAL
For the ASSESSMENT, assemble equipment like drape, gloves and
supplemental lighting. Explain to client what you are going to do. Perform hand
hygiene
For PLANNING, Provide client privacy
Determine client history of the following like: age and onset of menstruation,
LMP, pain during intercourse, blood in urine.
Position client in supine position with feet elevated on stirrups of exam table.
For IMPLEMENTATION,
Inspect distribution, amount and characteristics of pubic hair.
Inspect skin of pubic area for parasites, inflammation, swelling and lesions.
Separate the labia minora and labia majora.
Inspect clitoris, urethral orifice and vaginal orifice when separating labia minora.
Palpate inguinal lymph nodes.
For EVALUATION, Document findings in client record
 ASSESSING THE MALE GENITALIA AND INGUINAL
For the ASSESSMENT, assemble equipment like gloves Explain to client what
you are going to do. Perform hand hygiene
For PLANNING, Provide client privacy
Determine client history of the following like: usual voiding patterns and changes,
abdominal pain, symptoms of STI, swellings and family history of nephritis,
malignancy of prostate or kidney.
For IMPLEMENTATION,
PENIS - Inspect distribution, amount and characteristics of pubic hair.
Inspect penile shaft and glans penis for lesions. Inspect urethral meatus for
swelling and discharge.
Compress or ask client to compress glans to open urethral meatus.
If has discharge, instruct client to strip penis from base of urethra.
Palpate penis for tenderness and nodules. Use thumb and two fingers.
SCROTUM - Inspect scrotum for appearance, size, symmetry. Ask client to hold
penis out of way.
Inspect all skin surfaces as needed to observe posterior surfaces. Palpate
scrotum to assess testes, epididymis and spermatic cord
INGUINAL AREA – Inspect both inguinal area for bulges while client is standing.
Have client remain at rest. Have client hold breath and strain or bear down.
Palpate hernias.
For EVALUATION, Document findings in client record
 ASSESSING THE RECTUM AND ANUS
For the ASSESSMENT, assemble equipment like gloves and supplemental
lighting. Explain to client what you are going to do. Perform hand hygiene
For PLANNING, Provide client privacy
Determine client history of the following like: blood in stools, black stools,
colorectal cancer, last stool specimen and signs and symptoms of prostate in
men.
For adults, position client in left sims position with upper leg flexed.
For females, dorsal recumbent position hips externally rotated with knees flexed
or lithotomy can be used.
For males, standing position while client bends over the exam table.
For IMPLEMENTATION,
Inspect anus and surrounding tissue for color, integrity and skin lesions.
Ask client to bear down as if defecating.
Describe all abnormal findings in terms of a clock with 12 oclock positioned
toward pubic symphysis.
Palpate rectum for anal sphincter tonicity, nodules, masses and tenderness.
On withdrawing finger from rectum and anus, observe for feces.
For EVALUATION, Document findings in client record
NORMAL FINDINGS
MUSCULOSKELETAL SYSTEM – Erect posture with good balance and normal gait while
walking. Joints and muscles are symmetrical with no swelling, redness, or deformity. Active
range of motion of all joints without difficulty. No spine curvature from posterior view.
NEUROLOGICAL SYSTEM – The patient is alert and oriented to person, place, and time with
normal speech. No motor deficits are noted, with muscle strength 5/5 bilaterally. Sensation is
intact bilaterally.
FEMALE GENITALIA – Female genitalia are normal, without abnormalities or lesions. Both
external and internal structures, are within the normal range without visible or palpable
abnormalities, masses, or tenderness. No signs of swelling, redness, tenderness, discharge,
odor, itching, or abnormal lumps or lesions are present.
MALE GENITALIA – Male genitalia are normal in appearance, with no abnormalities,
swelling, or lesions. Urethral opening is normal. Testicular examination shows normal size,
shape, and consistency, without any palpable abnormalities or tenderness. Epididymis is
normal.
RECTUM AND ANUS – The anus appears normal without abnormalities like fissures,
hemorrhoids, or lesions. The rectal examination reveals no masses, tenderness, or
abnormalities in the rectal wall. There are no signs of abnormal discharge or bleeding.
Overall, the rectum and anus appear healthy.