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SUBMITTED TO: Dr J. Silvia Edison Principal Alshifa college of nursing
SUBMITTED BY: Dina Merlin Thomas and Divya K.V M.Sc Nursing 1st year
SUBMITTED ON :
INTRODUCTION Assessment of the musculoskeletal system begins with a health history and provides direction for further assessment. The musculoskeletal physical examination can be either general (as in a screening examination) or local (for a specific problem or injury). Musculoskeletal assessment can also include the client’s functional status and ability to perform activities of daily living (ADL) and to meet self-care needs. This aspect of the assessment involves evaluation of the client’s exercise habits and leisure activities that promote health. HISTORY The musculoskeletal history consists of the following: Biographical and demographic data Chief complaint (including symptom analysis) Past health history Family health history Psychosocial history Lifestyle data Review of systems (A) BIOGRAPHICAL AND DEMOGRAPHIC DATA The client’s age and gender may suggest possible causes of musculoskeletal problems. For example, 85% of people older than 70 years have some osteoarthritis. Osteoporosis (porus bone) occurs most often in post menopausal women. Reiter’s syndrome is most common in men between 20 and 40 years of age. Osteogenic sarcoma is rare after age 40 years. Carpal tunnel syndrome occurs more often in women than in men. CURRENT HEALTH (B) CHIEF COMPLAINT Ask the client to describe the reason for seeking health care. Common musculoskeletal clinical manifestations are pain, tenderness, muscle tightness or weakness, joint stiffness, crams, muscle spasms, swelling, redness, deformity, reduced movement or joint range of motion (ROM), sensory changes, and other abnormal sensations. ADL may be affected. Ask the client and significant others to recount their perceptions of the problem and its cause. Their answers often provide not only information about areas for further assessment but also clues about personal fears and concerns. SYMPTOM ANALYSIS Conduct a symptom analysis for each manifestation the client reports. Common musculoskeletal manifestations are pain, joint stiffness, swelling, deformity and immobility, and sensory changes.
PAIN:- Ask the client to point to the exact location of the pain. Poorly localized pain usually stems from problems in blood vessels, joints, fascia, or periosteum. Ask the client to describe the pain: sharp pain, a throbbing. What makes the pain worse: Temperature changes? Movement? Lifting or carrying something heavy? Is the pain worse at a particular time of day? Does it wake the client or prevent sleep and rest? Which medications help to reduce the pain? Have there been any recent injuries? Sometimes a client does not associate a fall or other injury with current pain manifestations. Is the pain associated with chills, fever, rash, or a sore throat? JOINT STIFFNESS:- Ask the client to point to joints that are stiff. Are they always stiff? How long does the stiffness last? At what time of day is the stiffness worst? What relieves the stiffness? Temperature changes? Exercise? Does the joint lock so it cannot move? Does the client hear or feel bones rubbing together? Does the client have pain or weakness in muscles with certain movements? SWELLING:- Ask how long the client has had swelling. Is there pain? Swelling and pain commonly accompany bone and muscle injury. Does swelling limit the client’s movement? Does rest or elevating the part give relief? Ask whether the body part was casted recently. Removing a cast can result in temporary swelling. A casted limb also may have muscle atrophy. Has the area been hot or red? DEFORMITY AND IMMOBILITY:- Has the deformity developed suddenly or gradually? A gradually developing mass may be a tumor. Is movement limited? Is this limitation always present? Is it worse after activity? Does any body position make it worse or better? Ask how the deformity affects the client’s daily activities. Does the client use any supportive equipment, such as crutches, a walker, or bandages? SENSORY CHANGES:- Does the client have a history of back pain or injury? If so, where is the pain located? Does the pain travel, for example, down the back of the leg? Does the client have trouble walking? Is there a loss of feeling anywhere? If so, is the loss of feeling associated with any pain? Does the client have any tingling or burning sensation? (C) PAST HEALTH HISTORY Carefully assess previous trauma, accidents, or surgery involving bones or joints. The client may have sustained fractures, dislocations, strains, or sprains. Previous accidents resulting in fractures may predispose to degenerative changes. Explore both childhood and adult-onset disorders because of their possible long-term effects. CHILDHOOD AND INFECTIOUS DISEASES Health conditions may affect the musculoskeletal system directly or indirectly. For example, diabetes mellitus may predispose a client to degenerative joint disease. Blood dyscrasias, such as hemophilia, may cause bleeding in joints that produces pain, swelling, tenderness, and deformity. Psoriasis may precede psoriatic arthritis. Cartilage damage from trauma may precipitate degenerative changes in a relatively young person. Ask about a history of tuberculosis, sickle cell disease, poliomyelitis, inflammatory or degenerative arthritis, scurvy, rickets, osteomyelitis, soft tissue infection, fungus infection of bones or joints, and streptococcal and neuromuscular disorders. MAJOR ILLNESS AND HOSPITALIZATIONS Besides inquiring about diseases, such as diabetes mellitus, tuberculosis, poliomyelitis, and arthritis, ask about hospitalizations related to musculoskeletal disorders or trauma.
If the client or significant others cannot remember details, ask for permission to obtain the medical records. Ask about past or present minor and major injuries, including (1) Circumstances of the injury, (2) Diagnosis of the injury, (3) Treatment received, (4) Duration of treatment, and (5) Current problems resulting from the injury. Musculoskeletal injury involves fractures, sprains, strains, and joint dislocations. Minor injuries may be treated on an ambulatory basis, whereas major injuries may require prolonged hospitalization, surgery, or rest and immobilization. Ask whether the client has residual imparirment from the injury, such as a need to use an assistive device (cane, crutches, or walker). Ask whether the client has had to change or adjust ADL because of lingering limitations. MEDICATIONS Question the client about past and present prescription and over-the-counter medications as well as herbal remedies. For each medication, find out (1) the reason for taking it, (2) the dose and frequency, (3) how long the client has taken it, and (4) any observed side effects. Ask about specific medications used for musculoskeletal problems, such as muscle relaxants, salicylates, NSAIDS, and steroids. Some medications may affect the musculoskeletal system adversely.
(D) FAMILY HEALTH HISTORY Some musculoskeletal problems with a familial predisposition are arthritis, osteoporosis, ankylosing spondylitis, gout, Heberden’s nodes in osteoarthritis, muscular dystrophy, and scoliosis. Thirty percent of people with psoriatic arthritis have a family history of psoriasis. (E) PSYCHOSOCIAL HISTORY The integrity of the musculoskeletal system enables a person to function effortlessly. However, many problems can disrupt that integrity, thus disrupting the coping ability of both the client and significant others. Ask about daily activities and habits. When assessing a client with a chronic illness or degenerative process, ask whether the disorders have affected the client’s interactions with others or view of self and others. Crippling illnesses often curtail social activity and result in lower self-esteem. OCCUPATION Ask whether heavy lifting or strenuous activity is common in the client’s life. Such activity can cause muscle strain, degenerative vertebral disk problems, and other trauma. Low back pain can arise from jobs involving extensive driving. Habitually carrying heavy objects, such as a mailbag, shoulder bag, attaché case, or other equipment, can place uneven pressure on the spinal column. Prolonged use of computers and keyboards can cause orthopedic injuries from respective strain. (F) ACTIVITIES OF DAILY LIVING Are there everyday activities that are difficult or impossible, such as (1) opening containers, pouring liquids, and cutting up food, (2) dressing, using zippers, and fastening or unfastening buttons, snaps, or hooks, (3) grooming, combing hair, and applying makeup, (4) running a
bath and testing water temperature, washing hair, and shaving, (5) writing, and (6) getting out of the house, climbing stairs, or getting in and out of chairs or cars? Ask whether physical limitations prevent performance of daily activities. Assess the client’s attention to safety and ask about safety practices used at work and at home. Does the client use recommended equipment, such as safety shoes or safety guards on power tools? There is a high incidence of accidental injury among people who pay little attention to safety practices. EXERCISE Document the details of the client’s typical recreational activities and exercise pattern Lack of exercise produces poor muscle tone, which leads to muscle strain. Sporadic exercise of poorly toned muscles is more likely to cause muscle injury and spasm. Lack of warm-up exercises increases the likelihood of injury as well. NUTRITION A well-balanced diet helps maintain the structure of the bones and muscles and a dietary history can provide clues to musculoskeletal problems. Inquire about recent weight changes. Excessive weight gain can place stress on the musculoskeletal system. HABITS AND SAFETY Health promotion habits and a positive lifestyle can reduce the risk for development of musculoskeletal disorders. Increasing dietary calcium and weight-bearing activities, such as walking, can help prevent osteoporosis and improve strength and flexibility. (G) REVIEW OF SYSTEMS Ask about musculoskeletal problems such as (1) muscle pain, spasm, or tenderness; (2) joint pain, stiffness, other discomfort, swelling, or redness; (3) weakness; (4) limited movement; (5) clumsiness; (6) crepitus ; (7) back ache; and (8) changes in joints or bones. Investigate each reported problem. Inquire about the effect of the problem on the client’s ability to perform ADL. Assessment findings from other body systems may indicate musculoskeletal problems. The following are example: Pain or burning when urinating, which is associated with Reiter’s syndrome. Tachycardia and hypertension, which may accompany gout. Chronic diarrhea, which may occur when arthritis is associated with colitis or other GI problems. Conjunctivitis, which may indicate Reiter’s syndrome, and nongranulomatous uveitis, which may occur with ankylosing-spondylitis. Skin changes, which may indicate musculoskeletal problems (dry skin over the thumb and the first two fingers suggests carpal tunnel syndrome, for example) Cramping leg pain with activity, which may signal intermittent claudication. Generalized muscle cramping, which may result from electrolyte imbalances. Joint pain with recent chills, fever, or sore throat, which may result from rheumatic fever.
Assessment of the musculoskeletal system should proceed systematically to avoid missing hidden problems. Use an examining room big enough for the client to move around. Natural lighting is best for assessing skin color changes and swelling. Artificial light distorts some assessment findings. During the examination, have the client sit, stand, and walk unless a position is contraindicated by the client’s condition. Musculoskeletal assessment consists of inspecting and palpating (1) muscle masses for symmetry, involuntary movements, tenderness, tone, and strength, (2) joints for symmetry, crepitus, tenderness or pain, and ROM, and (3) bones for deformity and limb length discrepancy. Use inspection and palpation to examine each body part. First, examine the body at rest, then assess ROM and muscle strength. Go for GALS G – Gait A – Arms L – Legs S – Spine When the client enters the examination room, assess the gait, body mobility, posture, general joint motion, and balance. While observing movement and gait, watch for (1) gait patterns associated with specific disorders, (2) objective evidence of discomfort, and (3) indications of joint stiffness or muscle weakness, lack of coordination, and deformities. Then have the client sit on the edge of the examination table. Observe general appearance and body build. Examine the head, neck, shoulders, and upper extremities. Have the client stand, and examine the chest, back, and ilium. Observe posture, body build, body contours, body alignment, and the cervical, thoracic, and lumbar spine. Observe the relationships of various body parts to one another, such as the relationship of feet to legs, legs to hips, and hips to pelvis. Observe the client’s stance and note spinal deformities or other abnormalities, such as the following: Kyphosis, an abnormally increased roundness of the thoracic curve or hump-back. Scoliosis, a lateral deformity of the spine. Lordosis, an abnormal increase in the lumbar curve, or swayback. Genu Varum or bowleg. Genu Valgum or knock-knee.
Last, with the client supine, examine the hips, knees, ankles, and feet for alignment, symmetry, and deformities. Determine any discrepancy between leg lengths by measuring from the anterior iliac spine to the medical malleolus. Measurements should be within 1 cm of each other. If a discrepancy is noted, determine whether it exists above or below the knee. MUSCLES
Compare each muscle group with its contralateral side. Muscles should be free of fasciculations (fine muscle twitches) and smooth, without bulgets or lumps. Palpate muscle groups gently, from proximal to distal, feeling the muscle tone (the state of tension in a muscle at rest, which is felt as firmness). Muscles should feel firm and should be bilaterally equal in size and non-tender. A slight increase in mass, or hypertrophy, on the dominant side is normal, whereas atrophy, or decrease in muscle mass, on either side is abnormal. If muscle groups are noticeably unequal in size, use a tape measure to assess limb circumferences. Differences of 1 cm or less between the two sides are considered within normal variation. Assess muscle strength while putting joints through active ROM. ASSESSING MUSCLE STRENGTH Muscle Group Deltoid Biceps Triceps Wrist and finger muscles Grip strength Hip muscles Hip muscles abduction) Hamstrings Quadriceps Technique Push down client’s arm while it is held up and client resists. Hold client’s arm in extension while it is fully extended and client flexes arm. Keep client’s arm in flexion while it is flexed and client extends arm. Push client’s fingers together while client spreads them and resists. Pull your own crossed index and middle fingers from the client’s grasp. Hold down client’s leg while it is fully extended and while client lifts it off the table (client is supine). ( Prevent client from spreading legs apart against resistance applied to the lateral surfaces of the knees (client is supine with legs extended). Straighten client’s knees while client is supine with knees flexed and resists. Flex client’s knee while client is supine with knee partially in extension and resists.
Ankle and foot muscles Dorsiflex client’s foot while client resists. Plantiflex client’s foot while client resists.
Rate muscle strength numerically as follows: 0 = Muscle is paralyzed with no visible or palpable contraction (zero) 1 = Contraction is palpable but muscle does not move (trace) 2 = Full ROM is present with the joint supported to eliminate gravity (poor) 3 = Full ROM is present with gravity as the only resistance (fair) 4 = Full ROM is present against moderate resistance (good) 5 = Full ROM is present against normal resistance and gravity (normal) Include the muscle strength rating scale as part of the client’s record to ensure understanding and consistency with other health care providers.
JOINTS AND BONES Inspect the client’s joints and bones, and compare finding bilaterally. Symmetry should be found without redness, swelling, enlargement, or deformity. Palpate each joint and bone for edema and tenderness, which should be absent. Palpate joints during movement for crepitus, which is abnormal. Joints should feel smooth as they move, and nodules should be absent. ROM is the maximum range of movement attainable by a healthy joint. ROM is measured with a goniometer, a flexible protatctor-type instrument placed on a joint to measure the angles created by joint movement. As needed, assess ROM in all joints. ASSESSING JOINT FUNCTION shoulder Test Adson’s maneuver Purpose Evaluates blood flow in subclavian artery; tests for thoracic outlet syndrome Technique Palpate radial artery while abducting , extending and externally rotating the arm; have client take a deep breath and turn head toward arm being tested. Have the client reach behind the head and touch the top of the opposite scapula. Then have the client reach behind the back and touch the bottom of the opposite scapula Abduct client’s shoulder to 90 degrees and instruct client to slowly lower the arm to side Findings Negative: pulse remains strong Positive: marked decrease or loss of radial pulse during the test. Comments Blood flow can be compromised by cervical rib , tumour hematoma, or infection that has tightened neck muscles.
Apley’s scratch test
Evaluates shoulder ROM
Inability to perform as indicated instructs less than normal ROM for shoulder.
Limited ROM decreases functional ability for activities such as combing hair.
Drop arm test
Evaluates for rotator cuff tear.
Negative: able to comply with instructions . Positive: arm drops suddenly or severe pain is felt in the shoulder as arm is lowered.
Positive findings indicate tear in rotator cuff
Elbow Test Tennis elbow test Purpose Evaluates for lateral epicondylitis Technique Hold the clients elbow( thumb on lateral epicondyle) pronate the client’s forearm, flex the wrist fully, and extend the elbow Findings Negative : no pain Positive: pain over the lateral epicondyle of the humerus Comments Lateral epicondylitis is seen in people who work at the computers
Wrist and hand Test Finkelstein’s test Purpose Test for de quervain’s disease. Technique Have the client make a fist with the thumb inside the fingers , then hold the client’s forearm, steady and deviate the wrist toward the ulnar side Have the client hold the back of hands together with the wrist flexed 90 degrees, position is held for 60 seconds Findings Negative: no pain with the maneuver Positive : client feels pain over abductor pollicis longus and extensor pollicis longus tendons Negative : no symptoms Positive: tingling or burning in area of hand inervated by median nerve Comments Test may cause some discomfort in normal persons : therefore compare pain caused on the affected side with that on the normal side
Evaluates for pressure on median nerve
Lumbar spine Straight leg raising Evaluates for presence of HNP Involved leg: with client supine, passively raise the clients leg with the knee extended until pain is felt, then extend the leg slowly until there is no pain or tightness; dorsiflex the client’s foot Uninvolved leg: with client supine , raise the leg as described for the
Negative: no pain Positive: pain with dorsiflexion of the foot Positive: pain in opposite leg strongly suggests HNP
Pain in posterior thigh indicates harmstring tightness Pain down entire leg indicates sciatic nerve involvement
involved leg Knee Drawer test ( anterior) Evalutes stability of ACL Have client lie on back with knee flexed 90 degrees and hip to 45 degrees. Hold the foot of the test leg in place and then draw the tibia forward on the femur ( place your hands around tibia with the thumbs on the medial and lateral joint lines of the knee.) Position client as described for anterior test and push tibia back on femur Negative: movement 6mm or less Positive movement more than 6mm indicates tear in ACL If PCL is injured, result may be false- positive If PCL injury is suspected check for posterior sag sign ( gravity and drawer test)
Drawer test (posterior)
Evaluates stability of PCL
Gravity test ( Evaluates posterior sag sign) integrity of PCL
Evaluates injury to the ACL
Evaluates for medial and lateral meniscus injury
Have client lie supine with hips flexed to 45 degrees and knees to 90 degrees together Have client lie supine with the knees between full extension and 30 degrees: then use one hand to stabilize the femur and the other hand to move the tibia forward Have client supine with the injured leg fully flexed; then cup the heel with one hand and place your other hand
Negative : tibia doesnot move back Positive: backward movement of tibia felt or observed indicates injury to PCL Positive: tibia sagging back on the femur indicates that PCL is torn Positive: when tibia moves forward the infrapatellar tendon slope disappears
With minimal swelling sag is very evident, as is obvious concavity distal to the patella This test is the best indicator of the ACL injury
Positive: if a snap or click is heard , there is probably a meniscal tear
Evaluation of meniscal njuries is difficult and requires considerable experience; because menisci
on the knee ( fingers on the medial joint line , thumb on the lateral joint line) first rotate the tibia medially, changing degrees of flexion; then rotate the tibia laterally, repeatedly changing degrees of flexion
have no blood or nerve supply, there may be no pain or swelling with injury.
CONCLUSION Assessment of musculoskeletal system consist of a complete history, including symptom analysis and physical examination. Diagnostic studies can also be done for a complete assessment. To be a complete musculoskeletal system assessment neurological assessment can also be done along with it to understand any nerve involvement. Diagnostic studies commonly include X rays and in recent years arthroscopy has evolved to allow the diagnosis and treatment of joint disorders during one procedure. BIBLIOGRAPHY Black m Joyce ,Jane hokanson,Medical surgical nursing. 7th edition.Missouri: Elsevier publications.2005. pageno: Lewis Sharon manic,Heitkemper,Medical surgical nursing. 6th edition. Missouri:Elsevier publication.2004.page no: Lippincott. Manual of nursing practice .7th edition. International student edition:Philadelphia Jarvis, Physical examination and health assessment, elseviers publication, Potter , perry, publications. Smeltzer, Bare, Medical Surgical Nursing, 10th edition. Philadelphia.2005 American Journal of Preventive Medicine 2005, 29(3) , 185 193. Fundamentals of nursing, 4th edition,.Missouri, Mosby 5th edition, Missouri,