Assessment of Musculoskeletal system

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PHYSICAL ASSESSMENT OF MUSCULOSKELTAL SYSTEM
This system encompasses the muscles, bones and joints. The nurse usually assess the muscle, strength, tone, size and symmetry of muscle development, and fasciculation's and tremors.
Preparation 
Articles: -Goniometer, measuring tape, muscle grading scale, percussion hammer and cotton.
 Patient preparation
Explain procedure, maintain privacy, position sitting/lying down on bed, adequate space.
A fasciculation is an abnormal contraction of a bundle of muscle fibres.
A tremor is an involuntary trembling of a limb or body part.
Tremors may involve large group of muscle fibres or small bundles of muscle fibres.
 An intention tremor becomes more apparent when an individual attempts a voluntary movement, such as holding a cup of coffee.
 A resting tremor is more apparent when an individual is at rest and diminishes with activity.
Bones are assessed for normal form.
Joints are assessed for tenderness, swelling and thickening, crepitation (the sound of bone Grating on bone), presence of nodules, and range of motion. Body posture is assessed in normal standing and sitting positions.
Health history: Chief complaint
·         Pain onset
·         intensity
·         quality
·         Timing
·         Location
·         Stiffness
·         Swelling
·         Heat
·         Redness
          Fracture: Sharp pain, Movement increases pain
Rheumatoid arthritis: Symmetric joints pain, worse in the morning, Stiffness in the morning
Inspection
Gait and posture- sitting, walking, rising from sitting position. Note foot dragging, limping, and shuffling. Look for extremities for size, gross deformity, alignment, symmetry.
Postural abnormalities:
·         Lordosis- increased lumbar curvature
·         Kyphosis (hunch back)- is an exaggeration of posterior curvature of thoracic spine
·         Scoliosis- lateral spinal curvature
Gait and body posture
-joint pain, Stiffness, muscle weakness can cause change in gait and posture
SPINE CURVATURE



Palpation: Tenderness, Edema, Muscle should be firm
Functional deformities: Bow leg
Assessment of Muscles:
Inspect the muscles for size. Compare the muscles on one side of the body to the same muscle on the other side. For any differences measure with a tape.
Equal size on both sides of the body.
Inspect the muscles and tendons for contractures, inspect the muscles for fasciculation and tremors. Inspect any tremors of the hands and arms by having the client hold the arms out in front of the body.

No fasciculation's or tremors

Palpate the muscles at rest to determine muscle tonicity
Palpate the muscles while the client is active and passive for flaccidity, spasticity and smoothness of movement.

Normally firm


Smooth coordinated movements.

Test muscle strength.
Inspect the skeleton for normal structure and deformities
Palpate the bones to locate any areas of edema and tenderness


Equal in size
No deformities
No tenderness


Deviations from Normal
·         Atrophy (a decrease in size)
·         Hypertrophy (an increase in size).
·         Malposition of body part, e.g., foot drop (foot flexed downward).
·         Presence of fasicululation or tremor.
·         Atonics (lacking tone)
·         Flaccidity (weakness and laxness)
·          spasticity (sudden involuntary muscle contraction) 25% or less of normal strength
·         Muscle wasting
·         Foot drop

Testing and grading the muscle strength
Sternocleidomastoid: client turns the head to one side against the resistance of your hand. Repeat with the other side.
Trapezius: client shrugs the shoulder against the resistance of in your hands.
Deltoid: client holds arm up and resists while you try to push it down.
Biceps: client fully extends each arm and tries. To flex it while you attempt to hold arm in extension
Triceps: client flexes each arm and then tries to extend it against your attempt to keep arm in flexion.
Wrist and finger muscles: Client spreads the finger and resists as you attempt to push the fingers together.
Grip strength: Client grasps your index and middle fingers while you try to fingers out.
Gastrocnemius: patient sits while examiner holds shin of flexed leg. Ask patient to straighten leg against resistance
Hip muscles: Client is supine, both 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 resistance.
Hamstrings: Client is supine, both knees bent. Client resists while 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.
Grading muscle strength
0:   0% of normal Strength: complete paralysis.
1:   10% of normal strength: no movement, contraction of muscle is palpable or visible.
2:    25% of normal strength full muscle movement against gravity with support.
3.   50% of normal strength; normal movement against gravity.
4. 75% of normal strength; normal full movement against gravity and against minimal resistance.
5.  100% of normal strength; normal full movement against gravity and against full resistance.

Muscle                                Clients Instruction
Ocular muscle                      close eye tightly
Finger muscle                       shake hand and able to make fist
Facial muscle                        blow out cheeks
Tongue                                  can move in and out
Hip muscle                            raise leg straight while supine
Neck muscle                         bend head forward and backward
Gluteal muscle                    alternately cross while sitting
Deltoid                                  hold arms up
Biceps                                    bend the arm
Triceps muscle                       straighten the arm
Wrist                                      band hand forward and backward
Quadriceps muscle              straighten leg
Joints:
Inspect the joints for swelling.
Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and presence of nodules.

No swelling
No tenderness, swelling and crepitation or nodules

 Assess joint range of motion.
Ask the client to move selected body parts.
The amount of joint movement can be measured by a GONIOMETER.
It is a device that measures the angle of the joint in degrees.

Varies some degrees in accordance with person’s genetic makeup and degree of physical activity.

Temporomandibular joints
Open and close the mouth
Move the lower jaw to each side (1-2cm)
Protrude and extract chin
Strength  of temporalis muscle checked by asking to clench the teeth


Cervical spine
Position, alignment of head, symmetry of skin folds and muscles
Cervical and lumbar spine should be concave

Flexion and extension at 450
Lateral bending at 40 degrees

Lumber  spine
Observations
Body type
Postural alignments and asymmetries should be observed from all views
Palpation  and  ROM
Flexion 70 to 90 degree
Extension 30 degree
Lateral  bending 35 degree
Rotation 30 degree
Elbows
Bend and straighten the elbows. Flexion at  160 degree
Full extension at 180 degree

Shoulders Inspect symmetry and contour of shoulder. Palpate the joints
Examine following ROM. Shrug the shoulders. Raise both arms forward and straight up. Stretch both arms behind back
Adduction, Internal rotation, and external rotation

Hand and  wrist
Inspect the dorsal and palmer aspects of the hands. Identify deviations of fingers
Examine ROM of Hand and  wrist
            - bend the fingers at metacarpals
            - touch the thumb to each fingertips
            - bend the hand at wrist up and down
            - with the palm side down, turn each hand right and left

Hips
Inspect the symmetry of the iliac crest
ROM. Raise the leg with knee Extended above the body. Swing the straightened leg either standing or prone. Raise knee to the chest while keeping other leg straight
Rotate inward and outwardly.

Knees
Inspect the Popliteal area. Observe the lower leg alignment (genu valgum/knock knees, genu varum /bow legs). Bend knees for flexion130 degree.
Full extension

Ankles 
Inspection
Palpation
ROM
20 degree dorsiflexion
45 degree planter flexion
30 degree inversion
20 degree eversion

Finger 
Inspection
Palpation
ROM
Flexion
Extension
Abduction
adduction

Toes  joint
Inspection
Palpation
ROM

20 degree dorsiflexion
45 degree planter flexion
30 degree inversion
20 degree eversion



Range of motion
Start by asking the patient to move through an active range of motion (joints moved by patient). Proceed to passive range of motion (joints moved by examiner) if active range of motion is abnormal.
Specific joints
·         Temporo-mandibular joints
·         Cervical spine
·         Thoracic and  lumbar spine
·         Shoulders
·         Elbows
·         Hands and wrists
·         Hips
·         Knees
·         Feet and ankles
 Congenital deformity
1)      Genu varum also called bowleg. A deformity in which one or both legs are bent out at the knee.
2)      Genu valgum, knock-knee, also called knock-knee. A deformity in which the legs are curved in so that the knees are close together, knocking as the person walks.
3)      Pes planus (flat foot)
4)      Pes cavus; A defect of the foot with a very high arch and very long toes
5)      Metatarsus varus, intoe, toeing in, also called intoe, metatarsus adductus, pigeon-toed, toeing in. A birth defect of the foot in which the front part points in toward the middle of the body and the heel remains straight.
6)       In a clubfoot the bones in the front part of the foot are misaligned. In 95 percent of clubfoot deformities the front half of the foot turns in and down
7)      Hallux valgus, a deformity in which the great toe is bent to the outside toward the other toes; in some cases the great toe rides over or under the other toes.
8)      Polydactyl: excess number of fingers.

Assessment of bones
Inspect the skeleton for normal structure and deformities. Palpate the bones to locate any areas of edema or tenderness
Deviations from Normal:  Bones misaligned
Presence of tenderness or swelling (may indicate fracture, neoplasms, or osteoporosis). One or more swollen joints. Presence of tenderness, swelling, crepitation, or nodules. Limited range of motion in one or more joints.
Synovitis: inflammation of synovial fluid
Ostegenesis imperfecta

Special test
Bulge test /ballottement test
Thomas test for hip contraction
Straight leg test
Reflexes: abnormal findings: Clonus - Rapid rhythmic contraction of the same muscle
Hyperreflexia - exaggerated reflex
Hyporeflexia- Absence of Reflex
Grading scale for reflexes
0 for no response
1+ for diminished, low response
2+ for Average or normal
3+ for Brisker than average, May indicate disease
4+ for very brisk, hyper active with clonus
Biceps reflex (C5 to C7)
Triceps Reflex (C7 to C8)
Brachioradialis Reflex (C5 to C6)
Quadriceps Reflex (L2 to L4)
Achilles reflex (L5 to S2)
Plantar reflex (L4 to S2)


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notes.nursium.com: Assessment of Musculoskeletal system
Assessment of Musculoskeletal system
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