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.
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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.
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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
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Elbows
Bend and straighten the elbows. Flexion at 160 degree
Full extension at 180 degree
|
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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
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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)
COMMENTS