Musculoskeletal Assessment Unit 8 Overview

A&P Developmental Musculoskeletal Assessment Nursing Diagnoses Plan and Implement nursing care Teaching

Anatomy & Physiology

Musculoskeletal system provides

support for body protection of internal organs mobility to engage in physical activities production of RBCs storage of minerals

For proper functioning, must be integration between neurologic and musculoskeletal systems M-S system provides mobility and stability through the integration of muscles, bones and joints which are assessed together

A&P
Structures of the MS System

Bones - how many ? Muscles - myo voluntary/striated involuntary/smooth

joints - arthro held together by ligaments

tendons - join muscle to bone

ligaments and muscles give joint stability cartilage - pads joints during weight bearing

A&P
Structures of the MS System Joint is the functional unit of the MS system Skeletal muscles attach to each of 2 bones flexor extensor Which is stronger ? ROM is maximum possible joint movement Synovial joint motion/ ROM (freely movable)

Flexion Extension Hyperextension Abduction Adduction Int. rotation Ext. rotation Circumduction

Bending a joint; decreases < straightening joint; > moving past extension moving away from midline moving toward the midline rotating toward midline rotating away from midline rotating in complete circle

Developmental Considerations
Infants birth Apgar (muscle tone assessed) Hips- congenital dislocation walk 12 - 14 mos wide gait lack coordination bowlegged NL > 18 mos School age check for spinal deformities/scoliosis degree sports participation/injuries

Adolescents injuries, Osgood-Schlatter Young adults injuries (check pulses with Fx) Adult (degenerative)

degenerative joint disease (DJD) non-inflammatory weight bearing joints

osteoarthritis inflammation of the joint

rheumatoid arthritis systemic disease chronic inflammation leads to erosion/destruction of joint

osteoporosis loss of bone mass; more common after menopause calcium, exercise

Elderly Assess for falls, injuries changes 20 decreased muscle mass changes in bone collapse of intervertebral discs decreased stature kyphosis barrel chest (increased AP diameter) Decreased mobility decreased endurance 20 decreased muscle strength decreased fear of falling decreased CV disease decreased vision decreased bone mass fear falling, death loss of independence

Musculoskeletal Assessment

Current concerns General health Life style/ADL/functional status o employment (repetitive motions) o activity level o recent or past injuries Generally assess (screen):
o o o o

joint inspection/ROM muscle strength ADL/functional abilities activity tolerance

Further assessment based on findings in history and physical exam

History

Previous occurrences of the problem Past history of trauma to bones, joints, nerves, soft tissue Orthopedic surgery Congential deformities Chronic illness Pain Assessment o Frequently the reason for seeking care o Character o Intensity o Precipitating events o Onset o Location o Timing o Referred pain o Aggravating factors o Alleviating factors Arthritis o osteoarthritis o rheumatoid Gout Ankylosing spondylitis Congenital Disorders o hip o foot Scoliosis or back problems

Family History

Arthritis osteoarthritis-disintegration of cartilage that covers ends of bones rheumatoid- inflammatory changes in connective tissue gout- excessive uric acid production ankylosing spondylitis- spine

Risk Factors

Osteoarthritis o age > 50 o Family history o Obesity o Joint abnormality o History of trauma, RA, or other degenerative process Osteoporosis o age o gender o family history o estrogen deficiency o small stature o race o Northern European descent o Heavy cigarette and/or ETOH use o Poor diet with low Ca intake o Periods of immobilization o Use of steroids o Sedentary lifestyle

Musculoskeletal Assessment
Begins with the meet and greet

Watch as rise from seat ("get up and go")

climb onto examining table Watch for coordination Note speed of movement Assess muscles, bones and joints of: spine, shoulder, posterior iliac crest

head, neck, thorax upper extremities lower extremities

Inspection
Inspect for: position, deformity surrounding tissue swelling atrophy ROM Inspect gait and stance
o o o

gait -characteristic pattern of walk stance - posture spinal curves

Range of Motion Assessment and Exercises

Active (isotonic) Active-assistive Passive Static (isometric) Resistive

Range of Motion Exercises

Active (isotonic) Active-assistive Passive Static (isometric) Resistive

Ask pt to do help pt (or self-help) do for pt tense muscle without moving joint builds strength

Range of Motion
Active

joint movement should be smooth and painless ask that joint be moved through full range of movement less muscle tension and joint compression is seen with active ROM compared to movement against resistance Rationale for assessing ROM before strength

Passive

move relaxed joint through limits of movement if ROM is limited try to determine if: o excess fluid in joint o loose bodies are present o joint surface irregularity or contracture of muscle

Palpation
During active or passive ROM, palpate bones, muscles and joints. Palpate temperature infection, inflammation? paresthesia? sensation edema crepitus nodules 0-5 scale, active/resistive strength COMPARE, expect dominant side to be stronger tone tension at rest and passive ROM

Terms related to muscle assessment

Atrophy Hypertrophy Contracture Fasciculation

muscle wasting increased muscle mass muscle shortening involuntary muscle movement

Nursing Diagnoses

Impaired physical mobility Risk for injury Pain Chronic Pain Activity intolerance Risk for disuse syndrome

Fatigue

Range of Motion Exercises

Nursing order - Frequently encouraged for the bed ridden, immobile Frequently incorporated into care o bathing o getting OOB Support joints Avoid pain, overexertion, over extension Move joint to point of resistance- not pain

Range of Motion Exercises

Active Independent muscle mass muscle tone muscle strength jt mobility Active-Assistive Some support muscle mass muscle tone some strength Passive Full support jt mobility

jt mobility

Musculoskeletal injuries

Check for fracture If fracture check pulses Rest Ice (20 on/20 off) 24 hours Compression Elevation

Teaching Opportunities

Risk factors for injury, trauma Prevention of injuries Risk for osteoporosis Benefits of exercise

Musculoskeletal findings
Upright posture, good alignment, no evidence of abnormal spinal curvature. Symmetrical musculature, equal strength bilaterally. No atrophy, hypertrophy or masses noted. Symmetrical joints, full ROM head, neck, spine, upper and lower extremities. No swelling, tenderness or crepitation. Bones symmetrical, aligned. No tenderness, masses.

Case Study
KA, a 17-yr-old high school gymnast, fell and fractured his L femur several weeks ago. He has been on bedrest in skeletal traction since then. Because of painful muscle spasms, he often refuses to be turned or to move voluntarily. Nursing Diagnosis? Goals/Expected Outcomes? Nursing Orders?