Musculoskeletal and Neurological Assessment Powerpoint


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  • Gait Abnomalities
  • injuries to the legs, feet, brain, spine, or inner ear Propulsive gait -- a stooped, rigid posture, with the head and neck bent forward Scissors gait -- legs flexed slightly at the hips and knees, giving the appearance of crouching, with the knees and thighs hitting or crossing in a scissors-like movement Spastic gait -- a stiff, foot-dragging walk caused by one-sided, long-term, muscle contraction Steppage gait -- foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking Herniated lumbar disk Waddling gait -- a distinctive duck-like walk that may appear in childhood or later in life Hip dysplasia Spinal muscular atrophy
  • Stance widens as they try to steady themselves
  • Treatment     Return to top Treatment depends on the cause of the disorder: Congenital kyphosis requires corrective surgery at an early age. Scheuermann's disease is initially treated with a brace and physical therapy. Occasionally surgery is needed for large (greater than 60 degrees), painful curves. Multiple compression fractures from osteoporosis can be left alone if there is no neurologic problems or pain, but the osteoporosis needs to be treated to help prevent future fractures. For debilitating deformity or pain, surgery is an option. Kyphosis caused by infection or tumor needs to be treated more aggressively, often with surgery and medications. Treatment for other types of kyphosis depends on the cause. Surgery may be necessary if neurological symptoms develop. Expectations (prognosis)     Return to top Adolescents with Scheuermann's disease tend do well even if they need surgery, and the disease stops once they stop growing. If the kyphosis is due to degenerative joint disease or multiple compression fractures, correction of the defect is not possible without surgery, and improvement of pain is less reliable. Complications     Return to top Disabling back pain Neurological symptoms including leg weakness or paralysis Decreased lung capacity Round back deformity
  • There are three general causes of scoliosis: Congenital scoliosis is due to a problem with the formation of vertebrae or fused ribs during prenatal development. Neuromuscular scoliosis is caused by problems such as poor muscle control or muscular weakness or paralysis due to diseases such as cerebral palsy , muscular dystrophy , spina bifida, and polio. Idiopathic scoliosis is of unknown cause, and appears in a previously straight spine. Idiopathic scoliosis in adolescents is the most common type. Some people may be prone to the curving of the spine. Most cases occur in girls. Curves generally worsen during growth spurts. Scoliosis in infants and juveniles are less common. They commonly affect a similar number of boys and girls. Scoliosis may be suspected when one shoulder appears to be higher than the other, or the pelvis appears to be tilted. Untrained observers usually can't notice the curving. Routine scoliosis screening is now done in middle and junior high schools. Many cases, which  previously would have gone undetected until they were more advanced, are now being caught at an early stage. There may be fatigue in the spine after prolonged sitting or standing. Pain will become persistent if irritation results. The greater the initial curve of the spine, the greater the chance the scoliosis will get worse after growth is complete. Severe scoliosis (curves in the spine greater than 100 degrees) may cause breathing problems. Symptoms     Return to top The spine curves abnormally to the side (laterally) Shoulders or hips appearing uneven Backache or low-back pain Fatigue Treatment depends on the cause of the scoliosis, the size and location of the curve, and how much more growing the patient is expected to do. Most cases of adolescent idiopathic scoliosis (less than 20 degrees) require no treatment, but should be checked often, about every 6 months. As curves get worse (above 25 to 30 degrees in a child who is still growing), bracing is usually recommended to help slow the progression of the curve. There are many different kinds of braces used. The Boston Brace, Wilmington Brace, Milwaukee Brace, and Charleston Brace are named for the centers where they were developed. Each brace looks different. There are different ways of using each type properly. The selection of a brace and the manner in which it is used depends on many factors, including the specific characteristics of your curve. The exact brace will be decided on by the patient and health care practioner. A back brace does not reverse the curve. Instead, it uses pressure to help straighten the spine. The brace can be adjusted with growth. Bracing does not work in congenital or neuromuscular scoliosis, and is less effective in infantile and juvenile idiopathic scoliosis. Curves of 40 degrees or greater usually require surgery because curves this large have a high risk of getting worse even after bone growth stops. Surgery involves correcting the curve (although not all the way) and fusing the bones in the curve together. The bones are held in place with one or two metal rods held down with hooks and screws until the bone heals together. Sometimes surgery is done through a cut in the back, on the abdomen, or beneath the ribs. A brace may be required to stabilize the spine after surgery.
  • Each joint is in the book
  • Extension Abduction Adduction Hyperextension Internal rotation External rotation Atrophy Hypertrophy
  • What determines the direction of the contracture.
  • What is the difference in level of consciousness and orientation? Allows the nurse to ascertain whether the patient understands the treatment plan and if he will be able to cooperate with the plan
  • The difference between orientation and consciousness is that consciousness is the patients response to environmental stimuli.
  • One of the study questions the vagus nerve is sometimes called the “wandering nerve” because it wanders through the body. It is a parasympathetic nerve therefore has a cholinergic effect. Stimulation of the vagus nerve can cause increased gastric secretion, bradycardia. Giving an enema or taking a rectal temperature can stimulate the vagus nerve. Ptosis (III) Facial Droop or Asymmetry (VII) Hoarse Voice (X) Articulation of Words (V, VII, X, XII) Abnormal Eye Position (III, IV, VI) Abnormal or Asymmetrical Pupils (II, III)
  • I Observation Involuntary Movements Muscle Symmetry Compare Left to Right Compare Proximal vs. Distal Atrophy Pay particular attention to the hands, shoulders, and thighs. Gait II. Muscle Tone Ask the patient to relax. Flex and extend the patient's fingers, wrist, and elbow. Flex and extend patient's ankle and knee. There is normally a small, continuous resistance to passive movement. Observe for decreased (flaccid) or increased (rigid/spastic) tone. Muscle Strength Test strength by having the patient move against your resistance. Always compare one side to the other. Grade strength on a scale from 0 to 5 "out of five": Pronator Drift Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed. Instruct the patient to keep the arms still while you tap them briskly downward. The patient will not be able to maintain extension and supination (and "drift into pronation) with upper motor neuron disease.
  • 0: absent reflex 1+: trace, or seen only with reinforcement 2+: normal 3+: brisk 4+: nonsustained clonus (i.e., repetitive vibratory movements) 5+: sustained clonus
  • Spasticity - marked by stiff or rigid muscles and exaggerated, deep tendon reflexes
  • Point to Point Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task. Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move their arm and return to your finger with their eyes closed. Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient's eyes closed. Romberg Be prepared to catch the patient if they are unstable. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support. The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem).
  • Clonus Support the knee in a partly flexed position. With the patient relaxed, quickly dorsiflex the foot. Observe for rhythmic oscillations.
  • General Explain each test before you do it. Unless otherwise specified, the patient's eyes should be closed during the actual testing. Compare symmetrical areas on the two sides of the body. Also compare distal and proximal areas of the extremities. Subjective Use your fingers to touch the skin lightly on both sides simultaneously. [ 13 ] Test several areas on both the upper and lower extremities. Ask the patient to tell you if there is difference from side to side or other "strange" sensations. Discrimination Graphesthesia With the blunt end of a pen or pencil, draw a large number in the patient's palm. Ask the patient to identify the number. Stereognosis Use as an alternative to graphesthesia. ++ Place a familiar object in the patient's hand (coin, paper clip, pencil, etc.). Ask the patient to tell you what it is.
  • D – Motor testing of the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. All other are cerebral stimuli
  • A. Cranial nurse II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Testing the water would be useful for impaired peripheral nerves. Speaking loudly is Vestibulococlear VIII. VII facial and IX glossopharangeal for tongue
  • Musculoskeletal and Neurological Assessment Powerpoint

    1. 1. Musculoskeletal and Neurological Assessment
    2. 2. Objectives <ul><li>Define Gait, Stance, Posture </li></ul><ul><li>Discuss assessment of joints and muscles </li></ul><ul><li>Outline a Neuro Exam </li></ul><ul><li>Identify reflexes </li></ul><ul><li>Identify function of the cranial nerves </li></ul>
    3. 3. Musculoskeletal Assessment
    4. 4. Musculoskeletal System <ul><li>Bones, joints, and muscles </li></ul><ul><li>Needed for Support, Movement, Protection, and production of red blood cells, and storage for essential minerals </li></ul><ul><li>Fall Precaution </li></ul><ul><li>Do No Harm! </li></ul>
    5. 5. Gait <ul><li>The base is as wide as the shoulder width </li></ul><ul><li>Foot placement is accurate </li></ul><ul><li>Walk is smooth, even and well-balanced </li></ul><ul><li>Associated movements, such as arm swing, are present. </li></ul>
    6. 6. Gait Abnomalities <ul><li>Unusual and uncontrollable walking patterns, usually caused by disease or injury. </li></ul><ul><ul><li>Propulsive </li></ul></ul><ul><ul><li>Scissors </li></ul></ul><ul><ul><li>Spastic </li></ul></ul><ul><ul><li>Steppage </li></ul></ul><ul><ul><li>Waddling </li></ul></ul>
    7. 7. Stance <ul><li>Symmetrical </li></ul><ul><li>Width </li></ul><ul><li>Steady </li></ul><ul><li>Assistive Devices </li></ul>
    8. 8. Posture <ul><li>Normal - Comfortably erect </li></ul><ul><ul><li>Look for straight lines across body parts </li></ul></ul><ul><li>Normal Aging </li></ul>
    9. 9. Lordosis - Increased Curvature of the Spine
    10. 10. Kyphosis is a curving of the spine that causes a bowing of the back, which leads to a hunchback or slouching posture.
    11. 11. Scoliosis – curvature of the spine away from middle or sideways
    12. 12. Examination of Joints <ul><li>Inspection </li></ul><ul><ul><li>Size and contour: redness, atrophy, deformity, swelling </li></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>Crepitious, thickening, swelling, or tenderness </li></ul></ul>
    13. 13. Range of Motion <ul><li>Full Mobility of each joint </li></ul><ul><li>Deliberate, accurate, smooth, and coordinated </li></ul><ul><li>No involuntary movement </li></ul>
    14. 14. Muscle Atrophy
    15. 15. Subluxation <ul><li>A partial or incomplete dislocation </li></ul>
    16. 16. Contractures <ul><li>A contracture is a fixed tightening of muscle, tendons, ligaments, or skin. Shortening of longest or strongest muscle. </li></ul><ul><li>Prevents normal movement of the associated body part. Impaired ROM </li></ul><ul><li>Skin becomes scarred and nonelastic which limits the range of movement of the affected area. </li></ul>
    17. 17. Neurological Assessment
    18. 18. General appearance, Personal Hygiene <ul><li>Appropriately dressed </li></ul><ul><li>Well-Groomed </li></ul><ul><li>Odor </li></ul><ul><li>Eye contact </li></ul><ul><li>Posture </li></ul>
    19. 19. Orientation <ul><li>Person </li></ul><ul><li>Place </li></ul><ul><li>Time </li></ul><ul><li>Can a person be oriented and still be confused? </li></ul>
    20. 20. Level of Consciousness: response to environmental stimuli <ul><li>Awake, alert </li></ul><ul><li>lethargic-stuporous-comatose-coma </li></ul><ul><li>If not fully alert, may need increased stimulus </li></ul><ul><li>Note any change in Level of Consciousness </li></ul><ul><li>Variety of Questions </li></ul><ul><li>One part or two part commands </li></ul>
    21. 21. Glascow Coma Scale <ul><li>Quantitative tool </li></ul><ul><li>Eye opening, verbal response, motor response </li></ul><ul><li>Fully alert score is 15 </li></ul><ul><li>Coma is 7 or less </li></ul>
    22. 22. 12 Cranial Nerve Stick out tongue, move tongue side to side XII hypoglossal Shrug shoulders, turn head against resistance XI spinal accessory X vagus Gag reflex, swallowing, taste; IX glossopharnxgeal hearing VIII acoustic Taste, smile, frown, close eyes tightly VII facial Assessed with III and VI VI abducens Facial sensations, corneal reflex V trigeminal IV trochlear Eye movements, PERRLA, eyelids III oculomotor Vision II optic Smell I olfactory Assessment Cranial Nerve
    23. 23. Motor <ul><li>Observation </li></ul><ul><li>Muscle Tone </li></ul><ul><li>Muscle Strength </li></ul><ul><ul><li>Squeeze hands </li></ul></ul><ul><ul><li>Pronator Drift </li></ul></ul>
    24. 24. Deep Tendon Reflex <ul><li>Biceps C5, C6 </li></ul><ul><li>Brachioradialis C6 </li></ul><ul><li>Triceps C7 </li></ul><ul><li>Patellar L4 </li></ul><ul><ul><li>Babinski Abnormal Reflex Toes Fan </li></ul></ul><ul><li>Achilles Tendon S1 </li></ul><ul><li>Rated from 0 to 5+ </li></ul>
    25. 25. Rating Scale <ul><li>0: absent reflex </li></ul><ul><li>1+: trace, or seen only with reinforcement </li></ul><ul><li>2+: normal </li></ul><ul><li>3+: brisk </li></ul><ul><li>4+: nonsustained clonus (i.e., repetitive vibratory movements) </li></ul><ul><li>5+: sustained clonus </li></ul>
    26. 26. Motor Abnormalities <ul><li>Spasticity </li></ul><ul><li>Flaccidity </li></ul><ul><li>Tremor </li></ul>
    27. 27. Coordination and Gait <ul><li>Point to Point Movements </li></ul><ul><li>Romberg </li></ul><ul><li>Gait </li></ul>
    28. 28. Reflexes <ul><li>Deep Tendon Reflexes </li></ul><ul><li>Clonus </li></ul><ul><li>Babinski </li></ul>
    29. 29. Sensory <ul><li>General </li></ul><ul><li>Soft/Sharp Touch </li></ul><ul><li>Discrimination </li></ul>
    30. 30. NCLEX Question <ul><li>A nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain. </li></ul><ul><ul><li>Sternal rub </li></ul></ul><ul><ul><li>Pressure on the Orbital rim </li></ul></ul><ul><ul><li>Squeezing of the sternocleidomastoid muscle </li></ul></ul><ul><ul><li>Nail bed pressure </li></ul></ul>
    31. 31. NCLEX Question <ul><li>A client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety? </li></ul><ul><ul><li>Provide a clear path for ambulation without obstacles </li></ul></ul><ul><ul><li>Test the temperature of the shower water </li></ul></ul><ul><ul><li>Speak Loudly to the client </li></ul></ul><ul><ul><li>Check the temperature of the food on the dietary tray. </li></ul></ul>