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Assessment of the           Musculoskeletal                   systemMaria Carmela L. Domocmat, RN, MSNInstructor, Nursing ...
TMJMaria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
• Inspect and palpate the TMJ• Test ROM• Test CN V functionOverview                           Maria Carmela L. Domocmat, R...
o   normal finding:         jaws move laterally 1 to 2 cm        (+) snapping and clicking – may be felt and heard        ...
TMJ palpation                Maria Carmela L. Domocmat, RN, MSN
Test ROM           Maria Carmela L. Domocmat, RN, MSN
Test ROM           Maria Carmela L. Domocmat, RN, MSN
Test CN V function– contract temporal and massetermuscle                       Maria Carmela L. Domocmat, RN, MSN
o normal   finding:   full ROM against contraction   contraction palpated with no pain or spasmso abnormal   finding:   la...
Sternoclavicular joint    Maria Carmela L. Domocmat, RN, MSN
•   Inspection and palpation    o normal finding:         no visible bony growth, swelling, redness         joint – nonten...
Maria Carmela L. Domocmat, RN, MSNhttp://www.orthoandsportspt.com/media/img/1076/shoulder_anatomy_bones03.jpg
Cervical, Thoracic and Lumbar Spine                  Maria Carmela L. Domocmat, RN, MSN
o normal   finding:    cervical and lumbar spines – concave    thoracic spine – convex    spine –straight; 24 vertebrae   ...
http://parentingteens.about.com/library/graphics/normalspine.gif   Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
o abnormal   finding:   flattened lumbar curvature – herniated lumbar   disc, ankylosing spondylitis   scoliosis - lateral...
Maria Carmela L. Domocmat, RN, MSN
.    Maria Carmela L. Domocmat, RN, MSN
.-.     Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
http://www.s-o.k12.ia.us/teacher_web/wedgem/Sites/ANATOMY/SKELETAL%20SY/Axial%20Skeleton.html                             ...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Palpate spinous processes and theparavertebral muscles on both sides of thespine for tenderness or pain                   ...
paravertebral muscles                        Maria Carmela L. Domocmat, RN, MSN
o normal   finding:   nontender spinous processes   well-developed firm and smooth, nontender   paravertebral muscles   no...
o abnormal   finding:   pain and tenderness of spinal processes and   paravertebral muscles – compression   fractures, lum...
o flexion  – touch chin; hyperextension –   look up o lateral bending – touch ear o rotation o repeat all against resistan...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
o normal finding:    flexion - 450; extension - 450    rotation -700    full ROM against resistance                       ...
pain and tenderness of spinal processes and  paravertebral muscles compression fractures ad  lumbosacral muscle strain  ce...
o flexion  – bendforward, touch toes o lateral bending o hyperextension o rotationTest ROM of thoracic and lumbarspine    ...
o normal   finding:   flexion – 750- 900   smooth movement, lumbar concavity   flattens out, spine remains straight   late...
o   abnormal finding:      lateral curvature disappears- functional scoliosis      unilateral exaggerated thoracic convexi...
◦ Lasègue’s test   o Or straight leg raising   o if (+) low back pain that radiates down the back   o to check for herniat...
Lasègue’s test Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
o normal   finding:   able to raise leg to 90 degree angle   mild pain of hamstring                              Maria Car...
o abnormal   finding:   pain that shoots and radiates down one or both   legs (sciatica) below the knees – herniated   int...
o leg   lengths - if suspect client has 1 leg longer        distance from anterior superior iliac spine and        medial ...
o normal   finding:   equal or within 1 cmo abnormal   finding:   unequal leg lengths – scoliosis   equal true leg lengths...
Shoulders, Arms, and Elbows                  Maria Carmela L. Domocmat, RN, MSN
o normal   finding:    shoulders –symmetrically round, no redness,    swelling, deformity or heat, no tenderness    muscle...
.    Range Of Motion             Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
o abnormal   finding:   flat, hollow, less rounded shoulders –   dislocation   muscle atrophy – nerve or muscle damage or ...
o flexion – move arms forward elbows straight ;  hyperextension – move arms backwardo adduction – hands front of body past...
o normal   finding:   flexion - 1800 ; hyperextension - 500   adduction - 500 ; abduction - 1800   external and internal r...
o   abnormal finding:      painful and limited abduction, muscle weakness &      atrophy – rotator cuff tear      sharp ca...
Elbows         Maria Carmela L. Domocmat, RN, MSN
•   Inspect for size, shape, deformities, redness, or    swelling    o elbows flex and extended    o elbows relaxed and fl...
o   normal finding:     symmetric, without deformity, redness,     swelling     nontender, without nodules                ...
Elbow Palpation         Maria Carmela L. Domocmat, RN, MSN
o abnormal   finding:   redness, heat, swelling- bursitis of olecranon   process- trauma or arthritis   firm, nontender, s...
Maria Carmela L. Domocmat, RN, MSN
o flexion – flex elbow, bring hand to  foreheado extension – straighten elbowo pronation – arm out, turn palm downo supina...
.    Range Of Motion             Maria Carmela L. Domocmat, RN, MSN
o normal   finding:   flexion – 1600   extension – 900   pronation – 900   supination – 900   some – lack 5 to 10 0 ; or h...
o abnormal   finding:   decreased muscle strength against resistance   – muscle and joint dse                             ...
Wrists         Maria Carmela L. Domocmat, RN, MSN
o palpate   anatomic snuffbox  o hollow area on back of wrist at base of fully    extended thumb o normal    finding:     ...
1. Maintain wrist flexion while you try to extend the wrist.2. Try to extend the wrist as you try to flex itTo assess wris...
Maria Carmela L. Domocmat, RN, MSN
o abnormal   finding:   rheumatoid arthritis – swelling, tenderness,   nodules   ganglion - nontender, round, enlarged,   ...
The scaphoid bone is a carpal bonenear the base of the thumb. Thecarpal bones connect the two bonesof the forearm, the rad...
the metacarpals attach to the phalanges, which arethe bones in the fingers and thumb.One reason that the wrist is so compl...
The wrist is made up of eightseparate small bones, called thecarpal bones                    Maria Carmela L. Domocmat, RN...
Maria Carmela L. Domocmat, RN, MSN
ganglion           Maria Carmela L. Domocmat, RN, MSN
scaphoid fracture                    Maria Carmela L. Domocmat, RN, MSN
The scaphoid is a         small bone located         on the thumb side         of your wrist. It is         the most commo...
Maria Carmela L. Domocmat, RN, MSN
o flexion   – bend down ; extension – bend  backo deviation – client hold wrist straight;  move hand outward and inwardTes...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Range Of MotionWrists, Hands, and Fingers.              Maria Carmela L. Domocmat, RN, MSN
o normal finding:    flexion - 90 0    hyperextension - 700    ulnar deviation - 55 0    radial deviation - 200    Swedes,...
o   abnormal finding:      ulnar deviation of wrist and fingers with limited      ROM – rheumatoid arthritis      epicondy...
◦ Phalen’s test ◦ Tinel’s signTest for Carpal Tunnel Syndrome                    Maria Carmela L. Domocmat, RN, MSN
Progressive sensory changes including paresthesias and numbness of the thumb, index finger, and ring finger of the involve...
http://www.rnpedia.com/home/notes/medical-surgical-nursing-          Maria Carmela L. Domocmat, RN, MSNnotes/carpal-tunnel...
place backs of both hand against each  other while flexing wrists 900 downward  hold for 60 secPhalen’s test              ...
In the first of thesetests, for 1 minute.The experience ofnumbness andparesthesia over thepalmar surface of thehand and th...
tapping over the median nerve (palmar aspect of wrist). The client’s sensation of tingling or prickling is known as Tinel’...
Maria Carmela L. Domocmat, RN, MSN
http://www.rnpedia.com/home/notes/medical-surgical-   Maria Carmela L. Domocmat, RN, MSNnursing-notes/carpal-tunnel-syndrome
o normal   finding:   no tingling, numbness, paino abnormal   finding:   (+)tingling, numbness, pain – (+) carpal tunnel  ...
Hands and Fingers                    Maria Carmela L. Domocmat, RN, MSN
o normal   finding:    symmetric, nontender, without nodules    fingers – lie in straight line    no swelling, deformities...
Palpate the jointsbetween the carpal, meta-carpal, and phalangealbones.Use your thumbs and indexfingers to palpate each of...
ask the client to squeeze your first two fingers as hard as he or she can. If you cross your fingers, you will not feel as...
o   abnormal finding:       swollen, stiff, tender finger joints – acute rheumatoid       arthritis       boutonnière defo...
swan-neck deformity       boutonnière deformity                      Maria Carmela L. Domocmat, RN, MSN
o   abnormal finding:       thenar atrophy (atrophy thenar prominence) – carpal tunnel       syndrome       osteoarthritis...
thenar atrophy                 Maria Carmela L. Domocmat, RN, MSN
o abduction   – spread fingers apart ; adduction  – make a fisto flexion – bend fingers down ; hyperextension  – bend upo ...
http://www.ncbi.nlm.nih.gov/books/N                               Maria Carmela L. Domocmat, RN, MSNBK27290/bin/ch4f4-57.jpg
Maria Carmela L. Domocmat, RN, MSN
ROMhttp://www.tpub.com/content/armymedical/MD0556/MD05560063i   Maria Carmela L. Domocmat, RN, MSNm.jpg
1.   Extend the fingers while you push down on the     dorsal surface2.   Flex the fingers while you push up on the     ve...
http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9423.jpgCarmela L. Domocmat, RN, MSN                         ...
http://www.heatedmouse.info/upload                              Maria Carmela L. Domocmat, RN, MSNed_images/hand_finger_jo...
o normal   finding:   abduction - 20 0   adduction - 900   flexion - 900   hyperextension - 300   thumb flexion/adduction-...
o abnormal   finding:   Dupuytren’s contracture – inability to   extend ring and little fingers   tenosynovitis (infection...
Dupuytren’s contracture http://advanceddynamic.com/Injuries-Conditions/Hand/Hand-Issues/Dupuytren-s- Contracture/a~285/art...
It is a very common problem and often arises in     the hands of middle aged persons; however, it can     be seen as early...
Maria Carmela L. Domocmat, RN, MSN
o abnormal   finding:   Tenosynovitis    infection of flexor tendon sheathes    painful extension of finger   decreased mu...
When a tendon (a fibrous, non-elastic band of tissue which attaches a muscle to a bone) and its surrounding soft tissue (c...
affects two thumb tendons: the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). These tendons connec...
Pathology: Normally, the APL and EPB glideeasily back and forth within this tunnel as theymove the thumb. When the APL and...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Hips       Maria Carmela L. Domocmat, RN, MSN
•   Inspect and palpate    o stand    o normal finding:         buttocks – equally sized         iliac crests – symmetric ...
o abnormal   finding:   instability, inability to stand, and/or   deformed hip area – fractured hip   tenderness, edema, d...
o supineo hip   flexion    flexion with knees straight - raise extended leg    flexion with knee flexed - flex knee to che...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
o abduction – move extended leg away from  midline of body as far as possible ; adduction –  toward midline of body as far...
Maria Carmela L. Domocmat, RN, MSN
http://www.aidmypain.com/muscle/groin-anatomy.php   Maria Carmela L. Domocmat, RN, MSN
o normal finding:    flexion with knees straight – 900    flexion with knee flexed -1200    abduction – 45-500 ; adduction...
o abnormal finding:    inability to abduct hip – hip dse    pain, decrease internal hip rotation –    osteoarthritis, femo...
evaluates flexion contractures of the hip With the client in the supine position, ask the client to pull one knee up towar...
normal finding: ◦ when the hip is flexed, the opposite   leg remains flat on the examination   table abnormal finding ◦ fo...
Maria Carmela L. Domocmat, RN, MSN
Knees        Maria Carmela L. Domocmat, RN, MSN
• Supine, sitting• Inspect size, shape, symmetry, swelling, deformities,  alignment, qudricep muscle atropy• Palpate tende...
Knee palpation            Maria Carmela L. Domocmat, RN, MSN
http://www.sciencephoto.com/image/265069/350wm/M3301436-Swollen_knee-SPL.jpg                                              ...
http://www.marvistavet.com/assets/images/knee_meniscus_model.gif                Maria Carmela L. Domocmat, RN, MSN
o indication: if (+) swelling to determine cause    of swelling (if due to accumulation of fluid or    soft tissue swellin...
A test for small effusions in the knee joint is called the bulge sign. Take the ball of your hand and firmly milk the medi...
http://www.hipandkneeadvice.com/index.php/knee-procedures/                                   Maria Carmela L. Domocmat, RN...
1. Quadriceps Tendon      2. Patella      3. Patellar Tendon      4. Tibia      5. Fibula      6. Posterior Cruciate Ligam...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
http://www.trialsightmedia.com/exhibit_store/images/kneeanatomy.jpg   Maria Carmela L. Domocmat, RN, MSN
http://static.howstuffworks.com/gif/adam/images/en/knee-arthroscopy-normal-anatomy-picture.jpg                            ...
http://www.healthscout.com/common/images/8/8716_11265_5.jpg                                                              M...
The ligaments which attach the upper leg bone(femur) to the large lower leg bone (tibia)create a hinge joint called the kn...
Maria Carmela L. Domocmat, RN, MSN
o normal   finding:    no bulge of fluid appears on medial side of    knee o abnormal   finding:    bulge of fluid on medi...
Maria Carmela L. Domocmat, RN, MSN
When considerable fluid is present in the suprapatellar pouch, ballottement of the patella may be possible. Ballottement i...
o helps detect large amts of fluid in kneeo client supineo firmly press nondominant thumb and index  finger on each side o...
o normal   finding:   no movement of patella   patella rests firmly over femuro abnormal   finding:   (+) ballottement tes...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
o as compress the patella –     slide it distally against     the underlying femur   o normal finding:        no pain     ...
o flexiono extensiono hyperextensiono full   ROM against resistanceTest ROM                             Maria Carmela L. D...
o normal   finding:   flexion – 1200 to 1300   extension - 00   hyperextension - 150   full ROM against resistance        ...
o abnormal   finding:   decreased ROM with synovial thickening –   osteoarthritis   inability to extend knee fully - flexi...
. To test range of motion of the   knee, ask the client to do the   following:   Straighten and stretch the leg.   Bend th...
To test muscle strength in the  knee, ask the client to do the  following:  Extend the leg as you try to bend  it (quadric...
Maria Carmela L. Domocmat, RN, MSN
McMurray’s testTest pain and injury                       Maria Carmela L. Domocmat, RN, MSN
if complains of a “giving in” or “locking” of knee  supine; flex one knee and hip  place your thumb and index finger on 1 ...
http://3.bp.blogspot.com/_ZWqgYBROGHw/TQx2wAOhcaI/AAAAAAAACAQ/OkboYJC8Zfk/s1600/p4a04203.jpg        http://www.theshoulder...
o normal   finding:   no pain or clickingo abnormal   finding:   (+) pain, clicking – torn meniscus of knee               ...
Maria Carmela L. Domocmat, RN, MSN
Ankles and Feet                  Maria Carmela L. Domocmat, RN, MSN
client sit, stand, walk: inspect position,alignment, shape skin                             Maria Carmela L. Domocmat, RN,...
Maria Carmela L. Domocmat, RN, MSN
o   normal finding:      toes        • usually point forward and lie flat        • may point in – pes varus        • may p...
o abnormal finding:     hallux valgus – laterally deviated great toe; possible overlapping of     2nd toe; formation enlar...
hallux valgushttp://www.rucosm.com/IMAGES/foot1.jpg                           Maria Carmela L. Domocmat, RN, MSN
pes planus or flat feet                                                                  Maria Carmela L. Domocmat, RN, MS...
pes cavus            Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Corns are areas of thick, hardened, dead skin. They form to protect the skin and structures  under the skin from pressure,...
calluses           Maria Carmela L. Domocmat, RN, MSN
Corns and calluses form on the skin because of repeated pressure   or friction. A corn is a small, tender area of thickene...
Warts, also called verrucae, are small benign growths usually   caused by a viral infection of the skin or mucous membrane...
plantar warts                Maria Carmela L. Domocmat, RN, MSN
hammertoes are a contracture of the toes as a result of a muscle     imbalance between the tendons on the top and the tend...
http://images.rxlist.com/images/SlideShow/diabetes_foot_problems_s8_corns.jpgA hammertoe is a toe that is bent because of ...
Maria Carmela L. Domocmat, RN, MSN
http://feetdoc.com/hammer_toes.ht   Maria Carmela L. Domocmat, RN, MSNm
o normal finding:      no tenderness, heat, swelling, nodules  o abnormal finding:      gouty arthritis- tender, painful, ...
o dorsiflexion – point toes upward ;  plantar flexion –downwardo eversion – turn soles outward;  inversion – inwardo abduc...
http://t2.gstatic.com/images?q=tbn:ANd9GcTUKOyFEo1NWEb03sa5NBCCpyzzUwyt4   Maria Carmela L. Domocmat, RN, MSNC8d61SUoBwq6O...
Maria Carmela L. Domocmat, RN, MSN
o abduction– rotate foot outward ; adduction – inward                          Maria Carmela L. Domocmat, RN, MSN
.    Maria Carmela L. Domocmat, RN, MSN
o normal   finding:   200 dorsiflexion ankle and foot; 45 0 plantar   flexion   200 eversion; 300 inversion   100 abductio...
o abnormal   finding:   decreased ROM without or against   resistance – muscle and joint dse   hammer toe – hyperextension...
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musculoskeletal system

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  1. 1. Assessment of the Musculoskeletal systemMaria Carmela L. Domocmat, RN, MSNInstructor, Nursing Health AssessmentSchool of NursingNorthern Luzon Adventist College Maria Carmela L. Domocmat, RN, MSN
  2. 2. TMJMaria Carmela L. Domocmat, RN, MSN
  3. 3. Maria Carmela L. Domocmat, RN, MSN
  4. 4. • Inspect and palpate the TMJ• Test ROM• Test CN V functionOverview Maria Carmela L. Domocmat, RN, MSN
  5. 5. o normal finding: jaws move laterally 1 to 2 cm (+) snapping and clicking – may be felt and heard mouth opens 1-2 inches (distance bet upper and lower teeth) jaw protrudes and retracts easily o abnormal finding: decreased ROM, swelling, tenderness, crepitus – arthritis decreased muscle strength – muscle and joint dse decreased ROM, clicking, popping, grating sound – TMJ dysfunctionInspect and palpate the TMJ Maria Carmela L. Domocmat, RN, MSN
  6. 6. TMJ palpation Maria Carmela L. Domocmat, RN, MSN
  7. 7. Test ROM Maria Carmela L. Domocmat, RN, MSN
  8. 8. Test ROM Maria Carmela L. Domocmat, RN, MSN
  9. 9. Test CN V function– contract temporal and massetermuscle Maria Carmela L. Domocmat, RN, MSN
  10. 10. o normal finding: full ROM against contraction contraction palpated with no pain or spasmso abnormal finding: lack of full contraction – CN V lesion Pain or spasms – myofacial pain syndromeROM & CN V function Maria Carmela L. Domocmat, RN, MSN
  11. 11. Sternoclavicular joint Maria Carmela L. Domocmat, RN, MSN
  12. 12. • Inspection and palpation o normal finding: no visible bony growth, swelling, redness joint – nontender o abnormal finding: swollen, red, enlarged joint or tender painful joint – joint inflammationSternoclavicular joint Maria Carmela L. Domocmat, RN, MSN
  13. 13. Maria Carmela L. Domocmat, RN, MSNhttp://www.orthoandsportspt.com/media/img/1076/shoulder_anatomy_bones03.jpg
  14. 14. Cervical, Thoracic and Lumbar Spine Maria Carmela L. Domocmat, RN, MSN
  15. 15. o normal finding: cervical and lumbar spines – concave thoracic spine – convex spine –straight; 24 vertebrae African Americans – large gluteal prominence – spine appear lumbar lordosis variation number of vertebrae •Afr Ame women – 23 vertebrae •Eskimo, Indian women – 25 vertebraeObserve the cervical, thoracic, andlumbar curves from side then frombehind Maria Carmela L. Domocmat, RN, MSN
  16. 16. http://parentingteens.about.com/library/graphics/normalspine.gif Maria Carmela L. Domocmat, RN, MSN
  17. 17. Maria Carmela L. Domocmat, RN, MSN
  18. 18. Maria Carmela L. Domocmat, RN, MSN
  19. 19. Maria Carmela L. Domocmat, RN, MSN
  20. 20. o abnormal finding: flattened lumbar curvature – herniated lumbar disc, ankylosing spondylitis scoliosis - lateral curvature of thoracic spine with increase in convexity on curved side lordosis – exaggerated lumbar curve; pregnancy, obesity kyphosis – rounded thoracic convexityObserve the cervical, –thoracic, lengths unequal heights of hips unequal leg andlumbar curves from side then frombehind Maria Carmela L. Domocmat, RN, MSN
  21. 21. Maria Carmela L. Domocmat, RN, MSN
  22. 22. . Maria Carmela L. Domocmat, RN, MSN
  23. 23. .-. Maria Carmela L. Domocmat, RN, MSN
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  26. 26. Maria Carmela L. Domocmat, RN, MSN
  27. 27. http://www.s-o.k12.ia.us/teacher_web/wedgem/Sites/ANATOMY/SKELETAL%20SY/Axial%20Skeleton.html Maria Carmela L. Domocmat, RN, MSN
  28. 28. Maria Carmela L. Domocmat, RN, MSN
  29. 29. Maria Carmela L. Domocmat, RN, MSN
  30. 30. Palpate spinous processes and theparavertebral muscles on both sides of thespine for tenderness or pain Maria Carmela L. Domocmat, RN, MSN
  31. 31. paravertebral muscles Maria Carmela L. Domocmat, RN, MSN
  32. 32. o normal finding: nontender spinous processes well-developed firm and smooth, nontender paravertebral muscles no muscle spasms Maria Carmela L. Domocmat, RN, MSN
  33. 33. o abnormal finding: pain and tenderness of spinal processes and paravertebral muscles – compression fractures, lumbosacral muscle strain Maria Carmela L. Domocmat, RN, MSN
  34. 34. o flexion – touch chin; hyperextension – look up o lateral bending – touch ear o rotation o repeat all against resistanceTest ROM of cervical spine Maria Carmela L. Domocmat, RN, MSN
  35. 35. Maria Carmela L. Domocmat, RN, MSN
  36. 36. Maria Carmela L. Domocmat, RN, MSN
  37. 37. Maria Carmela L. Domocmat, RN, MSN
  38. 38. o normal finding: flexion - 450; extension - 450 rotation -700 full ROM against resistance Maria Carmela L. Domocmat, RN, MSN
  39. 39. pain and tenderness of spinal processes and paravertebral muscles compression fractures ad lumbosacral muscle strain cervical strain • impaired ROM and neck pain – form abnormalities soft tissue (muscles, ligaments, nerves) – due straining or injuring neck (i.e, sleeping in wrong position, carrying heavy suitcase, automobile crash) impaired ROM, pain that radiates to back, shoulder, arms - cervical disc degenerative dse, spinal cord tumors neck pain with loss of sensation in legs – cervical spinal cord compression impaired ROM, neck pain assoc with fever, chills, headache – serious infection (e.g., meningitis)abnormal finding Maria Carmela L. Domocmat, RN, MSN
  40. 40. o flexion – bendforward, touch toes o lateral bending o hyperextension o rotationTest ROM of thoracic and lumbarspine Maria Carmela L. Domocmat, RN, MSN
  41. 41. o normal finding: flexion – 750- 900 smooth movement, lumbar concavity flattens out, spine remains straight lateral bending - 350 hyperextension - 300 rotation - 300 Maria Carmela L. Domocmat, RN, MSN
  42. 42. o abnormal finding: lateral curvature disappears- functional scoliosis unilateral exaggerated thoracic convexity – structural scoliosis impaired ROM, pain lumbar and thoracic regions - low back strain from injury to soft tissues impaired ROM lumbar and thoracic regions – osteoarthritis, ankylosing spondylitis, congenital abnormalities Maria Carmela L. Domocmat, RN, MSN
  43. 43. ◦ Lasègue’s test o Or straight leg raising o if (+) low back pain that radiates down the back o to check for herniated nucleus pulposus o client lie flat and raise each relaxed leg independently to point of pain o at point of pain – dorsiflex foot o note degree of elevation when pain occurs; distribution and character of pain, results from dorsiflexionTest for back and leg pain Maria Carmela L. Domocmat, RN, MSN
  44. 44. Lasègue’s test Maria Carmela L. Domocmat, RN, MSN
  45. 45. Maria Carmela L. Domocmat, RN, MSN
  46. 46. o normal finding: able to raise leg to 90 degree angle mild pain of hamstring Maria Carmela L. Domocmat, RN, MSN
  47. 47. o abnormal finding: pain that shoots and radiates down one or both legs (sciatica) below the knees – herniated intervertebral disc continuous, aching pain at night not relieved by rest – metastases lower back pain with tenderness and limited ROM – osteoporosis Maria Carmela L. Domocmat, RN, MSN
  48. 48. o leg lengths - if suspect client has 1 leg longer distance from anterior superior iliac spine and medial malleolus; cross tape on medial side of knee o if still look unequal – assess apparent leg lengths measure from nonfixed point (umbilicus) to a fixed point (medial malleolus) each legMeasure leg length Maria Carmela L. Domocmat, RN, MSN
  49. 49. o normal finding: equal or within 1 cmo abnormal finding: unequal leg lengths – scoliosis equal true leg lengths but unequal apparent leg lengths – abnormalities in structure or position of hips and pelvis Maria Carmela L. Domocmat, RN, MSN
  50. 50. Shoulders, Arms, and Elbows Maria Carmela L. Domocmat, RN, MSN
  51. 51. o normal finding: shoulders –symmetrically round, no redness, swelling, deformity or heat, no tenderness muscles -fully developed clavicle and scapulae – even and symmetricInspect and palpate shoulders andarms Maria Carmela L. Domocmat, RN, MSN
  52. 52. . Range Of Motion Maria Carmela L. Domocmat, RN, MSN
  53. 53. Maria Carmela L. Domocmat, RN, MSN
  54. 54. Maria Carmela L. Domocmat, RN, MSN
  55. 55. o abnormal finding: flat, hollow, less rounded shoulders – dislocation muscle atrophy – nerve or muscle damage or lack of use tenderness, swelling, heat – shoulder stains, sprains, arthritis, bursitis, degenerative joint dse Maria Carmela L. Domocmat, RN, MSN
  56. 56. o flexion – move arms forward elbows straight ; hyperextension – move arms backwardo adduction – hands front of body past midline ; abduction – hands together overheado external rotation – hands together behind head, elbows flexed ; internal rotation – behind backo shrug shoulderso repeat all against resistanceTest ROM Maria Carmela L. Domocmat, RN, MSN
  57. 57. o normal finding: flexion - 1800 ; hyperextension - 500 adduction - 500 ; abduction - 1800 external and internal rotation - 900 Maria Carmela L. Domocmat, RN, MSN
  58. 58. o abnormal finding: painful and limited abduction, muscle weakness & atrophy – rotator cuff tear sharp catches of pain when bringing hands overhead – rotator cuff tendinitis chronic pain and severe limitation of all shoulder motions – calcified tendinitis unable shrug shoulders against resistance - lesion of CN XI decreased muscle strength against resistance – muscle and joint dse Maria Carmela L. Domocmat, RN, MSN
  59. 59. Elbows Maria Carmela L. Domocmat, RN, MSN
  60. 60. • Inspect for size, shape, deformities, redness, or swelling o elbows flex and extended o elbows relaxed and flexed abt 700 – palpate olecranon process and epicondyles use thumb and middle fingersInspect for size, shape,deformities, redness, or swelling Maria Carmela L. Domocmat, RN, MSN
  61. 61. o normal finding: symmetric, without deformity, redness, swelling nontender, without nodules Maria Carmela L. Domocmat, RN, MSN
  62. 62. Elbow Palpation Maria Carmela L. Domocmat, RN, MSN
  63. 63. o abnormal finding: redness, heat, swelling- bursitis of olecranon process- trauma or arthritis firm, nontender, subq nodules – rheumatoid arthritis or rheumatic fever tenderness or pain over epicondyles – epicondylitis (tennis elbow) – repetitive movements of forearm or wrists Maria Carmela L. Domocmat, RN, MSN
  64. 64. Maria Carmela L. Domocmat, RN, MSN
  65. 65. o flexion – flex elbow, bring hand to foreheado extension – straighten elbowo pronation – arm out, turn palm downo supination – turn palm upTest ROM Maria Carmela L. Domocmat, RN, MSN
  66. 66. . Range Of Motion Maria Carmela L. Domocmat, RN, MSN
  67. 67. o normal finding: flexion – 1600 extension – 900 pronation – 900 supination – 900 some – lack 5 to 10 0 ; or have hyperextension Maria Carmela L. Domocmat, RN, MSN
  68. 68. o abnormal finding: decreased muscle strength against resistance – muscle and joint dse Maria Carmela L. Domocmat, RN, MSN
  69. 69. Wrists Maria Carmela L. Domocmat, RN, MSN
  70. 70. o palpate anatomic snuffbox o hollow area on back of wrist at base of fully extended thumb o normal finding: symmetric without redness, swelling nontender, free of nodules no tenderness anatomic snuffboxInspect and palpate Maria Carmela L. Domocmat, RN, MSN
  71. 71. 1. Maintain wrist flexion while you try to extend the wrist.2. Try to extend the wrist as you try to flex itTo assess wrist strength Maria Carmela L. Domocmat, RN, MSN
  72. 72. Maria Carmela L. Domocmat, RN, MSN
  73. 73. o abnormal finding: rheumatoid arthritis – swelling, tenderness, nodules ganglion - nontender, round, enlarged, swollen, fluid-filled cyst ; dorsum of wrist snuffbox tenderness – scaphoid fracture – result of falling on outstretched hand Maria Carmela L. Domocmat, RN, MSN
  74. 74. The scaphoid bone is a carpal bonenear the base of the thumb. Thecarpal bones connect the two bonesof the forearm, the radius andthe ulna, to the bones of the hand.Themetacarpal bones are the longbones that lie underneath the palm. Maria Carmela L. Domocmat, RN, MSN
  75. 75. the metacarpals attach to the phalanges, which arethe bones in the fingers and thumb.One reason that the wrist is so complicated isbecause every small bone forms a joint with thebone next to it.This means that what we call the wrist joint isactually made up of many small joints. Ligamentsconnect all the small bones to each other, and tothe radius, ulna, and metacarpal bones.The scaphoid bone is a small carpal bone on thethumb side (radial side) of the wrist. It is the mostcommonly fractured carpal bone. Maria Carmela L. Domocmat, RN, MSN
  76. 76. The wrist is made up of eightseparate small bones, called thecarpal bones Maria Carmela L. Domocmat, RN, MSN
  77. 77. Maria Carmela L. Domocmat, RN, MSN
  78. 78. ganglion Maria Carmela L. Domocmat, RN, MSN
  79. 79. scaphoid fracture Maria Carmela L. Domocmat, RN, MSN
  80. 80. The scaphoid is a small bone located on the thumb side of your wrist. It is the most commonly broken bone in the wrist. Because symptoms can be minimal, scaphoid fractures are frequently mistaken as sprained wrists. Scaphoid fractures require casting or surgery. scaphoid fracturehttp://www.vermontorthoclinic-edu.org/tabid/14407/mid/24836/ContentPubID/108/ContentClassificationGroupID/- Maria Carmela L. Domocmat, RN, MSN1/ViewIndex/0/Default.aspx
  81. 81. Maria Carmela L. Domocmat, RN, MSN
  82. 82. o flexion – bend down ; extension – bend backo deviation – client hold wrist straight; move hand outward and inwardTest ROM Maria Carmela L. Domocmat, RN, MSN
  83. 83. Maria Carmela L. Domocmat, RN, MSN
  84. 84. Maria Carmela L. Domocmat, RN, MSN
  85. 85. Range Of MotionWrists, Hands, and Fingers. Maria Carmela L. Domocmat, RN, MSN
  86. 86. o normal finding: flexion - 90 0 hyperextension - 700 ulnar deviation - 55 0 radial deviation - 200 Swedes, Chinese – unequal lengths of ulna and radius Maria Carmela L. Domocmat, RN, MSN
  87. 87. o abnormal finding: ulnar deviation of wrist and fingers with limited ROM – rheumatoid arthritis epicondylitis of lateral side of elbow– increased pain with extension of wrist and fingers against resistance epicondylitis of medial side of elbow– increased pain with flexion of wrist and fingers against resistance decreased muscle strength against resistance – muscle and joint dse Maria Carmela L. Domocmat, RN, MSN
  88. 88. ◦ Phalen’s test ◦ Tinel’s signTest for Carpal Tunnel Syndrome Maria Carmela L. Domocmat, RN, MSN
  89. 89. Progressive sensory changes including paresthesias and numbness of the thumb, index finger, and ring finger of the involved hand; leads to pain waking the patient up at night. Motor changes beginning with clumsiness and progressing to weakness; edema and thenar atrophy may be noted. Positive Tinel’s sign: Increased paresthesias on tapping of tendon sheath (ventral surface of central wrist). Positive Phalen test: Increased symptoms with acute palmar flexion for 1 minute.Carpal Tunnel Syndrome Maria Carmela L. Domocmat, RN, MSN
  90. 90. http://www.rnpedia.com/home/notes/medical-surgical-nursing- Maria Carmela L. Domocmat, RN, MSNnotes/carpal-tunnel-syndrome
  91. 91. place backs of both hand against each other while flexing wrists 900 downward hold for 60 secPhalen’s test Maria Carmela L. Domocmat, RN, MSN
  92. 92. In the first of thesetests, for 1 minute.The experience ofnumbness andparesthesia over thepalmar surface of thehand and the firstthree fingers and partof the fourth is calledPhalen’s sign. Thesymptoms resolvequickly after the handreturns to the restingPhalen’s testposition. Maria Carmela L. Domocmat, RN, MSN
  93. 93. tapping over the median nerve (palmar aspect of wrist). The client’s sensation of tingling or prickling is known as Tinel’s sign.Tinel’s sign Maria Carmela L. Domocmat, RN, MSN
  94. 94. Maria Carmela L. Domocmat, RN, MSN
  95. 95. http://www.rnpedia.com/home/notes/medical-surgical- Maria Carmela L. Domocmat, RN, MSNnursing-notes/carpal-tunnel-syndrome
  96. 96. o normal finding: no tingling, numbness, paino abnormal finding: (+)tingling, numbness, pain – (+) carpal tunnel syndrome numbness, pain , impaired function of hand and fingers - median nerve entrapped in carpal tunnel Maria Carmela L. Domocmat, RN, MSN
  97. 97. Hands and Fingers Maria Carmela L. Domocmat, RN, MSN
  98. 98. o normal finding: symmetric, nontender, without nodules fingers – lie in straight line no swelling, deformities rounded protuberance – next to thumb over thenar prominence smaller protuberance adjacent small fingerInspect and palpate Maria Carmela L. Domocmat, RN, MSN
  99. 99. Palpate the jointsbetween the carpal, meta-carpal, and phalangealbones.Use your thumbs and indexfingers to palpate each ofthese joints.Interphalangeal jointsMetacarpophalangeal jointsRadiocarpal groove andwrist Maria Carmela L. Domocmat, RN, MSN
  100. 100. ask the client to squeeze your first two fingers as hard as he or she can. If you cross your fingers, you will not feel as much discomfort if the client is exceptionallyTo assess grip strong. strength Maria Carmela L. Domocmat, RN, MSN
  101. 101. o abnormal finding: swollen, stiff, tender finger joints – acute rheumatoid arthritis boutonnière deformity – flexion of proximal interphalangeal joint and hyperextension of distal interphalangeal joint swan-neck deformity - hyperextension of proximal interphalangeal joint with flexion of distal interphalangeal joint Maria Carmela L. Domocmat, RN, MSN
  102. 102. swan-neck deformity boutonnière deformity Maria Carmela L. Domocmat, RN, MSN
  103. 103. o abnormal finding: thenar atrophy (atrophy thenar prominence) – carpal tunnel syndrome osteoarthritis • Heberden’s nodes - hard, painless nodules over distal interphalangeal joints • Bouchard’s nodes - hard, painless nodules over proximal interphalangeal joints Maria Carmela L. Domocmat, RN, MSN
  104. 104. thenar atrophy Maria Carmela L. Domocmat, RN, MSN
  105. 105. o abduction – spread fingers apart ; adduction – make a fisto flexion – bend fingers down ; hyperextension – bend upo thumb abduction - move thumb away; thumb adduction – touch thumb base of sml fingero repeat all against resistanceTest ROM Maria Carmela L. Domocmat, RN, MSN
  106. 106. http://www.ncbi.nlm.nih.gov/books/N Maria Carmela L. Domocmat, RN, MSNBK27290/bin/ch4f4-57.jpg
  107. 107. Maria Carmela L. Domocmat, RN, MSN
  108. 108. ROMhttp://www.tpub.com/content/armymedical/MD0556/MD05560063i Maria Carmela L. Domocmat, RN, MSNm.jpg
  109. 109. 1. Extend the fingers while you push down on the dorsal surface2. Flex the fingers while you push up on the ventral surface.3. Spread the fingers as far apart as possible while you try to push them together.4. Push the fingers as close together as possible while you try to pull them apart.To assess finger strength Maria Carmela L. Domocmat, RN, MSN
  110. 110. http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9423.jpgCarmela L. Domocmat, RN, MSN Maria
  111. 111. http://www.heatedmouse.info/upload Maria Carmela L. Domocmat, RN, MSNed_images/hand_finger_joint_causes01-722880.jpg
  112. 112. o normal finding: abduction - 20 0 adduction - 900 flexion - 900 hyperextension - 300 thumb flexion/adduction- 500 Maria Carmela L. Domocmat, RN, MSN
  113. 113. o abnormal finding: Dupuytren’s contracture – inability to extend ring and little fingers tenosynovitis (infection of flexor tendon sheathes) - painful extension of finger decreased muscle strength against resistance – muscle and joint dse Maria Carmela L. Domocmat, RN, MSN
  114. 114. Dupuytren’s contracture http://advanceddynamic.com/Injuries-Conditions/Hand/Hand-Issues/Dupuytren-s- Contracture/a~285/article.htmlhttp://www.med.und.edu/users/jwhiting/dupdef.html Maria Carmela L. Domocmat, RN, MSN
  115. 115. It is a very common problem and often arises in the hands of middle aged persons; however, it can be seen as early as the twenties. This entity does run in families in some cases. It is seven times more common in men than women. It has been associated with diabetes and can be seen in alcoholics with cirrhosis of the liver. It has also been associated with epilepsy but may be a result of the use of anticonvulsant drugs rather than the presence of epilepsy itself. The underlying cause is unknown.Dupuytren’s contracture http://advanceddynamic.com/Injuries-Conditions/Hand/Hand-Issues/Dupuytren-s- Contracture/a~285/article.htmlhttp://www.med.und.edu/users/jwhiting/dupdef.html Maria Carmela L. Domocmat, RN, MSN
  116. 116. Maria Carmela L. Domocmat, RN, MSN
  117. 117. o abnormal finding: Tenosynovitis infection of flexor tendon sheathes painful extension of finger decreased muscle strength against resistance – muscle and joint dse Maria Carmela L. Domocmat, RN, MSN
  118. 118. When a tendon (a fibrous, non-elastic band of tissue which attaches a muscle to a bone) and its surrounding soft tissue (called the tenosynovium) are injured—either by a direct injury or due to micro-trauma like excessive repetitive movements—they become inflamed, swollen, and painful. This condition is called Tenosynovitis. (A less accurate and rarely used term to describe this condition is tendonitis.) While all of the tendons of the wrist and hand may become inflamed and painful, the most common form of tenosynovitis seen in the hand and wrist is called deQuervains Tenosynovitis. deQuervains Tenosynovitis affects the thumb and wrist.http://www.ourhealthnetwork.com/conditions/hand/deQuervainsTenosynovitis.asp Maria Carmela L. Domocmat, RN, MSN
  119. 119. affects two thumb tendons: the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). These tendons connect their respective muscles, which lie on the back of the forearm, to the thumb. These tendons are responsible for extending the thumb backwards, and for moving the thumb away from the palm of the hand. On their way to the thumb, the APL and EPB travel side-by-side along the inside of the wrist. They pass through a tunnel in the wrist which is covered by a non-elastic type of fibrous tissue called the Extensor Retinaculum. The function of this tunnel is to hold the tendons in place.deQuervainsTenosynovitis Maria Carmela L. Domocmat, RN, MSN
  120. 120. Pathology: Normally, the APL and EPB glideeasily back and forth within this tunnel as theymove the thumb. When the APL and EPBbecome inflamed and swollen, however, thetendons become compressed against eachother because the Extensor Retinaculum (thenon-elastic band of tissue that covers thetunnel) cannot expand to "make more room forthe swollen tendons." This leads to restrictedand painful tendon and thumb movements. Maria Carmela L. Domocmat, RN, MSN
  121. 121. Maria Carmela L. Domocmat, RN, MSN
  122. 122. Maria Carmela L. Domocmat, RN, MSN
  123. 123. Hips Maria Carmela L. Domocmat, RN, MSN
  124. 124. • Inspect and palpate o stand o normal finding: buttocks – equally sized iliac crests – symmetric height hips – stable, nontender, without crepitus Maria Carmela L. Domocmat, RN, MSN
  125. 125. o abnormal finding: instability, inability to stand, and/or deformed hip area – fractured hip tenderness, edema, decreased ROM, crepitus – hip inflammation, degenerative jt dse Maria Carmela L. Domocmat, RN, MSN
  126. 126. o supineo hip flexion flexion with knees straight - raise extended leg flexion with knee flexed - flex knee to chest; keep other leg extended Note: if had total hip replacement – do not test ROM unless physician gives permission; reduce risk of dislocating prosthesisTest ROM Maria Carmela L. Domocmat, RN, MSN
  127. 127. Maria Carmela L. Domocmat, RN, MSN
  128. 128. Maria Carmela L. Domocmat, RN, MSN
  129. 129. o abduction – move extended leg away from midline of body as far as possible ; adduction – toward midline of body as far as possibleo internal/ external hip rotation – bend knee and turn leg inward then outwardo hyperextension – prone, lift extended leg off table ; or client stand and swing extended leg backwardo repeat all against resistance Maria Carmela L. Domocmat, RN, MSN
  130. 130. Maria Carmela L. Domocmat, RN, MSN
  131. 131. http://www.aidmypain.com/muscle/groin-anatomy.php Maria Carmela L. Domocmat, RN, MSN
  132. 132. o normal finding: flexion with knees straight – 900 flexion with knee flexed -1200 abduction – 45-500 ; adduction – 20 to 300 internal hip rotation - 400 ; external hip rotation - 450 hyperextension - 150 Maria Carmela L. Domocmat, RN, MSN
  133. 133. o abnormal finding: inability to abduct hip – hip dse pain, decrease internal hip rotation – osteoarthritis, femoral neck stress fracture pain or palpation of greater trochanter; pain as client moves from standing to lying down – bursitis of hip Maria Carmela L. Domocmat, RN, MSN
  134. 134. evaluates flexion contractures of the hip With the client in the supine position, ask the client to pull one knee up toward the chest as far as possible. Approximate the extent of the flexion contracture by noting the degree of flexion of the opposite leg (the angle between the client’s leg and the table).Thomas test Maria Carmela L. Domocmat, RN, MSN
  135. 135. normal finding: ◦ when the hip is flexed, the opposite leg remains flat on the examination table abnormal finding ◦ for the individual with an immobile hip, the opposite hip and leg flex in response to flexion of the leg.Thomas test Maria Carmela L. Domocmat, RN, MSN
  136. 136. Maria Carmela L. Domocmat, RN, MSN
  137. 137. Knees Maria Carmela L. Domocmat, RN, MSN
  138. 138. • Supine, sitting• Inspect size, shape, symmetry, swelling, deformities, alignment, qudricep muscle atropy• Palpate tenderness, warmth, consistency, nodules o begin 10 cm above patella o use fingers and thumb to move downward the knee Maria Carmela L. Domocmat, RN, MSN
  139. 139. Knee palpation Maria Carmela L. Domocmat, RN, MSN
  140. 140. http://www.sciencephoto.com/image/265069/350wm/M3301436-Swollen_knee-SPL.jpg Maria Carmela L. Domocmat, RN, MSN
  141. 141. http://www.marvistavet.com/assets/images/knee_meniscus_model.gif Maria Carmela L. Domocmat, RN, MSN
  142. 142. o indication: if (+) swelling to determine cause of swelling (if due to accumulation of fluid or soft tissue swelling) o helps detect small amts of fluid in knee o client supine – use ball of your hand firmly to stroke the medial side of knee upward, 3-4x – to displace any accumulated fluid o then press lateral side of knee o look for bulge on medial side of kneeBulge test Maria Carmela L. Domocmat, RN, MSN
  143. 143. A test for small effusions in the knee joint is called the bulge sign. Take the ball of your hand and firmly milk the medial aspect of the knee upward two to three times to displace fluid Then press or tap behind the lateral margin of the knee. A positive bulge sign will show a swelling or bulge of fluid in the hollow area medial to the patella. The bulge sign is useful for assessing small effusions, but It may be absent in large effusions.Bulge sign Maria Carmela L. Domocmat, RN, MSN
  144. 144. http://www.hipandkneeadvice.com/index.php/knee-procedures/ Maria Carmela L. Domocmat, RN, MSN
  145. 145. 1. Quadriceps Tendon 2. Patella 3. Patellar Tendon 4. Tibia 5. Fibula 6. Posterior Cruciate Ligament 7. Anterior Cruciate Ligament 8. Lateral Collateral Ligament 9. Lateral Meniscus 10. Lateral Femoral Condyle 11. Femurhttp://www.hipandkneeadvice.com/wp-content/uploads/2009/07/pic_knee_anatomy__big1.jpg Maria Carmela L. Domocmat, RN, MSN
  146. 146. Maria Carmela L. Domocmat, RN, MSN
  147. 147. Maria Carmela L. Domocmat, RN, MSN
  148. 148. http://www.trialsightmedia.com/exhibit_store/images/kneeanatomy.jpg Maria Carmela L. Domocmat, RN, MSN
  149. 149. http://static.howstuffworks.com/gif/adam/images/en/knee-arthroscopy-normal-anatomy-picture.jpg Maria Carmela L. Domocmat, RN, MSN
  150. 150. http://www.healthscout.com/common/images/8/8716_11265_5.jpg Maria Carmela L. Domocmat, RN, MSN
  151. 151. The ligaments which attach the upper leg bone(femur) to the large lower leg bone (tibia)create a hinge joint called the knee. Theanterior and posterior cruciate ligaments are 2short, strong ligaments which criss-cross eachother in the middle of the joint. Maria Carmela L. Domocmat, RN, MSN
  152. 152. Maria Carmela L. Domocmat, RN, MSN
  153. 153. o normal finding: no bulge of fluid appears on medial side of knee o abnormal finding: bulge of fluid on medial side; with sml amt of joint effusionBulge test Maria Carmela L. Domocmat, RN, MSN
  154. 154. Maria Carmela L. Domocmat, RN, MSN
  155. 155. When considerable fluid is present in the suprapatellar pouch, ballottement of the patella may be possible. Ballottement involves applying downward pressure with one hand while pushing the patella backward against the femur with a finger of the opposite hand. Examine the popliteal region with the client in the prone position or while standing. Swelling of the joint in the region, which is called Baker’s cyst, is generally an extension of the articular cavity.Ballottement of thepatella Maria Carmela L. Domocmat, RN, MSN
  156. 156. o helps detect large amts of fluid in kneeo client supineo firmly press nondominant thumb and index finger on each side of patella this displaces fluid in suprapatellar bursa located between femur and patellao with dominant fingers – push patella down on femuro feel fluid wave or a click Maria Carmela L. Domocmat, RN, MSN
  157. 157. o normal finding: no movement of patella patella rests firmly over femuro abnormal finding: (+) ballottement test – meniscal tears (+) fluid wave or click – large amts of joint effusion Maria Carmela L. Domocmat, RN, MSN
  158. 158. Maria Carmela L. Domocmat, RN, MSN
  159. 159. Maria Carmela L. Domocmat, RN, MSN
  160. 160. o as compress the patella – slide it distally against the underlying femur o normal finding: no pain crepitus may be present o abnormal finding: (+) pain and crepitus - patellofemoral disorderPalpate tibiofemoral space Maria Carmela L. Domocmat, RN, MSN
  161. 161. o flexiono extensiono hyperextensiono full ROM against resistanceTest ROM Maria Carmela L. Domocmat, RN, MSN
  162. 162. o normal finding: flexion – 1200 to 1300 extension - 00 hyperextension - 150 full ROM against resistance Maria Carmela L. Domocmat, RN, MSN
  163. 163. o abnormal finding: decreased ROM with synovial thickening – osteoarthritis inability to extend knee fully - flexion contractures decreased muscle strength against resistance – muscle and joint dse Maria Carmela L. Domocmat, RN, MSN
  164. 164. . To test range of motion of the knee, ask the client to do the following: Straighten and stretch the leg. Bend the knee.Range of Motion Maria Carmela L. Domocmat, RN, MSN
  165. 165. To test muscle strength in the knee, ask the client to do the following: Extend the leg as you try to bend it (quadriceps muscle strength) Bend the knees as you try to straighten them(hamstring muscle strength)Muscle Strength Maria Carmela L. Domocmat, RN, MSN
  166. 166. Maria Carmela L. Domocmat, RN, MSN
  167. 167. McMurray’s testTest pain and injury Maria Carmela L. Domocmat, RN, MSN
  168. 168. if complains of a “giving in” or “locking” of knee supine; flex one knee and hip place your thumb and index finger on 1 hand on either side of knee other hand – hold heel of foot up rotate lower leg and foot laterally slowly extend knee – note pain or clicking repeat – rotate leg mediallyMcMurray’s test Maria Carmela L. Domocmat, RN, MSN
  169. 169. http://3.bp.blogspot.com/_ZWqgYBROGHw/TQx2wAOhcaI/AAAAAAAACAQ/OkboYJC8Zfk/s1600/p4a04203.jpg http://www.theshoulderdoc.com/content/assets/mcmurray.gi f Maria Carmela L. Domocmat, RN, MSN
  170. 170. o normal finding: no pain or clickingo abnormal finding: (+) pain, clicking – torn meniscus of knee Maria Carmela L. Domocmat, RN, MSN
  171. 171. Maria Carmela L. Domocmat, RN, MSN
  172. 172. Ankles and Feet Maria Carmela L. Domocmat, RN, MSN
  173. 173. client sit, stand, walk: inspect position,alignment, shape skin Maria Carmela L. Domocmat, RN, MSN
  174. 174. Maria Carmela L. Domocmat, RN, MSN
  175. 175. o normal finding: toes • usually point forward and lie flat • may point in – pes varus • may point out – pes valgus toes and feet – in alignment with lower leg smooth, rounded medial malleolar prominences with prominent heels and metatarsophalangeal joints skin – smooth, free of corns and calluses longitudinal arh – most of weight bearing is on foot midline Maria Carmela L. Domocmat, RN, MSN
  176. 176. o abnormal finding: hallux valgus – laterally deviated great toe; possible overlapping of 2nd toe; formation enlarged, painful, inflamed bursa (bunion) on medial side pes planus or flat feet – feet with no arches pes cavus – feet with high arches corns – painful thickening of skin over bony prominences and at pressure points calluses – nonpainful thickened skin that occurs at pressure points verruca vulgaris- painful warts plantar warts – warts under a callus; appear as tiny dark spots hammer toe – hyperextension at metatarsophalangeal joint with flexion at proximal interphalangeal joint; common 2nd toe Maria Carmela L. Domocmat, RN, MSN
  177. 177. hallux valgushttp://www.rucosm.com/IMAGES/foot1.jpg Maria Carmela L. Domocmat, RN, MSN
  178. 178. pes planus or flat feet Maria Carmela L. Domocmat, RN, MSNhttp://www.eorthopod.com/images/ContentImages/child/child_foot_flatfoot_congenital/child_flatfoot_causes01.jpg
  179. 179. pes cavus Maria Carmela L. Domocmat, RN, MSN
  180. 180. Maria Carmela L. Domocmat, RN, MSN
  181. 181. Corns are areas of thick, hardened, dead skin. They form to protect the skin and structures under the skin from pressure, friction, and injury. They may look grayish or yellowish, be less sensitive to the touch than surrounding skin, and feel bumpy.Corns Corns are usually found where toes rub together. A soft corn is found between toes (usually between the fourth and fifth toes), while a hard corn is often found over a bony part of a toe (usually on the fifth toe). Maria Carmela L. Domocmat, RN, MSN http://images.rxlist.com/images/SlideShow/diabetes_foot_probl ems_s8_corns.jpg
  182. 182. calluses Maria Carmela L. Domocmat, RN, MSN
  183. 183. Corns and calluses form on the skin because of repeated pressure or friction. A corn is a small, tender area of thickened skin that occurs on the top or side of a toe. A callus is a rough, thickened area of skin that appears because of repeated irritation orCorns & callues pressure to an area of skin. Calluses usually develop on the palms of the hand and soles of the feet. Maria Carmela L. Domocmat, RN, MSN http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19657.jpg
  184. 184. Warts, also called verrucae, are small benign growths usually caused by a viral infection of the skin or mucous membrane. The virus infects the surface layer of skin. The viruses that cause warts are members of the human papilloma virus (HPV) family, of which there are many different strains. Warts are not cancerous but some strains of HPV, usually not associated with warts, have been linked with cancer formation. Warts are contagious from person to person and from one area of the body to another on the same person.verruca vulgaris Maria Carmela L. Domocmat, RN, MSN
  185. 185. plantar warts Maria Carmela L. Domocmat, RN, MSN
  186. 186. hammertoes are a contracture of the toes as a result of a muscle imbalance between the tendons on the top and the tendons on the bottom of the toe. Hammer toe is a condition where a toe bends downward like a claw. You can be born with hammer toe or develop it from wearing short, narrow shoes. Symptoms of hammer toe include foot pain, calluses on the sole of the foot, or corns on the top of the toe. Treatment of mild cases and cases in children can include foot manipulation and splinting of the toe. More severe cases may need surgery to straighten the toe joint.http://0.tqn.com/f/p/440/graphics/images/en/9360.jpg Maria Carmela L. Domocmat, RN, MSN
  187. 187. http://images.rxlist.com/images/SlideShow/diabetes_foot_problems_s8_corns.jpgA hammertoe is a toe that is bent because of a weakened muscle. The weakened muscle makes the tendons (tissues thatconnect muscles to bone) shorter, causing the toes to curl under the feet. Hammertoes can run in families. They can alsobe caused by shoes that are too short. Hammertoes can cause problems with walking and can lead to other foot problems,hammer toesuch as blisters, calluses, and sores. Splinting and corrective footwear can help in treating hammertoes. In severe cases,surgery to straighten the toe may be necessary. Maria Carmela L. Domocmat, RN, MSN
  188. 188. Maria Carmela L. Domocmat, RN, MSN
  189. 189. http://feetdoc.com/hammer_toes.ht Maria Carmela L. Domocmat, RN, MSNm
  190. 190. o normal finding: no tenderness, heat, swelling, nodules o abnormal finding: gouty arthritis- tender, painful, reddened, hot, swollen metatarsophalangeal joint of great toe rheumatoid arthritis – nodules of posterior ankle pain and tenderness metatarsophalangeal joints – inflammation of joints, rheumatoid arthritis, degenerative joint dse plantar fasciitis – tenderness of calcaneus of bottom of footpalpate tenderness, heat, swelling,nodules Maria Carmela L. Domocmat, RN, MSN
  191. 191. o dorsiflexion – point toes upward ; plantar flexion –downwardo eversion – turn soles outward; inversion – inwardo abduction – rotate foot outward ; adduction – inwardo flexion – turn toes under foot ; extension – upwardo repeat all with resistanceTest ROM Maria Carmela L. Domocmat, RN, MSN
  192. 192. http://t2.gstatic.com/images?q=tbn:ANd9GcTUKOyFEo1NWEb03sa5NBCCpyzzUwyt4 Maria Carmela L. Domocmat, RN, MSNC8d61SUoBwq6OQqhHMX8g
  193. 193. Maria Carmela L. Domocmat, RN, MSN
  194. 194. o abduction– rotate foot outward ; adduction – inward Maria Carmela L. Domocmat, RN, MSN
  195. 195. . Maria Carmela L. Domocmat, RN, MSN
  196. 196. o normal finding: 200 dorsiflexion ankle and foot; 45 0 plantar flexion 200 eversion; 300 inversion 100 abduction; 200 adduction 400 flexion; 400 extension Maria Carmela L. Domocmat, RN, MSN
  197. 197. o abnormal finding: decreased ROM without or against resistance – muscle and joint dse hammer toe – hyperextension of metatarsophalangeal joint and flexion of proximal interphalangeal joint Maria Carmela L. Domocmat, RN, MSN
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