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Musculoskeletal System

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  • 1. Musculoskeletal System Nursing 330 Governors State University Shirley Comer
  • 2. Relevant History
    • Joint pain, swelling, stiffness, heat, ROM
    • Muscles pain, cramps weakness
    • Bone pain, deformity, trauma
    • Functional assessment
    • Self care habits, lifting repetitive motions
    • Exercise program
    • Recent weight gain or loss
  • 3. Movements
  • 4. Inspection/Palpation
    • Observe posture and spinal alignment
      • Kyphosis
        • Normal convex curvature of cervical spine
      • Lordosis
        • Normal concave curvature of the lumbar spine
      • Scoliosis
        • Abnormal side to side curvature of the spine
    • Assess spinal alignment
      • Bend at waist and touch toes
        • Hips, scapulas and shoulders should be symmetrical in height
      • Stand against wall to assess Lordosis
    • Observe Gait
  • 5. Cervical Spine
    • Inspect – heal alignment and spine straightness
    • Palpate – spinous processes and stenomastoid, trapezious and paravertebral muscles
    • Ask pt touch chin to chest, lift chin to ceiling, touch chin to opposite shoulders (do not attempt is neck trauma suspected)
  • 6. Inspection/palpation cont
    • Compare joints on both limbs
      • Length
      • Symmetry
      • Function-ROM
      • Size and contour
      • Skin for color, edema, masses or deformity
    • Palpate
      • Note temperature
      • Swelling
      • masses
      • Crepitus
      • Tone
  • 7. Range of Motion
    • Active – Ask Pt to move each joint through it’s appropriate range of motion
    • Passive – done by assessor.
      • Do not force a joint to move beyond it’s capability
      • If pt is contractured, gently try to extend the joint but do not force
      • Estimate the angle of the extension of impaired joint
  • 8. Pix ROM shoulder
  • 9. JOINT ANGLE
  • 10. Muscle Testing
    • Test each muscle group
    • Ask pt to flex and hold
    • Attempt to extend the joint
    • Pt should resist your attempts to extend joint
    • If pt’s resistance is easily overcome then muscle strength is weakened
  • 11. Rating Muscle Strength
    • 5 - Normal- Active motion against full resistance
    • 4 – Sl Weakness – active motion against some resistance
    • 3 – Average weakness – Active motion against gravity
    • 2 – Poor ROM – Passive ROM
    • 1 – Severe Weakness - Slight flicker of contraction
    • 0 – paralysis – no muscular contraction
  • 12. Normal Spinal Curvatures
  • 13. Upper Extremities
    • Inspect and palpate – shoulders and arms
    • Ask pt to rotate arms internally and externally, lift above head and move arm in circle
    • Test shoulder strength by asking pt to shrug against your hands (CN XII)
    • Bend elbow and have pt try to flex against your resistance
    • Inspect and Palpate wrist joint and hands
    • Perform active and passive ROM of fingers and hand
  • 14. Lower Extremities
    • Inspect and palpate Hip –raise leg then bend to chest, swing leg outward and inward, and front to back
      • Crepitation
      • Pain
      • Decreased ROM
    • Knee – Bend and extend
      • Crepitation
      • Moveable patella
    • Foot – point toes up and then to floor, rotate foot, move laterally- flex and extend toes
      • Deformities
      • Swelling, inflammation
      • Decreased ROM
  • 15. Tests for Common Joints Abnormalities
    • Pronator Drift- Used to detect weakness in arms
      • Extend supinated arms and close eyes. Should be able to hold position for 20-30 sec
    • Straight Leg Raising- Used to assess for herniated disk when pt c/o LBP with radiation down leg
      • Raise affected leg to the point of pain and dorsiflex the foot. Pain is positive for herniated disk
  • 16. Tests for Common Joints Abnormalities cont
    • Thomas Test – Assess hip flexure contractures hidden by increased lordosis
      • Flex knee to chest- other knee should stay on table
    • Trendelenburg test – Assess dislocated hip and gluteus medius muscle strength
      • Shifting weight from 1 foot to another should not result in movement of iliac crest
  • 17. Test for Knee complaints
    • Bulge Test – Small amt of fluid
      • Stroke upward medial side of knee then press lateral side and look for bulge on medial side
    • Patellar Ballottement – Large amount of fluid
      • Press firmly on each side of patella then tap patella. If fluid present, will bounce back
    • Lachmean test – instability
      • Flex knee to 30 degrees. Try to move the lower leg from side to side
  • 18. Test for Knee complaints
    • Drawer test- ACL and PCL
      • Flex knee to 90 degrees and apply pressure to anterior and posterior to tibia. Movement = tear
    • McMurray’s test – tears in meniscus
      • Positive if clicking with internal and external rotation
    • Apley’s Test – Damage to meniscus
      • Knee in 90 degrees, put pressure on knee and heel and rotate foot. Clicks = damage
  • 19. Age Specific Consideration
    • Infants
      • lift to observe back, passive ROM, observe spontaneous movements
    • Children
      • shoulders and scapula should be level
      • 1 to 2 yrs old have broad gait and use arms for balance and place weight on inside of foot
      • Weight shifts to outside of foot through childhood /c arms closer to body
  • 20. Age Specific Continued
    • Adolescents
      • Screen for scoliosis beginning at age 10 to 12
      • Have child bend over and look for hump on one side of spine
      • Differentiate from poor adolescent posture
    • Pregnant Female
      • Waddling gait
      • pronounced Lordosis
  • 21. Age Specific Continued
    • Aging Adult
      • Decreased height
      • Shortened trunk makes arms look longer
      • Kyphosis common /c backward head tilt to compensate- makes shape of “3”
      • Decreased fat to limbs and increased to trunk
      • Bony prominences more pronounced
      • Shuffling gait
      • Decreased sense of balance
  • 22. Practice Exam Question
    • Mr. Jones is 70 years old and just suffered a mild CVA. He appears to be functionally safe but you want to be sure before you let him ambulate alone. While assisting him to ambulate he begins to sway. What piece of equipment should you have placed on Mr. Jones before ambulation?
    • A. Walker
    • B. Gait belt
    • C. Wheel chair
    • D. heart Monitor
  • 23. Rationale
    • B is the correct answer. A gait belt will assist you in preventing the pt from falling. It lets you maneuver him at his center of gravity no matter your respective sizes.