Musculoskeletal System

Nursing 330

Governors State University

Shirley Comer

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

Movements

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

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)

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

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

Pix ROM shoulder

JOINT ANGLE

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

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

Normal Spinal Curvatures

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

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

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

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

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

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

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

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

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

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

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.