Chapter 14: Musculoskeletal System

Which movement does a nurse expect to find when assessing the ankle range of a healthy person? Quiz Q

- Inversion and eversion - Plantar flexion and dorsiflexion - adduction and abduction - Rotation

Scoliosis

- S-shaped deformity of vertebrae - Skeletal deformity on three planes: - Lateral curvature, spinal rotation, and thoracic kyphosis - Caused by congenital , neuromuscular disease, traumatic injury, unequal leg length - Manifestations- unleveled shoulder and hips - Curvature less than 10% is normal variation - 10-20% is mild - Severe deformity may compromise lungs, spine, and pelvis

Describe abduction and adduction of the shoulders

Abduction- raise arm to side above head with pal away from head Adduction- place arm across body (50 degree)

Antigravity muscles

Assessment process for muscle strength: Patient - Walk on toes - Walk on heels

Facial Musculature

Assessment process for muscle strength: Patient - Blow out cheeks - Place tongue in cheek - Stick out tongue-move right and left Nurse - Assess pressure in cheeks - Observe strength and coordination of thrust and exertion

Discuss the following ROM (range of motion) of the hip - Hyperextension:

Assist the patient to a prone position. Test hyperextension of the hip by raising the leg upward with the knee straight. Repeat the procedure with the other leg. This assessment can also be performed with the patient in the standing position. The expected range of movement is up to 30 degrees.

How would you document expected findings for the musculoskeletal system?

Coordinated smooth gait, complete range of motion against gravity with full resistance (5/5) in all joints without pain, muscle size symmetric bilaterally, shoulders aligned, and vertebral column straight.

What movement from the patient does a nurse request to assess for hyperextension of the hip? Quiz Q

Raise one leg at a time while lying prone

Fingers

Range of motion: Condyloid hinge - Flexion- make fist (90 degrees) - Extension- straighten fingers - Hyperextension- bend fingers back as far as possible (70 degrees) - Abduction- spread fingers apart - Adduction- bring fingers together

Toes

Range of motion: Condyloid joint Flexion- curl toes downward Extension- straighten toes Abduction- spread toes apart Adduction- bring toes together

Foot

Range of motion: Gliding Inversion- turn sole of foot medially Eversion- turn sole of foot laterally

How should you assess for symmetry and alignment of the knees?

The knees should be lined up with the tibia and ankle and symmetric without medial or lateral deviation.

Which patient's description of pain is consistent with injury to a bone? Review Q

"Deep, dull, and boring"

Describe internal rotation of the shoulders

Internal rotation- rotate shoulder until thumb is turned inward and toward back

Which findings are expected from a musculoskeletal assessment of a left-handed healthy adult? Quiz Q

- Cervical concave, thoracic convex, and lumbar concave contour of the spine - Circumference of the left upper arm larger than right upper arm - Lumbar and thoracic spine flexion of 75 degrees - External rotation and abduction of the left arm of 90 degrees

Rheumatoid arthritis

- Chronic autoimmune inflammation - Gradual onset - Morning stiffness (last >1 hour) - Synovial lining becomes inflamed - Deterioration of cartilage- erosion of surface - Ligaments/tendons shorten and cause contracture - Low grade fever and fatigue (systemic manifestations) - Ulner deviation and swan neck deformity

Osteoarthritis

- Degenerative changes in articular cartilage - Affects weight bearing joints (hips, knees, ankles, vertebra, fingers) - Occurs in joints with repetitive movement - Bone against bone cause inflammation - Joint edema and pain - Heberden's nodes- DIP joints - Bouchard's nods PIP joints

Describe the process to assess musculature of the face and neck for symmetry. List two potential causes for facial asymmetry of the facial/neck musculature.

- Do this during interview session - Ask patient to open and close mouth - Ask patient to smile - Use finger to palpate front of tragus to detect smooth movement of temporomandibular joint - Palpate neck for tenderness and lymph notes Asymmetric- may indicate facial surgery , bells palsy Pain or crepitus of TMG may indicate TMG disorder. Facial asymmetry occurs with Bell's palsy (facial cranial nerve palsy) or after cerebrovascular accidents in certain areas of the brain.

Describe Heberden's nodes and Bouchard's nodes. What type of arthritis are these seen in?

- Heberden's nodes- DIP joints - Bouchard's nods PIP joints *Osteoarthritis may cause Bouchard's nodes in the proximal interphalangeal (PIP) joints, whereas Heberden's nodes form in the distal interphalangeal (DIP) joints.

Gout

- Hereditary disorder caused by elevated uric acid - Decreased excretion or increased production - Caused by lack of enzyme to metabolize purines in renal excretion - High purine foods- poultry, liver, kidney, legumes - Often accumulates in great toe, wrists, hands, ankles and knees - Manifestations- erythema, edema, sever pain, limited ROM, tophi, kidney stones, costovertebral tenderness

Bursitis

- Inflammation of bursa (connective tissue surrounding joint - Inflamed by constant friction - May be precipitated by arthritis, infection, injury or excess exercise - Manifestations- Pain, Limited ROM, Erythema - Commonly effected joints- shoulder, elbow, hand, knee, greater trochanter of hip

Herniated nucleus pulposus

- Intervertebral disc are cushioned between two vertebrae - When disk ruptures -nucleus pulpous is displaced and compresses spinal nerve - AKA herniated disk and slipped disk - Usually occurs in lumbar spine - Manifestations- depend on location: Pain, numbness, pain with straight leg raise with pain - Deep tendon reflexes may be depressed or absent

Osteoporosis

- Loss of bone mineral density (BMD) of 2.5 SD below mean - ½ all postmenopausal women have - Fractures are common - Bone mineral density more than 2.5 standard deviation below healthy - Caused by aging - Decline in estrogen - Declines in calcium - Lack of weight bearing exercises - Immunosuppression therapy (glucocorticoids) - Manifestations- silent disease, height changes, spontaneous fracture, kyphosis

Fracture (open and closed)

- Partial or complete break - Closed fracture- skin is unbroken - Open fracture- skin is broken - Spontaneous fracture-pathological - Bone weakness, osteoporosis or neoplasm - Fractures are most common in children (forearm) and older adults (hip) - Manifestations: pain, loss of function (caused by shortening of tissue around bone and edema)

Carpal tunnel syndrome

- When medial nerve is compressed between flexor retinaculum and other structures - Caused by repetitive movements, rheumatoid arthritis, gout, hypothyroidism fluid retention associated with pregnancy and menopause - Manifestations- burning, numbness, tingling of hands (often at night) - Pain, numbness, paresthesia with Phalen's or Tinels sign

Deltoid

Assessment process for muscle strength: Patient - Hold arms upward Nurse - Push down on arms

Hip musculature

Assessment process for muscle strength: Patient - In supine position raise extended leg Nurse - Push down on leg above knee

Hamstring, Gluteal, Abductor, and Adductor muscles of leg

Assessment process for muscle strength: Patient - Sit and perform alternate leg crossing Nurse - Push in opposite direction of crossing limb

What test is used to assess the presence of a meniscal tear? Describe the test.

Apley Test - Procedure: With the patient in prone position, flex the knee 90 degrees. Press down on the patient's foot so the tibia is firmly against the femur; then rotate the knee externally. - Findings: No pain or locking is a negative test

Discuss the following ROM (range of motion) of the hip - Flexion with knee flexed:

Ask the patient to alternately pull each knee up to the chest. The patient should achieve 120-degree flexion from the straight, extended position

During an assessment of a young adult, the nurse notes that the patient's shoulders are uneven. Which further examination would the nurse perform for further data? Review Q

Ask the patient to bend forward at the waist while the nurse checks the alignment of the patient's vertebrae.

Discuss the following ROM (range of motion) of the hip - Internal rotation:

Ask the patient to flex the knee and turn medially (inward) as you pull the heel laterally (outward). Repeat the procedure with the other hip. Rotation should reach 40 degrees from the straight midline position

Discuss the following ROM (range of motion) of the hip - Abduction and adduction:

Ask the patient to move one leg laterally with the knee straight to test abduction and medially to test adduction. Repeat the procedure with the other leg. The expected range for abduction is up to 45 degrees; the expected range for adduction is up to 30 degrees

How do you assess cranial nerve XI (The spinal accessory). What muscle may indicate compression of this nerve?

Ask the patient to shrug the shoulders while you attempt to push them down. This also tests function of cranial nerve XI (CN XI; spinal accessory). Weakness of the trapezius muscles may indicate compressed spinal nerve root or compression of spinal accessory CN XI.

Describe the assessment process of inspecting shoulders for equality of height. What are some possible causes of inequality of height?

Ask the patient to stand; while you stand to his or her side, observe the cervical concave, the thoracic convex, and the lumbar concave. Note the landmarks on the back: spinous processes protruding slightly at C7 and T1, paravertebral muscles, and the alignment across the iliac crests at L4 and the posterior superior iliac spine at S2. Ask the patient to touch the toes. Move behind the patient to inspect the spine. Possible causes: scoliosis, lordosis, kyphosis

A patient reports a history of compression of the left cranial nerve XI (spinal accessory nerve) from an old sports injury. Based on this information, what technique does the nurse include in the focused assessment? Quiz Q

Asking the patient to shrug the shoulders while the nurse attempts to push them down

Ocular musculature

Assessment process for muscle strength: Eyelids and eye muscles - Patient closes eyes tightly - Nurse attempts to resist closure

Ankle and foot muscles

Assessment process for muscle strength: Patient - Bend foot up (dorsiflexion) Bend foot down (plantar flexion) Nurse - Push to plantar flexion Push to dorsiflexion

Hamstring

Assessment process for muscle strength: Patient - Bend knees to flex strong Nurse - Push to extend

Triceps

Assessment process for muscle strength: Patient - Extend arm Nurse - Push to flex arm

Wrist musculature

Assessment process for muscle strength: Patient - Extend elbow - Flex elbow Nurse - Push to flex - Push to extend

Finger muscles

Assessment process for muscle strength: Patient - Extend fingers - Flex fingers - Spread fingers Nurse - Push dorsal surface of fingers - Push ventral surface of fingers - Hold fingers together

Neck muscles

Assessment process for muscle strength: Patient - Extend head backward - Flex head forward - Rotate head side to side - Touch shoulders with head Nurse - Push head forward - Push head backward - Monitor mobility and coordination - Observe ROM

Quadriceps

Assessment process for muscle strength: Patient - Extend leg Nurse - Push leg to flex

Biceps

Assessment process for muscle strength: Patient - Flex arm Nurse - Push down on arm

How are expected findings for the musculoskeletal system determined during an examination? Review Q

Compare the patient's left side with the right side.

Describe extension and hyperextension of the shoulders

Extension- return arm to side of body (0 degree) Hyperextension- move arm behind body (keep elbow straight) (50 degree)

Describe external rotation of the shoulders

External rotation- rotate elbow until thumb is upward and lateral to head

Describe the criteria of grading and recording muscle strength using the Lovett scale. How would you document muscle strength bilaterally with full resistance?

Findings: Expect muscle strength to be 5, bilaterally symmetric, with full resistance to opposition. The patient's muscle strength is documented as 5/5 (or normal on the Lovett scale), with the patient's value in the numerator and the expected value in the denominator. - Muscle weakness may indicate a muscular or joint disease or atrophy from disuse. A muscle strength of 1/5 means that the patient has slight muscle contraction, with 1 representing the patient's value and 5 representing the expected value.

While testing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform which motion? Review Q

Flexion of the arm

While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements? Review Q

Flexion, extension, and hyperextension

Range of motion for the elbow joint

Hinge joint: Flexion- bend elbow so lower arm moves toward should and hand is level with shoulder Extension- straighten elbow Hyperextension- bend arm back as far as possible (not everyone can hyperextend)

How would you assess for hip flexion contractures?

Thomas test - Have the patient lie supine and ask him or her to fully extend one leg on the table and flex the other knee up to the chest as far as possible. Observe if the extended leg remains flat on the table when the other leg is flexed, which indicates a negative Thomas test

When a nurse asks a patient to place the right arm behind the back, so that the back of the hand is touching the lower spine, the nurse is testing for which range of motion? Quiz Q

Internal rotation and adduction of the shoulder

Describe the differences between kyphosis, lordosis, and scoliosis

Kyphosis: hunchback, post. curvature of the thoracic spine Lordosis: ant. curvature of the spine (concavity) Scoliosis: "S" shape, lateral curvature of the spine

With the patient lying supine, a nurse raises the patient's leg to flex the hip. The patient complains of pain when the leg is raised to 40 degrees. The nurse correlates this finding with which disorder? Quiz Q

Lumbar nerve compression

What test is used to assess the presence of a damaged medial or lateral meniscus? Describe the test

McMurray Test - Procedure: Ask the patient to lie supine with one foot flat on the table to the knee. Place the thumb and index finger of one hand on either side of the joint space to maintain flexion and stabilize the knee. With the other hand, grasp the patient's heel, raise the lower leg parallel with the table (knee will be flexed 90 degrees), and rotate the knee. External rotation tests the lateral meniscus, and internal rotation tests the medial meniscus - Findings: The knee should rotate without pain, clicking, or locking

The nurse is comparing the right and left legs of a patient and notices that they are asymmetric. Which additional data does the nurse collect at this time? Review Q

Measures the length of each leg and compares the findings

A nurse palpates the patient's jaw movement by placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What movement does the nurse ask the patient to do next? Quiz Q

Move the jaw side to side

Assessment process for determining size and symmetry of extremities

Muscle size should appear relatively symmetric bilaterally. (No person has exact side-to-side symmetry.) Muscle circumference can be measured with a cloth or paper tape measure to provide a baseline for future comparisons and make side-to-side comparisons. The dominant side usually is slightly larger than the nondominant side. To ensure consistency of measurement, record the number of centimeters above or below the joint where the muscle was measured or include a diagram

Discuss the following ROM (range of motion) of the hip - Hip flexion with leg extended:

Next have the patient raise the leg to flex the hip as far as possible without bending the knee. Repeat the procedure with the other leg. Results should be 90 degrees from the straight extended position

The nurse testing the patient's muscle strength finds that the patient has complete range of motion with gravity. Using Table 14-3, how would this finding be documented? Review Q

Normal or 5/5

A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for the nurse to use with this patient? Review Q

Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and tenderness

How do you assess muscle strength of the hips?

Patient: In supine position raise extended leg Nurse: Push down on leg above knee Assist the patient to a supine position. Ask him or her to attempt to raise the legs while you try to hold them down. Evaluate one leg at a time, noting if the response is bilaterally strong and if you are unable to interfere with the movement. Use the criteria from Table 14-3 for grading muscle strength. It should be 5/5 or normal bilaterally.

How would you assess for nerve root compression?

TEST the trapezius muscles for strength. - Ask the patient to shrug the shoulders while you attempt to push them down. This also tests function of cranial nerve XI (CN XI; spinal accessory). - Weakness of the trapezius muscles may indicate compressed spinal nerve root or compression of spinal accessory CN XI. MAYBE?: To evaluate for nerve root irritation or lumbar disk herniation, perform straight leg raises. With the patient supine, raise one leg, keeping the knee straight.

Shoulder

Range of motion: Ball and socket - Flexion- raise arm from side to forward position (180 degree) - Extension- return arm to side of body (0 degree) - Hyperextension- move arm behind body (keep elbow straight) (50 degree) - Abduction- raise arm to side above head with pal away from head - Adduction- place arm across body (50 degree) - Internal rotation- rotate shoulder until thumb is turned inward and toward back - External rotation- rotate elbow until thumb is upward and lateral to head - Circumduction- move arm in full circle (combines all ball and socket joint)

Hip

Range of motion: Ball and socket Flexion-move leg forward and up Extension- move leg back and beside other leg Hyperextension- move leg behind body Abduction- move leg laterally away from body Adduction- move leg medially toward body Internal rotation- turn knee toward inside External rotation- turn knee toward outside Circumduction- move leg in circle

Ankle

Range of motion: Hinge Dorsiflexion- move foot so toes are pointed upward Plantar flexion- point toes downward

Knee

Range of motion: Hinge Joint Flexion- bring heel back toward thigh Extension- return heel to floor

Elbow

Range of motion: Hinge joint - Flexion- bend elbow so lower arm moves toward should and hand is level with shoulder (160 degrees) - Extension- straighten elbow (180 degrees) - Hyperextension- bend arm back as far as possible (not everyone can hyperextend)

Forearm

Range of motion: Pivotal Supination- palm up Pronation- palm down

Neck and Cervical Spine/ Head and Neck

Range of motion: Pivotal Joint - Flexion- chin to chest (45 degree) - Extension- return to erect position (0 degree) - Hyperextension- bend head back as far as possible (55 degree) - Lateral flexion- tilt head toward each shoulder (40 degree) - Rotation- turn head to right and left (70 degree)

Thumb

Range of motion: Saddle joint - Flexion- move thumb across palmer surface - Extension- move thumb away from hand - Abduction- extend thumb laterally (usually done during abduction) - Opposition- touch thumb to each finger of same hand

Wrist

Range of motion: Condyloid Flexion- move palm toward forearm Extension- fingers, hands, forearm all in same plane Hyperextension- bring dorsal surface back as far as possible Radial flexion- bend wrist medially Ulnar flexion- bend wrist laterally

Discuss ROM (Range of motion) of the ankles and feet

Range of motion: Ankles Hinge - Dorsiflexion- move foot so toes are pointed upward - Plantar flexion- point toes downward Range of motion: Foot Gliding - Inversion- turn sole of foot medially - Eversion- turn sole of foot laterally To evaluate the range of motion of both feet and ankles, ask the patient to: • Dorsiflex the ankle by pointing the toes toward the face. Dorsiflexion should reach 20 degrees from midline. • Plantar flex the ankle by pointing the toes toward the floor. Plantar flexion should reach 45 degrees from midline. • Evert the foot by rotating it inward so the little toe is not touching the floor. (Note: You may need to stabilize the heel during these maneuvers.) Eversion should be 20 degrees. • Invert the foot by rotating it outward so the great toe is not touching the floor. Inversion should be 30 degrees from midline position. • Abduct the foot by turning it away from midline. Expected abduction is 10 degrees. • Adduct the foot by turning it inward toward midline. Expected adduction is 20 degrees. • Flex and extend the toes. These should be active movements.

How do you complete the drop arm test? How is the significance of this assessment?

Rotator cuff damage can be determined with the drop arm test. Abduct the patient's affected arm and ask the patient to lower the arm slowly. The expected response is a slow, controlled adduction of the arm. Inability to lower the arm slowly and smoothly or severe shoulder pain while adducting the arm may indicate rotator cuff damage.

What type of arthritis causes swan neck and boutonniere deformities?

Swan-neck and boutonniere deformities of interphalangeal joints may be related to rheumatoid arthritis

What are the two tests that assess for fluid in the knee joint?

The ***bulge sign tests for small effusions of the knee. Assist the patient to a supine position. Elicit the bulge sign by extending the knee and milking the medial aspect upward two or three times. Then tap on the lateral side of the patella. No fluid waves or bulging should be seen on the opposite side of the joint. the ***ballottement, is used for larger effusions. With the knee extended, apply downward pressure on the suprapatellar pouch with the thumb and fingers of one hand, and with the other hand push the patella firmly against the femur. Release the pressure from the patella, but leave your fingers in contact with the knee to detect any fluid wave . Palpation of a fluid wave after release of pressure against the patella is ballottement, indicating excess fluid in the knee joint.

To assess the triceps and biceps muscle strength, the nurse applies resistance to the patient's arm. What should be done to ensure the appropriate muscle is being assessed? Quiz Q

The patient pushes forward against the nurses hand to extend the triceps muscle and pulls backward against the nurses hand to flex the biceps muscle

What is the significance of a positive Phalen's sign

The test for Phalen's sign is performed by asking the patient to flex both wrists and press the dorsum of the hands against each other for 1 minute. No report of numbness, tingling, or pain is a negative test. A positive Phalen's sign occurs if the patient complains of numbness, pain, or paresthesia over the palmar surface of the hand and the first three fingers and part of the fourth. This positive finding may indicate ***carpal tunnel syndrome.

What is the significance of a positive Tinel's sign

The test for Tinel's sign is performed by tapping on the median nerve where it passes through the carpal tunnel under the flexor retinaculum (carpal ligament) and volar carpal ligament. No report of tingling sensation is a negative Tinel's sign. - tap on wrist A positive Tinel's sign occurs when the patient reports a tingling sensation or pain radiating from the wrist to the hand along the median nerve. This positive finding may indicate ***carpal tunnel syndrome.

Discuss the following ROM (range of motion) of the hip - External rotation:

To test external hip rotation (Patrick text), ask the patient to place the heel of one foot on the opposite patella. Apply gentle pressure to the medial aspect of the flexed knee as the patient externally rotates the hip until the knee or lateral thigh touches the examination table. Repeat the procedure with the other hip. Rotation should reach 45 degrees from the straight midline position

In assessing a patient with a history of poliomyelitis, the nurse suspects the right leg muscles are smaller than the left leg. What is the best approach for the nurse to confirm or reject this suspicion? Quiz Q

Use a tape to measure each leg's circumference at the same location, above or below the nearest joint

Describe the assessment of the temporomandibular joints for movement, sounds, and tenderness. What are some of the symptoms for TMJ.

Use the pads of the first two fingers in front of the tragus of each ear to palpate the temporomandibular joint (TMJ) with the mouth closed and open. The mandible should move smoothly and painlessly. An audible or palpable snapping or clicking in the absence of other symptoms is not unusual. Symptoms: Pain or crepitus of the TMJ with locking or popping may indicate a TMJ disorder.

What additional assessment should be completed if unequal leg length is suspected?

When unequal leg length is suspected, measure the leg from the anterior superior iliac spine to the medial malleolus

Anticipated curvature of spine

spine should be straight with expected curvatures: - cervical concave - thoracic convex - lumbar concave