Health Assessment | Musculoskeletal System | Midterms

The gait assessment involves observing the client's walking pattern, base of support, weight-bearing stability, foot position, stride length and cadence, arm swing, and posture. Normal findings include evenly distributed weight, the ability to stand on heels and toes, straight toes, erect posture, and coordinated and rhythmic movements. Abnormal findings may include uneven weight bearing, inability to stand on heels and toes, pointing toes in or out, limping, shuffling, propelling forward, or having a wide-based gait. Older clients may have an impaired sense of position in space, which may increase the risk of falling. The "nudge test" can be used to assess the risk of falling backward. Falling backward easily may be seen in clients with cervical spondylosis or Parkinson's disease.

1. GAIT INSPECTION

During a knee examination, the healthcare provider inspects the knees for size, shape, symmetry, swelling, deformities, and alignment. They also palpate the knees for tenderness, warmth, consistency, and nodules. Tests are done for swelling by performing the bulge test. In this test, the medial side of the knee is stroked upwards to displace any accumulated fluid, and then the lateral side of the knee is pressed, looking for a bulge on the medial side of the knee. The appearance or absence of a bulge indicates the presence or absence of fluid in the knee joint. Additionally, knock knees (genu valgum) and bowed legs (genu varum) are observed, and asymmetrical muscular development in the quadriceps may indicate atrophy. Finally, the older adult population may have a bow-legged appearance due to decreased muscle control, and tenderness and warmth with a boggy consistency may be symptoms of synovitis. The ballottement test can detect large amounts of fluid in the knee. The client is in a supine position and the healthcare provider presses their thumb and index finger on each side of the patella to displace fluid in the suprapatellar bursa. Then, with their dominant fingers, they push the patella down and feel for a fluid wave or click. If there is no movement of the patella, it rests firmly over the femur. If there is a fluid wave or click, it could indicate large amounts of joint effusion, which may be present with meniscal tears. During knee examination, palpate the tibiofemoral space to note any crepitus or pain when compressing the patella against the underlying femur. Test the range of motion (ROM) by flexing and extending the knee and walking normally, repeating these against resistance. Normal ranges for ROM are 120-130 degrees of flexion, 0-15 degrees of hyperextension. Full ROM against resistance is expected, while decreased ROM with synovial thickening and crepitation is a sign of osteoarthritis, and flexion contractures of the knee indicate an inability to fully extend the knee. Decreased muscle strength against resistance may indicate muscle and joint disease. To test for knee pain and injury, perform McMurray's test if the client complains of a "giving in" or "locking" of the knee. With the client in the supine position, flex one knee and hip, then rotate the lower leg and foot laterally and medially while extending the knee. Pain or clicking indicates a torn meniscus of the knee.

10. HIPS INSPECTION/PALPATION

During the examination, the position, alignment, shape, and skin of the feet are inspected while the client is sitting, standing, and walking. Normally, the toes point forward and lie flat, but they may point inwards (pes varus) or outwards (pes valgus). The toes and feet should be in alignment with the lower leg, with smooth and rounded medial malleolar prominences and prominent heels and metatarsophalangeal joints. The skin should be smooth and free of corns and calluses. The longitudinal arch should be present, and most of the weight bearing should be on the foot midline. Some common abnormalities include hallux valgus, which is characterized by a laterally deviated great toe with possible overlapping of the second toe and a possible formation of an enlarged, painful, inflamed bursa on the medial side. Other abnormalities include feet with no arches (pes planus or "flat feet"), feet with high arches (pes cavus), painful thickening of the skin over bony prominences and at pressure points (corns), nonpainful thickened skin that occurs at pressure points (calluses), and painful warts (verruca vulgaris) that often occur under a callus (plantar warts). During the examination, the ankles and feet are palpated for tenderness, heat, swelling, or nodules. The toes are also palpated from the distal end proximally, checking for tenderness, swelling, bony prominences, nodules, or crepitus of each interphalangeal joint. No abnormalities are noted. Ankle sprains are the most common injury at this site, involving stretched or torn ligaments. Gouty arthritis can cause a tender, painful, reddened, hot, and swollen metatarsophalangeal joint of the great toe. Rheumatoid arthritis can cause nodules to be palpated in the posterior ankle. Tendons are tough bands of fibrous tissue connecting muscles to bones in a joint. The metatarsophalangeal joints are assessed by squeezing the foot from each side with the thumb and fingers and palpating each metatarsal for swelling or tenderness. The plantar area of the foot is also palpated for pain or swelling. Inflammation of the joints, rheumatoid arthritis, and DJD can cause pain and tenderness in the metatarsophalangeal joints. Plantar fasciitis, which is the irritation and inflammation of the supportive tissue in the arch of the foot, can cause tenderness of the calcaneus of the bottom of the foot. The Ottawa ankle and foot rules are used to determine the need for X-ray referral. The range of motion (ROM) of the ankle and foot can be assessed by testing dorsiflexion, plantarflexion, eversion, inversion, abduction, adduction, flexion, and extension. Normal ranges of motion include 20 degrees of dorsiflexion and 45 degrees of plantarflexion, 20 degrees of eversion and 30 degrees of inversion, 10 degrees of abduction and 20 degrees of adduction, and 40 degrees of flexion and extension. Decreased strength against resistance may indicate muscle and joint disease. Hammer toe, which is the hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint, is an abnormal finding.

11. ANKLES AND FEET INSPECTION/PALPATION

The assessment of the temporomandibular joint (TMJ) involves inspecting and palpating the joint while asking the client to perform certain movements, such as opening and closing the mouth, moving the jaw from side to side, and protruding and retracting the jaw. Snapping and clicking may be normal, while decreased ROM, swelling, tenderness, or crepitus may indicate arthritis, and decreased muscle strength and clicking, popping, or grating sounds may suggest TMJ dysfunction. During the assessment of the temporomandibular joint (TMJ), the healthcare provider inspects and palpates the joint to assess for normal and abnormal findings. Normal findings include smooth jaw movement, lateral movement of 1-2 cm, and a mouth that opens 1-2 inches. Snapping and clicking may be felt and heard in the normal client. Abnormal findings include decreased range of motion, swelling, tenderness, and crepitus in arthritis, and decreased muscle strength and a clicking, popping, or grating sound in TMJ dysfunction. The healthcare provider should also test the integrity of cranial nerve V by asking the client to open the mouth and move the jaw laterally against resistance while feeling for the contraction of the temporal and masseter muscles.

2. TMJ INSPECTION/PALPATION

To inspect and palpate the sternoclavicular joint, the client should be sitting. First, check for location, color, swelling, and masses. Then, palpate the joint for tenderness or pain. Normal findings include no visible bony overgrowth, swelling, or redness, and a nontender joint. Abnormal findings may include a swollen, red, or enlarged joint or a tender, painful joint indicating inflammation of the joint.

3. SCJ INSPECTION/PALPATION

During the assessment of the cervical, thoracic, and lumbar spine, the nurse should observe the curves of the spine from the side and behind and note any differences in height between the shoulders, iliac crests, and buttock creases. Normal findings include a straight spine when viewed from behind, concave cervical and lumbar curves, and a convex thoracic curve. Abnormal findings may include an exaggerated thoracic curve (kyphosis) commonly seen with aging, a flattened lumbar curvature associated with herniated lumbar disc or ankylosing spondylitis, lateral curvature of the thoracic spine (scoliosis), and an exaggerated lumbar curve (lordosis) seen in pregnancy or obesity. Unequal heights of the hips suggest unequal leg lengths. The nurse should also palpate the spinous processes and paravertebral muscles for tenderness or pain, which can be caused by compression fractures or muscle strain. Cultural variations should also be considered, such as the number of vertebrae and gluteal prominence in some African Americans. To test ROM of cervical spine, client is asked to touch the chin to the chest (flexion) and look up at the ceiling (hyperextension). Normal flexion of the cervical spine is 45 degrees and normal extension is 45 degrees. Impaired ROM and neck pain can be caused by cervical strain, cervical disc degenerative disease, spinal cord tumors, or cervical spinal cord compression. Neck pain with fever, chills, and headache could indicate a serious infection like meningitis. Abnormal curvatures of the spine, such as kyphosis, lordosis, and scoliosis, can affect ROM and cause pain or discomfort. Kyphosis is an exaggerated thoracic curve that is commonly seen with aging, while lordosis is an exaggerated lumbar curve that can be seen in pregnancy or obesity. Scoliosis is a lateral curvature of the thoracic spine with an increase in convexity on the curved side. Compression fractures and lumbosacral muscle strain can cause pain and tenderness of the spinal processes and paravertebral muscles. Cervical strain is the most common cause of neck pain and can be due to sleeping in the wrong position, carrying a heavy suitcase, or being in an automobile crash. Limited ROM is seen with neck injuries, osteoarthritis, spondylosis, or with disc degeneration. In addition, impaired ROM and pain associated with fever, chills, and headache could be indicative of a serious infection such as meningitis. The passage describes techniques for assessing the range of motion and potential causes of back and leg pain. The examiner is advised to have the client bend sideways, backwards, and twist their shoulders to assess their lateral bending capacity, hyperextension, and rotation. The normal ranges of motion for each are given. The examiner is also advised to perform the straight leg test to check for a herniated nucleus pulposus and to measure the client's leg length to check for abnormalities. Unequal leg lengths can be associated with scoliosis or abnormalities in the hips and pelvis. Various causes of impaired range of motion and pain in the back and legs are also mentioned.

4. CERVICAL, THORACIC, AND LUMBAR SPINE INSPECTION/PALPATION

The article provides instructions for healthcare professionals to inspect and palpate the shoulders and arms of a client for symmetry, color, swelling, masses, tenderness, and heat. They should test the range of motion (ROM) of the shoulders, consisting of flexion, extension, adduction, abduction, and motion against resistance. Various conditions such as rotator cuff tear, tendinitis, and joint disease are associated with painful and limited shoulder motions and muscle weakness. Lesion of cranial nerve XI (spinal accessory) can cause inability to shrug shoulders against resistance.

5. SHOULDERS, ARMS, AND ELBOWS INSPECTION/PALPATION

During an examination of the elbows, the healthcare provider inspects and palpates for size, shape, deformities, redness, and swelling. They check for tenderness or nodules and assess range of motion by asking the client to perform flexion, extension, pronation, and supination. Normal ranges of motion are provided, and decreased range of motion against resistance may indicate joint or muscle disease or injury. Pain or tenderness over the epicondyles may indicate epicondylitis. Bursitis may cause redness, heat, and swelling of the olecranon process. The client should have full range of motion against resistance.

6. ELBOWS INSPECTION/PALPATION

During the wrist examination, the healthcare provider inspects for size, shape, symmetry, color, and swelling. They also palpate for tenderness and nodules. Swelling, tenderness, and nodules may indicate rheumatoid arthritis or a ganglion cyst. Signs of a wrist fracture include pain, tenderness, swelling, and inability to hold a grip. Palpation of the anatomic snuffbox is done to check for tenderness, which may indicate a scaphoid fracture resulting from falling on an outstretched hand. No tenderness should be present in the anatomic snuffbox during the examination. To test wrist range of motion, the client is asked to perform flexion and extension, as well as deviation, against resistance. Normal ranges of motion are described, with full range of motion expected against resistance. Cultural considerations are noted regarding potential differences in ulna and radius length among different ethnic groups. Various conditions that may affect wrist range of motion and strength, such as rheumatoid arthritis and epicondylitis, are also described. To test for carpal tunnel syndrome, the healthcare provider can perform Phalen's test and Tinel's sign test. For Phalen's test, the client rests their elbows on a table, places the backs of their hands against each other while flexing the wrists 90 degrees, with fingers pointed downwards and wrists dangling. If symptoms such as tingling, numbness, and pain develop within a minute, carpal tunnel syndrome is suspected. Tinel's sign test involves the healthcare provider percussing lightly over the median nerve, located on the inner aspect of the wrist. If the client experiences a tingling or shocking sensation, it indicates that the median nerve is entrapped in the carpal tunnel, causing pain, numbness, and impaired function of the hand and fingers. It is important to note that a negative test does not completely rule out carpal tunnel syndrome, and further evaluation may be necessary if symptoms persist. To test for carpal tunnel syndrome, healthcare providers may perform the Phalen's test by asking the client to flex their wrists with fingers pointed downward for 60 seconds. If tingling, numbness, or pain develops within a minute, carpal tunnel syndrome may be suspected. Another test is the Tinel's sign, in which the healthcare provider lightly taps the inner aspect of the wrist to check for a tingling or shocking sensation. The flick signal may also be observed by asking the client what they do when their symptoms are worse. If the client responds with a motion resembling shaking a thermometer, carpal tunnel syndrome may be suspected. Additionally, thumb weakness may be tested by asking the client to raise their thumb up from the plane of the palm and stretch the thumb so that its pad rests on the pad of the little finger pad. If the client cannot raise the thumb up and stretch it to the little finger pad, this may indicate thumb weakness in carpal tunnel syndrome.

7. WRISTS INSPECTION/PALPATION

During a physical examination of the hands and fingers, the healthcare provider should inspect for size, shape, symmetry, swelling, and color. Palpation should be performed to assess for tenderness, swelling, bony prominences, nodules, or crepitus of each interphalangeal joint and each metacarpal of the hand. Abnormal findings such as pain, tenderness, swelling, or deformities may indicate finger fractures, acute rheumatoid arthritis, long-term rheumatoid arthritis (e.g. boutonnière deformity, swan-neck deformity), atrophy of the thenar prominence in carpal tunnel syndrome, or hard, painless nodules in osteoarthritis. The median nerve can be entrapped in the carpal tunnel, resulting in pain, numbness, and impaired function of the hand and fingers. To summarize, during the assessment of hand and finger function, the healthcare provider should test the range of motion (ROM) of the fingers and thumb, including abduction, adduction, flexion, hyperextension, and thumb flexion. Resistance testing should also be performed to check for full ROM. Inability to extend the ring and little fingers may indicate Dupuytren's contracture, while painful extension of a finger may indicate tenosynovitis. Decreased muscle strength against resistance may be associated with muscle and joint disease.

8. HANDS AND FINGERS INSPECTION/PALPATION

The assessment of the hips involves inspecting symmetry and shape, palpating for stability, tenderness, and crepitus. The buttocks should be equally sized, and the iliac crests should be symmetric in height. The hips should be stable, non-tender, and without crepitus. Fractured hips present with instability, inability to stand, and/or a deformed hip area. Hip inflammation and DJD present with tenderness, edema, decreased ROM, and crepitus. Groin pulls and hamstring strains are common injuries in athletes in the hip and groin region. Strains are a stretch or tear of muscle or tendons and often occur in the lower back and the hamstring muscle. To test hip range of motion, the client should perform various movements while supine, prone, or standing. The normal range of motion includes flexion, abduction, adduction, rotation, and hyperextension. The inability to abduct the hip may indicate hip disease, while pain and decreased internal hip rotation may be signs of osteoarthritis or femoral neck stress fracture. Pain in the greater trochanter and during transitions may indicate bursitis. Decreased muscle strength against resistance can be seen in muscle and joint disease. Testing ROM should be avoided in clients with total hip replacements unless approved by a physician to prevent dislocation.

9. HIPS INSPECTION/PALPATION

Calluses

? are nonpainful, thickened skin that occur at pressure points

Corns

? are painful thickenings of the skin that occur over bony prominences and at pressure points. The circular, central, translucent core resembles a kernel of corn

Articular

? cartilage smooths and protects the bones that articulate with each other.

Cartilaginous

? joints (e.g., joints between vertebrae) are joined by cartilage.

Synovial

? joints (e.g., shoulders, wrists, hips, knees, ankles) contain a space between the bones that is filled with synovial fluid, a lubricant that promotes a sliding movement of the ends of the bones.

Fibrous

? joints (e.g., sutures between skull bones) are joined by fibrous connective tissue and are immovable.

Synovial

? joints are enclosed by a fibrous capsule made of connective tissue and connected to the periosteum of the bone.

Skeletal

? muscles assist with posture, produce body heat, and allow the body to move.

Joints

? provide a variety of ranges of motion (ROM) for the body parts and may be classified as fibrous, cartilaginous, or synovial.

Bones

? provide structure, give protection, serve as levers, store calcium, and produce blood cells.

Hallux

? valgus is an abnormality in which the great toe is deviated laterally and may overlap the second toe. An enlarged, painful, inflamed bursa (bunion) may form on the medial side.

Plantar

? warts are painful warts (verruca vulgaris) that often occur under a callus, appearing as tiny dark spots.

flat

A ? foot (pes planus) has no arch and may cause pain and swelling of the foot surface.

scoliosis

A lateral curvature of the spine with an increase in convexity on the side that is curved is seen in ?

kyphosis

A rounded thoracic convexity (?) is commonly seen in older adults.

206

A total of ? bones make up the axial skeleton (head and trunk) and the appendicular skeleton (extremities, shoulders, and hips; Fig. 24-1).

lumbar

An exaggerated lumbar curve (? lordosis) is often seen in pregnancy or obesity

carpal tunnel syndrome

Atrophy of the thenar prominence due to pressure on the median nerve is seen in ?

Flexion

Bending the extremity at the joint and decreasing the angle of the joint

shapes

Bone ? vary and include short bones (e.g., carpals), long bones (e.g., humerus, femur), flat bones (e.g., sternum, ribs), and bones with an irregular shape (e.g., hips, vertebrae).

osteoblasts/osteoclasts

Bone tissue is formed by active cells called ? and broken down by cells referred to as ?.

red/yellow

Bones contain ? marrow that produces blood cells and ?marrow composed mostly of fat.

ligaments

Bones in synovial joints are joined by ? which are strong, dense bands of fibrous connective tissue.

Physical assessment of the musculoskeletal system involves examining posture, gait, bone structure, muscle strength, and joint mobility, and the ability to perform ADLs. This includes inspecting and palpating joints, muscles, and bones, testing ROM, and assessing muscle strength. To prepare the client, the room should be comfortable, with adequate draping, and clear directions should be given throughout the examination. Demonstrating how to move body parts and providing verbal directions can help facilitate the examination.

COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION

Assessing the musculoskeletal system is important for evaluating a client's ability to perform daily activities. Clients can provide information about pain, stiffness, and range of motion, as well as their nutrition, activities, and exercise habits. Pain assessments may be necessary. The neurologic system plays a role in coordinating the musculoskeletal system, so it's important to ask appropriate questions. The assessment provides information about the client's exercise patterns, and teaching about exercise, diet, positioning, posture, and safety habits can promote musculoskeletal health.

COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY

chronic

Chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints, limited range of motion, and finger deviation toward the ulnar side are seen in ? rheumatoid arthritis

Circumduction

Circular motion

compact & spongy

Composed of osseous tissue, bones can be divided into two types: ? bone, which is hard and dense and makes up the shaft and outer layers; and ? bone, which contains numerous spaces and makes up the ends and centers of the bones.

musculoskeletal

Controlled and innervated by the nervous system, the ? system's overall purpose is to provide structure and movement for body parts.

ankylosing

Flattening of the lumbar curvature may be seen with a herniated lumbar disc or ? spondylitis

boutonnière/swan-neck

Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint (? deformity) and hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint (? deformity) are also common in chronic rheumatoid arthritis

Gen. Inspection

Gait Posture (Standing & Sitting)

hammer

Hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint (? toe) commonly occurs with the second toe.

gouty

In ? arthritis, the metatarsophalangeal joint of the great toe is tender, painful, reddened, hot, and swollen.

Hyperextension

Joint bends greater than 180 degrees

tendons

Made up of long muscle fibers (fasciculi) that are arranged together in bundles and joined by connective tissue, skeletal muscles attach to bones by way of strong, fibrous cords called ?.

Abduction

Moving away from midline of the body

Retraction

Moving backward

Protraction

Moving forward

Inversion

Moving inward

Eversion

Moving outward

Adduction

Moving toward midline of the body

ganglion

Nontender, round, enlarged, swollen, fluid-filled cyst (?) is commonly seen at the dorsum of the wrist.

Osteoporosis is a disease characterized by reduced bone strength, leading to an increased risk of fractures. Bones become porous and fragile due to demineralization. Osteoporosis affects women more frequently than men, especially those who have reached menopause, and the elderly. The disease progresses silently, without symptoms, until the first fracture occurs, making screening important. The International Osteoporosis Foundation notes that people at high risk for osteoporosis, who have already experienced at least one osteoporotic fracture, are often neither identified nor treated. The Healthy People 2020 goal is to prevent illness and disability related to osteoporosis and chronic back conditions. Objectives include reducing the proportion of adults with osteoporosis and the number of hip fractures in adults aged 65 years and older. The U.S. Preventive Services Task Force recommends screening for osteoporosis in women aged 65 years or older and younger women whose fracture risk is equal to or greater than that of a 65-year-old Caucasian woman who has no additional risk factors. Risk factors for osteoporosis include age, female gender, family history, previous fracture, race/ethnicity, menopause/hysterectomy, long-term glucocorticoid therapy, rheumatoid arthritis, primary/secondary hypogonadism in men, alcohol consumption, smoking, low body mass index, poor nutrition, vitamin D deficiency, eating disorders, and insufficient exercise.

OSTEOPOROSIS

Heberden's/Bouchard's

Osteoarthritis (degenerative joint disease) nodules on the dorsolateral aspects of the distal interphalangeal joints (? nodes) are due to the bony overgrowth of osteoarthritis. Usually hard and painless, they may affect middle-aged or older adults and often, although not always, associated with arthritic changes in other joints. Flexion and deviation deformities may develop. Similar nodules on the proximal interphalangeal joints (? nodes) are less common. The metacarpophalangeal joints are spared.

tenosynovitis

Painful extension of a finger may be seen in acute ? (infection of the flexor tendon sheaths).

bursae

Some synovial joints contain ? which are small sacs filled with synovial fluid that serve to cushion the joint. Box 24-2 (p. 511) reviews the appearance, characteristics, and motion of major joints

Extension

Straightening the extremity at the joint and increasing the angle of the joint

acute

Tender, painful, swollen, stiff joints are seen in ? rheumatoid arthritis

joint

The ? (or articulation) is the place where two or more bones meet.

periosteum

The ? covers the bones; it contains osteoblasts and blood vessels that promote nourishment and formation of new bone tissues.

musculoskeletal

The body's bones, muscles, and joints compose the ? system.

650

The musculoskeletal system is made up of ? skeletal (voluntary) muscles, which are under conscious control (Fig. 24-2, p. 509).

Dorsiflexion

Toes draw upward to ankle

Plantar flexion

Toes point away from ankle

External rotation

Turning of a bone away from the center of the bod

Rotation

Turning of a bone on its own long axis

Internal rotation

Turning of a bone toward the center of the body

Pronation

Turning or facing downward

Supination

Turning or facing upward

3 types of muscles

skeletal, smooth, and cardiac