ASSESSING THE MUSCULOSKELETAL SYSTEM (Chapter 24)

Describe your activities during a typical day. How much time do you spend in the sunlight?

A sedentary lifestyle increases the risk of osteoporosis. Prolonged immobility leads to muscle atrophy. Exposure to 20 minutes of sunlight per day promotes the production of vitamin D in the body. Vitamin D deficiency can cause osteomalacia and limit calcium absorption.

Concept Mastery Alert

A client with arthritis in the jaw has decreased range of motion of the jaw, and crepitus is felt when the jaw is palpated. A grating sound may be heard in a client with temporomandibular joint (TMJ) dysfunction.

Describe your typical 24-hour diet. Are you able to consume milk or milk-containing products? Do you take any calcium supplements?

Adequate protein in the diet promotes muscle tone and bone growth; vitamin C promotes healing of tissues and bones. A calcium deficiency increases the risk of osteoporosis. Vitamin D intake via sun exposure, dietary sources and/or supplement is required to absorb calcium (Usual recommendations vary between 400 IU and 1,000 IU per day, varying with age. The Institute of Medicine notes that a safe upper limit for vitamin D intake is 4,000 IU daily for most adults A diet high in purine (e.g., meat, liver, sardines) and alcohol can trigger gouty arthritis.

Test ROM

Ask the client to open the mouth and move the jaw laterally against resistance. Next, as the client clenches the teeth, feel for the contraction of the temporal and masseter muscles to test the integrity of cranial nerve V (trigeminal nerve). Jaw has full ROM against resistance. Contraction palpated with no pain or spasms. Lack of full contraction with cranial nerve V lesion. Pain or spasms occur with myofascial pain syndrome.

How did you view yourself before you had this musculoskeletal problem, and how do you view yourself now?

Body image disturbances and chronic low self-esteem

Describe any joint, muscle, or bone pain you have. Where is the pain? What does the pain feel like (stab, ache)? When did the pain start? When does it occur? How long does it last? Any stiffness, swelling, limitation of movement?

Bone pain is often dull, deep, and throbbing. Joint or muscle pain is described as aching, but has been differentiated between mechanical- and inflammatory-type pains. Sharp, knife-like pain occurs with most fractures and increases with motion of the affected body part. Osteoarthritis pain usually begins in one set of joints and on one side of the body, with a feeling of pain deep in the joint, improving with rest but worsening with rainy weather, perhaps a sensation of bones grating together, with stiffness early in the morning improving with movement. Rheumatoid arthritis pain is varied and may feel burning, throbbing, occurs on both sides of the body, worsens after sitting for long periods, has inconsistent pattern of worse and less pain, and with a feeling of heat and soreness in joints. Fibromyalgia, a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood changes, or cognitive disorders, is hard to diagnose (Mayo Clinic, 2015). Causes seem to be genetic or from triggers such as infections or physical or emotional trauma. Females, those with family history, or those having a rheumatic disease are at risk. Diagnosis no longer includes specific pressure points for pain, but only the history of widespread pain for 3 months with no underlying cause for the pain. Although nonspecific, blood tests for CBC, sedimentation rate, and thyroid function are often performed.

Older Adult Considerations

Bones lose their density with age, putting the older client at risk for bone fractures, especially of the wrists, hips, and vertebrae. Older clients who have osteomalacia or osteoporosis are at an even greater risk for fractures.

Describe your occupation.

Certain job-related activities increase the risk for development of musculoskeletal problems. For example, incorrect body mechanics, heavy lifting, or poor posture can contribute to back problems; consistent, repetitive wrist and hand movements can lead to the development of carpal tunnel syndrome.

Assess for the risk of falling backward in the older or handicapped client by performing the "nudge test." Stand behind the client and put your arms around the client while you gently nudge the sternum.

Client does not fall backward. Falling backward easily is seen with cervical spondylosis and Parkinson disease.

Describe any difficulty that you have chewing. Is it associated with tenderness or pain?

Clients with temporomandibular joint (TMJ) dysfunction may have difficulty chewing and may describe their jaws as "getting locked or stuck." Jaw tenderness, pain, or a clicking sound may also be present with TMJ.

Has your musculoskeletal problem added stress to your life? Describe.

Musculoskeletal problems often greatly affect ADLs and role performance, resulting in changed relationships and increased stress.

Do you drink alcohol or caffeinated beverages? How much and how often?

Excessive consumption of alcohol or caffeine can increase the risk of osteoporosis.

Inspect and palpate the TMJ.

Have the client sit; put your index and middle fingers just anterior to the external ear opening Ask the client to open the mouth as widely as possible. (The tips of your fingers should drop into the joint spaces as the mouth opens.) Move the jaw from side to side. Protrude (push out) and retract (pull in) jaw. Snapping and clicking may be felt and heard in the normal client. Mouth opens 1-2 in (distance between upper and lower teeth). The client's mouth opens and closes smoothly. Jaw moves laterally 1-2 cm. Jaw protrudes and retracts easily. Decreased ROM, swelling, tenderness, or crepitus may be seen in arthritis. Decreased muscle strength with muscle and joint disease. Decreased ROM, and a clicking, popping, or grating sound may be noted with TMJ dysfunction.

Have you ever been diagnosed with diabetes mellitus, sickle cell anemia, systemic lupus erythematosus (SLE), or osteoporosis?

Having diabetes mellitus, sickle cell anemia, or SLE places the client at risk for development of musculoskeletal problems such as osteoporosis and osteomyelitis. Type 1 diabetes increases risk of low bone density, and may increase fracture risk, but fractures may be related to poor vision and nerve damage, which are likely to produce falls. Although clients with type 2 diabetes often have increased body weight and thereby increased bone density, they too are likely to have an increased risk of fractures due to vision and nerve damage Clients who are immobile or have a reduced intake of calcium and vitamin D are especially prone to develop osteoporosis.

Do you have difficulty performing normal activities of daily living (bathing, dressing, grooming, eating)? Do you use assistive devices (e.g., walker, cane, braces) to promote your mobility and activities of daily living?

Impairment of the musculoskeletal system may impair the client's ability to perform normal ADLs. Correct use of assistive devices can promote safety and independence. Some clients may feel embarrassed and not use their prescribed or needed assistive device.

Bones lose their density with age, putting the older client at risk for bone fractures, especially of the wrists, hips, and vertebrae. Older clients who have osteomalacia or osteoporosis are at an even greater risk for fractures.

Joint stiffening and other musculoskeletal symptoms may be a transient effect of the tetanus, whooping cough, diphtheria, or polio vaccines

Older Adult Considerations

Joint-stiffening conditions may be misdiagnosed as arthritis, especially in the older adult.

Cultural Considerations

Lactose intolerance (a deficiency of the lactase enzyme) affects up 65% of adult humans (and animals) due to decreased production of the lactase enzyme at weaning. Between 80% and 100% of Asians and Native Americans are lactose intolerant. Most of the world's population is between 50% and 90% intolerant. Only those of Northern European descent have only a 5-20% intolerance (Lactose Intolerance by Ethnicity and Region, 2010).

How have your musculoskeletal problems interfered with your ability to interact or socialize with others? Have they interfered with your usual sexual activity?

Musculoskeletal problems, especially chronic ones, can disable and cripple the client, which may impair socialization and prevent the client from performing the same roles as in the past. Back problems, joint pain, or muscle stiffness may interfere with sexual activities.

Observe gait

Observe the client's gait as the client enters and walks around the room. Note: Base of support Weight-bearing stability Foot position Stride and length and cadence of stride Arm swing Posture Evenly distributed weight. Client able to stand on heels and toes. Toes point straight ahead. Equal on both sides. Posture erect, movements coordinated and rhythmic, arms swing in opposition, stride length appropriate. Uneven weight bearing is evident. Client cannot stand on heels or toes. Toes point in or out. Client limps, shuffles, propels forward, or has wide-based gait. (See Chapter 25, Assessing Neurologic System, for specific abnormal gait findings.)

Observe posture.

Observe the client's posture while standing with the feet together, noting alignment of the head, trunk, pelvis, and extremities. Also observe client's posture while sitting. Posture is erect and comfortable for age. Slumped shoulders may result from poor posture (especially while seated) or from depression. Abnormal curvatures of the spine include lordosis, scoliosis, or kyphosis

Older Adult Considerations

Osteoporosis is more common as a person ages because that is when bone resorption increases, calcium absorption decreases, and production of osteoblasts decreases.

Describe your posture at work and at leisure. What type of shoes do you usually wear? Do you use any special footwear (i.e., orthotics)?

Poor posture, prolonged forward bending (as in sitting) or backward leaning (as in working overhead), or long-term carrying of heavy objects on the shoulders can result in back problems. Contracture of the Achilles tendon can occur with prolonged use of high-heeled shoes.

Describe any routine exercise that you do.

Regular exercise promotes flexibility, muscle tone, and strength, while weight-bearing exercises are the only exercises that can promote bone density. Regular exercise can also help to slow the usual musculoskeletal changes, progressive loss of total bone mass (osteopenia/osteoporosis), and degeneration of skeletal muscle fibers (sarcopenia) that occur with aging. Improper body positioning in contact sports results in injury to the bones, joints, or muscles.

Do you smoke tobacco? How much and how often?

Smoking increases the risk of osteoporosis

What medications are you taking?

Some medications can affect musculoskeletal function. Diuretics, for example, can alter electrolyte levels, leading to muscle weakness. Steroids can deplete bone mass, thereby contributing to osteoporosis. Adverse reactions to HMG-CoA reductase inhibitors (statins) can include myopathy, which can cause muscle pain, soreness, tiredness, or weakness

Older Adult Considerations

Some older clients have an impaired sense of position in space, which may contribute to the risk of falling.

Have you ever had a bone density screening? When was your last one?

The U.S. Preventive Services Task Force (USPSTF, 2011) recommends that women younger than age 60 get bone density scans if they have risk factors for osteoporosis, including a history of fractured bones, being Caucasian, smoking, alcohol abuse, or a slender frame. Bone density screening is recommended for all women at age 60.

With client sitting, inspect the sternoclavicular joint for location in midline, color, swelling, and masses. Then palpate for tenderness or pain.

There is no visible bony overgrowth, swelling, or redness; joint is non-tender. Swollen, red, or enlarged joint or tender, painful joint is seen with inflammation of the joint.

Do you have a family history of rheumatoid arthritis, gout, or osteoporosis?

These conditions tend to be familial and can increase the client's risk for development of these diseases.

Describe any past problems or injuries you have had to your joints, muscles, or bones. What treatment was given? Do you have any aftereffects from the injury or problem?

This information provides baseline data for the physical examination. Past injuries may affect the client's current ROM and level of function in affected joints and extremities. A history of recurrent fractures may be seen with osteomalacia but should also raise the question of possible physical abuse.

What activities do you engage in to promote the health of your muscles and bones (e.g., exercise, diet, weight reduction)?

This question provides the examiner with knowledge of how much the client understands and actively participates in activities to promote the health of the musculoskeletal system.

Have you had any recent weight gain?

Weight gain can increase physical stress and strain on the musculoskeletal system.

For middle-aged women: Have you started menopause? Are you taking estrogen or hormone replacement therapy?

Women who begin menarche late or begin menopause early are at greater risk for development of osteoporosis because of decreased estrogen levels, which tend to decrease the density of bone mass

Osteoporosis

disease in which bones demineralize and become porous and fragile, making them susceptible to fractures. The bone loss occurs silently and progressively, and often no symptoms are noted until the first fracture occurs. Normally, bones are densest during the early 20s, but aging causes the bone remodeling process (bone resorption and bone formation) to change, leading to lower bone mass and osteoporosis, when bone resorption outpaces reformation