Module 1
Testing for Meningeal Irritation/Inflammation
> Brudzinski > Kernig's
A client presents to the health care facility for a routine health checkup. The nurse learns that the client has a long history of cardiovascular disease, including hypertension and carotid artery disease. When assessing this client for potential problems in the nervous system, which question by the nurse is appropriate?
"Are you having any dizziness or lightheadedness?"
A nurse conducts a physical examination of the musculoskeletal system of a client who reports upper arm pain. Which instruction should the nurse provide the client when assessing flexion of the elbow?
"Bend your elbow."
The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?
"Effective blood glucose regulation can prevent this problem."
The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply.
> Cranial nerves > Reflexes > Sensory system > Mental status > Motor system
Abnormal Spinal Curvatures
> Flattening of the lumbar curve > Kyphosis > Lumbar lordosis > Scoliosis
Examples of Subjective Data
> History of present health concern > Past health history > Family history > Lifestyle and health practices
Reduce Reduction of Osteoporosis
> Increase physical activity; increase calcium and vitamin D intake. > Avoid excessive caffeine, alcohol, steroids, smoking. > Estrogen replacement therapy; prevent falls
Objective Data on Elbows
> Inspect for size, shape deformities, redness, or swelling > Test ROM: Flexion, extension, pronation, supination > Full ROM of elbows bilaterally
Collecting Objective Data Ankles and Feet
> Inspect position, alignment, shape, and skin. > Palpate ankles and feet for tenderness, heat, swelling, or nodules > Test ROM > Dorsiflexion, plantar flexion, inversion, eversion, circumduction
Collecting Objective Data Hands and Fingers
> Inspection, palpation, ROM, grasp strength > Flexion, extension, hyperextension
Collecting Objective Data Hips
> Inspection, palpation, test ROM > Flexion, extension, circumduction
Test ROM of the Cervical, thoracic, lumbar spine
> Leaning side-side, front, back > Full ROM of cervical, thoracic, and lumbar spine
Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply.
> Maintaining a healthy weight > Quitting smoking > Regularly exercising
Assessment
> Observe gait and posture. > Inspect joints, muscles, and extremities for size, symmetry, and color. > Palpate joints, muscles, and extremities for tenderness, edema, heat, nodules, or crepitus. > Test muscle strength and ROM of joints. > Compare bilateral findings of joints and muscles. > Perform special tests for carpal tunnel syndrome. > Perform the "bulge," "ballottement," and McMurray knee tests.
Collecting Objective Data
> Observe gait, assess risk of falling > Observe for obvious tremors or abnormal findings
Objective Data About the Spine
> Observe the cervical, thoracic, lumbar curves (no abnormal curves) > Palpate the spinous processes and paravertebral muscles for tenderness or pain (no vertebral tenderness) > Test ROM of cervical, thoracic, and lumbar spine > Observe leg length (legs equal length)
Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply
> Quitting smoking > Regularly exercising > Maintaining a healthy weight
Wrist and Hand Abnormalities
> Rheumatoid arthritis > Swan neck deformities > Ganglion > Osteoarthritis > Tenosynovitis > Thenar atrophy
Objective Data Shoulders, arms, elbows
> Shoulders, arms, and Elbows; Inspection, palpation, ROM > Elbows
Observe Gait, assess Risk of Fall
> Weight evenly distributed > Arms should swing in opposite direction of step > Client should be able to stand on toes or heels without staggering > No shuffling > Coordinated > Balanced
Inspect the following for symmetry, color and mobility:
>Temporomandibular joint (TMJ) > Sternoclavicular joint > Cervical, thoracic, and lumbar spine > Shoulders, arms, and elbows > Wrists, hands, and fingers > Hips, knees, ankles, and feet
Palpate the following for tenderness, heat, swelling, or nodules
>Temporomandibular joint (TMJ) > Sternoclavicular joint > Cervical, thoracic, and lumbar spine > Shoulders, arms, and elbows > Wrists, hands, and fingers > Hips, knees, ankles, and feet > Test for carpal tunnel syndrome. > Test for thumb weakness. > Observe for the "flick" signal. > Perform "squeeze test" of hand and foot. > Measure leg length. Perform the bulge test. > Perform the ballottement test.
Absence of Reflex
May indicate motor neuron disorder
A client expresses to the nurse that he has a "giving in" or "locking" sensation in the knee. Which test should the nurse perform to elicit related findings of a possible tear in the meniscus of the client's knee?
McMurray's
A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?
Measure movement with a goniometer
Observe Posture and Gait
Measure the ROM with a goniometer of each of the following: >Temporomandibular joint (TMJ) > Cervical and lumbar spine > Shoulders > Elbows, wrists, and fingers > Hips, knees, ankles, and toes
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. > Erect posture and comfortable
Spinal Accessory (XI)
Motor: turn head, shrug shoulders, some actions for phonation
What task should a nurse ask a client to perform to assess the function of cranial nerve XII?
Move the tongue from side to side
Abduction
Moving away from the midline of the body
Retraction
Moving backward
Protraction
Moving forward
Inversion
Moving inward
Eversion
Moving outward
Adduction
Moving toward midline of the body
Client Teaching with Musculoskeletal System
Regarding exercise, diet, positioning, posture, and safety habits
When providing teaching to clients in the community, a nurse is accurate in stating that the musculoskeletal system is most closely aligned with which other body system?
neurological system
While assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible
rotator cuff tear.
The subacromial bursae are contained in the
shoulder joint
The diencephalon of the brain consists of the
thalamus and hypothalamus
Reflexes Scale
0- No response 1+ Decreased, less active than normal 2+ Normal, usual response 3+ More brisk than normal; not indicative of a disorder 4+ Hyperactive, very brisk; indicative of a disorder
How many bones?
206
How many vertebrae make up the spinal column?
33
How would the nurse document normal muscle strength?
5/5
Parkinson's Disease
A disorder of the central nervous system that affects movement, often including tremors.
Lordosis
Abnormal anterior curvature of the lumbar spine (sway-back condition)
Scoliosis
Abnormal lateral curvature of the spine
Knee
Articulation of the femur, tibia, and patella; contains fibrocartilaginous discs (medial and lateral menisci) and many bursae.
The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?
Assess for nonverbal signs
Tendons
Attaches skeletal muscles to bones; strong, fibrous cords
Osteoclasts
Degrades bone tissue
Osteoporosis Fractures most Commonly Occur
In spine, wrist, and hip
Motion of Foot
Inversion Eversion
Ganglion
Nontender, round, enlarged, swollen, fluid-filled cyst (ganglion) is commonly seen at the dorsum of the wrist.
Bones are composed of
Osseous Tissue
Active Bone Tissue Cells
Osteoblasts and osetoclasts
Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis?
Calcium
Red Marrow
Produces blood cells
Callus
Calluses are nonpainful, thickened skin that occurs at pressure points.
Have you had any recent weight gain?
Weight gain can increase physical stress and strain on the musculoskeletal system
A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction should the nurse give the client first?
"Walk across the room and back."
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.
Muscle Strength
0- 0% of normal strength; complete paralysis 1- 10% of normal strength; no movement, but muscle contraction is palpable or visible 2- 25% of normal strength; muscle movement against gravity WITH SUPPORT 3- 50% of normal strength; normal movement against gravity 4- 75% of normal strength; full movement against gravity and minimal resistance 5- 100% of normal strength, full movement against gravity, and can push/pull against resistance
Rating Muscle Strength (0-5)
0: No muscular contraction (paralysis) 1: Slight flicker of contraction (severe weakness) 2: Passive ROM (gravity removed and assisted by examiner) (poor ROM) 3: Active motion against gravity (average weakness) 4: Active motion against some resistance (slight weakness) 5: Active motion against full resistance (normal)
Inspecting Joints
1. Inspect size, shape, color, and symmetry. Note any masses, deformities, or muscle atrophy. Compare bilateral joint findings. 2. Palpate for edema, heat, tenderness, pain, nodules, or crepitus. Compare bilateral joint findings. 3. Test each joint's range of motion (ROM). Demonstrate how to move each joint through its normal ROM, then ask the client to actively move the joint through the same motions. Compare bilateral joint findings.
Skeletal Bones
206
Musculoskeletal System is made up of
650 skeletal (voluntary) muscles
Range of Motion
> Abduction vs Adduction > Flexion vs. extension > Circumduction > Inversion vs Eversion > Pronation vs Supination > Internal vs External Rotation
Feet and Toe Abnormalities
> Acute Gouty Arthritis > Hallux valgus > Flat feet > Corn > Hammer Toe > Plantar Wart
Osteoporosis
A 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. > When bone resorption outpaces reformation
Fibromyalgia
A disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood changes, or cognitive disorders, is hard to diagnose; causes seem to be genetic or from triggers like infection or physical/emotional trauma > Females, those with family history, or those with rheumatic disease are at risk > Widespread pain for 3 months with no underlying cause
Flat Feet
A flat foot (pes planus) has no arch and may cause pain and swelling of the foot surface.
Ankylosing Spondylitis
A form of rheumatoid arthritis that primarily causes inflammation of the joints between the vertebrae
Stroke
A sudden attack of weakness or paralysis that occurs when blood flow to an area of the brain is interrupted
A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type?
Absence
Fixed Risk Factors for Osteoporosis
Age Female gender Family history of osteoporosis Previous fracture Ethnicity Menopause/hysterectomy Long-term glucocorticoid therapy Rheumatoid arthritis Primary/secondary hypogonadism in men
Risk Factors for Fracture
Age 65 or older Vertebral compression fracture Fracture with minimal trauma after age 40 Family history of osteoporotic fracture (especially parental hip fracture) Long-term (more than 3 months continuously) use of glucocorticoid therapy such as prednisone Medical conditions (such as celiac disease, Crohn disease) that inhibit absorption of nutrients Primary hyperparathyroidism Tendency to fall Spinal fracture apparent on x-ray Hypogonadism (low testosterone in men, loss of menstrual periods in younger women) Early menopause (before age 45) Rheumatoid arthritis Hyperthyroidism Low body weight (<60 kg) If present weight is more than 10% below weight at age 25 Low calcium intake Excess alcohol (consistently more than 2 drinks a day) Smoking Low bone mineral density (BMD)
Modifiable Risk Factors for Osteoporosis
Alcohol (greater than 2 drinks a day) Smoking (past or current history) Low body mass index (<20 kg/m2) Poor nutrition (low calcium intake and low protein intake) Vitamin D deficiency Eating disorders (leading to nutrition deficiencies) Low dietary calcium intake Insufficient exercise (especially sedentary lifestyle) Frequent falls
Hallux Valgus
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.
A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of
Arthritis
Wrist, Fingers, Thumb
Articulation between the distal radius, ulnar bone, carpals, and metacarpals. Contains ligaments and is lined with a synovial membrane
Hip
Articulation between the head of the femur and the acetabulum. Contains a fibrous capsule.
Ankle and Foot
Articulation between the talus (large posterior foot tarsal), tibia, and fibula. The talus also articulates with the navicular bones. The heel (calcaneus bone) is connected to the tibia and fibula by ligaments.
Temporomandibular Joint
Articulation between the temporal bone and mandible
Elbow
Articulation between the ulna and radius of the lower arm and the humerus of the upper arm; contains a synovial membrane and several bursae.
Shoulder
Articulation of the head of the humerus in the glenoid cavity of the scapula. The acromioclavicular joint includes the clavicle and acromion process of the scapula. It contains the subacromial and subscapular bursae
A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented, with no signs of neurologic degeneration. What is an appropriate action by the nurse?
Ask the client about the presence of contact lenses
After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? (Select all that apply.)
Asked the client to open and close the mouth Asked the client to jut the jaw forward Asked the client to rock the jaw laterally
Flexion
Bending the extremity at the joint and decreasing the angle of the joint
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.
A nurse observes a client's gait and notes it to be wide based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait?
Cerebellar ataxia
The nurse is assessing the client's coordination and finds that her movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The nurse notes that client has dysmetria. What would the nurse know this client has?
Cerebellar disease
The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem?
Cerebellum
A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action?
Check for pulse, color, temperature, and capillary refill.
Chronic Rheumatoid Arthritis
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 chronic rheumatoid arthritis.
Circumduction
Circular motion
The nurse is performing the Romberg test. Which of the following indicate a normal finding?
Client stands erect with minimal swaying
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
Two Types of Bones
Compact and Spongy
A nurse notices that a client has decreased range of motion with lateral bending of the cervical spine to the left side. What should the nurse do next in relation to this finding?
Compare this finding to the range of motion to the right side
Yellow Marrow
Composed mostly of fat
Synovial Joints
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 (Ex. Shoulders, wrists, hips, knees, ankles)
Spongy Bone
Contains numerous spaces and makes up the end and centers of the bones
A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?
Coordination
Flattening of Lumbar Curvature
Could be herniated disc or ankylosing spondylitis
Periosteum
Covers the bones and contains osteoblasts and blood vessels that promote nourishment and formation of new bone tissues
Swan Neck Deformity
Deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it
The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what?
Delirium
African Americans have
Denser bones than Caucasians
Men have
Denser bones than women
Goniometer
Device that measures movement in degrees
Bones are Densest During
Early 20s
When testing the biceps reflex, what type of response should the nurse expect if normal?
Elbow flexes and muscle contracts
Synovial Joints are
Enclosed by fibrous capsule made of connective tissue and connected to the periosteum of the bone
Teach Clients to Prevent Bone Loss
Ensure a nutritious diet and adequate calcium intake. Avoid undernutrition, particularly the effects of severe weight-loss diets and eating disorders. Maintain an adequate supply of vitamin D. Participate in regular weight-bearing activity. Avoid smoking and second-hand smoking. Avoid heavy drinking.
Teach Parents of Children and Adolescents to Help Their Children
Ensure a nutritious diet with adequate calcium intake. Avoid protein malnutrition and undernutrition. Maintain an adequate supply of vitamin D. Participate in regular physical activity. Avoid the effects of second-hand smoke.
Thenar Atrophy
Erosion of the muscles that make up the thick pad underneath the thumb.
Preparing Client for Musculoskeletal Assessment
Examination is lengthy, be sure that the room is at a comfortable temperature and provide rest periods as necessary > Provide adequate draping to avoid unnecessary exposure of the client yet adequate visualization of the part being examined > Explain that you will ask the client frequently to change positions and to move various body parts against resistance and gravity > Clear, simple directions need to be given throughout the examination to help the client understand how to move body parts to allow you to assess the musculoskeletal system. > Demonstrating to the client how to move the various body parts and providing verbal directions facilitate examination
Kyphosis
Excessive outward curvature of the spine, causing hunching of the back.
A nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which intervention is the most effective for temporary relief of the symptoms?
Exercising the legs
Appendicular Skeleton
Extremities, shoulders, and hips
Trochlear (IV)
Eye movement (Down and in)
Oculomotor (III)
Eye movement (UP, DOWN)
After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.
False
The nurse instructs the client to raise his arm out to the side and overhead. The nurse is asking the client to adduct his arm.
False
Joints are Classified as
Fibrous, cartilaginous, synovial
Motion of Fingers
Fingers: Flexion, extension, hyperextension, abduction, and circumduction
A client has osteoarthritis of the elbow. Which assessment approach should the nurse expect to be impacted by this health problem?
Flexion
What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor?
Flexion
Motion of Toes
Flexion Extension Abduction Adduction
Motion of Vertebrae
Flexion Hyperextension Lateral bending Rotation
Motion of Knee
Flexion Extenson
Motions of Shoulder
Flexion and extension Abduction and adduction Circumduction Rotation (internal and external)
Motion of Elbow
Flexion and extension of the forearm Supination and pronation of the forearm
Motion of Hip
Flexion with knee flexed and with knee extended Extension and hyperextension Circumduction Rotation (internal and external) Abduction Adduction
Motion of Thumb
Flexion, extension, and opposition
Shoulders, Arms, Elbows ROM
Flexion, extension, circumduction, rotation
Osteoblasts
Forms bone tissue
Unmodifiable Factors of Osteoporosis
Gender, age, body size, ethnicity, history of bone fractures
Only Client can
Give you data regarding pain, stiffness, and levels of movement and how ADLs are affected
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the
Glossopharyngeal
A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?
Glossopharyngeal (IX)
The nurse is assessing the range of motion (ROM) of a client's joints. What would the nurse use to assess flexion and extension of a joint if the client complains of pain on examination?
Goniometer
Compact bone
Hard and dense and makes up the shaft and outer layers
Some Older Clients
Have an impaired sense of position in space, which may contribute to the risks of falling.
Joint stiffening and other musculoskeletal symptoms may be a transient effect of the tetanus, whooping cough, diphtheria, or polio vaccines
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
Axial Skeleton
Head and trunk
Acoustic (VIII)
Hearing equilibrium
Assessment of Musculoskeletal System
Helps to evaluate the client's level of functioning with activities of daily living (ADLs); system affects the entire body from head to toe > Will provide nurse with information about client's daily activity and exercise patterns that promote either healthy or unhealthy functioning of the system
When the client performs straight leg flexion, the client complains of pain that radiates down his leg. The nurse understands that this may indicate what?
Herniated disc
Lumbar Hyperlordosis
Hip flexion contracture and hip extensor weakness drive the lumbar spine into increasing lordosis to balance head over pelvis. Note the use of the hands for stability
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam?
Hop on one foot
Hammer Toe
Hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint (hammer toe) commonly occurs with the second toe.
Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?
Hypothalamus
Clients more Prone to Osteoporosis
Immobile or have reduced intake of calcium and vitamin D
Actual Diagnoses
Impaired Physical Mobility related to impaired joint movement, decreased muscle strength, or fractured bone Activity Intolerance related to muscle weakness or joint pain Constipation related to decreased gastric motility and muscle tone secondary to immobility Ineffective Sexuality Pattern related to lower back pain Acute (or Chronic) Pain related to joint, muscle, or bone problems Impaired Skin Integrity related to prolonged pressure on the skin secondary to immobility Impaired Social Interaction related to depression or immobility Disturbed Body Image related to skeletal deformities
The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client?
Impaired physical mobility
Acute Gouty Arthritis
In gouty arthritis, the metatarsophalangeal joint of the great toe is tender, painful, reddened, hot, and swollen
A nurse is reviewing a client's health record while interviewing her. The nurse sees in the client's record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands that this finding indicates which of the following?
Increased or brisk, but not pathologic
Subjective Data
Information the patient gives us
Objective Data
Information we collect with evidentiary support
Physical Assessment Includes
Inspecting and palpating the joints, muscles, and bones, testing ROM, and assessing muscle strength
Collecting Objective Data Knees
Inspection, palpation > Assess for swelling > Test for ROM > Assess for pain and injury
Collecting Objective Data Wrist
Inspection, palpation, test ROM > Flexion, extension, hyperextension > Full ROM of wrists bilaterally
Bone Density of Chinese & Japanese
Is below that of caucasians
Cartilaginous Joints
Joined by cartilage (Ex. Joints between vertebrae)
Fibrous Joints
Joined by fibrous connective tissue and are immovable (Ex. Sutures between skull bones)
Bones in Synovial Joints
Joined by ligaments
Hyperextension
Joint bends greater than 180 degrees
When were your last tetanus and polio immunizations?
Joint stiffening and other musculoskeletal symptoms may be a transient effect of the tetanus, whooping cough, diphtheria, or polio vaccines
Sternoclavicular Joint
Junction between the manubrium of the sternum and the clavicle; has no obvious movements.
The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what?
Kyphosis
Modifiable Factors of Osteoporosis
Lack of exercise, low calcium, anorexia nervosa, low estrogen levels, smoking, caffeine, alcohol, medication intake
Spinal Fractures
Lead to loss in height and development of a curved upper back
Kernig's
Leg cannot be completely extended after flexion....+ Kernig
A client makes this movement when the nurse assesses for the plantar response. What should this movement indicate to the nurse?
Lesion of the corticospinal tract
Fasciculi
Long muscle fibers arranged together in bundles and joined by connective tissue
Abducens (VI)
Look side to side
Ankle X-Ray Indicators
Malleolar-area pain and bone tenderness at the tips of 6-cm edges of the lateral malleolus or medial malleolus, or the inability to bear weight immediately or during examination indicate the need for an ankle x-ray
Joint-Stiffening Conditions
May be misdiagnosed as arthritis especially in older adults
The nurse is planning a presentation on osteoporosis to a group of high school students. Which of the following should the nurse plan to include in the presentation?
Moderate strenuous exercise tends to increase bone density.
Information Regarding Client's
Nutrition, activities, and exercise is a significant part of the musculoskeletal assessment
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, can stand on heels and toes, toes point straight, rhythmic arm swings
Motion of Temporomandibular Joint
Opens and closes mouth Projects and retracts jaw Moves jaw from side to side
Osteoarthritis
Osteoarthritis (degenerative joint disease) nodules on the dorsolateral aspects of the distal interphalangeal joints (Heberden 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, are associated with arthritic changes in other joints. Flexion and deviation deformities may develop.
Foot x-ray indicators
Pain in the midfoot area and bone tenderness at the base of the fifth metatarsal or the navicular bone area, or the inability to bear weight immediately or during examination, indicate the need for a foot x-ray
Often chief concern with Musculoskeletal Problems
Pain or stiffness
Tenosynovitis
Painful extension of a finger may be seen in acute tenosynovitis (infection of the flexor tendon sheaths)
Corn
Painful thickenings of the skin that occur over bony prominences and at pressure points. The circular, central, translucent core resembles a kernel of corn
Plantar Wart
Painful warts (verruca vulgaris) that often occur under a callus, appearing as tiny dark spots.
Health Promotion Diagnoses
Readiness for Enhanced Health Management: activity and exercise patterns related to expressed desire to improve status
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.
The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this client?
Phalen's
Joint (Articulation)
Place where two bones meet
Motion of Ankle
Plantar flexion Dorsiflexion
Glossopharyngeal (IX)
Posterior 1/3 of the tongue; speech
Skeletal Muscles Assist With
Posture, produce body heat, and allow the body to move
Cerebellum
Primary function is coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone
Bones
Provide structure and protection, serve as levers, store calcium, and produce blood cells
Physical assessment of the musculoskeletal system
Provides data regarding the client's posture, gait, bone structure, muscle strength, and joint mobility, as well as the client's ability to perform ADLs.
Collaborative problems that may be identified when obtaining a general impression (Risk for Complication)
RC: Osteoporosis RC: Joint dislocation RC: Compartmental syndrome RC: Pathologic fractures
What finding should a nurse expect when performing Phalen's test on a client with suspected carpal tunnel syndrome?
Reports of tingling, numbness, and pain in the involved wrist
Neurologic System
Responsible for coordinating the functions of the skeleton and muscles
Risk Diagnoses
Risk for Trauma related to repetitive movements of wrists or elbows with recreation or occupation Risk for Injury: Pathologic fractures related to osteoporosis Risk for Injury to joints, muscles, or bones related to environmental hazards Risk for Disuse Syndrome Risk for Urinary Retention related to urine stasis secondary to immobility
A high school football player injured his wrist in a game. He is tender between the two tendons at the base of the thumb. Which of the following should be considered?
Scaphoid fracture
A client has uneven height of the shoulders and hips. What should the nurse suspect this client is demonstrating?
Scoliosis
The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. The nurse suspects that the client is experiencing
Scoliosis
The school nurse notes that the client carries her left shoulder higher than her right shoulder. You should recognize the likely presence of what health problem?
Scoliosis
Bone Shapes Include
Short bones (carpals) Long bones (humerus, femur) Flat bones (sternum, ribs) Irregular (hips, vertebrae)
Investigate
Signs and symptoms reported by the client
Three Types of Muscles
Skeletal, smooth, cardiac
Vagus (X)
Slowing the heart; increasing motility of the digestive tract
Bursae
Small sacs filled with synovial fluid that serve to cushion the joint
Olfactory Nerve (I)
Smell
When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?
Smile
Do you smoke tobacco? How much and how often?
Smoking increases risk of osteoporosis
Articular Cartilage
Smooths and protects the bones that articulate with each other
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
Extension
Straightening the extremity at the joint and increasing the angle of the joint
Ligaments
Strong, dense bands of fibrous connective tissue
The client is facing the nurse with his forearm turned so that his palm is up. What movement is the client exhibiting?
Supination
A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion?
Sympathetic nervous system
Inspecting Muscles
Test muscle strength by asking the client to move each extremity through its full ROM against resistance. Do this by applying some resistance against the part being moved. Document muscle strength by using a standard scale (see the following Rating Scale for Muscle Strength). If the client cannot move the part against your resistance, ask the client to move the part against gravity. If this is not possible, then attempt to move the part passively through its full ROM. If this is not possible, then inspect and feel for a palpable contraction of the muscle while the client attempts to move it. Compare bilateral joint findings.
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?
Test the client's hearing for lateralization and bone and air conduction
Equipment for Musculoskeletal Assessment
Tape Measure Goniometer Skin Marking pen
Facial (VII)
Taste for the anterior 2/3 of tongue; smile
The client presents to the nurse stating that his jaws feel "stuck". What joint should the nurse assess?
Temporomandibular
Acute Rheumatoid Arthritis
Tender, painful, swollen, stiff joints are seen in acute rheumatoid arthritis.
A high school soccer player "blew out his knee" when the opposing goalie's head and shoulder struck his flexed knee while the goalie was diving for the ball. All of the following structures were involved in some way in his injury, but which of the following is a nonarticular structure?
Tendons
Hypoglossal (XII)
Tongue movement
Validate
The musculoskeletal assessment data you have collected. This is necessary to verify that the data are reliable and accurate.
Peripheral Nervous System (PNS)
The sensory and motor neurons that connect the central nervous system (CNS) to the rest of the body.
Vertebrae
Thirty-three bones: 7 concave-shaped cervical (C); 12 convex-shaped thoracic (T); 5 concave-shaped lumbar (L); 5 sacral (S); and 3-4 coccygeal, connected in a vertical column. Bones are cushioned by elastic fibrocartilaginous plates (intervertebral discs) that provide flexibility and posture to the spine. Paravertebral muscles are positioned on both sides of vertebrae.
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.
Trigeminal (V)
Touch, pain: skin of face, chewing
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.
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 body
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
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
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
Optic Nerve (II)
Vision
The nurse is caring for an adult client who is in a cast because of a fractured arm. To promote healing of the bone and tissue, the nurse should instruct the client to eat a diet that is high in
Vitamin C
Musculoskeletal Muscles are
Voluntary (conscious control)
Brudzinski
When neck is flexed, hips & knees should remain relaxed and motionless.
Which tests are appropriate for a nurse to perform to test cranial nerve VIII?
Whisper, Rinne, and Weber tests
Which assessment procedure should a nurse institute to test a client for stereognosis?
With eyes closed, ask the client to identify a familiar object that is placed in their hand
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
Motion of Wrist
Wrists: Flexion, extension, hyperextension, adduction, radial and ulnar deviation
Osteoporosis is more common as
a person ages because bone resorption increases, calcium absorption decreases, and production of osteoblasts decreases as well.
Bones contain yellow marrow that is composed mainly of
fat
While examining the spine of an adult client, the nurse notes that the client has a flattened lumbar curvature. The nurse should refer the client to a physician for possible
herniated disc.
An older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of
herniated intervertebral disc.
Swan Neck Deformity
hyperextension of PIP joint and flexion of DIP joint
