Muskuloskeletal Assessment Health History Physical Assessment Inspection Palpation Range of Motion Muscular Strength Rachel S. Natividad, RN, MSN
Physical Assessment- Cont. Cervical spine Shoulders Elbows Wrists/hands Hips Knees Ankles/feet Spine Functional assessment
Inspection/Palpation Note size and symmetry color, swelling, masses & deformities of joints, limbs and body regions Palpate for temperature, pain, tenderness,
Spine
ROM’s Have the pt perform active ROM If unable to, use passive ROM
Assessing Muscles Strength against gravity, full resistance note as 0/5-5/5 “5/5” = normal
Rheumatoid arthritis Chronic, systemic, inflammatory disease that attacks the joints, and surrounding tissues, hand, knees, hips, and feet
Deformities of RA Swan neck deformity Boutinniere Deformity Ulnar Shift
Osteoarthritis A chronic degeneration of joint cartilage caused by aging or trauma
Osteoarthritis Heberden’s nodes on distal interphalangeal joints (DIP’s ) Bouchards nodes on proximal interphalangeal joints (PIPs) as disease progresses
Osteoporosis A decrease in bone mass, porous, brittle, and prone to fracture
Contractures
Assessment Guide: Activity & Rest Objective Data Activity Level and Tolerance: ambulates with walker independently/ with minimal assistance; bedrest; up in wheelchair
Assessment Guide: Activity & Rest Muscles and joints Description: fair muscle tone, no atrophy; atrophy to RLE. No stiffness or contractures; R wrist contracted Movement: limited ROM to RUE; FROM all extremities Strength: strong UE, LE; weak RUE & RLE Coordination: able to perform most ADLs; can comb hair and reach for water glass
Assessment Guide: Activity & Rest Posture/Gait Slumped, kyphosis, erect; gait unsteady, shuffling, ataxia
Assessment Guide: Activity & Rest Circulation, Sensation, and Movement Describe: CSM intact; no sensation to R big toe and second toe; numbness and tingling to LEs; Decreased ROM to LUE due to contractures
Assessment Guide: Activity & Rest Rest/Sleep Patterns Sleeps most of the day Takes midday naps
Assessment Guide: Activity & Rest Interventions in use: Assistive device, equipment Cast, trapeze, foot cradle, Special beds Air bed, eggcrate mattress Med List: Glucosamine, Allopurinol, NSAIDS, etc.