Transcript Assessment of musculo

Islamic University of Gaza
Faculty of Nursing
Chapter (10)
Assessment of musculo-skeletal system
1
• Subjective data: ask about:
• Pain: at rest, with exercise, changes in shape or
size of an extremity, changes in mobility to carry
out activities of daily living, sports, and works.
• Stiffness: time of day, relation to weight," bearing
or exercise".
• Decreased or altered or absent sensations.
• Redness or swelling of joints.
• History of fractures and orthopedic surgery.
• Occupational history.
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• Assessment of musculo-skeletal system done
firstly when the client walks, moves in bed or
performs any type of physical activity.
• - Determine Range of motion, muscle strength and
tone, joint and muscle condition.
• N.B: muscle problems commonly are
manifestations of neurological disease, so you
must do neurological assessment simultaneously.
• Joints vary in their degree of mobility, range from
freely movable e.g. knee, to slightly movable
joints e.g. the spinal vertebra.
3
• During assessment of muscle groups: assess
muscle weakness, or swelling, and size,
then compare between sides. Joints should
not be forced into painful positions.
• * Observer gait and posture as client walks
into room.
• Normally the client walks with arms
swinging freely at sides and the head and
the face leading the body.
4
• * Loss of height is frequently the first clinical sign
of osteoporosis.
• Small amount of height loss expected with aging.
• Ask client to put each joint through its full range
of motion, if there is weakness, gently supporting
& moving extremities through their Range of
motion, to assess abnormalities.
• * Normal joints are non tender, without swelling
and move freely.
• N.B: “You must assess these points”: In elderly
joints often become swollen & stiff, with reduced
Range of motion, resulting from cartilage erosion
and fibrosis of synovial membranes
5
Assessment of Neurological system
• You can assess this system when doing
physical examination e.g. cranial nerve
function can be testing during the survey of
the head and neck.
• * The neurological assessment consists of six
parts: (mental status, cranial nerves, sensory
functions, motor function, cerebellar
function, reflexes).
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Subjective data: ask about:
Loss of consciousness, dizziness, and fainting.
Headache: precipitating factors and duration.
Numbness and tingling or paralysis or neuralgia.
Loss of memory, confusion, visual loss, blurring,
and pain.
• Facial pain, weakness, twitching, speech problems
e.g. aphasia.
• Swallowing problems and drooling.
• Neck weakness or spasm
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• Mental and emotional status is observed as the
nursing history is collected, and by simply
interacting with client, e.g. “Nursing care plan”
• * Level of consciousness, which ranges from full
a wakening, “alertness” to unresponsiveness to
any form of external stimuli.
• * Alert client responds to questions spontaneously.
• * You can assess Level of consciousness by using
Glasgow coma scale
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Glasgow coma scale
Action
Response
Score
Open eyes
Spontaneous
4
To speech
3
To pain
2
None
1
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible sounds
2
None
1
Obeys commands
6
Localized pain
5
Flexion withdrawal
4
Abnormal flexion
3
Abnormal extension
2
Flaccid
1
Best verbal response
Best motor response
Total score
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9
• Assessment of behavior and Appearance
• * Behavior, mood, hygiene, grooming and choice
of dress reveal pertinent information about client’s
mental status.
• * Appearance reflects how a client feels about the
self.
• * Personal hygiene such as unkempt hair, a dirty
body, or broken, dirty fingernails should be noted.
• * Language: Assess ability of individual to
understand spoken or written words & how he
speak or writes.
10
• Assess intellectual function, which includes:
memory “recent, immediate, past”, knowledge,
abstract thinking, association and judgment.
• * Assess for sensory function:
• - Assess sensitivity to light touch “cotton”
• - Assess sensitivity to pain “pinprick”
• - Assess sensitivity to vibrations “tuning fork”
• - Assess sensitivity to positions.
• Don’t forget comparing both sides of body
11
Assessment of the breast
Subjective data: ask about:
• Tenderness, pain, swelling, or change in
size of breasts.
• Change in position of nipple or nipple
discharge.
• Presence of cysts, lumps, and lesions.
• History of prior breast surgery
12
• Female breast:
• Inspection: with the client sitting, arms relaxed at
sides. Inspect Areola and nipples for position,
pigmentation, inversion, discharge, crusting &
masses.
• Examine the breast tissue for size, shape, color,
symmetry, surface, contour, skin characteristics,
• Assess level of breasts, notes any retractions or
dimpling of the skin.
• Ask client to elevate her hands over her head,
repeat the observation.
• Ask client to press her hands to her hips and
repeat observation.
13
• Palpation: Best done in recumbent position:
• * Raise the arm of client on the side of the breast being
palpated above clients head.
• * palpate the breast from less painful or less diseased area
* Use on palpation palmer aspects of the fingers in a
rotating motion, compressing the breast tissue against the
chest wall, this is done quadrant by until the entire breast
has been palpated.
• *Note skin texture, moisture, temperature, or masses.
• *Gently squeeze the nipple and note any expressible
discharge. "Normally not present in non lactating women".
• *Repeat examination on the opposite breast & compare
findings.
• N.B: If mass is palpated, its location, size, shape,
consistency, mobility and associated tenderness are
reported
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• Male Breast:
• * Examination of male breast can be brief and
should never be omitted.
• *observe nipple & Arcola for ulceration, nodules,
swelling or discharge "normally not present"
• *Palpate the Areola for nodules or tenderness
• Genitourinary and reproductive Assessment
• you must focus you’re your questions on the following:
• Any bulges or pain when straining or lifting heavy
objects.
• Unusual drainage.
• Pain with urination or incontinence.
• Lower abdominal pain.
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