Transcript Assessment of musculo

Chapter (11)
Assessment of musculo-skeletal system
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*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.
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• During assessment of muscle groups: assess
muscle weakness, or swelling, and size,
then compare between sides. Joints should
not be forced into painful positions.
• Observe 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.
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• 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.
**Elderly joints often become swollen & stiff, with
reduced range of motion, resulting from cartilage
erosion and fibrosis of synovial membranes.
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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
awakening, “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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*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/she
speaks or writes.
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• 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
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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.
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*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.
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*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.
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-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 & Palpate Areola for
ulceration, nodules, swelling or discharge
(Normally not present).
*Genitourinary and reproductive assessment
• You must focus 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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