The Musculoskeletal System RACHEL S. Natividad, RN, MSN

The Musculoskeletal System

RACHEL S. Natividad, RN, MSN

Subjective and Objective Data

Obtaining a health history

Assessment Inspection/Palpation

Range of Motion passive and active

Muscular strength

Inspection/Palpation Inspect swelling, mass or deformities, stiffness

or instability of joints, limbs and body regions

Palpate for temperature, tenderness surrounding joint

ROM’s

Have the pt perform active ROM

If unable to, use passive ROM

Palpate for unusual joint movement during ROM

Measuring Range of Motion

Assessing Muscles Assess muscle

tone and strength

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

Deformitiesof RA

Swan neck deformity

Boutinniere Deformity

Ulnar Shift

Osteoarthritis A chronic

degeneration of joint cartilage caused by aging or trauma

Pain, stiffness, swelling

Osteoarthritis: Cont.

Heberdens Nodes

Bouchards Nodes

Hard, nontender nodes

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.