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ASSESSING THE MUSCULOSKELETAL SYSTEM

Implementation
Performance 3. Provide for client privacy
1. Explain to the client what you 4. Inquire if the client has any
are going to do, why it is history of the following:
necessary, and how he or she presence of muscle pain: onset,
can cooperate. Discuss how the location, character, associated
results will be used in planning phenomena, and aggravating
further care and treatments. and alleviating factors; any
2. Wash hands and observe limitations to movement or
appropriate infection control inability to perform activities of
procedures. daily living; previous sports
injuries; any loss of function
without pain.

Assessment Normal Findings Deviations from Normal


MUSCLES
5. Inspect the Equal size on both sides Atrophy (a decrease in
muscle for size. of the body size) or hypertrophy (an
Compare the increase in size)
muscles on one
side of the body
(arm, thigh, calf)
to the same
muscle on the
other side. For
any
discrepancies,
measure the
muscle with tape
6. Inspect the No contractures Malposition of body part
muscle and (footdrop)
tendons for
contractures
(shortening)
7. Inspect the No fasciculation or Presence of
muscles for tremors fasciculation and tremor
fasciculations and
tremors. Inspect
any tremors of
the hands and
arms by having
the client hold
arms out in fornt
of the body
8. Palpate muscles Normally firm Atonic (lacking tone)
at rest to
determine muscle
tonicity (the
normal condition
of tension, or
tone, of a muscle
at rest).
9. Palpate muscles Smooth coordinated Flaccidity (weakness or
while the client is movements laxness) or spasticity
active and (sudden involuntary
passive for muscle contraction)
flaccidity,
spasticity, and
smoothness of
movement
10.Test muscle Equal strength on each 25% or less of normal
strength. body side strength
Compare the
right side with the
left side
BONES
11.Inspect the No deformities Bones misaligned
skeleton for
normal structure
and deformities.
12.Palpate the bones No tenderness or Presence of tenderness
to locate any swelling or swelling (may
areas of edema indicate fracture,
or tenderness neoplasms, or
osteoporosis)
JOINTS
13.Inspect the joint No swelling One or more swollen
for swelling. No tenderness, swelling, joints
Palpate each joint crepitation, or nodules Presence of tenderness,
for tenderness, swelling, crepitation, or
smoothness of nodules
movement,
swelling,
crepitation, and
presence of
nodules.
14.Assess joint range Varies to some degree Limited range of motion
movement in accordance with the in one or more joints
person’s genetic
makeup and degree of
physical activity
15.Document
findings in the
client record
using forms or
checklists
supplemented by
narrative notes
when
appropriate.