Musculoskeletal Assessment

By Adrienne Carlson RN MS

Assigned Readings:
Berman Chapter 44 1105-1117 General information (Skip 1117-1121) 1122-1127 Assessment/NP 1127 skills Body mechanics /positioning 1158-9 case study Lewis et al. Chapter 62 Structure 1614-1618 Assessment 1618-1624 Diagnostic Studies 1624-1628

Jarvis reinforces in detail all assessment skills Chapter 22

Assessment Lecture template

1st hour Overview of appropriate Physiological structure Terminology and Concepts 2nd hour Assessment process Subjective Objective and then Application to the Nursing Process Case study

Mobility vs Activity
Mobility: The basic life process for activity whereby one moves or is moved. Activity: Body movement that serves various purposes, such as, carrying out daily living chores and protecting self and others from injury.

Activity Tolerance

A state in which an individual has insufficient physiologic or psychological energy to endure or complete required or desired daily activities.

The main functions of the Musculoskeletal System are:

1) Support 2) Protection of Vital Organs 3) Mineral Storage 4) Movement 5) Blood Cell Production

Movement. Results from contractions of muscles applied to bones which act as levers and joints which act as fulcrums.

Components of the Musculoskeletal System:

Bone: Cancellous, Compact. Joints: Classified by degree of movement. Cartilage: Hyaline, Elastic, Fibrous. Muscle: Cardiac, Smooth, Skeletal. Tendons and Ligaments Fascia Bursae

Normal movement and stability are the result of

An intact Musculoskeletal system An intact nervous system and An intact inner ear structure (equilibrium).

Body movement requires coordinated muscle activity and neurologic integration.

There are 5 basic elements involved in normal movement:

Posture Joint Mobility Balance Coordination Gait

Factors affecting Body Alignment and Activity:

Growth and Development Physical Health Mental Illness Nutrition Personal Values and Attitudes External (environmental) Factors Prescribed Limitations

The National Institute of Health defines:

Physical Activity as bodily movement produced by skeletal muscles that requires energy expenditure and produces progressive health benefits. Exercise as the type of physical activity that is planned, structured and repetitive bodily movement done to improve or maintain physical fitness.

Exercise:

Involves the active contraction and relaxation of muscles. Exercise can be classified according to: type of muscle contraction and source of energy. Activity tolerance is the type and amount of exercise or daily living activities an individual is able to perform

Types of Exercise

Isotonic: Dynamic exercise Isometric: Static exercise Isokinetic: Resistive exercise

Areobic: O2 taken into body is > or equal to requirement. Anaerobic: Requires O2 > that the body can draw in.

The Benefits of Exercise

The size, shape, tone & strength of muscle is maintained or increased. Increases joint mobility. Increases strength & rate of heart = > CO. Respiratory ventilation is increased and there is decreased pooling of secretions. It increases diaphragmatic excursion and decreases breathing effort.

The Benefits of Exercise cont

Bone density is maintained. It improves appetite and increases GI tract tone, improving digestion and elimination. It increases metabolic rate, production of body heat and wastes and increases use of triglycerides and fatty acids. It increases blood flow, promoting effective excretion of wastes.

The Benefits of Exercise cont

There is decreases stasis of UA in bladder. It produces a sense of well being and improves tolerance to stress. It may improve self-concept by reducing depression and improving body image. Energy levels increase and quality of sleep is enhanced.

Assessment of the Muculoskeletal System

Correct diagnosis depends on an accurate Patient history and a thorough examination. MS assessment can be made on a specific body part, as part of a general physical exam or as a examination in itself.

Complaints that should alert a nurse are:

Joint or muscle pain, joint swelling, decreased strength or function, change in size of extremity or muscle, deformity, spasm, crepitation, changes in sensation, stiffness and changes in gait. Accidents often result in trauma to the MS system and require a thorough examination.

Subjective Data Collection: (Nursing History)

Past Medical History: Take a detailed hx of disease course & also question p/c re: possible 2ndary infection. Medications: Prescribed and OTCs. Surgery or treatments Functional Health Patterns (see next slide)

Functional Health Patterns

Health perception / Health Management Nutrition / Metabolic Elimination Activity / Exercise Sleep / Rest Cognitive /Perceptual Self-perception / Self-concept Role / Relationship Sexual / Reproductive Coping / Stress-tolerance

Objective Data Collection: The physical examination

Inspection Palpation Movement Measurement Muscle-strength testing Gait

Posture Joint mobility Balance and Coordination Gait (Includes all 4 above)

Gait Disorders

ROM

Ataxia Normal Pressure Hydrocephalus Parkinsons Disease Spondylotic Cervical Myelopathy Senile Gait Hemiplegia Osteomalacia

Flexion Extension Hyperextention Abduction Adduction Pronation Supination Circumduction Rotation Inversion Eversion

Muscle Strength Scale

O No detection of muscular contraction. 1 A barely detectable trace of contraction. 2 Active movement of body part with elimination of gravity. 3 Active movement against gravity. 4 Active movement against gravity and some resistance 5 Active movement against full resistance without evident fatigue. (normal muscle strength).

A Normal Physical Assessment of Musculoskeletal System

Full range of motion No joint swelling, deformity or crepetation Normal spinal curvatures No tenderness on palpation of spine No muscle atrophy or asymmetry Muscle strength of 5

Mobility Problems as the Diagnostic Label

Activity Intolerance Impaired Physical Mobility Impaired Bed Mobility Impaired Walking Impaired wheelchair Mobility Impaired W/C Transfer ability Risk for Disuse Syndrome

Impaired Physical Mobility

Limited in independent, purposeful physical movement of the body or one or more extremities. Decreased reaction time, difficulty turning, engages in substitutions, exertional dyspnea, gait changes, jerky movements, limited gross motor skills, limited fine motor skills, limited ROM, movement induced tremor, postural instability, slow movement, uncoordinated movement.

Activity intolerance, altered metabolism, anxiety, inc BMI, cognitive impairment, contractures, cultural beliefs, deconditioning, dec endurance, depressive mood, dec muscle control, mass, muscle strength, knowledge deficit, dev delay, discomfort, disuse, joint stiffness, environment, CV, bone loss, malnutrition, medications, MS impairment, pain, prescribed limitations, reluctance, sedentary lifestyle, sensoriperceptual impairments

Mobility Problems as the Etiology (a cause)

Fear (of falling) Risk for Injury Powerlessness Self-Care Deficit (s) Self Esteem Disturbance Ineffective Individual Coping Ineffective Airway Clearance Risk for Infection

Applying the Nursing Process to a case study

1) obtain a Nursing History 2) perform a physical examination 3) analyze your data 4) list possible Nsg dx 5) choose a Nsg dx for intervention 6) write a PDR statement 7) set an expected outcome 8) choose an appropriate intervention 9) write a Care Plan and then . 10) carry it out your Care Plan 10) evaluate .. the success of your care plan by judging whether you were able to meet your expected outcomes.

ASSESSMENT

Nursing Diagnosis

Planning Intervention

Evaluation

PDR Statement
P: Problem or Diagnostic label________________ D: Defining Characteristics or S/S__________________________ R: Related Factors or Etiology /causative factor _____________________________

Expected Outcome

E.O.:______________________________________ Should have an action verb and a measurable criteria It should relate to the resolution of the D defining characteristics or the mitigation of the R the related factors. There may be appropriate conditional clauses included to narrow /define the intended outcome.

It should be: S.M.A.R.T. Specific, measurable, achievable, realistic and timed. (have a deadline)

Picking an Approach (NIC)

Nursing Interventions Classification Nursing Outcomes Classification Doing it on your own

Cook book references are not the only way ..