ASSESSMENT ON A PATIENT

WITH A MUSCULOSKELETAL
DISORDER
Ramya Ekanayake
 Health History
▪ Evaluation of the effects of the musculoskeletal problem from the past.
▪ Assisting patients who have musculoskeletal problems to,
- Maintain their general health
- Accomplish their daily living activities
- Manage their treatment programs
- Ensures systemic homeostasis
- Encourages optimal nutrition
- Prevents problems related to immobility.
- Individualized plan of nursing care
- Helps the patient achieve maximum health.
 Initial Interview
■ Obtains a general impression of the patient’s health status
■ Gathering subjective data
– patient concerning the onset of the problem
– how it has been managed
– patient’s perceptions and expectations
■ Concurrent health conditions and related problems
(eg; diabetes, heart disease, COPD, infection, preexisting disability)
■ history of medication use
■ Allergies
■ Use of tobacco, alcohol, and other drugs
■ Patient’s learning ability, economic status, and current occupation
- Needed for rehabilitation and discharge planning
 Assessment Data
■ During the interview and physical assessment, the patient may report
– Pain
– Tenderness
– Tightness
– Abnormal sensations.
■ Not only is pain and discomfort exhausting, if prolonged, it can force the
patient to become increasingly preoccupied and dependent.
 Pain
■ A dull, deep ache that is “boring” in nature – Bone pain
■ Soreness or aching and is referred to as “muscle cramps.” - Muscular pain
■ Sharp and piercing and is relieved by immobilization - Fracture pain
■ Sharp pain with muscle spasm or pressure on a sensory nerve - Bone
infection
■ Pain relieve by rest - acute injuries or strains
■ Pain increases with activity - Joint sprain or muscle strain
■ Steadily increasing pain - progression of an infectious
process (osteomyelitis), a malignant tumor, or neurovascular complications.
■ Radiating pain occurs in conditions in which pressure is exerted on a nerve
root
Questions Regarding Pain
■ How does the patient describe the pain?
■ Localized or radiate? If so, in which direction and to which body parts?
■ Pain in any other part of the body?
■ Intensity - pain scale of 0 to 10?
■ Characters of the pain (sharp, dull, boring, shooting, throbbing, cramping)?
■ Constant? Is it increasing or decreasing?
■ What relieves it? What makes it worse?
■ Patient’s reactions to pain? And Body alignment?
■ Pressure from traction, bed linens, a cast, or other appliances?
■ Tension on the skin at a pin site?
■ Discomfort and tiredness?
 Altered Sensation
■ Sensory disturbances are frequently associated with musculoskeletal problems.

■ The patient may describe paresthesias, which are burning, tingling sensations
or numbness.

■ These sensations may be caused by pressure on nerves or by circulatory

impairment.

■ Soft tissue swelling or direct trauma to these structures can impair their
function.

■ The nurse assesses the neurovascular status of the involved musculoskeletal

area.
 Question Regarding Altered Sensation

■ Patient experiencing any abnormal sensations or numbness?

■ When did this begin? Is it getting worse?
■ Can the patient move the affected part?
■ What is the color of the part distal to the affected area? Is it pale? Dusky?
Cyanotic?
■ Does rapid capillary refill occur?
- The nurse can gently squeeze a nail until it blanches, then release the
pressure. The amount of time for the color under the nail to return to
normal is noted. Color normally returns within 3 seconds. The return of
color is evidence of capillary refill.
■ Is a pulse palpable distal to the affected area?
 Physical Assessment
■ Ranges from a basic assessment of functional capabilities to sophisticated
physical examination maneuvers that facilitate diagnosis of specific bone,
muscle, and joint disorders.
■ Assessment depends on the patient’s
– health history
– physical complaints
– physical clues
■ Primarily a functional evaluation, focusing on the patient’s ability to perform
activities of daily living.
■ Inspection and palpation used to evaluate the patient’s
– Posture - Gait
– Bone integrity - Joint function
– Muscle strength and size
■ Assessing the skin and neurovascular status is an important part of a
complete musculoskeletal assessment.
■ Perform correct assessment techniques on patients with musculoskeletal
trauma.
■ Carefully documents the examination findings and shares the information
with the physician,
– who may decide that more extensive examination and diagnostic workup
are necessary
 Posture
■ The normal curvature of the spine is convex through the thoracic portion and
concave through the cervical and lumbar portions.
■ Kyphosis
– Increased forward curvature of the thoracic spine
– Frequently seen in elderly patients with osteoporosis
– Some patients with neuromuscular diseases

■ Lordosis (swayback)
– Exaggerated curvature of the lumbar spine
– Frequently seen during pregnancy
(adjusts her posture in response to changes in her center of gravity)

■ Scoliosis
– Lateral curving deviation of the spine
– Congenital, idiopathic, or the result of damage to the para spinal muscles, as
in poliomyelitis.
Watch the video

■ How to perform physical assessment of musculoskeletal system

■ During inspection of the spine, the entire back, buttocks, and legs are
exposed.
■ The examiner inspects the spinal curves and trunk symmetry from
posterior and lateral views.
■ Standing behind the patient, the examiner notes any differences in the
height of the shoulders or iliac crests.
■ The gluteal folds are normally symmetric. Shoulder and hip symmetry, as
well as the line of the vertebral column, are inspected with the patient
erect and with the patient bending forward (flexion).
■ Older adults experience a loss in height due to loss of vertebral cartilage
and osteoporosis-related vertebral fractures.
■ Therefore, an adult’s height should be measured periodically.
Gait
■ Having the patient walk away from the examiner for a short distance.
■ Observes the patient’s gait for smoothness and rhythm.
■ Any frequently noted unsteadiness or irregular movements are considered
abnormal.
■ Limping motion is most frequently caused by painful weight bearing.
■ For further examination patient can pinpoint the area of discomfort.
■ If one extremity is shorter than another,
– Patient’s pelvis drops downward on the affected side with each step.
– Limited joint motion may affect gait.
■ Variety of neurologic conditions are associated with abnormal gaits.
– Spastic hemiparesis gait (stroke)
– Steppage gait (lower motor neuron disease)
– Shuffling gait (Parkinson’s disease)
Bone Integrity
■ The bony skeleton is assessed for deformities and alignment.
■ Symmetric parts of the body are compared.
■ Abnormal bony growths due to bone tumors may be observed.
■ Shortened extremities, amputations, and body parts that are not in anatomic
alignment are noted.
■ Fracture findings
– Abnormal angulation of long bones
– Motion at points other than joints,
– and crepitus (a grating sound) at the point of abnormal motion.
■ Movement of fracture fragments must be minimized to avoid additional
injury.
Joint Function
■ Evaluated by noting range of motion, deformity, stability, and nodular
formation.
■ Range of motion evaluated by
– Actively - the joint is moved by the muscles surrounding the joint
– Passively - the joint is moved by the examiner
■ Precise measurement of range of motion can be made by a goniometer.
■ Limited range of motion due to
– Skeletal deformity
– Joint pathology, or contracture of the surrounding
– Muscles, Tendons, and Joint capsule
Effusion

■ Excessive fluid within the capsule

■ Joint motion is compromised or the joint is painful

■ swelling, and increased temperature that may reflect active inflammation.

■ An effusion is suspected if the joint is swollen and the normal bony landmarks
are obscured.

■ The most common site for joint effusion is the knee.

■ Identify by Ballottement test.
 Ballottement test
Maneuver:
➢ Positioning:
Supine position with a fully extended leg.
➢ Downward stroke:
Start just above the patella and stroke downward
until reaching the supra-patellar pouch.
➢ Downward pressure:
With the other hand, press downward just below the
apex of the patella. Apply gentle pressure to
compress the joint.
➢ Patella assessment:
Press onto the patella and observe if the patella
moving freely. Positive result indicates accumulated
fluid.
■ Joint deformity may be caused by

– Contracture (shortening of surrounding joint structures)

– Dislocation (complete separation of joint surfaces)

– Subluxation (partial separation of articular surfaces)

– Disruption of structures surrounding the joint

■ Weak requires an external supporting appliance (eg; brace)

Normally, the joint moves smoothly.

A snap or crack sound

– Ligament is slipping over a
bony prominence
– Slightly roughened surfaces
(arthritic conditions)

Crepitus
(grating, crackling sound or
sensation)
– Irregular joint surfaces
Nodule formation
– Rheumatoid arthritis, gout, and osteoarthritis
– Rheumatoid arthritis
►soft and occur within and along tendons that provide
extensor function to the joints.
– Gout
►Hard and lie within and immediately adjacent to the joint
capsule itself
■ Osteoarthritic nodules
– Rupture, exuding white uric acid crystals
onto the skin surface.
– Hard and painless
– Resulted from destruction of the
cartilaginous surface of bone within the
joint capsule.
– frequently seen in older adults.

■ Rheumatoid arthritis
– Symmetric patterns
– Size of the joint is exaggerated by
atrophy of the muscles proximal and
distal to that joint
– In rheumatoid arthritis
Muscle Strength and Size
■ Assessed by noting the patient’s ability to change position, muscular strength
and coordination, and the size of individual muscles.
indicate a variety of conditions, such as polyneuropathy, electrolyte disturbances
(particularly potassium and calcium),
myasthenia gravis, poliomyelitis, and muscular dystrophy.
■ By palpating the muscle while passively moving the relaxed extremity, the
nurse can determine the muscle tone.
■ The nurse assesses muscle strength by having the patient perform certain
maneuvers with and without added resistance.
■ For example, when the biceps are tested, the patient is asked to extend the
arm
fully and then to flex it against resistance applied by the nurse.
Cont…
■ A simple handshake may provide an indication of grasp strength.
■ The nurse measures the girth of an extremity to monitor increased
size due to exercise, edema, or bleeding into the muscle.
■ Girth may decrease due to muscle atrophy. The unaffected extremity
is measured and used as the reference standard.
■ Measurements are taken at the maximum circumference of the
extremity.
It is important that the measurements be taken at the same location
on the extremity, and with the extremity in the same position, with the
muscle at rest.
Skin
■ Inspects the skin for edema, temperature, and color.
■ Palpation
– Warmer areas – increased perfusion or infection
– Cooler - decreased perfusion
– Whether edema is present
■ Cuts, Bruises and skin color
■ Evidence of decreased circulation
■ Evidence of infection
Neurovascular Status
■ Perform frequent neurovascular assessments of patients with musculoskeletal
disorders
– Especially of those with fractures
– Risk of tissue and nerve damage
■ Referred to as assessment of CMS (circulation, motion, and sensation)

• Color – pale or cyanotic

Circulation • Temperature – cool
• Capillary refill – less than 3 sec.
• Weakness
Motion
• Paralysis
• Paresthesia
• Unrelenting pain
Sensation
• Pain or passive stretch
• Absence of feeling
 Compartment syndrome
▪ Pressure within a muscle compartment
▪ Microcirculation diminishes
▪ Leading to nerve and muscle anoxia and necrosis.
▪ If continue longer than 6 hours function can be permanently lost
▪ Common site = leg and forearm
▪ Clinical Examination
- Monitoring the 5 P's: pain, pallor, pulse, paresthesia, and paralysis
- Look for Risk factors – fractures, thermal burns, crush and penetrating injuries, bleeding
disorders, vascular diseases

- Investigation – FBC, Creatinine Kinase , Muscle damage, Rhabdomyolysis, Urine analysis (dip
stick) - show red blood cells
- Pressure measurements
The Patient With Musculoskeletal Injury
Assess for soft tissue trauma, deformity, and neurovascular status.
■ If the patient has a possible cervical spine injury and is wearing a cervical collar, the
collar must not be removed until the absence of spinal cord injury is confirmed on x-ray.
■ When the collar is removed, the cervical spine area is gently assessed for swelling,
tenderness, and deformity.
■ Pelvic trauma
– abdominal organ injuries may occur.
– The patient is assessed for abdominal pain, tenderness, hematomas, and the
presence or absence of femoral pulses.
■ Blood is present at the urinary meatus, the nurse should
– Suspect bladder and urethral injury
– Patient should not be catheterized.
■ Such findings should be reported immediately to the primary health care provider
Questions ?
Thank you !