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Nursing 314: Assessing and Promoting Wellness > Exam 2: Musculoskeletal Assessment > Flashcards

Exam 2: Musculoskeletal Assessment Flashcards

1
Q

Subjective data for Musculoskeletal

A

Joints
—Pain, stiffness, swelling, limiting ROM
Muscles
— Trauma/pain, deformity, gain/loss
Exercise program
Weight gain and loss
ADLs
— Bathing. toileting, dressing, grooming, eating
Mobility/ADL aids
Occupational Hazards
— Lifting, repetition of joint movement, uneven surfaces

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2
Q

When obtaining objective data, INSPECT

A

Gait
mobility
balance
obvious deformities of muscles and bones
skin
spinal curvatures (lordosis, kyphosis, scoliosis)
Symmetry: size, structure, function of muscle mass

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3
Q

When obtaining objective data, palpate each join and note

A

Heat, edema, tenderness, swelling, masses

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4
Q

When assessing ROM, note

A

resistance and presence of pain

Any crepitation vs. discrete crack/pop

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5
Q

Active ROM assessment

A

Patient performs

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6
Q

Passive ROM assessment

A

nurse performs

— DO NOT FORCE into a painful position, mild stretching/discomfort OK, but we do not want to tear soft tissue

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7
Q

Crepitation

A

grinding in joints roughened joins as with rheumatoid arthritis

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8
Q

Cracking and popping in the joins is when

A

Fluid and gasses shift in the joint

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9
Q

Muscle testing during objective data assessment

A
  • Compare both sides at the same time if able

- Flex as you hold opposing force or resist that opposing force

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10
Q

Hypertonicity

A

increased tone/resistance

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11
Q

Hypotonicity

A

decreased tone/resistance… very relaxed, floppy or flabby

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12
Q

Atrophy

A

Reduced size, feels soft/boggy

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13
Q

Assessing cervical spine

A

Checking the alignment of head and neck

Palpate for spasms and tenderness

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14
Q

testing ROM of cervical spine

A 
Flexion (chin to chest) 
Hyperextension (look upward)
Lateral bend (ear to shoulder) 
Rotation (turn head to shoulder) 
--- then repeat with opposing force
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15
Q

Inspecting the lower spine (person should stand if able) and inspect

A

If spine is straight

shoulder evaluation, uneven scapula, iliac crest, gluteal folds, spacing between arm and lateral thorax

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16
Q

ROM assessment for lower spine

A

Bend and touch toes, bend sideways, backwards

Twist side to side

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17
Q

The vertebral column has four curves that are

A

Anterior-posterior curves

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18
Q

The cervical and lumbar curves are

A

Concave (inward)

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19
Q

The thoracic and sacrococcygeal curves are

A

Convex (outward)

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20
Q

What allows the spine to absorb shock

A

balance of the curves with the resilient intervertebral discs

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21
Q

Scoliosis

A

LATERAL S-shape curvature of the thoracic and lumbar spin

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22
Q

A normal spine has a double s-shape that is

A

Anterior/posterior, not lateral

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23
Q

Scoliosis ribs

A

Rib hump on forward flexion

24
Q

Scoliosis is more prevalent in

A

adolescence, especially girls

25
Q

what should be noted for scoliosis

A

unequal shoulders, scapular height, obvious curvature, unequal elbow level, etc.

26
Q

Kyphosis

A

Exaggerated posterior curvature of the thoracic spine, associated with aging. HUMPBACK

27
Q

Lordosis

A

Normal lumbar concavity is further accentuated forward towards the belly

28
Q

Lordosis is often associated with

A

pregnancy and obesity, can be present secondary to kyphosis without obesity

29
Q

Shoulder assessment

A

Inspect - redness, deformity-swelling

Palpate - heat, spasm, atrophy, tenderness

30
Q

When assessing upper extremity, test the

A

Strength of the shoulder muscles and cranial nerve XI: Spinal accessory

31
Q

Assess upper extremity for

A

Asymmetry
Pain with motion
Crepitus with motion
Bilateral/unilateral weakness

32
Q

When assessing elbow

A

Size and contour both flexed and extended

33
Q

When assessing elbow, palpate

A

redness, swelling, deformity

34
Q

When assessing elbow ROM

A

bend and straighten elbow - flexion and extension
Repeat with resistance
—- Supination/pronation

35
Q

When assessing wrist and hand, inspect

A

swelling, redness, deformity, nodules, skin

36
Q

When assessing wrist and hand, palpate

A

Joint surfaces, smooth, nodules, tenderness

37
Q

When assessing ROM for wrist and hand

A 
Bend hand up and down at wrist 
bend fingers up and down 
turn palms outward and inward 
spread fingers, make a fist 
touch thumb to each finger
----repeat with opposing force
38
Q

When assessing Hip, inspect

A

When standing

Symmetrical iliac crest, gluteal folds, buttock size and gait

39
Q

When assessing hip in supine position

A

Raise each leg with knee extended
bending knee to chest increases hip flexion
Internal/external rotation
Straighten knee swing leg lateral and medial

40
Q

Adduct

A

TOWARDS the body

41
Q

Abduct

A

AWAY from body

42
Q

Testing Hip movement

A

Squat and raise knee as high as possible (flexion)
leg cross body plane (adduction)
swing leg away from body (abduction)
When standing swing leg behind body (hypertension)
point toe in and out (internal/external rotation)
DUCK walk !!

43
Q

When assessing knee, inspect

A

skin, lesions, edema, shape/contour

44
Q

When assessing knee, assess

A

Quadriceps for atrophy

45
Q

ROM knee

A

Bend each knee (flexion)
extend each knee (extension)
—– Repeat with opposing force

46
Q

Abnormal knee issues

A

Pain, limps, popping, clicking, weakness, instability

47
Q

When assessing ankle and foot, inspect

A

feet, toes, joints, skin, alignment

— bunions, hammer toes, swelling, inflammation, calluses, ulcers

48
Q

ROM ankle and foot

A

point toes to floor (Plantar flexion)
toes to nose (Dorsiflexion)
soles in and out (Eversion and inversion)
flex and straighten toes

49
Q

Developmental considerations for infants

A

Normal C curve spine
Support head: the neck isn’t developed
ROM of extremities, toes up to the shin!

50
Q

Assess preschoolers

A

Observe crawling, walking, jumping

51
Q

Assessing toddlers

A

Protuberant abdomen
broad based gait
use arms of balance

52
Q

Assessing adolescents

A

Kyphosis with poor posture
Screen for scoliosis
Growth spurts can result in poor coordination

53
Q

Development in pregnant women

A

Lordosis

Waddle type gait due to relaxation of the hip joints in anticipation of childbirth

54
Q

Development in older adults

A

Loss of bone mass
Weaker bones
Smaller base of support so they shuffle feet
Increased risk for falls and also for fracture

55
Q

Common adaptations to aging

A 
Shuffling 
Holds on to rails, leads with favored leg 
Holds rail, lowers weak leg first 
bends at waist
pushes off chair 
rolls from one side 
pushes with arms

Nursing 314: Assessing and Promoting Wellness (26 decks)

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