Module 07: Neuromuscular Assessment (Part 02) Flashcards
How should the nurse perform the Musculo-skeletal examination?
(1) Inspection of muscles, joints, and skin changes
(a) Symmetry
(b) Change in size and shape
(2) Palpate joints, bony prominences, muscles for mass, sensation of pain and tenderness
(3) Feel skin for changes in temperature
What are the normal findings as per inspection during the musculoskeletal examination?
Symmetrical, non-tender, size of muscles and bones equal on lt and rt extremities
What are the abnormal findings as per inspection during the musculoskeletal examination?
(A) Deformity
(B) Atrophy
(C) Contraction
(D) Swelling
(E) Crepitation
(F) Pain and tenderness
(G) Asymmetry/unequal size
How should the nurse perform the range of motion (ROM) and strength of the upper extremities?
(1) Instruct patient to resist your hand during flexion and extension of extremities
(2) Rate the strength using the muscle power scale 5/5 for maximum strength
What are the three (3) positions of the patient when examining the range of motion (ROM) and strength of their upper extremities? Cite the positions along with the following instructions.
(1) Arms outstretched
(2) Arms flexed towards chest
(A) Perform flexion and extension procedures on all extremities as you apply resistance to each extremity
(B) Apply resistance on outstretched arms (superior and inferior) and with arms flexed one at a time. Grade strength 0-5.
(C) Stretch out hands straight
(D) Dorsiflex patient’s wrist with fingers extended
(E) Observe outstretched hands for “tremors” and asterixis
(3) Hand grip test (nurse with crossover hands)
What are the normal findings when assessing the range of motion (ROM) and strength of the upper extremities?
No tremors, muscle strength grade 5
Negative tremors
This condition is also known as the hepatic flap which is a classic sign of liver disease.
Asterixis
What are the abnormal findings when assessing the range of motion (ROM) and strength of the upper extremities?
Limited ROM with pain and crepitation Muscle strength 0 = paralysis + tremors, + asterixis
This scale is often used to probe into the range of motion (ROM) and strength of the upper extremities
MRC Muscle Power Scale
What composes the MRC Muscle Power Scale?
(0) No contraction
(1) Flicker or trace of contraction
(2) Active movement, with gravity eliminated
(3) Active movement against gravity
(4) Active movement against gravity and resistance
(5) Normal Power
How should the nurse perform the range of motion (ROM) and strength of the lower extremities?
Repeat procedure flexion and extension to the lower extremities with resistance:
(1) Knees
(2) Lower legs
(3) Feet: repeat flexion and extension assessment:
What positions should the patient do when assessing the full range of motion (ROM) or rotation of the lower extremities?
Instruct patient to rotate ankle:
(A) Dorsiflexion and plantar flexion
(B) Eversion-inversion of toes
(C) Abduction and adduction of the ankles
What are the normal findings when assessing the range of motion (ROM) and strength of the lower extremities?
(1) Full ROM
(2) Normal strength 5/5
What are the abnormal findings when assessing the range of motion (ROM) and strength of the lower extremities?
(1) Limited ROM with pain and crepitation
(2) Decreased strength below 3/5
What kind of assessment is being performed when assessing the dorsalis pedis pulse?
Vascular Assessment
How should the nurse assess the patient’s dorsalis pedis pulse?
(1) Locate dorsalis pedis using three (3) fingers on both Rt and Lt feet.
(2) Palpate dorsalis pedis pulses at the same time
(3) Compare strength of pulses from Rt and Lt foot
What are the normal findings when assessing the patient’s dorsalis pedis pulse?
(1) Bilateral pulses present; Strong and equal
What are the abnormal findings when assessing the patient’s dorsalis pedis pulse?
(1) Weak in one foot or Absent (ck popliteal)
How should the nurse assess the patient for visible signs of ankle edema?
Procedure:
(1) Press dorsal foot and ankle for 5 seconds; severe edema may require longer firm pressure
(2) Estimate depth of edema using the guide.
This usually performed with assessment of edema on the shin bone bilaterally.
Ankle Edema Assessment
This is a test of cerebellar
coordination; involvement or presence of hemispheric cerebellar lesion.
Heel to shin rub
How should the nurse assist the patient to perform the Heel to shin rub?
Procedure:
(1) Sitting or lying position
(2) Instruct patient to run heel down to opposite shin one at a time
(3) Repeat procedure on the opposite extremities
What are the normal findings as per the heel to shin rub?
Movement of legs smooth and straight
What are the abnormal findings as per the heel to shin rub?
Heel falls off the lower leg or inability to complete the movement.