Musculoskeletal Flashcards
Order of assessment
inspection and palpation
upper extremeties
finger tips to shoulders
lower extremeties
groin to feet
size and symmetry
expect to find bilateral symmetry in length, circumference, alignment, position and number of skin folds
Color/Texture of skin and nailbeds
Capillary refill and clubbing
Capillary refill
normal= 2 seconds or less sluggish= 3-4 seconds abnormal= >4 seconds
inspect upper and lower extremities
clubbing
inspect for clubbing using the shamroth technique
put phalanges together, the space should be diamond shaped and small. when clubbing occurs there is no space between the nail beds.
clubbing suggest hypoxia and lung cancer
arterial insufficiency
3 p’s: pain, pallor, and pulselessness.
usually in the lower extremities
will experience pain, decreased or absent peripheral pulses, pale skin color, cool skin temp, thin and shiny skin, and thickened nails
pigmentation rashes, scars, ulcers
inspect on the upper and lower extremities.
ulcers may or may not be present on the lower extremities with arterial insufficiency
Venous pattern
have client stand for lower extremities
should be flat and barely visible
a prominence venous pattern and edema may suggest venous obstruction
inspect for impaired circulation
may be judged by skin color, skin temp, peripheral pulse, blanching nail beds, peripheral edema
inspect for edema
skin will appear swollen, shiny, tight
compare to scale 1+: slightly pit, fairly normal contour 2+: deeper pit, fairly normal contour 3+: puffy, appearance of deeper pit 4+: extremely deep pit
hair distribution
lower extremities; loss of hair over the feet and toes is also associated with arterial insufficiency
do they shave their legs?
Palpation
lymph nodes, tenderness, edema, calf for deep phlebitis
lymph nodes
epitrochlear, superficial inguinal
epitrochlear
located by having the person flex the elbow to a 90 degree angle while you palpate the depression between the tricep and bicep.
very hard to palpate
if enlarged, can mean infection with the hand or forearm
Superficicial inguinal
may palpate a nontender node up to 2 cm in this area
Femoral vein
demo, on self
tenderness in region
Homan’s sign
indicator of deep phlebitis
to test have the patient dorsiflex the foot- note any pain or soreness in the calf area, which would indicate a postive homan’s sign
Range of motion
move a joint through its intended sequences
active: voluntary
passive: assisted
look for pain in moving joint, limited movement, spastic movement, deformity, joint instability, contractures- may indicate a problem with joint, muscle group, nerve supply
