Musculoskeletal

Question 1

Order of assessment

Answer 1

inspection and palpation

Question 2

upper extremeties

Answer 2

finger tips to shoulders

Question 3

lower extremeties

Answer 3

groin to feet

Question 4

size and symmetry

Answer 4

expect to find bilateral symmetry in length, circumference, alignment, position and number of skin folds

Question 5

Color/Texture of skin and nailbeds

Answer 5

Capillary refill and clubbing

Question 6

Capillary refill

Answer 6

normal= 2 seconds or less
sluggish= 3-4 seconds
abnormal= >4 seconds

inspect upper and lower extremities

Question 7

clubbing

Answer 7

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

Question 8

arterial insufficiency

Answer 8

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

Question 9

pigmentation rashes, scars, ulcers

Answer 9

inspect on the upper and lower extremities.

ulcers may or may not be present on the lower extremities with arterial insufficiency

Question 10

Venous pattern

Answer 10

have client stand for lower extremities

should be flat and barely visible
a prominence venous pattern and edema may suggest venous obstruction

Question 11

inspect for impaired circulation

Answer 11

may be judged by skin color, skin temp, peripheral pulse, blanching nail beds, peripheral edema

Question 12

inspect for edema

Answer 12

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

Question 13

hair distribution

Answer 13

lower extremities; loss of hair over the feet and toes is also associated with arterial insufficiency

do they shave their legs?

Question 14

Palpation

Answer 14

lymph nodes, tenderness, edema, calf for deep phlebitis

Question 15

lymph nodes

Answer 15

epitrochlear, superficial inguinal

Question 16

epitrochlear

Answer 16

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

Question 17

Superficicial inguinal

Answer 17

may palpate a nontender node up to 2 cm in this area

Question 18

Femoral vein

Answer 18

demo, on self

tenderness in region

Question 19

Homan’s sign

Answer 19

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

Question 20

Range of motion

Answer 20

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