Week 1 Nursing Flashcards
Developmental Considerations
- Infants and children
- Spinal curve changes
- Developmental dysplasia of the hip
- The pregnant woman
- Increased joint mobility (relaxation of joints due to oestrogen and relaxing
- Progressive lordosis
- Late adulthood
- Osteoporosis
- Postural changes
- Musculoskeletal changes
Subjective Data — General Principles
- Presenting complaint
- Gait, arms, legs and spine (GALS) screening assessment
- Joints
- Muscles
- Bones
- Functional assessment (ADLs)
- Health and lifestyle management
- Additional history for adolescents
– Sport participation
– Special equipment/training
– Warm-ups
– Bone/spine deformity - Additional history for infants and children
– Labour trauma, resuscitation
– Motor milestones
– Wellness
– Broken bones/bruising/dislocations
– Bone deformity - Additional history for the older adult
– Change/increasing in weakness
– Increase in falls/stumbling (falls assessment)
– Walking aids
Objective Data—The Physical Examination
- Systematic approach
– Head to toe
– Proximal to distal
– Compare corresponding paired joints
– Neurovascular assessment of upper and lower limbs - Order of the examination
– Look (inspect)
– Feel (palpate)
– Then move - Inspection
– Size and contour of joint
– Colour, swelling and masses/deformity - Palpation
– Temperature, muscles, bony articulations, area of joint capsule
– Tenderness, crepitus, swelling or masses
– Boggy synovial membrane (not normally palpable) - Muscle testing
– Equal bilateral strength and should resist opposing force - Movement and ROM
– without resistance
– with resistance
Temporomandibular joint
* Inspect joint area
* Palpate as person opens mouth
* Motion and expected range
– Open mouth maximally
– Protrude lower jaw and move side to side
– Stick out lower jaw
* Palpate muscles of mastication
GALS screening assessment
▪ Validated quick and
efficient MSK
assessment system
– Gait
– Arms
– Legs
– Spine
- Range of motion
-Ask for active movement
-Passive motion
-Goniometer (Physio and OT)
-Crepitation (Crunching or grating sound on movement)
Cervical spine
▪ Inspect alignment of head and neck
▪ Palpate spinous processes and muscles ▪ Motion and expected range
– Chin to chest
– Lift chin
– Each ear to shoulder
– Turn chin to each shoulder
Cervical spine – NEXUS CRITERIA
Nurses can and should use NEXUS as an assessment technique that will help decision about immobilisation.
In the setting of patient who has experienced a trauma AND there is NO:
▪ Focal neurologic deficit present (e.g. altered sensation along C5 dermatome)
▪ Midline spinal tenderness present
▪ Altered level of consciousness present
▪ Intoxication (e.g. alcohol, drugs)
▪ Distracting injury present (e.g. # femur)
Shoulders
▪ Inspect joint (posterior and anterior)
▪ Palpate shoulders and axilla
▪ Motion and expected range
- Arms forwards and up
- Arms behind back and hands up
- Arms to sides and up over head
- Touch hands behind head
Elbow
▪ Inspect joint in flexed and extended positions
▪ Palpate joint and bony prominences
▪ Motion and expected range
- Bend and straighten elbow
- Pronate and supinate hand
▪ Muscle strength
- Person flexes elbow and nurse applies resistance at wrist
Wrist and Hand
▪ Inspect joints on dorsal and palmar sides
▪ Palpate each joint
▪ Motion and expected range
- Bend hand up, down
- Bend fingers up, down
- Turn hands out, in
- Spread fingers, make fist
- Touch thumb to each finger
- Muscle strength: flex the wrist against resistance at the palm
▪ Phalen’s test- numbness and burning in carpel tunnel syndrome
▪ Tinel’s sign- a positive sign is when percussion of the median nerve produces burning and tingling
Hip
▪ Inspect as person stands
▪ Palpate with person supine
▪ Motion and expected range
- Raise leg
- Knee to chest
- Flex knee and hip; swing foot out, in
- Swing leg laterally, medially
- Stand and swing leg back
Knee
▪ Inspect joint and muscle
- can have leg extended or dangling
- shape and contour
- atrophy of quadriceps muscle
▪ Palpate
- note consistency of tissues
- note any warmth, tenderness or thickening
▪ Bulge sign
- for swelling in suprapatellar notch.
- confirms the presence of fluid as you move fluid from one side of joint to the other.
▪ Ballottement of patella
- reliable when large amounts of fluid present in knee
- check for crepitus by holding hand on the patella while flexing and extending knee
▪ Motion and expected range
- Bend knee
- Extend knee
- Check knee during ambulation
▪ Muscle strength
- Ask person to flex the knee while you try and pull leg forward
Ankle and foot
▪ Inspect with person sitting, standing and walking
▪ Palpate joints
▪ Motion and expected range
- Point toes down, up
- Turn soles out, in
- Flex and straighten toes
- Muscle strength: dorsiflexion and plantar flexion against resistance
Spine
▪ Inspection from behind and side
▪ ROM
- Flexion
- Extension
- Rotation
▪ Straight Leg Raising (or Lasegue’s Test)
▪ Positive if it produces sciatic pain
▪ Confirms the presence of a herniated nucleus pulposis
Osteoporosis
▪ Bone remodelling
▪ Osteoporosis = disease characterised by low bone mass and microarchitectural deterioration of bone tissue/fragility
▪ Bone loss occurs silently
▪ Risk factors: Family history, increasing age, low dietary calcium intake, vitamin D deficiency and/or lack of sunlight, medical history, corticosteroid therapy, early menopause, late menarche, low testosterone (men), malabsorption syndromes, certain chronic diseases, some medications, lifestyle factors
Abnormal Findings -Affecting Multiple Joints
▪ Inflammatory conditions
- Rheumatoid arthritis
- Ankylosing spondylitis
▪ Degenerative conditions
- Osteoarthritis (degenerative joint disease)
- Osteoporosis
Abnormal Findings of the Shoulder
- Atrophy
- Fracture
- Dislocated shoulder
- Subluxation
- Joint effusion
- Tear of the rotator cuff
- Frozen shoulder— adhesive capsulitis
- Sub-acromial bursitis
Abnormal Findings of the Wrist and Hand
▪ Ganglion cyst
▪ Colles fracture
▪ Carpal tunnel syndrome
▪ Ankylosis
▪ Dupuytren’ s contracture
▪ Swan-neck and boutonnière deformities
▪ Ulnar deviation or drift
▪ Degenerative joint disease or osteoarthritis
▪ Acute rheumatoid arthritis
▪ Syndactyly
▪ Polydactyly
Abnormal Findings of the Elbow
- Fracture
- Olecranon bursitis
- Gouty arthritis
- Subcutaneous nodules
- Epicondylitis—tennis elbow
Abnormal Findings of the Knee
- Patella dislocation
- Septic arthritis
- Mild synovitis
- Pre-patellar bursitis
- Swelling of menisci
- Osgood-Schlatter disease
- Chondromalacia patellae
Abnormal findings of the Ankle and foot
*Sprain
*Achilles tenosynovitis
*Chronic/acute gout
*Hallux valgus with bunion and hammertoes
*Callus
*Tophi with chronic gout
*Plantar fasciitis
*Ingrown toenail
Abnormal Findings of the spine
- Scoliosis
- Herniated nucleus pulposus
- Kyphosis
- Lordosis
- Degenerative changes
- Chronic pain
Abnormal Findings for Advanced Practice
Common Congenital or Paediatric Abnormalities
* Congenital or developmental hip dysplasia
* Talipes (clubfoot)
* Spina bifida
* Coxa plana (Legg-CalvéPerthes syndrome)
Diagnostic studies
- They perform the diagnosis and prognosis of musculoskeletal disorders
- Provides information on bone density, calcification in soft tissues and fractures
- Also used in inflammatory and metabolic disorders
Immobilisation
▪ Fractures
- Sling - triangular bandages
- Collar & cuff
- Plaster-of Paris (POP)
- Traction (more in 2nd year)
▪ Soft tissue injuries
- Compression bandaging
▪ Treatment (surgical & non-surgical)
- Open reduction & internal fixation (ORIF)
- Local anaesthetic, manipulation and plaster (LAMP)
General anaesthetic, manipulation and plaster (GAMP)
Neurovascular Assessment
▪ The musculoskeletal system is prone to accidents and injuries which cause alterations in normal function.
▪ Injuries and haemorrhage can cause interruptions to normal nerve and vascular supply.
▪ Early detection of musculoskeletal deterioration is important to prevent tissue and limb loss.
▪ Distance of peripheral limbs from the heart and lack of potential secondary sources of supply place them at risk.
Neurovascular observations (NVO)
NVO includes assessing the peripheral pulses and neurological functioning of the limbs to detect pressure on the nerves and vascular supply which will determine compromised vascular or neurological function
