FINALS MUSCULOSKELETAL ASSESSMENT Inspection Observe for size, contour, bilateral symmetry, and involuntary movement. Look for gross deformities, edema, presence of trauma such as ecchymosis or other discoloration. Always compare both extremities. Palpation Feel for evenness of temperature. Normally it should be even for all the extremities. Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s fingers and noting for equality of contraction). Perform range of motion. Test for muscle strength. (performed against gravity and against resistance) Table showing the Lovett scale for grading for muscle strength and functional level Functional level Lovett Scale Grade Percentage of normal No evidence of contractility Zero (Z) 0 0 Evidence of slight contractility Trace (T) 1 10 Complete ROM without gravity Poor (P) 2 25 Complete ROM with gravity Fair (F) 3 50 Complete range of motion against gravity with some resistance Good (G) 4 75 Complete range of motion against gravity with full resistance Normal (N) 5 100 Normal Findings Both extremities are equal in size. Have the same contour with prominences of joints. No involuntary movements. No edema Color is even. Temperature is warm and even. Has equal contraction and even. Can perform complete range of motion. No crepitus must be noted on joints. Can counteract gravity and resistance on ROM. BODY PART TECHNIQUE NORMAL FINDINGS UPPER EXTREMITIES Arms Inspection Support hands at chest level. Note the color of skin, length, hair distribution, presence of visible veins. » Skin color varies (pinkish, tan, dark brown), symmetrical, fine hair evenly distributed, presence/absence of visible veins. Palpation Palpate arms for temperature, moisture, lumps, masses, and areas of tenderness. Note for muscle size and tone. Palms and Dorsal Surfaces » Warm, dry and elastic, no areas of tenderness. Muscle appears equal with good muscle tone. Inspection Note the color, temperature, thickness, moisture, and turgor. » Palms pinkish (dorsal surface), warm; males – thick; females – softer; elastic. Nails Inspection Inspect for color, thickness, shape and curvature. » Nails are transparent, smooth and convex with pink nailbeds and white translucent tips. Count the number of fingers. » Five fingers in each hand. Palpation Gently grasps the client’s fingers and observe the color of the nailbeds, then gently apply pressure with the thumb to the nailbed quickly and release. » As pressure is applied to the nailbed, appears white or blanched, and pink color returns immediately as pressure is released. Manipulation – the process of moving or attempting to move the part being examined. Limitation of movements can be discovered. Shoulders Range of motion 1. 2. 3. Raise both arms to vertical position. Place head behind the neck. Place hands behind the small of the back. » Performs with relative ease. Arms Range of motion 1. 2. 3. Abduct – away from the body Adduct – towards the body Rotate – internal and external (one arm at a time) » Performs with relative ease » No relative difficulties Elbows Range of motion 1. Bend and straighten elbow » Performs with relative ease. Hands and wrists Range of motion 1. 2. Extend and spread the fingers Make a fist, thumb across the knuckles. » Performs with relative ease LOWER EXTREMITIES Inspection Legs Note the color of skin, hair distribution, and presence of varicose veins, length, and symmetry of muscle. Palpation Let the client tiptoe. Palpate the muscles for warmth and strength. » Skin color varies (pinkish, tan, dark brown) skin is smooth, fine hair evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical. » Muscles appear equal, warm and with good muscle tone. Toes Inspection Inspect for the number of toes, texture of sole and dorsal surface, toe nails. Palpation Gently grasps the client’s toenails nailbeds. Gently apply pressure with the thumb to the nailbed quickly and release. » Five toes in each foot; sole and dorsal surface is smooth; with pink nail beds and white translucent tips. » As pressure is applied, the nailbed appears white or blanched; pink color returns when pressure is released. Legs (one leg at a time) Range of motion 1. 2. 3. 4. 5. Abduct Adduct Rotate Hop (both feet) Walk to and from » Performs with relative ease Knees Range of motion Let the client sit down on a chair and bend foot at the knee 1. » Performs with relative ease Bend and extend Ankles Range of motion 1. 2. Toes Flexion and extension Rotation (internal and external) Range of motion 1. Spread and wiggles » Performs with relative ease » Performs with relative ease Nursing Concepts 1. Reflexes usually tested during neurologic assessment, but could be included here as well 2. Could use a goniometer to assess degree of flexion or extension of joints The musculoskeletal system assessment usually is conducted at the last part of a comprehensive physical examination. It is important that nurses are able to accurately and comprehensively assess this system. It is important because it shows the physical ability of the patient to physical tasks and follow physical commands. These may indicate normal functioning not only of the musculoskeletal aspect but also the neurologic aspect of the patient. PERIPHERAL VASCULAR ASSESSMENT Assessing the peripheral vascular system includes measuring the blood pressure, palpating peripheral pulses, and inspecting the skin and tissues to determine perfusion (blood supply to an area) to the extremities. Certain aspects of peripheral vascular assessment are often incorporated into other parts of the assessment procedure. For example, blood pressure is usually measured at the beginning of the physical examination. Peripheral Pulses Palpate the peripheral pulses on both sides of the client's body individually, simultaneously (except the carotid pulse), and systematically to determine the symmetry of the pulse volume. If you have difficulty palpating some of the peripheral pulses, use a Doppler ultrasound probe. There should be symmetric pulse volumes and full pulsations. Peripheral Veins Inspect the peripheral veins in the arms and legs for the presence and/or appearance of superficial veins when limbs are dependent and when limbs are elevated. In dependent position, there is the presence of distention or nodular bulges at calves. When limbs are elevated, veins collapse (veins may appear tortuous or distended in older people). Assess the peripheral leg veins for signs of phlebitis. Inspect the calves for redness and swelling over vein sites. Palpate the calves for firmness of tension of the muscles, presence of edema over the dorsum of the foot, and areas of localized warmth. Push the calves from side to side to test for tenderness. Firmly dorsiflex the client's foot while supporting the entire leg in extension (Homan's test), or have the person stand or walk. Limbs should not be tender. The limbs should be symmetric in size. Peripheral Perfusion Inspect the skin of the hands and feet for color, temperature, edema, and skin changes. Assess the adequacy of arterial flow if arterial insufficiency is suspected. It is normal if the skin color is pink, the temperature is not excessively warm of cold, no edema, and skin texture is resilient and moist. Buerger's test (Arterial Adecuacy test) Assist the client to a supine position. Ask the client to raise one leg or one arm about 30 cm or 1 ft above heart level, move the foot or hand briskly up and down for about 1 minute, then sit up and dangle the leg or arm. Observe the time elapsed until return of original color and vein filling. It is normal if the original color returns in 10 seconds; and about 15 seconds for the vein to fill in the hands or feet. Capillary Refill Test Squeeze the client's fingernail and toenail between your fingers sufficiently to cause blanching (about 5 seconds). Release the pressure, and observe how quickly normal color returns. Color normally returns immediately (less than 2 seconds). Deviations From Normal Asymmetric volumes (may indicate impaired circulation). Absence of pulsations may indicate arterial spasm or occlusion. Decreased, weak, thready pulsations may indicate impaired cardiac output. Increased pulse volume may indicate hypertension, high cardiac output, or circulatory overload. Distended veins in the thigh and/or lower leg or on posterolateral part of calf from knee to ankle. Tenderness on palpation. Pain in calf muscles with forceful dorsiflexion of the foot (positive Homan's test). Swelling of one calf or leg. Cyanotic (venous insufficiency) Pallor that increases with limb elevation Dependent rubor, a dusky red color when limb is lowered (arterial insufficiency). Brown pigmentation around ankles(arterial or chronic venous insufficiency) Skin cool (arterial insufficiency) Marked edema (venous insufficiency) Mild edema (arterial insufficiency) Skin thin and shiny or thick, waxy, shiny, and fragile, with reduced hair and ulceration (venous or arterial insufficiency). Delayed color return or mottled appearance, delayed venous filling and marked redness of arms and legs after Buerger's test. It indicates arterial insufficiency. Nursing Concepts 1. Common to see peripheral vascular issues in patients with hyperlipidemia, diabetes, and peripheral vascular disease NEUROLOGICAL ASSESSMENT SIX MAJOR CATEGORIES A. Mental and Emotional Status Mental and emotional status can be learned through interaction with client. The nurse poses the questions throughout the examination to gather data and observe the client at times to detect the appropriateness of emotions and ideas of thoughts expressed. 1. Level of Consciousness a. Conscious – responds to questions quickly – perceives events occurring around him – awareness of time, place, and people b. Stupor - unable to recall who, where he is or the time of the day c. Comatose - unresponsive to verbal and painful stimuli 2. Behavior and Appearance - The client’s behavior, hygiene and grooming, and choice of dress reveal pertinent information regarding mental status. - Appearance reflects how a client feels about the self. 3. Language The ability of an individual to understand spoken or written words and to express the self through writing, words or gestures is a function of the cerebral cortex. An injury to the cortex my result in a disorder known as aphasia. There are three types of aphasia: 1.Sensory (or receptive), 2.Motor (or expressive), and 3.Global (mixed sensory and motor). 4. Intellectual Function a. Memory – Let the client recall past events such as birthday or an anniversary; previous health history or instructions given earlier *** Recent memory – The nurse asks the client to recall events during the same day (but it should be validated for accuracy) *** Remote memory – Ask client to recall previous medical history; ask client his birthday or anniversary *** Immediate memory – The nurse asks the client to repeat a series of numbers or repeat a series of numbers backward. b. Knowledge – Ask him what he knows about his health condition or the reason for seeking health care. c. Abstract Thinking – Ask the client to explain a phrase and note whether the explanations are relevant and concrete. d. Association – Finding similarities or association of concepts e. Judgment – The nurse asks the client to compare and evaluate facts and ideas to understand their relationship to form appropriate conclusions. B. Sensory Function The sensory pathways of the central nervous system conduct sensations of pain, temperature, vibrations, and crude and finely localized touch. Normally, a client has sensory responses to all stimuli tested. All sensory testing is performed with client’s eyes closed so he is unable to see when and where stimulus strikes the skin. C. Cerebellar Function 1. Coordination – performing rapid, rhythmical, alternating movements. Note for symmetry and speed of movement. a. Pats hands against thigh as fats as he can b. Touching each fingers with the thumb of the same hand in rapid succession c. Point to point test 2. Balance a. Stand with feet together, eyes closed (Romberg Test) b. Have the client close eyes and stand on one foot and then the other c. Ask the client to walk in a straight line by placing the heel of one foot directly in front of the toes of the other foot d. Heel and toe walking e. Hop on one foot, then on the other D. Motor Function The examiner applies a gradual increase in pressure to a muscle group. The client resists the pressure applied by the examiner by attempting to move against resistance. The client resists until instructed to stop. The examiner varies the amount of pressure applied, the joint moves. 1. Biceps – Pull down one forearm as client attempts to flex arms 2. Triceps – As client’s arm is flexed, apply pressure against the forearm. Ask client to straighten arm 3. Ask client to squeeze your fingers with both hands E. Reflexes Type Biceps Procedure Triceps Patellar Plantar Flex arm at the elbow with the palms down. Place the thumb in the antecubital fossa at the base of biceps tendon. Strike the thumb with the reflex hammer. Flex the client below, holding the upper arm horizontally and allow the lower arm to go limp. Strike the lower triceps tendon just above the elbow. Have the client sit with her legs hanging freely over the side of the bed or chair or have the client be in supine and support his knee in flexed position. Briskly tap patellar tendon just below the patella. Have the client lie in supine with legs straight and feet relaxed. Take the handle of the hammer and strike the lateral aspect of the sole from the heel to the ball of the foot curving across the ball of the foot towards the big toe. Normal Reflex Flexion of the arm and elbow Extension of elbow Extension of lower leg Flexion of the toe F. Cranial Nerves Cranial Nerve Name Type Function Assessment Method I Olfactory Sensory Smell » Ask client to close eyes and identify different mild aromas, such as coffee, tobacco, vanilla, oil of cloves, peanut butter, orange, lemon, lime, chocolate II Optic Sensory Vision and visual fields » Ask client to read Snellen chart, check visual fields by confrontation and conduct an opthalmoscopic exam Motor Extraocular eye movement (EOM); movement of sphincter of pupil; movement of ciliary mescles of lens » Assess six ocular movement and pupil reaction Motor EOM, specifically moves eyeball downward and laterally » Assess six ocular movement III IV Oculomotor Trochlear Trigeminal a. Opthalmic Branch Sensory Sensation of cornea, skin of face, and nasal mucosa » While client looks upward, lightly touch lateral sclera of eye to elicit blink reflex; to test light sensation, have client close eyes, wipe a wisp of cotton over the client’s forehead and paranasal sinuses; to test deep sensation, use alternating blunt and sharp ends of a safety pin over same areas. V » Assess skin sensation as for ophthalmic branch above b. Maxillary Branch Sensory Sensation of skin of face and anterior oral cavity (tongue and teeth) » Ask client to clench teeth Muscles of mastication, sensation of skin of face c. Mandibular Branch Motor and Sensory VI VII Abducens Facial EOM; moves eyeball laterally » Assess direction of gaze Motor and Sensory Facial expressions; taste (anterior 2/3 of the tongue) » Ask client to smile, raise the eyebrows, frown, puff out cheek, close eyes tightly; ask client to identify various tastes placed on tip and sides of tongue: sugar (sweet), salt (salty), lemon juice (sour), and quinine (bitter); identify areas of taste. Sensory Equilibrium » Assessment of same with cerebellar functions Sensory Hearing » Assess clients ability to hear spoken word and vibrations of tuning fork Motor Auditory a. Vestibular VIII Branch b. Cochlear Branch Glosso- IX phrayngeal Motor and Sensory Swallowing ability and gag reflex, tongue movement, taste (posterior tongue) » Use tongue blade on posterior tongue while client says “ah” to elicit gag reflex; apply tastes on posterior tongue for identification; ask client to move tongue from side and up and down. Sensation of pharynx and larynx; swallowing; vocal cord movement » Assessed with cranial nerve IX; Assess client’s speech for hoarseness X Vagus Motor and Sensory XI Accessory Motor Head movement; shrugging of shoulders » Ask client to shrug shoulders against resistance from your hands and turn head to side against resistance from your hand (repeat on the other side) XII Hypoglossal Motor Protrusion of tongue » Ask client to protrude tongue at midline, then move it side to side. Nursing Concepts 1. There are MANY things that could cause barriers to this assessment a. Use alternative assessments when needed b. Document objectively i. “Unable to assess” is appropriate A neurological assessment/exam is an evaluation of a person’s nervous system, which includes the brain, spinal cord, and the nerves that connect these areas to other parts of the body. To ensure reliability of neurological assessment and use of the GCS, it is important that all health professionals conducting these assessments are: Fully educated and competent in the use of the GCS and neurological observation tools being used within their health service. Neurological observations collect data on the patient’s neurological status and can be used for many reasons, including in order to help with diagnosis, as a baseline observation, following a neurosurgical procedure, and following trauma. Therefore, it is important that all healthcare professionals are efficient and accurate in assessing neurological functioning.
