NUR643E Develop Problem-Focused Exam Involving Musculoskeletal System And Extremities
NUR643E Develop Problem-Focused Exam Involving Musculoskeletal System And Extremities
NUR643E Develop Problem-Focused Exam Involving Musculoskeletal System And Extremities
DQ1 As an instructor, you are working with a nursing student to develop a problem-focused exam involving the musculoskeletal system and extremities. Formulate potential questions to support the student in soliciting specific information about the patient related to past history, drugs that may adversely affect the musculoskeletal system, family history, psychosocial profile, and provide rationale.
DQ2 The goal of a complete musculoskeletal assessment is to detect risk factors, potential problems, or musculoskeletal dysfunction early and then to plan appropriate interventions, including teaching health promotion and disease prevention, and implementing treatment measures. By doing so, you can play a signi?cant role in preventing pain and dysfunction in your patients. Describe a plan to provide patient teaching that incorporates health promotion and disease prevention. Provide rationale.
Technique
In examining the musculoskeletal system it is important to keep the concept of function in mind. Note any gross abnormalities of mechanical function beginning with the initial introduction to the patient. Continue to observe for such problems throughout the interview and the examination.
On a screening examination of a patient who has no musculoskeletal complaints and in whom no gross abnormalities have been noted in the interview and general physical examination, it is adequate to inspect the extremities and trunk for observable abnormalities and to ask the patient to perform a complete active range of motion with each joint or set of joints.
If the patient presents complaints in the musculoskeletal system or if any abnormality has been observed, it is important to do a thorough musculoskeletal examination, not only to delineate the extent of gross abnormalities but also to look closely for subtle anomalies.
To perform an examination of the muscles, bones, and joints, use the classic techniques of inspection, palpation, and manipulation. Start by dividing the musculoskeletal system into functional parts. With practice the examiner will establish an order of approach, but for the beginner it is perhaps better to begin distally with the upper extremity, working proximally through the shoulder. Then, beginning with the temporomandibular joint, pass on to the cervical spine, the thoracic spine, the lumbar and sacral spine, and the sacroiliac joints. Finally, in the lower extremity, again begin distally with the foot and proceed proximally through the hip.
Use the opposite side for comparisons: it is easier to spot subtle differences as well as identify symmetrical problems. If there is any question, use your own anatomy as a control.
Glean the maximum information from observation. Concentrating on one area at a time, inspect the area for discoloration (e.g., ecchymoses, redness), soft tissue swelling, bony enlargement, wasting, and deformity (abnormal angulation, subluxation). While noting these changes, attempt to determine whether they are limited to the joint or whether they involve the surrounding structures (e.g., tendons, muscles, bursae).
Observe the patient’s eyes while palpating the joints and the surrounding structures. A patient’s expression of pain depends on many factors. For this reason the verbalization of pain often does not correlate directly with the magnitude of the pain. The most objective indicator of the magnitude of tenderness produced by presence on palpation is involuntary muscle movements about the eyes. Therefore, the examiner should observe the patient’s eyes while palpating the joints and surrounding structures. With practice the examiner will become skilled in evaluating the magnitude of pain produced by the examination and will be able to do a skillful evaluation without producing excessive discomfort to the patient. Note areas of tenderness to pressure, and if possible identify the anatomic structures over which the tenderness is localized.
One should also note areas of enlargement while palpating the joints and surrounding structures. By noting carefully the consistency of the enlargement and its boundaries, one can decide whether this is due to bony widening, thickening of the synovial lining of the joint, soft tissue swelling of the structure surrounding the joint, an effusion into the joint capsule, or nodule formation, which might be located in a tendon sheath, subcutaneous tissue, or other structures about the joint.
While palpating the joints, note areas of increased warmth (heat). A method for doing this that will help even the most inexperienced to perceive subtle increases in heat is to choose the most heat-sensitive portion of the hand (usually the dorsum of the fingers) and, beginning proximally, lightly pass this part of your hand over all portions of the patient’s extremity several times. As you proceed from proximal to distal, the skin temperature gradually cools. If you find an area becoming slightly warmer, this represents increased heat.
Have the patient perform active movements through an entire range of motion for each joint. Defects in function can be most rapidly perceived by having the patient perform active functions with each region of the musculoskeletal system. This reduces examination time and helps the examiner to identify areas in which there is poor function for more careful evaluation.
Manipulate the joint through a passive range of motion only if the patient is unable actively to perform a full range of motion, or if there is obvious pain on active motion. In passively manipulating a joint, note whether there is a reduction in the range of motion, whether there is a pain on motion, and whether crepitus is produced when the joint is moved. Note also whether the joint is stable or whether abnormal movements may be produced.
Upper Extremity
Observe and palpate both hands and wrists, noting areas of color change, enlargement, and temperature change (described elsewhere). Also note deformities if present (contractures, subluxations, abnormal angulations). Look carefully for nail and cuticle abnormalities, atropy of the thenar or hypothenar eminences, and triggering. Triggering in a finger is caused by an inflammatory nodule within a tendon sheath. It is characterized by an inability to extend a finger until a larger than usual force is applied along the flexor tendon sheath and the finger snaps into extension. Ask the patient to make a tight fist with both hands. Ask the patient to grasp a small object such as a finger. If the patient is capable of making a tight fist and grasping a small object with no observable abnormality, then a passive manipulation of the metacarpophalangeal joints and proximal and distal interphalangeal joints need not be made; however, should an abnormality be detected, passive examination of the range of motion of each of the joints should be performed.
Normal range of motion for the fingers:
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Distal interphalangeal joints (digits 2–5): 0 to 80 degrees of flexion
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Proximal interphalangeal joints (digits 2–5): 9 to 120 degrees of flexion
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Interphalangeal joint of the thumb: 35 degrees hyperextension, 90 degrees flexion
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Metacarpophalangeal joints (digits 3–5): 30 degrees hyperextension, 90 degrees flexion
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Metacarpophalangeal joint of the thumb: 0 to 70 degrees of flexion
To examine range of motion of the wrist, ask the patient to assume an attitude with the elbows flexed and the forearms parallel to the floor, and then press the palms of the hands and the dorsum of the hands as closely together as possible, producing angulation of the wrist. The wrist can normally be dorsiflexed to 70 degrees and palmar flexions should be possible to approximately 80 or 90 degrees. Ask the patient to deviate the hand ulnarward; this should be possible to 50 to 60 degrees. Finally, ask the patient to deviate both hands radialward; this should be possible to approximately 20 degrees.
Observe and palpate both elbows and over the olecranon process, again noting areas of color change and enlargement. Be careful to observe for synovial thickening or effusion both in the joint itself and in the area of the olecranon bursa. Observe for subcutaneous nodules over the olecranon process. Ask the patient to extend both elbows fully and to flex them fully. The position of full extension is designated as 0 degrees, and flexion should be performed well to 160 degrees in the normal state.
The range of motion in the radiohumeral joints is then tested by asking the patient to pronate and supinate both hands fully. In the normal state the palm of the hand should be able to be placed flat on a table in pronation and the dorsum of the hand flat on the table in supination.
The examination of the shoulder is best performed with the patient sitting or standing in such a position that the examiner can move freely about the patient’s body. Range of motion of the shoulder should be examined with and without manual fixation of the shoulder.
The shoulder mechanism is a complicated system where several joints act in concert. The physician should be familiar with the anatomy of the shoulder and of the contiguous structures that act together. These include the glenohumeral joint, the acromioclavicular joint, the sternoclavicular joint, the gliding tissue space between the scapula and thorax, the shoulder capsule or rotator cuff, and the subacromial bursa.
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