Musculoskeletal System


CHAPTER 9






Musculoskeletal System


 

 





LEARNING OUTCOMES






 


Upon completion of this chapter, the nurse will:



1.  Outline the areas to include when assessing the musculoskeletal system


2.  Identify appropriate questions to assess the musculoskeletal system


3.  Analyze approaches to gather more information about the musculoskeletal system


THE MUSCULOSKELETAL SYSTEM


The musculoskeletal system includes the bones, joints, cartilage, ligaments, tendons, and muscles found within the body. Bones are identified according to shape, such as:



  Long


  Short


  Flat


  Irregular


The joints are where the bones meet and are categorized as being:



  Cartilaginous


  Fibrous


  Synovial


Cartilage is found between some bones and joints. Ligaments hold bones together.


The muscles within the human body are categorized as being either voluntary or involuntary. Tendons attach muscle to the bones.


ASSESSMENT OVERVIEW


As you might have realized by now, assessment of some of the body systems telephonically has particular challenges. The musculoskeletal system does also. You will not be able to:



  Inspect:


      Bone structure


      Posture


      Spinal structure


      Gait


      Range of motion


  Palpate:


      Muscle tone


      Muscle strength


      Joint edema


      Soft tissue swelling


You will need to use thoughtfully crafted questions to gain as much information as possible when conducting an assessment of the musculoskeletal system over the telephone. As with all of the body systems, the best approach is to ask the patient/client generally, “are you having or have you had any problems with your bones, joints, or muscles?” Depending on the response, you can plan and complete your assessment accordingly.


QUESTIONS TO ASSESS THE MUSCULOSKELETAL SYSTEM


To reduce redundancy, it is recommended that questions about the bones, muscles, and joints be grouped according to body location instead of asking all of the questions about the bones, then repeating the body areas for the muscles and joints.


 





































Body Area


Question


Head


Are you having any problems moving your jaw?


  If so, when did this start?


  What is the problem?


  Does it affect your ability to chew or eat food?


  Is your jaw making a clicking noise? (checking for crepitus)


  Have you talked with your doctor or health care provider about your jaw?


Neck


Are you having any problems moving your neck?


  If so, when did this start?


  What is the problem?


  Have you talked with your doctor or health care provider about your neck?


  Did you ever have surgery on your neck?


      If so, when was it done?


      What was the reason for the surgery?


  Are you able to bend your head down toward your chest? (flexion)


  Are you able to bend your head back and look toward the ceiling? (extension)


  Can you move your head to the right? (rotation)


  Can you move your head to the left? (rotation)


  Can you move your head to try to touch your right shoulder with your right ear? (lateral bending)


  Can you move your head to try to touch your left shoulder with your left ear? (lateral bending)


Shoulders


Are you able to freely move your arms from the shoulder?


  If not, what is the problem?


  When did this start?


  Have you talked with your doctor/health care provider about your shoulders?


  Did you ever have surgery on your shoulders?


      If so, when was it done?


      What was the reason for the surgery?


  Are you able to lift or carry things on the side that is affected?


  Are you able to shrug your shoulders (lift your shoulders toward your ears)?


  Can you lift your arms toward the ceiling? (extension)


  Can you touch your hands together behind your back? (internal rotation)


  Can you place both of your hands behind your neck? (external rotation)


  When standing up can you touch your left thigh with your right hand? (adduction)


  When standing up can you touch your right thigh with your left hand? (adduction)


  Are your shoulders making a clicking or any other type of noise when you move them? (checking for crepitus)


  Have you talked with your doctor or health care provider about your shoulders?


Elbows


Are you able to stretch out your arms? (extension)


  If not, what is the problem?


  When did this start?


  Have you talked with your doctor or health care provider about your elbows?


  Did you ever have surgery on your elbows?


      If so, when was it done?


      What was the reason for the surgery?


  Can you bend your arm at your elbow and touch your hand to your shoulder? (flexion)


Are you having any arm weakness?


  If so, when did this start?


  How much are you able to hold and carry with your arms?


  Is one arm weaker than the other?


Wrists and hands


Are you having any problems with your wrists or hands?


  If so, when did this start?


  What is the problem?


  Have you talked with your doctor or health care provider about your wrists and hands?


  Did you ever have surgery on your wrists or hands?


      If so, when was it done?


      What was the reason for the surgery?


  Are you having:


      Weakness


      Numbness


      Tingling


  Can you spread out your fingers?


  Can you make a fist?


  Have your hands or wrists changed in shape?


  Can you bend your hand toward the floor from the wrist?


  Are you able to pick up items with your hands?


  Can you “feel” your fingers?


  Do you drop things because of a hand problem?


Hips


Do you have any problems with your hips?


  If so, what is the problem?


  When did it start?


  Does it affect one hip or both?


  Have you talked with your doctor or health care provider about your hips?


  Did you ever have surgery on your hips?


      If so, when was it done?


      What was the reason for the surgery?


  Does the skin over your hips feel warm?


  Do your hips make a grating or clicking sound when you walk? (crepitus)


  Do you have pain in your hips when you:


      Walk


      Sit


      Cross the legs (adduction)


  Can you stretch out your leg at the hip? (extension)


  Can you raise your knees toward your chest? (flexion)


  Can you move your right leg out to the side? (abduction)


  Can you move your left leg out to the side? (abduction)


Knees


Do you have any problems with your knees?


  If so, what is the problem?


  Have you talked with your doctor or health care provider about your knees?


  Did you ever have surgery on your knees?


      If so, when was it done?


      What was the reason for the surgery?


  When did it start?


  Does it affect one knee or both?


  Does the skin over the knees feel warm?


  Does the tissue around the knee feel swollen?


  Can you bend your right knee? (flexion)


  Can you bend your left knee? (flexion)


Ankles and feet


Do you have any problems with your ankles?


  If so, what is the problem?


  Are your ankles swollen?


  Is the skin around your ankles red?


  Do your ankles hurt when you walk?


  Have you talked with your doctor or health care provider about your ankles?


  Did you ever have surgery on your ankles?


      If so, when was it done?


      What was the reason for the surgery?


  Are you able to move your feet toward the floor (push down on the gas pedal)? (extension)


  Are you able to point your toes toward the ceiling? (flexion)


Do you have any problems with your feet or toes?


  If so, what is the problem?


  Have you talked with your doctor or health care provider about your feet or toes?


  Did you ever have surgery on your feet or toes?


      If so, when was it done?


      What was the reason for the surgery?


  Are any of your toes swollen?


  Are any of your toes not straight?


  Do any of your toes overlap?


  Do you have any sores on your feet or toes?


  Are you able to curl your toes toward the floor? (flexion)


  Are you able to spread your toes out? (extension)


Spine


Do you have any problems with your back?


  If so, what is the problem?


  When did it start?


  Have you talked with your doctor or health care provider about your back?


  Did you ever have surgery on your back?


      If so, when was it done?


      What was the reason for the surgery?


  Are you able to walk?


  Do you use anything to keep yourself stable when you walk like a:


      Cane


      Walker


      Crutches


  Has anyone ever told you that you have one leg longer/shorter than the other?


  Are you able to bend over and touch the floor with your hands? (flexion)


  Do you have any pain or stiffness when you straighten your spine after bending over? (extension)


Do you have any problems keeping your balance?


  If so, what does it feel like?


  Have you fallen?


Have you had a change in your body height?


  If so, how tall were you?


  What is your height now?


  Did your doctor or health care provider tell you why your height has changed?


Have you ever been told that you have a spinal deformity such as:


  Lordosis


  Kyphosis


  Scoliosis


SPECIAL SITUATIONS


At times, a client may be enrolled in a disease management program for arthritis or other musculoskeletal system disorder and be home recovering from surgery. Suggestions to help with the assessment of these clients are as follows:


 




































































































Situation


Question


Hip replacement or other hip surgery


When did you have the surgery?


 


What did you have done?


 


Are you able to walk or bear any weight on the leg that was operated on?



What are you using to make sure that you walk safely?


 


What does the wound/incision look like?


 


Are you experiencing any problems such as:


  Increased pain


  Drainage from the surgical wound


  Increased swelling around the surgical wound


  Fever


 


When are you going to see your surgeon again?


 


Are you getting physical therapy at home?


  If so, how many times a week?



Have you been told to avoid doing anything in particular?


 


For what reasons did your doctor/health care provider tell you to contact the office?


Knee replacement or other knee surgery


When did you have the surgery?


 


What did you have done?


 


Are you able to walk or bear any weight on the leg that was operated on?


 


What are you using to make sure that you walk safely?


 


What does the wound/incision look like?


 


Are you experiencing any problems such as:


  Increased pain


  Drainage from the surgical wound


  Increased swelling around the surgical wound


  Fever


 


When are you going to see your surgeon again?


 


Are you getting physical therapy at home?


  If so, how many times a week?


  Are you doing your knee-bending exercises as instructed?


 


Have you been told to avoid doing anything in particular?


 


For what reasons did your doctor or health care provider tell you to contact the office?


Spinal/back surgery


When did you have the surgery?


 


What did you have done?


 


Are you able to walk without any pain or discomfort?


 


Are you supposed to:


  Wear a back brace


  Walk with a cane/walker


 


Are you permitted to take a shower?


 


Are you experiencing any problems such as:


  Increased pain


  Drainage from the surgical wound


  Increased swelling around the surgical wound


  Fever


 


When are you going to see your surgeon again?


 


Are you being visited by a home care nurse?


 


Have you been told to avoid doing anything in particular?


 


For what reasons did your doctor or health care provider tell you to contact the office?


ALGORITHM FOR ASSESSING THE MUSCULOSKELETAL SYSTEM


At times, you might be placing a call to a patient who is experiencing a new onset of symptoms. Suggestions for these situations are as follows:


 

































































































Finding


Action


Pain


Assess for the location of the pain.


 


Assess the level of pain using the standard 0–10 pain rating scale.


 


Assess for what might have caused the pain:


  Recent fall


 


Assess what has been done to treat the pain


 


Assess for any other associated symptoms such as:


  Inability to walk without severe pain (fracture or dislocation)


  Sudden shortening of one leg (dislocated or fractured hip)


 


Suspect fracture or dislocation and encourage to seek immediate medical attention.


Swollen joint


Assess the location of the joint



Assess for the length of time the joint has been swollen


 


Assess what has been done to try to relieve the swelling:


  Elevate on a pillow


  Wrap with an elastic bandage


  Apply ice


 


Assess the color of the skin over the joint:


  Red


  Bruised


 


Assess for any other symptoms:


  Fever


  Nausea


  Vomiting


 


Assess if there has been any change in ability to perform activities of daily living because of the swollen joint


 


Suspect acute joint inflammation and encourage to seek medical attention


Crepitus


Assess for the joint causing the crepitus


 


Assess for the length of time the crepitus has been occurring


 


Assess if the crepitus is associated with any pain


 


Suspect no acute disease process


 


Encourage to discuss the “noises” during the patient’s next visit to the doctor or health care provider


Numbness/tingling


Assess for the location of the numbness/tingling



Assess for the length of time the numbness/tingling has been occurring


 


Assess what has been done to try to alleviate the numbness/tingling:


  Elevating legs


  Removing compression stockings or gloves


  Rubbing the hands/feet


 


Assess for any other associated symptoms such as:


  New onset of limb weakness (stroke)


  Confusion (stroke)


  Blurred vision (stroke)


  Pain (acute venous or arterial occlusion)


  Skin over the area feels cold to the touch (acute venous or arterial occlusion)


 


Suspect an acute situation and encourage the patient to seek immediate medical attention


Muscle cramping/muscle spasms


Assess for the location of the muscle cramping/spasm



Assess for the length of time the muscle has been cramping/spasming


 


Assess for any activities that cause the cramping/spasming to occur or change in intensity


 


Assess for any other symptoms associated with the cramping/spasming such as:


  Nausea (electrolyte imbalance)


  Vomiting (electrolyte imbalance)


  Diarrhea (electrolyte imbalance)


 


Assess what has been done to relieve the cramping/spasms such as:


  Massage


  Elevation


  Exercise/stretching


 


Encourage to discuss cramping/spasms with doctor/health care provider soon


 


See Chapter 16 for additional information about musculoskeletal system disorders.


TIPS FOR ASSESSING THE MUSCULOSKELETAL SYSTEM


  Unless the client mentions body “aches and pains,” it is unlikely that you will need to complete a full musculoskeletal status assessment.


  Some older clients assume that body “aches and pains” are a normal part of aging and may not want to talk about it.


  Other clients may prefer to spend all of the time on the telephone talking about their “aches and pains.” Should this occur, work through the assessment, focusing on the areas in which the patient/client is experiencing difficulty.


  Be sure to find out what actions or activities make the body “aches and pains” better or worse. The pain and stiffness of arthritis can be more severe in the morning and improves with activity.


  If a client experiences numbness and tingling of the hands, be sure to find out what activities are routinely performed. This could indicate carpal tunnel syndrome.


  If any client reports a recent fall, be sure to follow up with questioning about the outcome of a health care provider appointment. Everyone who falls does not seek immediate medical attention, but depending on other health problems, the fall could have caused a break or other tissue injury. If the injury is not treated now, it could cause the patient/client problems in the future.


 

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Oct 5, 2017 | Posted by in NURSING | Comments Off on Musculoskeletal System
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