Musculoskeletal and Neurological Assessment

Objectives

Define Gait, Stance, Posture Discuss assessment of joints and muscles Outline a Neuro Exam Identify reflexes Identify function of the cranial nerves

Musculoskeletal Assessment

Musculoskeletal System

Bones, joints, and muscles Needed for Support, Movement,

Protection, and production of red blood cells, and storage for essential minerals

Fall Precaution Do No Harm!

Gait

1. The base is as wide as the shoulder width

2. Foot placement is accurate

3. Walk is smooth, even and well-balanced

4. Associated movements, such as arm swing, are present.

Gait Abnomalities

Unusual and uncontrollable walking patterns, usually caused by disease or injury.PropulsiveScissorsSpasticSteppageWaddling

Stance

Symmetrical Width Steady Assistive Devices

Posture

Normal - Comfortably erectLook for straight lines

across body parts

Normal Aging

Lordosis - Increased Curvature of the Spine

Kyphosis is a curving of the spine that causes a bowing of the back, which leads to

a hunchback or slouching posture.

Scoliosis – curvature of the spine away from middle or sideways

Examination of Joints

Inspection Size and contour: redness, atrophy, deformity,

swelling Palpation

Crepitious, thickening, swelling, or tenderness

Range of Motion

Full Mobility of each joint Deliberate, accurate, smooth, and

coordinated No involuntary movement

Muscle Atrophy

Subluxation

A partial or incomplete dislocation

Contractures

A contracture is a fixed tightening of muscle, tendons, ligaments, or skin. Shortening of longest or strongest muscle.

Prevents normal movement of the associated body part. Impaired ROM

Skin becomes scarred and nonelastic which limits the range of movement of the affected area.

Neurological Assessment

General appearance, Personal Hygiene Appropriately dressed Well-Groomed Odor Eye contact Posture

Orientation

Person Place Time Can a person be oriented and still be

confused?

Level of Consciousness: response to environmental stimuli

Awake, alert lethargic-stuporous-comatose-coma If not fully alert, may need increased stimulus Note any change in Level of Consciousness Variety of Questions One part or two part commands

Glascow Coma Scale

Quantitative tool Eye opening, verbal

response, motor response

Fully alert score is 15 Coma is 7 or less

12 Cranial NerveCranial Nerve Assessment

I olfactory Smell

II optic Vision

III oculomotor Eye movements, PERRLA, eyelids

IV trochlear

V trigeminal Facial sensations, corneal reflex

VI abducens Assessed with III and VI

VII facial Taste, smile, frown, close eyes tightly

VIII acoustic hearing

IX glossopharnxgeal Gag reflex, swallowing, taste;

X vagus

XI spinal accessory Shrug shoulders, turn head against resistance

XII hypoglossal Stick out tongue, move tongue side to side

Motor

Observation Muscle Tone Muscle Strength

Squeeze hands Pronator Drift

Deep Tendon Reflex

Biceps C5, C6 Brachioradialis C6 Triceps C7 Patellar L4

Babinski Abnormal Reflex Toes Fan Achilles Tendon S1

Rated from 0 to 5+

Rating Scale

0: absent reflex 1+: trace, or seen only with reinforcement 2+: normal 3+: brisk 4+: nonsustained clonus (i.e., repetitive

vibratory movements) 5+: sustained clonus

Motor Abnormalities

Spasticity Flaccidity Tremor

Coordination and Gait

Point to Point Movements

Romberg Gait

Reflexes

Deep Tendon Reflexes

Clonus Babinski

Sensory

General Soft/Sharp Touch Discrimination

NCLEX Question

A nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain.

A. Sternal rub

B. Pressure on the Orbital rim

C. Squeezing of the sternocleidomastoid muscle

D. Nail bed pressure

NCLEX Question

A client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety?

A. Provide a clear path for ambulation without obstacles

B. Test the temperature of the shower waterC. Speak Loudly to the clientD. Check the temperature of the food on the dietary

tray.