14 Focused Assessment- Musculoskeletal System/Mobility

Ching-Chuen Feng

Learning Objectives

At the end of the chapter, the learner will:

  1. Obtain a health history related to the musculoskeletal system.
  2. Perform physical examination of the musculoskeletal system using correct examination techniques.
  3. Assess the ability to perform activities of daily living.
  4. Discuss screening tools for falls risk assessment.
  5. Document the findings from the musculoskeletal assessment.

I. Overview: Focused Musculoskeletal System Assessment

A focused musculoskeletal assessment includes collecting subjective data about the patient’s mobility and exercise level, as well as the patient’s and family’s history of musculoskeletal conditions. The nurse should ask the patient about any signs and symptoms of musculoskeletal injury or conditions. Objective data will include assessing the patient’s range of motion and muscle strength. Additionally, the patient should be evaluated for fall risk.

II. Anatomy and Physiology Review:

III. Medical Terminology

Important Terms to know:
Ankylosis fixation of a joint, usually resulting from destruction of articular cartilage
Ataxia inability to coordinate muscular movement
Bradykinesia abnormal slowness of movement
Crepitus a grating, creaking, or cracking sound or sensation heard or felt when moving a join
Dyskinesia uncontrolled, involuntary movements
Erythema redness of the skin
Kyphosis abnormal outward curvature of the spine
Lordosis abnormal inward curvature of the lumbar spine
Muscle strength the muscle’s ability to contract and create force in response to resistance
Muscle tone the tension in a muscle at rest
Scoliosis lateral curvature of the spine
Sprain traumatic injury to the ligament
Strain traumatic injury to the muscle or the tendon
Tendinitis
 inflammation of a tendon

Illustrations of normal and abnormal spinal curvatures

The normal spine should be straight with expected curvatures, and the body should be symmetrical when comparing one side to the other.

Skeleton and bones - Normal, Scoliosis, Lordosis, and Kyphosis
Normal, Scoliosis, Lordosis, and Kyphosis

Range of Motion (ROM) Terms:

Abduction movement of a limb away from the body
Adduction movement of a limb toward the body
Circumduction circular movement of a limb
Dorsiflexion backward or upward motion of a body part
Eversion turning the sole of the foot away from the midline
Extension movement of bringing a joint into a straight position
External Rotation or lateral rotation, turning a limb outward from the mid line of the body
Flexion movement that brings a joint into a bent position
Hyperextension extension of a body part beyond normal limits of extension
Internal Rotation inward turning of a limb
Inversion turning the sole of the foot inwards towards the midline
Supination turning the forearm to keep palm facing up
Plantar Flexion bending of the foot or toes toward the sole of the foot
Pronation turning the forearm to keep palm facing down
Rotation turning the head to the left or the right

Illustrations of Range of Motion:

Body Movements
Flexion and Extension of Shoulders, Knees, and Neck
Body movements
abduction, adduction, and circumduction

Three types of ROM:

Active Range of Motion: Patient performs the exercise independently without any assistance.

Active Assisted Range of Motion: Patient moves the joints with some effort and requires some assistance from another person or equipment.

Passive Range of Motion: Patient does not perform any movement and depends totally on someone (therapist) or equipment to perform ROM.

Knowledge Check

Dorsiflexion and plantar flexion

IV. Step-by-step Assessment of the Musculoskeletal System

Safety considerations:
  • Perform hand hygiene.
  • Check room for contact precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Assess ABCCS/suction/oxygen/safety.
  • Apply principles of asepsis and safety.
  • Check vital signs.
Steps
 Additional Information
1. Check patient information prior to assessment:

  • Activity order
  • Mobility status
  • Falls risk (see Fall Risk Assessment below)
  • Need for assistive devices

2. Check alertness, medications, and pain levels.

3. Ask if the patient uses any assistive devices such as a walker, cane, wheelchair, or crutches.

4. Conduct a focused interview related to mobility and the musculoskeletal system.

 Determine patient’s activity as tolerated (AAT) or bed rest requirements.

Determine if patient has non-weight-bearing, partial weight-bearing, or full weight-bearing status.

Determine if the patient ambulates independently, with one-person assist (PA), two-person assist (2PA), standby assist, or requires a lift transfer.

Consider using non-slip socks, hip protectors, or a bed-chair alarm for safety.

Ask relevant questions related to the musculoskeletal system, including pain, function, mobility, and activity level (e.g., arthritis, joint problems, medications, etc.).
5. Inspect, palpate, and test muscle strength and range of motion:

  • Observe general appearance, body symmetry, gait, and posture.
    • Normal appearance should include erect posture, and smooth, coordinated movement.
  • Stand behind the patient to inspect the straightness of the spine.
  • Assess gross motor skills:
    • Have the patient perform range of motion (ROM) exercises for the neck, shoulders, elbows, wrists, hip, knees, and ankles.
  • Palpate the muscle to assess muscle tone.
    • Normal muscle tone helps maintain normal postures.
  • Assess muscle strength and ROM of the joints in the neck, the upper and lower extremities.
    • Have the patient perform active ROM while the examiner applies resistance using the 0-5 scale (Naqvi & Sherman, 2020).
Score Criteria of muscle strength
5 Full range of motion with full resistance
4 Full range of motion with some resistance
3 Full range of motion against gravity
2 Achieving full range of motion with gravity eliminated
1 No range of motion, evidence of muscle contractility such as a twitch
0 No muscle contractility
  • Assess the neck muscle strength by applying pressure while the patient rotates the head against it.
    • The patient should be able to rotate the neck and withstand the resistance.
  • Assess for bilateral handgrip strength.
    • Ask the patient to squeeze both of the examiner’s hands. The strength of handgrip should be strong and equal bilaterally.
  • Assess upper extremity strength.
    • Ask the patient to extend their forearms with palms facing up.
    • Hold the patient’s inner forearms with both hands and ask the pateint to pull their arms toward themselves while the examiner provides resistance. The patient should be able to strongly pull against the resistance with both arms.
    • Ask the patient to raise their hands in the air with the palms facing the examiner.
    • Place the palms against the patient’s palms and instruct them to push while the examiner provides resistance.
  • Assess lower extremity strength.
    • While the patient is in a sitting postion: Place the hands behind the calves and ask the patient to push against the examiner’s hands with their lower legs while the examiner applies resistance.
    • While the patient is still sitting: Place the hands on the patient’s thighs and ask them to lift their legs while the examiner applies pressure.
    • Expected findings: Strong and equal strength in both legs.
  • Assess for dorsiflexion and plantar flexion strength.
    • Have the patient sit or lie down with their legs extended and feet relaxed.
    • Place the hands on the top of the patient’s feet or on the toes. Ask the patient to lift their feet upward against the pressure applied by the examiner (dorsiflexion).
    • Then place the hands on the soles of the patient’s feet. Ask the patient to push downward while the examiner applies pressure (plantar flexion).
    • Expected findings: Strong and equal strength in both feet.
 If the patient states pain or tenderness in an area, conduct a further assessment.

  • Normal or abnormal findings should be elicited by observing and palpating the surrounding area for symmetry/asymmetry, skin appearance/discoloration, warmth/heat, erythema, ulcers, hair distribution, muscle tone, crepitus of joint, and ROM (Vilella & Reddivari, 2020).

The Adam’s Forward Bend Test is used to screen for scoliosis.

  • Ask the patient to bend forward with feet together, knees straight, and arms dangling at the sides.
  • The back should be completely straight. If one side of the back is higher than the other, this indicates a sign of scoliosis.
Forward bend test to screen for scoliosis
Adam’s Forward Bend Test
Assess grip strength
Assessing Handgrip Strength

 

Assessing for Equal Upper Extremity Strength
Assessing for Equal Strength in Upper Extremities
Assessing for Equal Strength in Lower Extremities
Assessing for Equal Strength in Lower Extremities
Assess strength on plantar flexion
Assessing Dorsiflexion Strength
Assess strength on dorsiflexion
Assessing Plantar Flexion Strength
6. Evaluate patient’s ability to sit up before standing.

7. Evaluate the patient’s ability to stand before walking.

8. Assess the patient’s walking ability.

  • Note patient’s gait, balance, and presence of pain.
Patient position prior to standing
Patient position prior to standing
7. Report and document assessment findings and related health problems according to agency policy. Accurate and timely documentation and reporting promote patient safety.

Fall Risk Assessment

Falls are a significant problem for hospitalized patients. Several tools are available for assessing and identifying fall risk in these patients (Aranda-Gallardo et al., 2013). The Morse Fall Scale (Morse, Morse, & Tylko, 1989) is a widely used tool for identifying risk factors for falls and preventing potential falls in hospitalized patients.

The Morse Fall Scale includes six categories that reflect fall risk: history of falls, secondary diagnosis, ambulatory aids, intravenous therapy, gait, and mental status. The nurse tallies the scores from these categories to objectively evaluate the patient’s fall risk and then provides necessary interventions to prevent falls (AHRQ, n. d.).

Morse Fall Scale

Item Item Score

Patient Score
1.      History of falling 0-   No

25- Yes
2.      Secondary diagnosis

(more than 2 medical diagnoses)

 0-   No

25- Yes
3.      Ambulatory aids 0-   None/bedrest/nurse assist

15-  Crutches/cane/walker

30 – Furniture
4.      Intravenous therapy 0-   No

25- Yes
5.      Gait 0-   Normal/bedrest/wheelchair

10- Weak (short steps)

20- Impaired (short steps with shuffle)
6.      Mental status 0-   Oriented to own ability

15- Overestimates/forgets limitations

Total Score:

Tally the patient’s score:

   0: No risk for falls

<25: Low risk

25-45: Moderate risk

>45: High risk

Additional Information

Falls are also a significant concern for older populations living at home or in long-term care facilities. Access additional health information to educate patients on fall prevention strategies. Fall Risk Assessment: https://medlineplus.gov/lab-tests/fall-risk-assessment/

V. Documentation

A sample narrative documentation:

Patient denies problems with muscle weakness or tremor, no history of falls. Performs ADL independently, denies problems with mobility. Steady coordinated gait with erect posture, full ROM, muscle strength (5/5) equal and strong bilaterally in all joints with smooth and nonpainful movements, muscle size symmetric bilaterally, shoulders aligned, spine straight and in midline. No pain or tenderness on palpation.

VI. Related Laboratory and Diagnostic Tests

Some blood tests used to diagnose musculoskeletal problems include:

  • Serum Calcium Levels: Abnormal levels can indicate osteomalacia or parathyroid problems.
  • Rheumatoid Factor (RF): Used to diagnose rheumatoid arthritis, an autoimmune disease.
  • HLA-B27: A specific gene tested for diagnosing ankylosing spondylitis, a disorder affecting the spine, pelvic bones, and hip joints.
  • White Blood Cell Count (WBC), Erythrocyte Sedimentation rate (ESR), and C-Reactive Protein (CRP): These may be checked to diagnose infection or inflammation.
  • Creatine Kinase (CK) or Creatine Phosphokinase (CPK): These enzymes are checked to diagnose muscular injuries such as myopathy, muscular dystrophy, or rhabdomyolysis. CK found in skeletal muscle, myocardium, and brain, will be elevated in the blood when muscle is damaged.

Some diagnostic tests used to diagnose musculoskeletal problems include:

  • X-Ray Studies: Identify and evaluate bone density and structure.
  • Computed Tomography (CT) Scan: Evaluates musculoskeletal trauma and bony abnormalities that may not able to be detectable with X-rays.
  • Magnetic Resonance Imaging (MRI): Assesses problems in bones and soft tissues, including torn muscles, disk abnormalities, ligament or cartilage tears, and other hip or pelvic conditions.
  • Bone Densitometry: Performed using X-rays or ultrasound to evaluate bone density in the spine, hip, wrist, and total body. It also predicts fracture risk and assesses treatment effectiveness for osteoporosis.
  • Bone Scan: Examines the entire skeletal system to evaluate unexplained bone pain, detect damage from infection or other disease, and discover cancer in bones caused by metastasis.
  • Arthroscopy: Uses a fiber-optic endoscope inserted into a joint to perform surgery and/or diagnose diseases of the patella, meniscus, and synovial membranes.
  • Electromyography (EMG): Evaluates the electrical activity of muscles and nerves to diagnose neuromuscular diseases and motor or nerve problems (Hinkle & Cheever, 2018).

VII. Learning Activity

Inversion and Eversion of the foot

VIII. Citations and Attributions

  • Agency for Healthcare Research and Quality (AHRQ). Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors.  https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html. Accessed July 15, 2021
  • Aranda-Gallardo, M., Morales-Asencio, J. M., Canca-Sanchez, J. C., Barrero-Sojo, S., Perez-Jimenez, C., Morales-Fernandez, A., de Luna-Rodriguez, M. E., Moya-Suarez, A. B., & Mora-Banderas, A. M. (2013). Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis. BMC health services research, 13, 122. https://doi.org/10.1186/1472-6963-13-122
  • Doyle, G. R. & McCutchen, J. A. Clinical procedures for safer patient care. https://opentextbc.ca/clinicalskills/chapter/introduction/

  • Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. (14th ed.). Philadelphia, PA: Wolters Kluwer.

  • MedlinePlus. Forward bend test. https://medlineplus.gov/ency/imagepages/19465.htm
  • Morse, J. M., Morse, R.M., & Tylko, S.J. (1989). Development of a scale to identify the fall-prone patient. Canadian Journal on Aging, 8(4), 366-377.
  • Naqvi, U. & Sherman, A. I. (2020). Muscle strength grading. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436008/  Accessed July 15, 2021
  • Vilella, R.C. & Reddivari, A. (2020). Musculoskeletal examination. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.  https://www.ncbi.nlm.nih.gov/books/NBK551505/ Accessed July 15, 2021.
  • “Neuro Exam Image 41.png” and “Neuro Exam Image 39.jpg” by Meredith Pomietlo for Chippewa Valley Technical College are licensed under CC BY 4.0
  • “Musculoskeletal Exam Image 2.png,” “Neuro Exam image 6.png,” and “Musculoskeletal Exam Image 7.png” by Meredith Pomietlo for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵

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Health Assessment Guide for Nurses Copyright © by Ching-Chuen Feng is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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