Musculoskeletal System Assessment Notes

Musculoskeletal System Assessment

Overview of the Musculoskeletal System

The musculoskeletal system comprises bones, muscles, tendons, ligaments, and soft tissues. These components work together to support the body's weight and facilitate movement. Injuries, diseases, and aging can lead to pain, stiffness, and impaired movement and function.

Age-Related Musculoskeletal Changes
  • Reduced Muscle Strength: Muscles weaken with age.
  • Reduced Mass and Range of Motion (ROM): Muscle mass decreases, and joints become less flexible.
  • Weakened Bone: Bone density declines, increasing the risk of fractures.

Aim of Musculoskeletal Assessment

The primary goals of a musculoskeletal assessment are:

  • To differentiate between inflammatory and degenerative/mechanical problems.
  • To identify patterns that may aid in diagnosis.
  • To assess the impact of the problem on the patient's overall well-being.
When to Assess
  • When a patient reports pain or loss of function in a joint or muscle.
  • After an injury.
  • As part of a mobility or falls risk assessment.

Preparing the Environment

The assessment environment should be set up to allow the patient to move around comfortably and safely.

Gathering Relevant Information

Obtain the following information from the patient:

  • Past Medical History: Any pre-existing conditions that might affect the musculoskeletal system.
  • Family History: Genetic predispositions such as osteoporosis.
  • Past Surgical History: Scars or previous surgeries related to the musculoskeletal system.
  • Medications: Current medications, including topical, systemic, and over-the-counter drugs.
  • Exposure to Environmental or Occupational Hazards: Factors like cigarette smoking and alcohol use.
  • Substance Abuse: History of substance abuse.
  • Calcium Intake: Dietary calcium intake, especially if less than 500mg daily.
  • Body Frame: Thin and light body frame.
  • Musculoskeletal Problems: Any prior issues with the musculoskeletal system.

Fundamentals of Musculoskeletal Assessment

Important steps in a musculoskeletal assessment include:

  • Review baseline assessment data.
  • Perform hand hygiene.
  • Ensure patient comfort and privacy; explain the procedure.
  • Position the patient appropriately for examination.
  • Observe the patient's ability to stand, transfer, and mobilize safely, noting the amount of assistance required.
  • Observe gait.
  • Inspect and gently palpate major joints for range of motion in arms, legs, and spine (when possible). Note any pain, swelling, warmth, or crepitus.
  • Assess muscle strength, comparing the right and left sides of paired muscle groups. Note any involuntary movements.
  • Determine the frequency of musculoskeletal assessment based on the patient's condition.

Inspection

  • Observe the patient’s capacity to stand, transfer and mobilise safely noting how much assistance is needed.
  • Note symmetry, atrophic muscles may indicate chronic disuse.

Palpation

  • Inspect and gently palpate major joints for ROM in arms, legs and spine when possible.
  • Note any pain, swelling, warmth or crepitus.

Additional Assessments

  • Assess muscle strength, compare right and left sides, and note involuntary movements.
  • Assess pain levels.
  • Take measurements.
  • Note any walking assistive devices.
  • Evaluate range of motion.
  • Conduct gait analysis.

Clinical Terminology

Familiarize yourself with the following terms:

  • Abduction
  • Adduction
  • Dorsiflexion
  • Eversion
  • Extension
  • External rotation
  • Flexion
  • Hyperextension
  • Internal rotation
  • Inversion
  • Plantar flexion
  • Pronation
  • Supination

Musculoskeletal Assessment Across the Lifespan

Assessment of height and weight
  • Observe for structural abnormalities and asymmetrical growth
  • Inspect posture and gait
  • Palpate the spine to assess curvature
  • Palpate bony structures for tenderness and masses/lesions
  • Assess muscle mass
Differences in Children
  • Skeletal growth is most rapid during infancy and adolescence, so assessing growth and development is crucial.
  • Children's bones are more resilient and pliable, which means they may bend or deform before breaking.
  • Blood supply to bone is richer in children, facilitating faster healing. Their periosteum is thicker, and osteogenic activity is higher.
  • Epiphyseal plate fractures can disrupt bone growth.
  • Musculoskeletal problems may be growth-related.
  • Rapid skeletal growth can exacerbate deformities.
Pregnancy
  • Lordosis (increased lower back curve)
    • Stretched and weakened abdominal muscles
  • Slight pelvic tilt in early pregnancy
  • Normal center of gravity
  • Increased pelvic tilt and stretched weakened muscles
  • Tightened and shortened muscles
  • The center of gravity shifts forward
Aging
  • Atrophy of muscles
  • Tendons shrink and harden
  • Reduction in bone mineral and mass
  • Loss of height
  • Decreased joint activity and motion
  • Increased risk of fractures

National Health Priorities

Musculoskeletal conditions such as arthritis and osteoporosis are national health priorities, as is injury prevention through falls risk assessment.

Falls Risk Assessment Tool (FRAT)

The FRAT is used to assess the risk of falls, considering factors such as:

  • Recent falls
  • Medications (sedatives, antidepressants, anti-Parkinson's drugs, diuretics, antihypertensives, hypnotics)
  • Psychological factors (anxiety, depression, cooperation, insight, judgment regarding mobility)
  • Cognitive status (using the Hodkinson Abbreviated Mental Test Score - AMTS)
  • Vision
  • Mobility
  • Transfers
  • Behaviors
  • Activities of Daily Living (ADLs)
  • Environment
  • Nutrition
  • Continence
Risk Factors for Falls
In hospitals:
  • Intrinsic: Age, fatigue, mental status, urinary issues, mobility issues, comorbidities (hypertension, anemia), medications (digoxin, antidepressants, polypharmacy).
  • Extrinsic: Environmental factors (flooring, cords), organization and people factors (staffing, footwear), socioeconomic factors (literacy, dependency).
In Residential Aged Care:
  • Number of medications, sedatives, antidepressants, walking aids, disability, history of falls, vision impairment, and incontinence.
  • Parkinson’s disease

Common Diagnostic Tests

  • Laboratory Tests: Such as the erythrocyte sedimentation rate (ESR), which measures the rate at which red blood cells settle in a test tube. Elevated ESR indicates inflammation.
  • Imaging Tests:
    • X-rays
    • Arthrography
    • Bone Scanning
    • Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)
    • Dual-Energy X-ray Absorptiometry (DXA)
    • Ultrasonography
  • Other Procedures:
    • Arthroscopy
    • Joint aspiration (arthrocentesis)
    • Nerve and muscle tests

Clinical Reasoning Cycle

The clinical reasoning cycle involves:

  • Collecting cues and information (subjective and objective data).
  • Comparing data against normal parameters.
  • Identifying health problems.
  • Setting realistic goals collaboratively.

Common Nursing Diagnoses

  • Activity Intolerance related to pain, weakness, and fatigue.
  • Chronic Pain related to joint inflammation or overuse.
  • Impaired Physical Mobility related to ineffective use of walking aids or decreased muscle strength.
  • Risk for Impaired Skin Integrity related to immobility or mobility aids.

Goal Setting

Goals should be realistic, timely, achievable, and collaborative, using the 'related to' factor to direct interventions. Addressing other health problems may be necessary to solve one (e.g., improving pain levels to address activity intolerance).

Documentation

  • Regularly assess and document findings.
  • Note any new abnormal findings or investigations.
  • Communicate abnormal findings.