Health Ass #3

Musculoskeletal System

  • List the functions of the musculoskeletal system.

    • The functions of the musculoskeletal system, which consists of bones, joints, and muscles, include:

      • Providing support and enabling the body to stand erect.

      • Facilitating movement.

      • Encase and protect inner vital organs.

      • Produce RBCs in the bone marrow.

      • Serving as a reservoir for storage of essential minerals.

  • Describe the normal/abnormal shape of the spine and its surface landmarks.

    • Normal Shape of the Spine

      • When viewed laterally, the vertebral column has four curves, forming a double-S shape.

        • The cervical and lumbar curves are concave (inward or anterior).

        • The thoracic and sacrococcygeal curves are convex. These balanced curves, along with the intervertebral discs, allow the spine to absorb shock. When inspecting the alignment of the head and neck, the spine should be straight and the head erect.

    • Spine Surface Landmarks

      • The spinous processes can be felt in the furrow down the midline of the back, and these landmarks help orient the examiner to their vertebral levels:

        • The spinous processes of C7 and T1 are prominent at the base of the neck.

        • The inferior angle of the scapula is normally located at the level of the interspace between T7 and T8.

        • An imaginary line connecting the highest point on each iliac crest crosses L4.

        • An imaginary line joining the two symmetric dimples that overlie the posterior superior iliac spines crosses the sacrum.

    • Abnormal Shape of the Spine

      • Scoliosis: An abnormal curve of the spine with an S-shaped spine.

      • Kyphosis: An enhanced thoracic curve, typically referred to as "hunch back" and seen in aging people.

      • Lordosis: A pronounced lumbar curve seen in obese people, and a progressive finding in pregnant women.

  • Know how to assess scoliosis.

    • Scoliosis screening is an age-specific measure for adolescents. The assessment uses the forward bend test:

      • 1. The child stands with feet shoulder width apart and is asked to bend forward slowly to touch the toes.

      • 2. While the person is bending over, the examiner may mark a dot on each spinous process; upon standing, the dots should form a straight vertical line.

      • 3. Expect a straight vertical spine while standing and while bending forward. The concave lumbar curve should disappear with this motion, resulting in a single convex C-shaped curve of the back.

      • 4. The posterior ribs should be symmetric, with equal elevation of shoulders, scapulae, and iliac crests.

  • Know how to assess muscle strength.

    • Muscle strength is tested by assessing the strength of the prime mover muscle groups for each joint.

      • 1. Ask the person to flex and hold the position.

      • 2. The examiner then applies opposing force.

      • 3. Muscle strength should be equal bilaterally and should fully resist the opposing force.

      • 4. Results are reported using a standardized grading scale (0 to 5 range).

  • Describe active and passive range of motion.

    • Active Voluntary Range of Motion (ROM): Asking the patient to perform voluntary ROM while the examiner stabilizes the body area proximal to the moving part.

    • Passive ROM: If a limitation is noted during active ROM, the examiner should gently use passive ROM.

  • Perform ROM for neck, hand, arm, leg, feet.

    • The sources identify specific movements associated with these regions:

      • Neck/Spine: Movements include flexion, extension, abduction, and rotation. Rotation is moving the head around a central axis.

      • Arm/Shoulder: The shoulder joint permits mobility on many axes due to its ball-and-socket action. General movements include flexion, extension, abduction, and adduction. Circumduction is moving the arm in a circle around the shoulder.

      • Hand/Wrist: The wrist permits movement in two planes at right angles: flexion and extension, and side-to-side deviation. The midcarpal joint allows for flexion, extension, and some rotation.

      • Leg/Hip: The hip, a ball-and-socket joint, permits a wide range of motion on many axes. Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease.

      • Leg/Knee: The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane.

      • Feet/Ankle: The ankle joint is a hinge joint limited to flexion (dorsiflexion) and extension (plantar flexion) in one plane. The subtalar joint permits inversion (moving the sole of the foot inward at the ankle) and eversion (moving the sole of the foot outward at the ankle).

  • Perform tests to rule out carpal tunnel syndrome.

    • Testing is performed to determine the presence of Carpal Tunnel Syndrome:

      • Phalen Test: Acute flexion of the wrist produces numbness and burning if the test is positive (+).

      • Tinel Sign: Percussion of the median nerve produces burning and tingling if the test is positive (+).

  • Identify signs/symptoms of joint problems.

    • Subjective data related to joint problems include:

      • Pain

      • Stiffness

      • Swelling

      • Heat

      • Redness

      • Limitation of movement

    • Objective signs observed during examination include:

      • Swelling.

      • Masses or deformity.

      • Heat or tenderness (joints are normally not tender to palpation).

      • Crepitation (can be noted during hip assessment).

        • Examples of specific joint abnormalities include Arthritis, Rheumatoid Arthritis (RA), Osteoarthritis (OA), Joint Effusion, Olecranon Bursitis, Tear of Rotator Cuff, and Swelling of Menisci.

  • Perform the MacMurray's test and know the purpose.

    • Purpose: The McMurray's Test is performed if a meniscal tear is suspected.

    • Positive Result: An audible click on examination is a positive (+) result for the presence of a tear.

  • Describe the Ballottement's test and know the purpose.

    • Purpose: The Ballottement of the Patella test is performed if swelling is observed in the knee. It is used to distinguish soft-tissue swelling or increased fluid in the joint.

  • Describe the Lasegue's test and know the purpose.

    • The Straight Leg Raising, or Lasègue’s Test, maneuvers reproduce back and leg pain and may confirm the presence of a herniated nucleus pulposus.

      • Procedure: Normally, straight leg raising while keeping the knee extended produces no pain. The examiner should raise the affected leg just short of the point where it produces pain, and then dorsiflex the foot.

      • Positive Result: The test is positive if it reproduces sciatic pain. If lifting the affected leg reproduces sciatic pain, it confirms the presence of herniated nucleus pulposus.

  • State the risk factors for bone fractures.

    • Low Bone Mineral Density (BMD) is a consistent predictor of hip and vertebral fractures.

    • The earlier peak and rapid decline of BMD are associated with increased fracture risk in Caucasian women.

    • Osteoporosis is a degenerative condition that involves a cyclic process of resorption and deposition in bone remodeling, increasing fracture risk.

    • Trauma is a general category for fractures, sprains, or dislocations mentioned in subjective data gathering.

  • Measure the leg length if hip fracture is suspected.

    • To measure leg length discrepancy:

      • True leg length is measured between fixed points: from the anterior iliac spine to the medial malleolus, crossing the medial side of the knee.

      • Normally, these measurements are equal or within 1 cm.

      • Apparent leg length is measured from a nonfixed point (umbilicus) to a fixed point (medial malleolus) on each leg.

  • Discuss the developmental differences regarding the musculoskeletal system.

    Developmental Stage

    Characteristics and Considerations

    Infants/Children

    The skeleton is formed as a cartilage model by 3 months gestation; ossification continues rapidly through infancy and steadily in childhood. Longitudinal growth continues until the closure of the epiphyses (growth plates), around age 20. Lordosis is common throughout childhood. Screening for congenital hip dislocation using Ortolani’s maneuver is necessary until age 1 year. Adolescents are screened for scoliosis with the forward bend test.

    Pregnant Woman

    Increased circulating hormones (Estrogen, relaxin, corticosteroids) lead to increased mobility in joints. The most characteristic change is progressive lordosis leading to back strain. Compensatory posture involves anterior flexion of the neck and slumping of the shoulder girdle. The characteristic “waddling” gait occurs due to a protuberant abdomen and relaxed joint mobility.

    Aging Adult

    There is an increased risk for osteoporosis due to shifts in bone remodeling. Postural changes include decreased height. Kyphosis is common, compensated by slight flexion of the hips and knees and backward head tilt. There is an absolute loss in muscle mass, leading to atrophy and weakness. Loss of subcutaneous fat causes bony prominences to become more marked. The Get Up and Go test can assess the risk for falling.

  • Incorporate health promotion concepts when performing an assessment of the musculoskeletal system.

    • Health promotion is incorporated by assessing function for Activities of Daily Living (ADLs). The purpose of the examination is to assess function for ADLs and to screen for abnormalities. Functional assessment is performed for aging adults.

  • Address patient center care (Musculoskeletal).

    • Patient-centered care includes incorporating subjective data questions about function related to ADLs. Furthermore, the examiner should provide instructions to the patient related to assessment activities.

Neurologic System

  • Demonstrate knowledge of the two parts of the nervous system.

    • The nervous system is divided into two parts:

      • 1. Central nervous system (CNS): Consists of the brain and spinal cord.

      • 2. Peripheral nervous system (PNS): Consists of all nerve fibers outside the brain and spinal cord, including 12 pairs of cranial nerves and 31 pairs of spinal nerves.

  • Describe the function of the peripheral nervous system.

    • The PNS carries sensory (afferent) messages to the CNS from sensory receptors. It also delivers motor (efferent) messages from the CNS to muscles and glands, internal organs, and blood vessels.

  • Perform 12 cranial nerve assessment AND Know the name/function of each.

    • The 12 pairs of cranial nerves supply primarily the head and neck, except for the vagus nerve, which travels to the heart, respiratory muscles, stomach, and gallbladder.

      CN

      Name

      Assessment/Function

      I

      Olfactory Nerve

      Tests the sense of smell (tested in those reporting loss of smell, head trauma, or abnormal mental status).

      II

      Optic Nerve

      Tests visual acuity and visual fields by confrontation. The ocular fundus is examined.

      III

      Oculomotor Nerve

      Checks pupils for size, regularity, equality, light reaction, and accommodation (PERRLA). Assesses extraocular movements.

      IV

      Trochlear Nerve

      Assesses extraocular movements.

      V

      Trigeminal Nerve

      Motor: Assess muscles of mastication by palpating temporal and masseter muscles as the person clenches teeth. Sensory: Test light touch sensation on the face (forehead, cheeks, chin) using a cotton wisp.

      VI

      Abducens Nerve

      Assesses extraocular movements.

      VII

      Facial Nerve

      Motor: Note mobility and facial symmetry as the person responds to selected movements (e.g., puffing cheeks). Sensory: Mediates taste (not routinely tested).

      VIII

      Acoustic Nerve

      Test hearing acuity by normal conversation and the whispered voice test.

      IX

      Glossopharyngeal Nerve

      Motor: Note pharyngeal movement (uvula/soft palate rise) and the gag reflex. Sensory: Mediates taste on the posterior one third of the tongue.

      X

      Vagus Nerve

      Motor: Note pharyngeal movement and the gag reflex; voice quality should sound smooth.

      XI

      Spinal Accessory Nerve

      Examine sternomastoid and trapezius muscles for equal size and strength (shrugging shoulders against resistance).

      XII

      Hypoglossal Nerve

      Inspect the tongue (no wasting or tremors), note forward thrust in midline, and check that lingual speech (l, t, d, n sounds) is clear.

  • Perform deep tendon reflexes correctly AND score the reflex degree accurately.

    • Deep Tendon Reflex (DTR) Performance

      • To test DTRs, the limb should be relaxed, and the muscle partially stretched. The examiner stimulates the reflex by directing a short, snappy blow of the reflex hammer onto the muscle’s insertion tendon. Responses should be equal bilaterally.

      • Examples of DTR testing:

        • Biceps Reflex (C5 to C6): Strike the examiner's thumb placed on the biceps tendon; normal response is contraction of biceps muscle and flexion of forearm.

        • Quadriceps Reflex/Knee Jerk (L2 to L4): Strike the tendon directly below the patella while legs dangle freely; normal response is extension of the lower leg.

        • Achilles Reflex/Ankle Jerk (L5 to S2): Hold the foot in dorsiflexion and strike the Achilles tendon directly; normal response is foot plantar flexion.

    • Scoring the Reflex Degree

      • The reflex response is graded on a 4-point scale:

        • 4 = very brisk, hyperactive with clonus, indicative of disease

        • 3 = brisker than average, may indicate disease

        • 2 = Average, normal

        • 1 = diminished, low normal, or occurs with reinforcement

        • 0 = no response

  • List developmental considerations for infants and older adults (Neuro).

    • Infants

      • The neurologic system is not completely developed at birth.

      • Movement is primarily directed by primitive reflexes. The persistence of these reflexes is an indication of CNS dysfunction.

      • Sensation is rudimentary at birth.

      • The Babinski Reflex (fanning of toes) is present at birth and normally disappears by 24 months.

    • Older Adults (Aging Adult)

      • Atrophy occurs with a steady loss of neuron structure in the brain and spinal cord.

      • The velocity of nerve conduction decreases, causing a slower reaction time.

      • Sensation is diminished (touch, pain, taste, and smell).

      • Motor movement, muscle strength, and agility decrease.

      • Gait may be slower and more deliberate.

      • Loss of vibration sensation at the ankle malleolus is common after age 65.

      • DTRs are typically less brisk; the ankle jerk is commonly lost, and reinforcement should be used when eliciting DTRs.

  • Incorporate health promotion concepts when performing an assessment of the neurologic system.

    • Health promotion is incorporated by asking subjective data questions regarding environmental/occupational hazards. It also involves awareness of stroke warning signs (F.A.S.T.: Face droops, Arm drifts, Speech slurs, Time to call 911), and being aware of the 10 Early Warning Signs of Alzheimer Disease.

  • Perform a complete neurological assessment.

    • The recommended sequence for a complete neurological examination includes assessing the following components:

      • 1. Mental status.

      • 2. Cranial nerves (I through XII).

      • 3. Motor system (including muscle size, strength, tone, rapid alternating movements, gait, and balance).

      • 4. Sensory system (including superficial pain and light touch, vibration, position sense, stereognosis, graphesthesia, and two-point discrimination).

      • 5. Reflexes (DTRs: biceps, triceps, brachioradialis, patellar, Achilles; and superficial reflexes like plantar).

  • Differentiate lower and upper neuron disorders/disease.

    Feature

    Upper Motor Neurons (UMNs)

    Lower Motor Neurons (LMNs)

    Tone

    Increased muscle tone (Spasticity)

    Loss of muscle tone (Flaccidity)

    Reflexes

    Hyperreflexia

    Hyporeflexia

    Babinski

    Positive Babinski

    Negative Babinski

    Muscle Atrophy

    No muscle atrophy

    Muscle atrophy

    Examples

    Cerebrovascular accident (stroke), cerebral palsy, multiple sclerosis.

    Spinal cord lesions, poliomyelitis, amyotrophic lateral sclerosis.

  • Perform PERRLA.

    • PERRLA is an assessment performed when checking Cranial Nerves III, IV, and VI. It involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation. In a neurological recheck, pupillary response is checked for PERRLA, noting size in millimeters.

  • Address patient center care (Neurologic).

    • Patient-centered care is addressed by obtaining subjective data, which includes asking questions about neurological symptoms (such as headache, seizures, weakness, difficulty swallowing, or difficulty speaking) and environmental/occupational hazards.

  • Know how to perform these tests:

    Test Name

    Description/Performance

    Romberg's test

    Ask the person to stand up with feet together and arms at sides. When stable, ask the person to close their eyes and hold the position for about 20 seconds. This tests cerebellar function.

    Babinski's test

    Part of the superficial cutaneous reflex (Plantar Reflex). With the thigh in slight external rotation, draw a light stroke up the lateral side of the sole of the foot and inward across the ball of the foot, like an upside-down “J”. (Normal response in adults is plantar flexion of toes).

    Graphesthesia test

    The ability to “read” a number by having it traced on the skin. This measures the discrimination ability of the sensory cortex.

    Stereognosis test

    The person’s ability to recognize objects by feeling their forms, sizes, and weights. This measures the discrimination ability of the sensory cortex.

    Rapid alternating movement test

    Ask the person to pat their knees with both hands, lift up, turn hands over, and pat knees with the backs of their hands, and then perform this faster. This is part of testing cerebellar coordination.

    Point location discrimination test

    Touch the skin and withdraw the stimulus promptly. Ask the person to put their finger where you touched. This measures the discrimination ability of the sensory cortex.

Peripheral Vascular System

  • Relate the structure and functions of arteries and veins.

    Feature

    Arteries (High Pressure System)

    Veins (Low Pressure System)

    Structure

    Vessels that transport freshly oxygenated blood. The vascular system delivers nutrients and oxygen. Arteries accessible for examination in the leg include the femoral, popliteal, anterior tibial to dorsalis pedis, and posterior tibial to plantar arteries.

    Vessels that parallel the course of arteries. The body has more veins, and they lie closer to the skin surface. Veins are called capacitance vessels because they have the ability to stretch. Veins contain intraluminal valves.

    Function

    To supply oxygen and essential nutrients to tissues. Peripheral arterial disease (PAD) affects noncoronary vessels in the limbs and can cause ischemia (deficient supply of oxygenated blood).

    To drain deoxygenated blood and its waste products from tissues and return it to the heart. The mechanism to keep blood moving includes contracting skeletal muscles, a pressure gradient caused by breathing, and intraluminal valves. In the legs, this mechanism is called the calf pump or peripheral heart.

  • Locate and palpate the pulses in the arm (radial, brachial).

    • Radial Pulse: Palpated in the arm. The amplitude is typically graded on a 3-point scale, with 2+ considered normal.

    • Brachial Pulse: Found in the arm, where the brachial artery bifurcates into the ulnar and radial arteries. The ulnar and brachial pulses are typically not assessed routinely during a screening examination.

  • Locate and palpate the pulses in the leg (femoral, popliteal, posterior tibial, dorsalis pedis).

    • Femoral Pulse: Located just below the inguinal ligament halfway between the pubis and anterior superior iliac spines.

    • Popliteal Pulse: Found in the popliteal fossa. Palpation is performed by anchoring your thumbs on the knee and curling your fingers around the fossa, with the leg extended but relaxed.

    • Posterior Tibial (PT) Pulse: Located by curving fingers around the medial malleolus and feeling the tapping right behind it in the groove between the malleolus and Achilles tendon.

    • Dorsalis Pedis (DP) Pulse: Normally located just lateral to and parallel with the extensor tendon of the big toe.

  • Describe deep vein thrombosis (DVT) with the causes, symptoms, & risk factors.

    • Description: Deep Vein Thrombosis (DVT), also known as Deep Vein Thrombophlebitis, is assessed using a clinical model that categorizes findings into low, moderate, or high probability of DVT.

    • Risk Factors/Causes: The clinical model focuses on 10 categories, including:

      • Malignancy.

      • Mobility limitations.

      • Swelling.

      • Non-varicose veins.

      • Previous history of DVT.

      • Alternative medical diagnosis at least as likely as DVT.

      • Other factors associated with increased DVT risk are prolonged bed rest, immobilization, and heart failure.

    • Symptoms: Venous disease generally causes symptoms related to metabolic waste build up. Swelling is a key assessment finding included in the DVT scoring model.

  • Describe varicose vein, the cause, and nursing interventions.

    • Description/Cause: Varicose veins are dilated and tortuous vessels. This condition results in incompetent valves, which increases venous pressure and further dilates the vein.

    • Interventions: Since varicose veins are a form of Peripheral Venous Disease (PVD), relevant interventions include:

      • Encouraging elevated legs.

      • Maintaining exercise to improve circulation.

      • Paying attention to seated positions during the day.

  • Distinguish between ARTERIAL ulcer/wound and VENOUS ulcer/wound.

    Feature

    ARTERIAL (Ischemic) Ulcer

    VENOUS (Stasis) Ulcer

    Underlying Cause

    Oxygen deficit.

    Metabolic waste build up.

    Pain

    Sharp, and is relieved at rest.

    Dull.

    Wound Location/Shape

    Typically round, located at the toes or feet.

    Typically irregular, located at the shin, calf, or side of the ankle.

    Skin Appearance

    Pale, cold, and shiny. Trophic changes associated with arterial insufficiency include thin, shiny skin; thick, ridged nails; and loss of hair on the lower legs.

    Warm, red, itchy, and dry.

    Edema

    May not be present.

    Present.

    Position Preference

    Dangle legs.

    Elevated legs.

  • List nursing interventions for patients with Peripheral arterial disease (PAD) and Peripheral venous disease (PVD).

    • General health promotion and intervention concepts apply to both PAD and PVD:

      • Maintain exercise to improve circulation.

      • Pay attention to seated positions during the day.

      • Inspect to identify possible abnormalities and skin breakdown.

      • Wear comfortable shoes that fit well and wear shoes outside to prevent potential injury.

      • Lubricate the skin on the feet to keep them hydrated.

    • Specific Interventions based on Disease Type:

      • PAD (Arterial): Because arterial insufficiency causes symptoms of oxygen deficit, patients may prefer to dangle legs.

      • PVD (Venous): Because venous insufficiency causes symptoms of metabolic waste build up, patients should use the position of elevated legs.

  • Identify signs/symptoms of the Raynaud's disease.

    • Raynaud Phenomenon is listed as an abnormal finding affecting the arms.

  • List the risk factors of peripheral vascular disease.

    • Traditional cardiac risk factors contribute to the development of Peripheral Arterial Disease (PAD):

      • Cigarette smoking.

      • Diabetes.

      • Hypertension (HTN).

      • Total levels of cholesterol.

      • Obesity.

      • Chronic kidney disease.

      • PAD disproportionally affects Black individuals, with non-Hispanic Blacks having the highest risk factors.

      • Gender differences exist in treatment and presentation, and high-risk groups include women with early onset of menopause and older women with osteoporosis.

      • Depression among women is also noted as a risk factor.

    • Risk factors for venous disease include factors leading to DVT, such as prolonged bed rest, immobilization, and heart failure.

  • Describe the lymph nodes in infant/children Vs. Aging adults.

    • Infants and Children: Lymph nodes are relatively large. Superficial nodes are often palpable even when the child is healthy. Palpable nodes are typically described as small, firm ("shotty"), mobile, and nontender. Infections can cause excessive swelling and hyperplasia, and vaccinations can produce local lymphadenopathy.

    • Aging Adults: There is a loss of lymphatic tissue, resulting in fewer numbers of lymph nodes and a decrease in the size of the remaining nodes.

  • Address patient center care (Peripheral Vascular System).

    • Patient-centered care is addressed through subjective data gathering by asking questions related to symptoms and history. Key subjective data points include:

      • Leg pain or cramps.

      • Skin changes on the arms or legs.

      • Swelling in the arms or legs.

      • Lymph node enlargement.

      • Medication usage.

      • Smoking history.

Preparation for the examination also involves ensuring the environmental temperature is comfortable for the patient.