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02.11 Musculoskeletal Assessment

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Overview

  1. Musculoskeletal system involves the muscles, bones, and joints
  2. This means we must assess structure AND function

Nursing Points

General

  1. If patient cannot stand, assessments should be performed in the bed to the best of your ability
  2. If they cannot perform Active Range of Motion (ROM), use Passive movements to determine ROM

Assessment

  1. For ALL joints:
    1. Inspect
      1. Muscle size/shape
      2. Skin color at joint
      3. Swelling, masses
      4. Deformity
      5. Pain with ROM
    2. Palpate
      1. Crepitus during ROM
      2. Heat at joint
      3. Strength
  2. Strength
    1. Grading
      1. 0 = no movement
      2. 1 = flicker
      3. 2 = passive movement only
      4. 3 = overcomes gravity
      5. 4 = overcomes some resistance
      6. 5 = overcomes strong resistance
    2. Upper extremities – perform these tasks against resistance
      1. Push hands
      2. Pull hands
      3. Raise arms to front and side
      4. Lower arms
      5. Grip hands
    3. Lower extremities – perform these tasks against resistance
      1. Raise legs
      2. Lower legs
      3. Push with feet
      4. Pull toes back
  3. Spine
    1. Inspect and Palpate
      1. Spinous processes should be in alignment vertically
      2. Look for any abnormal curvatures
        1. Kyphosis – excessive thoracic curvature
        2. Lordosis – excessive lumbar curvature
        3. Scoliosis – excessive lateral curvature
    2. Range of motion
      1. Cervical
        1. Chin to chest
        2. Chin up
        3. Head side to side
        4. Ears to shoulders
      2. Thoracic
        1. Twist side to side
      3. Lumbar
        1. Lean backwards
      4. All ROM should be smooth and coordinated without pain
  4. Upper extremities
    1. Shoulders
      1. ROM
        1. External and Internal Rotation
        2. Abduction
        3. Adduction
        4. Forward and backward
        5. Shrug
    2. Elbows
      1. ROM
        1. Flexion
        2. Extension
        3. Supination
        4. Pronation
    3. Wrists
      1. ROM
        1. Flexion
        2. Extension
        3. Rotation
        4. Supination
        5. Pronation
    4. Hands/Fingers
      1. ROM
        1. Flexion
        2. Extension
        3. Grips
  5. Lower extremities
    1. Hips
      1. ROM
        1. Flexion
        2. Extension
        3. Internal rotation
        4. External rotation
        5. Abduction
        6. Adduction
    2. Knees
      1. ROM
        1. Flexion
        2. Extension
    3. Ankles
      1. ROM
        1. Dorsiflexion
        2. Plantar flexion
        3. Supination
        4. Pronation
        5. Rotation
    4. Feet/Toes
      1. ROM
        1. Flexion
        2. Extension

Nursing Concepts

  1. Reflexes usually tested during neurologic assessment, but could be included here as well
  2. Could use a goniometer to assess degree of flexion or extension of joints

Patient Education

  1. Give clear, concise instructions for each ROM test – demonstrate as necessary

Reference Links

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Video Transcript

This video is going to be a review of a musculoskeletal assessment. Remember this will involve assessing muscles, bones, and joints – both structure AND function. A couple key points before we start. If your patient can’t stand, you can perform active range of motion in the bed to the best of your ability. If they can’t perform active range of motion, then you’ll use passive movements to help them through the range of motion exercises.

So there are 3 main areas we need to assess: the spine, the upper extremities, and the lower extremities. For each one you’ll inspect, palpate, and perform range of motion. To start assessing the spine, have the patient stand in front of you with their back towards you. You’re going to inspect and palpate for the spinous processes which should run vertically and in alignment.
You also want to look for any abnormal lateral curvature, which would indicate scoliosis, then look at the patient from the side to assess for kyphosis or lordosis.
For range of motion – check the cervical spine by having the patient put their chin up and down, turn their head left and right, and put their ears to each shoulder.
To test thoracic range of motion – have the patient lean side to side and twist left and right.
For lumbar range of motion, they can lean back slightly. They should be able to do all of these things smoothly and without pain.
Now we’ll move on to the extremities. For each joint you assess, starting at the shoulders, you want to inspect for the muscle size and shape – is there any atrophy? The skin color and condition – any redness or swelling, any masses or deformities?
Range of motion for the shoulders involves abduction, adduction, rotation, forward and backward motion, and shrugging. You’ll want to palpate the joint during range of motion – any heat at the joint? Any crepitus with movement? And of course ask if there’s any pain.
Repeat the same inspection and palpation for the elbows, taking them through flexion, extension, supination, and pronation.
Then the wrists, flexion, extension, rotation, supination, and pronation.
And finally the hands and fingers through flexion and extension. All the while inspecting and palpating the joints for any abnormalities.
Before you move on to the lower extremities, you’ll want to check strength of the uppers – We have the patient push against you, pull you towards them, lift their arms up, and put their arms down all against resistance. Check out your outline to see the grading scale for strength – it goes from 0 to 5. For this patient, she has full strength and full range of motion, so we’d say “5 out of 5”.
On the lower extremities, you’re going to inspect and palpate each joint just like you did on the uppers, looking for heat, deformity, pain, or swelling. Start at the hips and work your way down. The hips should flex, extend, abduct, adduct, and rotate internally and externally. If your patient has trouble with balance, you can do these motions in the bed, or just assist them with stability.
Then you’ll check the knees for flexion and extension – feeling and even listening for crepitus while they move.
Then the ankles should be able to dorsiflex, plantar flex, supinate, pronate, and rotate.
And finally, they should be able to flex and extend their toes.
We also do strength with the legs, push, pull, lift and lower. These things are often best done in a bed, but chance are if your patient can stand, balance, and perform all of these tasks without assistance, their strength will be a 5 out of 5 in the lower extremities.

You can also assess gait here, just make sure they have any assistive devices they need when they’re walking. We tested reflexes in the neurological assessment, but you can also assess them here in musculoskeletal.

Alright, that’s it for this assessment. Make sure you check out all the resources attached to this lesson and the rest of the health assessment lessons. Now, go out and be your best selves today. And, as always, happy nursing!

  • Question 1 of 4

The nurse is talking with a client who has just been diagnosed with Paget’s disease. The nurse knows that this is a disorder that affects which organ?

  • Question 2 of 4

A nurse who is working on the rehabilitation unit of the hospital has been assigned the following clients: Client A is a 39-year-old who has a musculoskeletal condition that requires chiropractic alignment once a week. Client B is a 50-year-old who has vision loss and needs 1-person assist with movement. Client C is a 68-year-old who suffers from tinnitus due to an inner ear disorder. In which order should the nurse see these clients to support their needs for movement and rehabilitation?

  • Question 3 of 4

A home care nurse is working with a client who has a self-care deficit related to a musculoskeletal disorder. The nurse notes that the home health aide who works with this client asks the client to try to eat independently as much as possible. Which of the following best describes the most likely rationale for this?

  • Question 4 of 4

A nurse who works in a rehabilitation unit is at the healthcare clinic for back pain. The nurse receives a diagnosis of an advanced-stage musculoskeletal injury in the lower back and has orders to remain on bed rest for the next week. Which best describes symptoms associated with an advanced stage musculoskeletal injury in this situation? Select all that apply.

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