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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. 2. 3. 4. The base is as wide as the shoulder width Foot placement is accurate Walk is smooth, even and well-balanced Associated movements, such as arm swing, are present. Gait Abnomalities Unusual and uncontrollable walking patterns, usually caused by disease or injury. Propulsive Scissors Spastic Steppage Waddling Stance Symmetrical Width Steady Assistive Devices Posture Normal - Comfortably erect Look 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 Nerve Cranial Nerve Assessment I olfactory Smell II Vision optic 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 XII hypoglossal Shrug shoulders, turn head against resistance Stick out tongue, move tongue side to side Motor Observation Muscle Tone Muscle Strength Squeeze hands Pronator Drift Deep Tendon Reflex Biceps Brachioradialis Triceps Patellar Babinski Achilles Tendon S1 Rated from 0 to 5+ C5, C6 C6 C7 L4 Abnormal Reflex Toes Fan 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. B. C. D. Sternal rub Pressure on the Orbital rim Squeezing of the sternocleidomastoid muscle 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. B. C. D. Provide a clear path for ambulation without obstacles Test the temperature of the shower water Speak Loudly to the client Check the temperature of the food on the dietary tray.
