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