Week 1 Nursing Flashcards
Developmental Considerations
- Infants and children
- Spinal curve changes
- Developmental dysplasia of the hip
- The pregnant woman
- Increased joint mobility (relaxation of joints due to oestrogen and relaxing
- Progressive lordosis
- Late adulthood
- Osteoporosis
- Postural changes
- Musculoskeletal changes
Subjective Data — General Principles
- Presenting complaint
- Gait, arms, legs and spine (GALS) screening assessment
- Joints
- Muscles
- Bones
- Functional assessment (ADLs)
- Health and lifestyle management
- Additional history for adolescents
– Sport participation
– Special equipment/training
– Warm-ups
– Bone/spine deformity - Additional history for infants and children
– Labour trauma, resuscitation
– Motor milestones
– Wellness
– Broken bones/bruising/dislocations
– Bone deformity - Additional history for the older adult
– Change/increasing in weakness
– Increase in falls/stumbling (falls assessment)
– Walking aids
Objective Data—The Physical Examination
- Systematic approach
– Head to toe
– Proximal to distal
– Compare corresponding paired joints
– Neurovascular assessment of upper and lower limbs - Order of the examination
– Look (inspect)
– Feel (palpate)
– Then move - Inspection
– Size and contour of joint
– Colour, swelling and masses/deformity - Palpation
– Temperature, muscles, bony articulations, area of joint capsule
– Tenderness, crepitus, swelling or masses
– Boggy synovial membrane (not normally palpable) - Muscle testing
– Equal bilateral strength and should resist opposing force - Movement and ROM
– without resistance
– with resistance
Temporomandibular joint
* Inspect joint area
* Palpate as person opens mouth
* Motion and expected range
– Open mouth maximally
– Protrude lower jaw and move side to side
– Stick out lower jaw
* Palpate muscles of mastication
GALS screening assessment
▪ Validated quick and
efficient MSK
assessment system
– Gait
– Arms
– Legs
– Spine
- Range of motion
-Ask for active movement
-Passive motion
-Goniometer (Physio and OT)
-Crepitation (Crunching or grating sound on movement)
Cervical spine
▪ Inspect alignment of head and neck
▪ Palpate spinous processes and muscles ▪ Motion and expected range
– Chin to chest
– Lift chin
– Each ear to shoulder
– Turn chin to each shoulder
Cervical spine – NEXUS CRITERIA
Nurses can and should use NEXUS as an assessment technique that will help decision about immobilisation.
In the setting of patient who has experienced a trauma AND there is NO:
▪ Focal neurologic deficit present (e.g. altered sensation along C5 dermatome)
▪ Midline spinal tenderness present
▪ Altered level of consciousness present
▪ Intoxication (e.g. alcohol, drugs)
▪ Distracting injury present (e.g. # femur)
Shoulders
▪ Inspect joint (posterior and anterior)
▪ Palpate shoulders and axilla
▪ Motion and expected range
- Arms forwards and up
- Arms behind back and hands up
- Arms to sides and up over head
- Touch hands behind head
Elbow
▪ Inspect joint in flexed and extended positions
▪ Palpate joint and bony prominences
▪ Motion and expected range
- Bend and straighten elbow
- Pronate and supinate hand
▪ Muscle strength
- Person flexes elbow and nurse applies resistance at wrist
Wrist and Hand
▪ Inspect joints on dorsal and palmar sides
▪ Palpate each joint
▪ Motion and expected range
- Bend hand up, down
- Bend fingers up, down
- Turn hands out, in
- Spread fingers, make fist
- Touch thumb to each finger
- Muscle strength: flex the wrist against resistance at the palm
▪ Phalen’s test- numbness and burning in carpel tunnel syndrome
▪ Tinel’s sign- a positive sign is when percussion of the median nerve produces burning and tingling
Hip
▪ Inspect as person stands
▪ Palpate with person supine
▪ Motion and expected range
- Raise leg
- Knee to chest
- Flex knee and hip; swing foot out, in
- Swing leg laterally, medially
- Stand and swing leg back
Knee
▪ Inspect joint and muscle
- can have leg extended or dangling
- shape and contour
- atrophy of quadriceps muscle
▪ Palpate
- note consistency of tissues
- note any warmth, tenderness or thickening
▪ Bulge sign
- for swelling in suprapatellar notch.
- confirms the presence of fluid as you move fluid from one side of joint to the other.
▪ Ballottement of patella
- reliable when large amounts of fluid present in knee
- check for crepitus by holding hand on the patella while flexing and extending knee
▪ Motion and expected range
- Bend knee
- Extend knee
- Check knee during ambulation
▪ Muscle strength
- Ask person to flex the knee while you try and pull leg forward
Ankle and foot
▪ Inspect with person sitting, standing and walking
▪ Palpate joints
▪ Motion and expected range
- Point toes down, up
- Turn soles out, in
- Flex and straighten toes
- Muscle strength: dorsiflexion and plantar flexion against resistance
Spine
▪ Inspection from behind and side
▪ ROM
- Flexion
- Extension
- Rotation
▪ Straight Leg Raising (or Lasegue’s Test)
▪ Positive if it produces sciatic pain
▪ Confirms the presence of a herniated nucleus pulposis
Osteoporosis
▪ Bone remodelling
▪ Osteoporosis = disease characterised by low bone mass and microarchitectural deterioration of bone tissue/fragility
▪ Bone loss occurs silently
▪ Risk factors: Family history, increasing age, low dietary calcium intake, vitamin D deficiency and/or lack of sunlight, medical history, corticosteroid therapy, early menopause, late menarche, low testosterone (men), malabsorption syndromes, certain chronic diseases, some medications, lifestyle factors
Abnormal Findings -Affecting Multiple Joints
▪ Inflammatory conditions
- Rheumatoid arthritis
- Ankylosing spondylitis
▪ Degenerative conditions
- Osteoarthritis (degenerative joint disease)
- Osteoporosis
Abnormal Findings of the Shoulder
- Atrophy
- Fracture
- Dislocated shoulder
- Subluxation
- Joint effusion
- Tear of the rotator cuff
- Frozen shoulder— adhesive capsulitis
- Sub-acromial bursitis
Abnormal Findings of the Wrist and Hand
▪ Ganglion cyst
▪ Colles fracture
▪ Carpal tunnel syndrome
▪ Ankylosis
▪ Dupuytren’ s contracture
▪ Swan-neck and boutonnière deformities
▪ Ulnar deviation or drift
▪ Degenerative joint disease or osteoarthritis
▪ Acute rheumatoid arthritis
▪ Syndactyly
▪ Polydactyly
