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Health History Physical Assessment Inspection Palpation Range of Motion Muscular Strength. Muskuloskeletal Assessment. Rachel S. Natividad, RN, MSN. Cervical spine Shoulders Elbows Wrists/hands Hips Knees Ankles/feet Spine. Functional assessment. Physical Assessment- Cont.
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Health History Physical Assessment Inspection Palpation Range of Motion Muscular Strength Muskuloskeletal Assessment Rachel S. Natividad, RN, MSN
Cervical spine Shoulders Elbows Wrists/hands Hips Knees Ankles/feet Spine Functional assessment Physical Assessment- Cont.
Inspection/Palpation • Note size and symmetry color, swelling, masses & deformities of joints, limbs and body regions • Palpate for temperature, pain, tenderness,
Have the pt perform active ROM If unable to, use passive ROM ROM’s
Strength against gravity, full resistance note as 0/5-5/5 “5/5” = normal Assessing Muscles
Chronic, systemic, inflammatory disease that attacks the joints, and surrounding tissues, hand, knees, hips, and feet Rheumatoid arthritis
Deformitiesof RA Ulnar Shift Boutinniere Deformity Swan neck deformity
A chronic degeneration of joint cartilage caused by aging or trauma Osteoarthritis
Osteoarthritis • Heberden’s nodes on distal interphalangeal joints (DIP’s ) • Bouchards nodes on proximal interphalangeal joints (PIPs) as disease progresses
A decrease in bone mass, porous, brittle, and prone to fracture Osteoporosis
Assessment Guide: Activity & Rest • Objective Data • Activity Level and Tolerance: • ambulates with walker independently/ with minimal assistance; bedrest; up in wheelchair
Assessment Guide: Activity & Rest Muscles and joints • Description: fair muscle tone, no atrophy; atrophy to RLE. No stiffness or contractures; R wrist contracted • Movement: limited ROM to RUE; FROM all extremities • Strength: strong UE, LE; weak RUE & RLE • Coordination: able to perform most ADLs; can comb hair and reach for water glass
Assessment Guide: Activity & Rest • Posture/Gait • Slumped, kyphosis, erect; gait unsteady, shuffling, ataxia
Assessment Guide: Activity & Rest • Circulation, Sensation, and Movement • Describe: • CSM intact; • no sensation to R big toe and second toe; • numbness and tingling to LEs; • Decreased ROM to LUE due to contractures
Assessment Guide: Activity & Rest • Rest/Sleep Patterns • Sleeps most of the day • Takes midday naps
Assessment Guide: Activity & Rest Interventions in use: • Assistive device, equipment • Cast, trapeze, foot cradle, • Special beds • Air bed, eggcrate mattress • Med List: • Glucosamine, Allopurinol, NSAIDS, etc.