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Musculoskeletal Assessment — Transcript

by Gina Kemper · 5,174 words · 945 segments · language en · Watch on YouTube

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0:00Hey, hey, hey. We're talking about
0:03muscles today. Here we go with
0:06muscularkeeletal
0:07assessment.
0:10So, here are our learning objectives for
0:13this lecture.
0:16And before we learn how to assess the
0:18muscularkeeletal system, let's review
0:20the basic structures we're assessing. So
0:24the muscularkeeletal system is made up
0:26of bones, muscles, joints, tendons,
0:29ligaments, and connective tissues. And
0:31they all work together to support
0:32movement and maintain our posture.
0:35Starting with bones, the adult human
0:37skeleton contains about 206 bones. And
0:41bones provide the framework of the body.
0:44They protect vital organs. They store
0:46minerals such as calcium and phosphorus.
0:48And they house bone marrow where blood
0:51cells are produced.
0:53So bones can be categorized by their
0:55structure. We have compact bones which
0:58are dense and strong. And then we have
1:00canulus or spongy bone which is lighter
1:03and contains narrow spaces.
1:06And bones are also classified by shape
1:08including long bones, short bones, flat
1:10bones and irregular bones.
1:13So as nurses, understanding these
1:15structures is going to help us recognize
1:17how fractures, osteoporosis, and other
1:20muscularkeeletal conditions can affect
1:22function and mobility.
1:25Now let's talk about muscles. So the
1:27body contains over 600 muscles which are
1:29responsible for movement, posture, and
1:31heat production. And there are three
1:33types of muscle tissue. Skeletal muscle
1:36which is attached to bones and it allows
1:39voluntary movement. Then we have cardiac
1:41muscle which makes up the heart. Smooth
1:43muscle which is found in organs such as
1:46intestines and blood vessels. And so our
1:48primary focus is going to be skeletal
1:51muscle because it directly affects
1:52mobility, strength, balance, and
1:54activities of daily living. And again,
1:56those skeletal muscles attach to bones
1:59through tendons. And when muscles
2:01contract, they pull on bones to create
2:03movement at joints. This relationship
2:05between bones, muscles, and joints is
2:08what we'll evaluate during our muscular
2:10skeletal assessment.
2:12And again, we're not just assessing
2:14anatomy. We're assessing the function.
2:16So, we're asking questions that may
2:18include, can the patient move normally?
2:20Do they have pain? Is strength equal
2:23bilaterally? Are there any limitations
2:25in their range of motion? Can they
2:27safely perform activities of daily
2:28living?
2:30And so all of these functional findings
2:32tell us more about the patients health
2:34status than their actual anatomy alone.
2:40So joints are the structures that
2:42connect those bones together and allow
2:44movement throughout the body. So when we
2:46perform a muscularkeeletal assessment,
2:48much of what we assess such as range of
2:50motion, gate, and mobility is directly
2:52related to joint function. So joints
2:56provide both mobility and stability. And
2:58some joints are designed for a large
3:01range of motion while others are built
3:03more for protection and support. So
3:06there's three main types of joints. We
3:08have fibrous joints also called
3:10synithroic joints. These are essentially
3:14immovable.
3:15An example would be the structure or the
3:17sutures of the skull. So and then we
3:20have cartilagages joints um which allow
3:24slight movement. An example would be the
3:26vertebrae of the spine.
3:29And then we have synenovial joints um
3:32which are freely movable joints. These
3:34are the joints we most commonly assess
3:36in nursing because they're responsible
3:38for most body movement. Makes sense. Um
3:41synenovial joints contain synovial fluid
3:44which lubricates the joint and helps
3:46reduce friction during movement. So
3:48conditions such as arthritis that can
3:50affect this lubrication and lead to
3:52pain, swelling and decrease mobility.
3:56The slide also lists the major joints we
3:58will assess during a focused
3:59muscularkeeletal exam. We have the
4:02temporalmandibular joint or TMJ. This is
4:06assessed by observing jaw movement and
4:08checking for clicking, tenderness or
4:10pain. The shoulders, these are evaluated
4:13for symmetry, strength and range of
4:15motion. Um, so shoulder injuries are
4:18common because this joint has a very
4:21wide range of motion but less stability.
4:25And for the elbows, wrists and hands, we
4:27assess movement, strength with a grip,
4:30swelling, deformities, and fine motor
4:32function. This is especially important
4:35for conditions like arthritis or nerve
4:37impairment.
4:39The hips, knees, ankles, and feet. These
4:41are critical for mobility and gate. And
4:43we assess alignment, weightbearing
4:45ability, balance, and range of motion.
4:48Pain or weakness in these joints can
4:50significantly increase fall risk. And
4:53finally, the spine, which provides
4:54support and flexibility while protecting
4:56the spinal cord. And during our
4:58assessment, we look for posture, spinal
5:01curvature, alignment, and limitations in
5:04movement.
5:07These are common terms you will use
5:09throughout muscularkeeletal assessment
5:10to describe joint movement and range of
5:13motion.
5:15Um it can look pretty overwhelming at
5:18first at these terms, but once you
5:20connect them to actual movement, they
5:22become much easier to remember. So when
5:24assessing joints, we compare movements
5:26bilaterally and we determine whether the
5:28patient can move smoothly, fully, and
5:30without pain. So let's go through each
5:32term. Flexion means bending a joint and
5:36decreasing the angle between body parts.
5:39For example, bending the elbow or
5:40bending the knee.
5:42So at the ankle, we use more specific
5:45terms like dorsif flexion, which means
5:47bringing the toes upward toward the shin
5:50and plantar flexion, which means
5:52pointing the toes downward like pressing
5:54on a gas pedal pedal.
5:56Then we have extension. This is the
5:58opposite of flexion. It means
6:00straightening a joint and increasing the
6:02angle between body parts.
6:05Abduction means moving a limb away from
6:08the midline of the body. So being
6:09abducted
6:11away from you know aliens taking you
6:14away. So moving the limb away from the
6:17midline of the body.
6:20Adduction means moving the limb back
6:22towards the midline. Rotation refers to
6:26turning a body part around its axis. For
6:28example, turning the head side to side
6:31or internally and externally rotating
6:33the hip. Circumduction. This is a
6:36circular movement that combines flexion,
6:38extension, abduction, and adduction. And
6:41the shoulder is a good example of a
6:42joint capable of circumduction
6:45where we can move our joint in a entire
6:49circle. Um, inversion and eversion,
6:52these are movements of the foot. So,
6:54inversion means turning the sole of the
6:56foot inward. Eversion means turning the
6:58sole outward.
7:00So these movement terms are important
7:02because they help us accurately document
7:04findings and identify limitations in
7:06mobility. And if a patient can't perform
7:09a movement fully or if pain occurs
7:11during movement they can indicate
7:13injury, inflammation, nerve impairment
7:15or muscularkeeletal disease.
7:19And as they are moving we are looking at
7:23symmetrical movement. Is there weakness?
7:25Is there pain guarding or stiffness? Is
7:27the movement itself smooth? Um, these
7:29are observations that are going to help
7:31us determine functional status and also
7:33patient safety risks.
7:38Back to older adults. So, when assessing
7:40older adults, it's important to
7:41recognize the normal age related
7:43muscularkeeletal changes that occur over
7:46time because these changes can affect
7:48mobility, balance, strength,
7:50independence, and their overall safety.
7:52So one major change is decreased bone
7:55density. So as people age, bones
7:58gradually lose calcium and become more
8:00porous and fragile. So this increases
8:03the risk for fractures, especially in
8:05conditions like osteoporosis.
8:08Um even minor falls can lead to serious
8:11injuries such as hip fractures. Um you
8:14may also notice increased bony
8:16prominences. This occurs because of both
8:19decreased muscle mass and changes in
8:21subcutaneous tissue. So bones may appear
8:24more visible or prominent especially
8:25over areas like the clavicles, spine,
8:27knees and hands. And another common
8:30change is cartilage degeneration. And
8:33over time the cartilage that cushions
8:35our joints wears down and it leads to
8:37stiffness, pain, crerepidus and
8:39decreased range of motion. And this is
8:42commonly seen um in patients who have
8:44osteoarthritis.
8:47Older adults, they also experience joint
8:49stiffness and lacks ligaments. So,
8:50ligaments lose elasticity with age while
8:53joints become less flexible. So,
8:56patients may report stiffness,
8:57especially in the morning or after
8:59periods of inactivity.
9:01You'll also commonly see muscle atrophy,
9:03which is the loss of muscle mass and
9:05strength. And this can contribute to
9:07weakness, slower movement, decreased
9:09endurance, and increased fall risk. So
9:11these changes are clinically important
9:13because they're going to directly affect
9:15our patients mobility, their ability to
9:17perform activities of daily living,
9:19balance and gate, risk for falls and
9:22injury, and their overall functional
9:24independence.
9:25So during our assessment, we want to
9:27determine whether findings are expected
9:30age related changes or signs um that
9:33require further evaluation.
9:40this back to cultural variations and
9:43health disparities. So this slide
9:45reminds us that muscularkeeletal health
9:47is influenced by much more than anatomy.
9:50So cultural background, environment,
9:52occupation, socioeconomic factors,
9:55nutrition and biologic differences can
9:57all affect muscularkeeletal development
9:59and disease risk risk. So first bone
10:02mineral density. This can vary among
10:04individuals and populations during
10:06genetics, nutrition, physical activity,
10:08hormone levels, and access to care. Um,
10:12loan when you have low bone density, it
10:14increases the risk for osteoporosis and
10:17fractures. So, keeping that in mind.
10:21Also, the curvature of long bones can
10:24vary depending on nutritional status and
10:27childhood development. For example,
10:29vitamin D deficiency during growth can
10:32contribute to abnormal bone development
10:34during um sometimes we see things like
10:38boeing of the legs.
10:41Um which connects us to the next point
10:43which is conversion of active uh
10:45metabolites by sunlight. So sunlight
10:48exposure helps the body synthesize
10:50vitamin D which is essential for calcium
10:52absorption and bone health. Hopefully we
10:55all know. And then individuals with
10:56darker skin pigment may require longer
10:59sun exposure to produce adequate vitamin
11:01D because increase in melanin reduces
11:04vitamin D synthesis. So this is
11:07important um clinically because vitamin
11:09D deficiency can contribute to
11:11osteomalia, osteoporosis, muscle
11:14weakness and increased fracture risk.
11:17The slide also mentions biologic sex and
11:20hormone exposure. Hormones such as
11:22estrogen and testosterone play important
11:24roles in bone density and muscle mass.
11:28For example, estrogen helps maintain
11:29bone density. And after menopause,
11:32declining estrogen levels increase um
11:34women's risk for osteoporosis,
11:38whereas testosterone can contribute to
11:40muscle mass and bone strength. So
11:43considering the impact um of that along
11:46with working conditions and lifestyle
11:49factors like repetitive movements or
11:52heavy lifting, poor ergonomics,
11:54prolonged standing or a sedentary
11:56lifestyle. These can all contribute to
11:58muscularkeeletal strain and injury. So
12:01repetitive wrist motion may contribute
12:03to carpal tunnel syndrome or being on
12:06your phone too long. You know, I'm
12:08noticing holding my phone up um is
12:11really doing a number on my wrists
12:13recently, so I need to it's a reminder
12:16to put it down. Um anyway, poor posture
12:20and ergonomics may contribute to chronic
12:22back pain. Lack of movement can lead to
12:25muscle weakness and decreased joint
12:27flexibility.
12:28So, keeping that in mind.
12:34So this slide focuses on the priorities
12:37of a muscularkeeletal assessment. Um so
12:39our goal isn't simply to identify
12:41abnormalities. We want to determine what
12:43requires immediate attention and how
12:45muscularkeeletal findings impact patient
12:47safety and function. So the first focus
12:50is identifying the specific problem. We
12:52want to determine what symptoms the
12:54patient is experiencing, when it
12:56started, whether it affects movement,
12:58strength or daily activities, whether
13:00the issue is acute or chronic. For
13:03example, sudden severe joint pain after
13:05a fall. This is very different from
13:07chronic stiffness that develop gradually
13:09over years. Another priority is going to
13:12be alleviating pain. U muscularkeeletal
13:15pain can significantly limit mobility
13:17and quality of life. So pain may also
13:19prevent patients from participating
13:21fully in assessments or rehabilitation
13:24activities. So we're assessing location
13:27of pain, severity, quality, triggers or
13:30relieving factors, impact on mobility
13:33and function. We also focus on
13:35preventing complications. So limited
13:37mobility can quickly lead to
13:39complications like falls, pressure
13:42injuries, muscle deconditioning,
13:44contraurs,
13:46um blood clots, loss of independence,
13:50pneumonia from adalcttois.
13:53So next we're going to inspect proper
13:56alignment of the limbs, joints, and
13:58spine. And normal alignment helps
14:01maintain balance, posture, and efficient
14:03movement. So during inspection, we're
14:05looking for deformities, swelling,
14:07unequal limb positioning, curvature of
14:10the spine, any contraures,
14:13also guarding behaviors. We also observe
14:16for symmetry of size, shape, position,
14:18and movement of the extremity. So, we're
14:20comparing one side of the body to the
14:23other.
14:30Some muscular skeletal findings that
14:32require urgent intervention would be
14:34suspected fractures, neurovvascular
14:36compromise, severe pain, loss of
14:39circulation, inability to bear weight,
14:42and acute spinal injury. These are
14:45situations um where safety and
14:47stabilization come before completing a
14:49full assessment.
14:53So this slide focuses on the nursing
14:55priorities and screening tools we use
14:57during a muscular skeletal assessment.
14:59So when a patient presents with a
15:01muscularkeeletal injury or complaint,
15:04one of our first priorities is assessing
15:05overall stability and circulation. So
15:08this includes obtaining their vital
15:10signs because blood loss, pain or
15:13systemic complications can affect heart
15:15rate, blood pressure, respiratory rate
15:17and oxygenation. So we also are
15:20monitoring pulses distal to the injury.
15:23So distal means below the site of
15:25injury. For example, if a patient has a
15:27fractured wrist, we're going to assess
15:30radial pulses and circulation in the
15:32hands and fingers. So in addition to
15:35pulses, we also assess color,
15:37temperature, capillary refill distal to
15:39the injury. And these assessments are
15:42going to help us determine whether blood
15:43flow and perfusion are still intact. Um
15:46if we see things like pale or cool
15:48extremities, delayed cap refill, weak or
15:51absent pulses, this could indicate
15:53impaired circulation or neurovvascular
15:55compromise, which is going to require
15:57immediate attention. So hopefully
15:59you're, you know, letting your provider
16:01know. We also assess for sensation,
16:04movement, increasing pain, swelling,
16:07especially after fractures, casts or
16:10orthopedic surgery.
16:12And the second part of the slide
16:14introduces the gals locomot screen. Gals
16:17stands for gate, arms, legs, spine. This
16:20is a quick screening assessment used to
16:22identify muscularkeeletal abnormalities
16:24and determine whether a more focused
16:26assessment is needed. So first we
16:27observe gate. Is the patient walking
16:30steadily? our movement smooth and
16:32coordinated. Is there any limping,
16:35shuffling, guarding or imbalance? Then
16:37we assess the arms by observing range of
16:40motion, symmetry, and strength. Next are
16:42the legs where we look at mobility,
16:44alignment, joint movement, and
16:45weightbearing ability. And finally, we
16:48assess the spine. So observing posture,
16:50alignment, spinal curvature, and range
16:52of motion. So the GAL screening is
16:55especially useful because it provides a
16:57rapid overview of muscularkeeletal
16:59function while also helping to identify
17:02fall risk, weakness, pain or mobility
17:04limitations.
17:09So this slide is going to focus on
17:10collecting subjective data during our
17:12muscularkeeletal assessment. Um so this
17:15is includes the information the patient
17:17tells us about their symptoms, their
17:18health history and risk factors. So, one
17:21major area to assess is the patient's
17:23past medical history. We want to ask
17:24about previous fractures or injuries,
17:27arthritis, osteoporosis,
17:30chronic pain conditions, neuromuscular
17:32disorders, falls, surgeries, or joint
17:35replacements. Um, past injuries can
17:38affect current mobility and function
17:40even years later. We also want to assess
17:42lifestyle and personal habits because
17:44these greatly influence muscularkeeletal
17:46health. So questions may include what
17:49types of work does do you do? Uh do you
17:53exercise regularly? Do they participate
17:55in repetitive activities or heavy
17:57lifting? What is their activity level?
18:00Have they ever experienced a fall or
18:02have they had a recent fall? What's
18:05their diet like? Um because lifestyle
18:08factors such as inactivity, smoking,
18:10poor nutrition, or repetitive strain can
18:12contribute to muscularkeeletal problems.
18:16And next, we're reviewing the patients
18:17medications. So, certain medications can
18:19affect bones, muscles, or joints. Um,
18:22things like long-term corticosteroid use
18:24can increase osteoporosis risk. Statins
18:28may cause muscle pain or weakness.
18:30Anti-coagulants increase bleeding risk
18:33after injury. Um, some medications can
18:36contribute to dizziness and falls. I'm
18:38sure you've learned from the
18:40anti-hypertensive medications. So we're
18:42also con we're always considering
18:44whether medications could be
18:46contributing to the patient's symptoms.
18:48And finally we're assessing family
18:50history. Some muscularkeeletal
18:51conditions have genetic components. This
18:54includes osteoporosis, rheumatoid
18:56arthritis, osteoarthritis, and certain
19:00connective tissue disorders. Um so
19:02family history can help us identify
19:04patients at an increased risk for future
19:07disease.
19:08It's also important to explore the
19:10patient's current symptoms. Like any
19:11common questions would be, do you have
19:13pain? Where is it located? What makes it
19:15better or worse? Have you notice
19:17weakness or stiffness? Have you had any
19:20difficulty walking or performing daily
19:22activities? And remember, we're, you
19:24know, collecting facts and it's helping
19:27us to understand how muscularkeeletal
19:29issues affect the patients daily life,
19:31their mobility, independence, and
19:33safety.
19:39So teaching and health promotion related
19:41to muscularkeeletal health. Um one
19:44important goal is reducing fall related
19:46deaths among older adults.
19:51Falls are one of the leading causes of
19:53injury and loss of independence in older
19:56adults. So when assessing fall risk, we
19:58consider muscle strength, balance,
20:00mobility, vision,
20:02medications, environmental fac uh
20:05hazards like throw rugs, which older
20:09adults really love. I'm not sure where
20:11that why. Um history of previous falls,
20:16even one fall can significantly affect
20:18an older adult's confidence and
20:20independence.
20:22Another focus is increasing screening
20:25for osteoporosis
20:27um because it often develops silently
20:29until a fracture occurs. So early
20:31screening helps identify patients at
20:33risk before major injury happens. And
20:36our patients at higher risk include
20:38older adults, post-menopausal women,
20:40patients on long-term corticosteroids,
20:43and individuals with low calcium or
20:45vitamin D intake. Also patients with low
20:48physical activity levels like a
20:50sedentary lifestyle. Um related to this
20:54is the goal of reducing hip fractures
20:56among uh older adults. Hip fractures can
20:59lead to major complications like loss of
21:02mobility, long-term rehabilitation,
21:05increased dependence on others, uh
21:08increased mortality risk, preventing
21:10falls, and maintaining bone health are
21:12essential nursing priorities. Um, so
21:14we're emphasizing increasing physical
21:17activity, regular movement, uh,
21:20maintaining muscle strength, improving
21:22balance, preserving joint flexibility,
21:25increasing bone density, and reducing
21:27fall risk.
21:30You'll also see the short
21:32muscularkeeletal function assessment,
21:34which is a tool used to evaluate how
21:36muscularkeeletal conditions affect daily
21:38functioning and quality of life. Um
21:40functional assessments are important
21:42because patients may appear physically
21:44stable but they still struggle with
21:46activities like walking, climbing
21:48stairs, dressing, bathing, or carrying
21:50objects. So this slide also references
21:55bone density testing which is commonly
21:57done using DEXA scans to evaluate
22:00osteoporosis risk. And I feel like
22:03everyone um is normally screened maybe
22:07around their like 60if late like late
22:0950s 60s
22:11um with a DEXA scan to evaluate this
22:13risk. Um finally scoliosis screening.
22:17This is used to identify abnormal spinal
22:19curvature especially during adolescence.
22:21I remember getting this screening when I
22:23was in
22:25grade school. So
22:28because that is when rapid growth
22:30occurs. So
22:32they'll do that screening. Then um as
22:36nurses, we're teaching and preventing
22:39um as an our assessment. Uh our
22:43education may include fall prevention
22:45strategies, safe exercise, proper
22:47footwear, nutrition with calcium and
22:50vitamin D, smoking sessation, and home
22:53safety modification. So the overall goal
22:56here is helping patients maintain
22:58mobility, independence, and quality of
23:00life across the lifespan.
23:04This slide reviews some of the most
23:06common symptoms that patients are going
23:08to report during a muscular skeletal
23:09assessment. And these are going to help
23:11guide our focused assessment and
23:13clinical judgment. So the first most
23:16common symptom is pain or discomfort.
23:19Um so pain involving muscles is called
23:22myalgia while pain involving joints is
23:24called arthralgia. Um so when we're
23:27assessing pain we want to explore the
23:29location severity, timing, quality,
23:32triggers, what relieves it, how it
23:34affects function.
23:37Another common symptom is weakness.
23:39Patients may describe weakness as
23:41difficulty lifting objects, trouble
23:43climbing stairs, fatigue and walking,
23:46feeling unstable. So we want to
23:48determine whether weakness is
23:49generalized or is it isolated to one
23:51area and whether affects safety or
23:54mobility. Next is stiffness or limited
23:57mobility and this can occur from pain,
23:59inflammation, injury or long-term
24:01immobility.
24:03The slide also mentions contraurs
24:06um which are permanent tightening or
24:08shortening of muscles, tendons or joints
24:10that limit movement. So contraurs are
24:13often seen in patients with prolonged
24:15immobility. sometimes neurologic
24:17disorders or chronic conditions. We also
24:20assess for deformity. So deformities may
24:23result from arthritis, fractures,
24:25congenital conditions, chronic joint
24:27disease. Um an example of this would be
24:30spinal curvature changes, joint
24:32enlargement or abnormal alignment.
24:36Another major symptom is lack of balance
24:38and coordination also called atexia.
24:41Patients with atexia may have unsteady
24:43unsteady gate, difficulty coordinating
24:46movements, increased fall risk, and this
24:48can result from muscularkeeletal
24:50problems, but also potentially
24:52neurologic conditions um even weakness
24:55or just inner ear disorders.
25:00And the slide also reminds us um about
25:04older adults again who commonly
25:06experience things like decreased muscle
25:07mass, reduced flexibility, slower
25:09movement, balance changes. Um and we
25:13need to again differentiate normal aging
25:16from abnormal findings. And finally,
25:19we're just again considering cultural
25:22considerations.
25:23Um, patients may express pain
25:25differently depending on their
25:27background, beliefs or past experiences
25:29with healthcare. Um, some patients may
25:32openly describe pain while others may
25:34minimize symptoms.
25:38Um, cultural and occupational factors
25:40can also affect muscular skeletal health
25:42through activity level, repetitive
25:44movements, access to care, nutrition,
25:47exercise habits. So combining subjective
25:50symptoms with objective findings to
25:52determine how muscularkeeletal issues
25:54are affecting function, safety, and
25:56quality of life.
26:00Now we're getting into the objective
26:02portion of the muscularkeeletal
26:04assessment, including the equipment
26:06needed and how to properly prepare both
26:08the environment and the patient. So
26:10first, let's talk about equipment. Um, a
26:13gometer. This is a tool used to measure
26:16joint angles and range of motion.
26:19While you may not use one during every
26:22routine nursing assessment, it can be
26:24useful in rehabilitation settings,
26:26orthopedic care, or when monitoring
26:28progress over time. I've seen a lot of
26:30physical therapists use this tool. Um,
26:33also a tape measure. This may also be
26:35useful to compare muscle size, swelling,
26:38edema, or limb circumference
26:40bilaterally. Um so things like measuring
26:43calf circumference can help monitor for
26:45asymmetry or muscle atrophy.
26:49Preparation is also important part of
26:50the assessment. Um so before beginning
26:53we want to assemble all of our supplies
26:55so the assessment can flow smoothly and
26:57safely. Um the environment should be
26:59warm and private. Patients may need to
27:02remove clothes or move through different
27:04positions. So maintaining comfort and
27:06dignity is important. always performing
27:08hand hygiene before and after. You may
27:11need to assist the patient into a gown
27:13and proper uh provide proper draping to
27:16maintain privacy while still allowing
27:18visualization of the areas being
27:20assessed. It's also important to explain
27:22the process to the patient before
27:24beginning. So patients are often more
27:25relaxed and cooperative when they
27:28understand what you're assessing and
27:29why.
27:33Patients may need to also walk or change
27:35positions, lift extremities, bend
27:37joints, perform resistance movements. So
27:40safety is always a priority.
27:45Um
27:46especially patients who are experiencing
27:48pain, weakness, balance or have um that
27:52fall risk.
27:57This slide outlines the components of
28:00our initial survey, muscularkeeletal
28:03survey. So
28:06the first thing we need to assess is
28:07posture. We look at how the patient
28:09naturally holds themselves while
28:11sitting, standing and walking. Um normal
28:14posture should appear upright, aligned
28:15and balanced. Abnormal findings may
28:18include a stooped posture, uneven
28:20shoulders or hips, spinal curvature,
28:23guarding due to pain.
28:26Posture can provide clues about pain,
28:27weakness, spinal disorders, or
28:29neurologic impairment. So, we're looking
28:31closely at that. Next, we observe gate
28:34and mobility. And we want to watch how
28:36the patient walks. Is the gate smooth
28:38and coordinated? Are their movements
28:40steady? Is the patient favoring one
28:42side? Do they need assisted devices? Um,
28:46any abnormal gate pattern such as
28:48limping, shuffling, or unsteadiness. It
28:51can indicate things like pain, weakness,
28:54neurologic issues or balance problems.
28:57Uh to balance, so balance is crucial for
29:01safety and fall prevention. So patients
29:03with impaired balance, they may sway
29:05when they're standing upright. Um they
29:08may require support or appear unstable
29:11when standing or walking. So closely
29:14related to this is coordination. So
29:17coordination involves smooth purposeful
29:19movement
29:22and so things like difficulty
29:23coordinating movements may suggest
29:25muscularkeeletal neurologic or
29:27vestibular problems with the ears.
29:31Next we perform inspection and palpation
29:34of the extremities. So during inspection
29:36we assess for symmetry, swelling,
29:38redness, deformities, muscle size,
29:40alignment.
29:42And then during palpation we assess for
29:44tenderness, warmth, crerepidus, edema,
29:47and muscle tone. And we're assessing
29:49each joint in the spine with our
29:52inspection and palpation. We're also
29:54looking at range of motion, muscle
29:57strength. Um
30:00and muscle strength is commonly graded
30:02on a 0 to5 scale with five being full
30:04strength against resistance. And finally
30:07we assess fall risk. Um the slide
30:09mentions tools s such as the Morse fall
30:12scale and Hendrickk 2 fall risk model.
30:15And these are just tools that help
30:17identify patients at increased risk for
30:19falls based on factors like mobility
30:22limitations, mental status, medications,
30:25history of falls, gate abnormalities,
30:28um fall prevention. That's a major
30:30nursing responsibility because again
30:32muscularkeeletal impairment directly
30:34affects patient safety and independence.
30:39So with the fall risk um in clinical you
30:42might have seen what scale they utilize
30:44for fall risk. If not I would advise you
30:47to next time you go uh ask your clinical
30:50instructor to show you uh how they
30:52calculate the fall risk.
30:59So this slide um I know I mentioned
31:01muscle strength um a little bit but this
31:04slide really outlines the standard
31:06grading scale used to assess muscle
31:07strength during our uh muscularkeeletal
31:11exam. So again muscle strength is
31:13typically graded on a 0 to five scale
31:16with five being normal strength and zero
31:18indicating no muscle activity.
31:20Um so when we're testing strength we
31:22usually compare both sides of the body
31:24and we assess the patients ability to
31:26move against gravity and resistance. Um,
31:28and so
31:30through this slide, it kind of talks you
31:32through how you would grade muscle
31:35strength depending on your patient's
31:37ability.
31:42And let's just finally go through some
31:44of the specific lab and diagnostic tests
31:46commonly associated with
31:47muscularkeeletal disorders and what they
31:50can tell us clinically. Um, so
31:55LDH, this is lactate dehydroxinase.
31:59Um, and LDH is an enzyme found in many
32:01tissues throughout the body, including
32:03muscle tissue. So when cells are
32:06damaged, LDH can be released into the
32:08bloodstream and elevated. Um, so you
32:11might see that elevated with muscle
32:14injury, tissue breakdown, trauma,
32:16certain inflammatory conditions like
32:20sepsis.
32:22um LDH is non-specific meaning it can
32:25increase for many reasons. So usually we
32:28need to interpret um these findings
32:30along with other things like clinical
32:33manifestations.
32:36CK this is creatin kynise um this is one
32:40of the most important labs related to
32:41muscle injury. So CK rises when muscle
32:45cells are damaged and elevated CK may
32:48occur with muscle trauma, rabdtomyosis
32:51which is rapid muscle breakdown,
32:54meioitis,
32:56intense exercise like if you go to spin
32:58class, um certain medications such as
33:02statins
33:04and very high CK levels can be dangerous
33:06because muscle breakdown um products can
33:09damage those kidneys. the kidneys cannot
33:11filter that muscle breakdown out fast
33:14enough and they can actually get
33:16injured.
33:18Especially patients who have
33:19rabdtomyosis.
33:21Um they might present with clinical
33:23manifestations such as severe muscle
33:25pain, weakness, dark urine and again
33:28those elevated CK levels. So that's
33:30important priority and um especially the
33:32risk for acute kidney injury.
33:36ALT and AS um these are liver enzymes
33:40but they can also increase with muscle
33:42injury because these enzymes exist in
33:44muscle tissues too. Um so seeing
33:47elevated A and ALT may occur with muscle
33:50trauma, muscle inflammation that
33:52rabdtomyosis
33:54and this is why providers look at the
33:56whole clinical picture rather than
33:57assuming abnormal A and ALT always
34:00indicate liver disease.
34:03Alkaline phosphotase or ALP. This is
34:06associated with bone activity and liver
34:09function. So in muscularkeeletal
34:10conditions, elevated ALT ALP
34:14may suggest increased burn uh wow
34:18increased bone turnover, bone healing
34:20after fractures, bone disorders such as
34:23pageant disease and bone uh
34:28cancer. Um,
34:32a note though, children and adolescence
34:35may naturally have higher ALP levels
34:38because they are growing.
34:40Uric acid, uric acid is most commonly
34:42associated with gout. So, when uric acid
34:45accumulates, crystals can form in joints
34:47and cause intense inflammation. Um,
34:50classic findings with gout include
34:53sudden severe joint pain, redness,
34:56swelling. It's often affected the big
34:59toe because um it's a cooler area and
35:02uric acid loves to build up in cooler
35:04areas of our body.
35:06But elevated uric acid supports the
35:08diagnosis of gout although patients can
35:12sometimes have gout symptoms even with
35:14normal levels during an acute attack.
35:18ESR
35:19uh ariththraite sedimentation rate. This
35:22is a non-specific inflammatory marker
35:25and when inflammation is present, red
35:26blood cells settle faster in a test tube
35:29that increases the ESR. So elevated ESR
35:33may occur with rheumatoid arthritis,
35:35infection, autoimmune disorders,
35:37inflammatory conditions. Um, and because
35:40ESR is non-specific, it doesn't tell us
35:42exactly what's causing the inflammation,
35:44only that inflammation is occurring.
35:48Also, C reactive protein CRP. This is
35:51another inflammatory marker. Um, it does
35:54rise quicker than ESR and it's often
35:56used to monitor acute inflammation,
35:58infection, autoimmune flare-ups,
36:01response to treatment. But again, this
36:03is a non-specific inflammatory uh
36:05marker.
36:08Rheumatoid factor or RF, this is an
36:11antibbody often associated with
36:12rheumatoid arthritis. So, a positive RF
36:16may support the diagnosis of RA,
36:18especially when it's combined with
36:19symptoms such as symmetrical joint pain,
36:21morning stiffness,
36:23swelling of small joints. Um, but some
36:26patients with rheumatoid arthritis may
36:28have negative RF and some healthy
36:30individuals may also test positive for
36:32RF. Um, so again, it can be
36:35non-specific.
36:39Diagnostics like X-rays. We know these
36:42are commonly used to assess fractures,
36:44joint alignment, degenerative changes,
36:46osteoarthritis or bone deformities.
36:48These are excellent for evaluating bone
36:50structures.
36:51And then MRI, this is a more detailed
36:54image of soft tissues, especially useful
36:57for ligaments, tendons, um, miniski,
37:00minis,
37:02however you say it, discs, spinal cord,
37:05and muscle injuries.
37:08Again, we talked about this a little
37:10bit, but DEXA scan, a bone density scan
37:13to look at osteoporosis or osteopenia,
37:16especially in older adults,
37:18post-menopausal women.
37:21And the next step is going to be
37:23prioritizing your hypothesis, right, and
37:25taking action. So, using our assessment
37:27finding to determine what's most urgent,
37:29what could be causing the symptoms, what
37:31interventions are needed immediately.
37:34Um
37:36and then muscularkeletal conditions can
37:38change over time. So we always are
37:39reassessing or monitoring for increasing
37:42pain, changes in circulation, swelling,
37:45mobility, decline, neurovvascular
37:47changes, and any improvement we've done
37:49um they've had after our interventions.
37:52And then always good documentation which
37:54helps communicate patient status clearly
37:57and support continuity of care.
38:02Interprofessional collaboration. Maybe
38:04we're working with occupational therapy,
38:06physical therapy,
38:08um, orthopedics, rehab, rehab
38:10specialists, or case management, um, to
38:13help improve our patients outcomes. And
38:16then coming up with a plan of care based
38:18on our patients specific needs. Maybe
38:20that's pain management, maybe fall
38:22prevention or uh, exercise programs,
38:26assisted devices. And then finally,
38:28we're evaluating our outcomes. Did the
38:30pain improve? Is mobility better? has
38:33strength increased. Um, so clinical
38:36decision-m is really about connecting
38:37our assessment findings to coming up
38:40with a safe, individualized plan of care
38:43for our patient.
38:46And that's it. That was great. I hope
38:49you have a good day. I can't wait to
38:52work with you for our muscularkeeletal
38:55focused assessment. Yeah. See you later.

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