BACHELOR OF SCIENCE IN NURSING:

HEALTH ASSESSMENT
COURSE MODULE COURSE UNIT WEEK
3 15 14

Adult Physical Assessment: Musculoskeletal System

✓ Read course and unit objectives

✓ Read and comprehend study guide prior to class
attendance
✓ Read and comprehend required learning resources
✓ Engage in classroom discussions
✓ Participate in weekly discussion board (Canvas)
✓ Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Describe the structure and the function of the musculoskeletal system.
2. Describe the findings frequently seen with assessing the older client’s musculoskeletal
system.
3. Document and verbally report accurate assessment findings of the musculoskeletal system.
4. Differentiate between normal and abnormal findings of the musculoskeletal system.
5. Analyze the data from the interview and physical assessment to formulate nursing
diagnosis, collaborative problems, and/or referrals.
Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.

Psychomotor:
1. Participate actively during class discussions
2. Confidently express personal opinion and thoughts in front of the class

Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing 6th Edition, Philadelphia:
Wolters Kluwer

ASSESSMENT OF THE MUSKULO - SKELETAL

Major Bones Of The Skeleton

Muscles Of The Body - Anterior

Muscles Of The Body - Posterior

Structure and Function
• The bones, muscles and joints make up the musculoskeletal system.
• Controlled and innervated by the nervous system.
• Bones
o Provide, structure, protection, serve as storage of calcium and produced blood cells
o 206 bones: axial and appendicular skeleton
o Composed of osseous tissue
▪ Compact
• hard and dense, outer layer
▪ Spongy
• contains numerous spaces, inner layer
o Osteoblasts
▪ bone formers
o Osteoclasts
▪ bone destroyers
o Red marrow
▪ produces blood cells
o Yellow marrow
▪ composed mostly of fats
• Skeletal Muscles
o Types: skeletal, smooth muscle, cardiac
o 650 skeletal (voluntary) muscle, which are under conscious control
o Assist with posture, produces body heat and allow body to move

Skeletal Muscle Movements

• Abduction
o moving away from midline of the body
• Adduction
o moving toward midline of the body
• Circumduction
o circular motion

• Inversion
o moving inward
• Eversion
o moving outward

• Extension
o straightening the extremity at the joint and increasing the angle of the joint
• Flexion
o bending the extremity at the joint and decreasing the angle of the joint

• Pronation
o turning or facing downward
• Supination
o turning or facing upward
 • Protraction
o moving toward
• Retraction
o moving backward

• Rotation
o turning head to the right shoulder then back to the midline, next turning the head to
left shoulder then back to midline

Joints (Articulation)
• Provide a variety of range of motion (ROM ) for the body parts
• Fibrous
o are joined by fibrous connective tissue and are immovable
▪ (sutures bet. Skull bones)

• Cartilaginous
o are joined by cartilage
▪ joints bet. Vertebrae
• Synovial
o contain a space between the bones that is filled with synovial fluid, a lubricant that
promotes a sliding movement of the ends of the bones

• TemporomandibularJoints
o open and closes the mouth
o projects and retracts the jaw
o moves jaw from side to side

• Sternoclavicular Joints
o has no obvious movements
o junction between the manubrium of the sternum and the clavicle

• Shoulder
o Flexion and extension
o Abduction and adduction
o Circumduction
o Rotation (internal and external)
• Hip
o Flexion with knee flexed and with knee extended
o Extension and hyperextension
o Circumduction
o Rotation (internal and external)
o Abduction and adduction

• Wrists, Fingers & Thumb

o Wrists
▪ flexion, extension
▪ hyperextension
▪ adduction
• radial and ulnar deviation
o Fingers
▪ flexion, extension
▪ hyperextension
▪ abduction
▪ circumduction
o Thumb
▪ flexion, extension
▪ opposition
• Elbow
o flexion and extension of the forearm
o supination and pronation of the forearm
• Knee
o flexion and extension
• Ankle And Foot
o Ankle
▪ plantar flexion and dorsiflexion
o Foot
▪ inversion and eversion
o Toes
▪ flexion, extension
▪ abduction, adduction
 • Vertebrae (Lateral View)
o 33 bones
▪ C – 7 concave-shaped
▪ T – 12 convex-shaped
▪ L – 5 concave-shaped
▪ S–5
▪ Cx – 3-4
o flexion
o hyperextension
o lateral bending
o rotation

ASSESSMENT PROPER
• Inspection
o Inspect Muscles for Size
▪ Compare each muscle on one side of the body to the same muscle on the
other side
▪ For any apparent discrepancies, measure the muscles with a tape
▪ Normal
• equal size on both sides of body
▪ Deviations from normal
• ATROPHY (a decrease in size) or HYPERTROPHY (an increased in
size)
o Inspect Muscles and Tendons for Contractures
▪ Normal
• no contractures
▪ Deviations from normal
• Malposition of body part (foot drop or foot flexed forward)
o Inspect Muscles for Tremors
▪ Inspect any tremors of the hands and arms by having the client hold arms out
in front of body
▪ Normal
• no fasciculation or tremors
▪ Deviations from normal
• presence of fasciculation or tremors

• Palpation
o Palpate muscles at rest to determine muscle tonicity
▪ Normal
• normally firm
 ▪ Deviations from normal
• atonic (lacking tone)
o Palpate muscles while the client is active and passive for flaccidity, spasticity, and
smoothness of movement
▪ Normal Findings
• smooth coordinated movements
▪ Deviations from normal
• flaccidity (weakness or laxness) or spasticity (sudden involuntary
muscle contraction)
o Test muscle strength. Compare the right side with left side.
▪ Normal
• equal strength on each body side
▪ Deviations from normal
• 25% or less muscle strength
▪ GRADING MUSCLE STRENGTH

o Sternocleidomastoid
▪ Client turns the head to one side against the resistance of your hand. Repeat
with the other side.
o Trapezius
▪ Client shrugs the shoulders against the resistance of your hands.
o Deltoid
▪ Client holds arm up and resists while you try to push it down.
o Biceps
▪ Client fully extends each arm and tries to flex it while you attempt to hold arm
in extension.
o Triceps
▪ Client flexes each arm and then tries to extends it against your attempt to
keep in flexion
o Wrist and Finger Muscles
 ▪ Client spreads the fingers and resists as you attempt to push the fingers
together.
o Grip Strength
▪ Client grasps your index finger and middle fingers while you try to pull the
fingers out.
o Hip Muscles
▪ Client is supine, both legs extended; client raises one leg at a time while you
attempt to hold it down.
o Hip Abduction
▪ Client is supine, both legs extended. Place your hands on the lateral surface
of each knee; client spreads the legs apart against your resistance.
o Hip Adduction
▪ Client is in same position as in hip abduction. Place your hands between the
knees; client brings the legs together against your resistance.
o Hamstrings
▪ Client is supine, both knees bent.
▪ Client resists while you attempt to straighten the legs.
o Quadriceps
▪ Client is supine, knee partially extended; client resists while you attempt to
flex the knee.
o Muscles of the Ankle and Feet
▪ Client resists while you attempt to dorsiflex the foot and again resists while
you attempt to flex the foot.
• Palpation & Inspection
o Bones
▪ Inspect the skeleton for normal structure and deformities.
• Normal
o no deformities
• Deviation from normal
o bones misaligned
▪ Palpate the bones to locate any areas of edema or tenderness.
• Normal
o no tenderness of swelling
• Deviation from normal
o presence of tenderness of swelling
o Joints
▪ Inspect the joint for swelling.
• Normal
o no swelling
• Deviation from normal
o one or more swollen joints
 ▪ Palpate each joint for tenderness, smoothness of movement, swelling,
crepitation, and presence of nodules.
• Normal Findings
o No tenderness, swelling, crepitation, or nodules
• Deviation from normal
o Presence of tenderness, swelling, crepitation, or nodules

RANGE OF MOTION (ROM)

• Ask the client to move selected body parts. If available, use a goniometer to measure the
angle of the joint in degrees.
• Normal
o Varies to some degree in accordance with person’s genetic makeup and degree of
physical activity
• Deviations from normal
o Presence of tenderness, swelling, crepitation, or nodules

Range of Motions

• Flexion
o Move the head from the upright midline position forward, so that the chin rests on the
chest
• Extension
o Move the head from the flexed position to the upright position
• Hyperextension
o Move the head from the upright position back as far as possible
• Lateral Flexion
o Move the head laterally to the right and left shoulders

• Rotation
o Move the head laterally to the right and left shoulders

• Flexion
o Raise each arm from a position by the side forward
and upward to a position beside the head
• Extension
o Move each arm from a vertical position beside the
head forward and down to a resting position at the side
of the body
• Hyperextension
o Move each arm from a resting side position to behind
the body

• Abduction
o Move each arm laterally from a resting position at the
sides to a side position above the head, palm of the hand
away from the head
• Adduction (Anterior)
o Move each arm from a position at the sides across the
front of the body as far as possible
o The elbow may be straight or bent
• Circumduction
o Move each arm forward, up, back, and down in a full
circle

• Flexion
o Move each arm forward, up, back, and down in a full
circle
• Extension
o Bring each lower arm forward and downward,
straightening

• External Rotation
o With each arm held out to the side at shoulder level and
the elbow bent to a right angle, fingers pointing down,
move the arm upward so that the fingers point up
• Internal Rotation
o With each arm held out to the side at shoulder level and
the elbow bent to a right angle, fingers pointing up, move
the arm forward and down so that the fingers point down

• Rotation for supination

o Turn each hand and forearm so that the palm is facing
upward
• Rotation for pronation
o Turn each hand and forearm so that the palm is facing
downward
• Flexion
o Bring the fingers of each hand toward the
inner aspect of the forearm
• Extension
o Straighten each hand to the same plane as
the arm

• Hyperextension
o Bend the fingers of each hand back as far as
possible

• Radial Flexion (Abduction)

o Bend each wrist laterally toward the thumb side with
hand supinated
• Ulnar Flexion (Adduction)
o Bend each wrist laterally toward the fifth finger with the
hand supinated

• Flexion
o Make a fist with each hand; Extension.
Straighten the fingers of each hand
• Hyperextension
o Bend the fingers of each hand back as far
as possible
• Abduction
o Spread the fingers of each hand apart
• Adduction
o Bring the fingers of each hand together

• Flexion
o Move each thumb across the palmar surface of the hand
toward the fifth finger
• Extension
o Move each thumb away from the hand

• Abduction
o Extend each thumb laterally
• Adduction
o Move each thumb back to the hand

• Opposition
o Touch each thumb to the top of each finger of the same
hand.
o The thumb joint movements involved are abduction,
rotation, and flexion.
• Flexion
o Move each leg forward and upward.
o The knee may be extended or flexed.

• Extension
o Move each leg back inside the other.
• Hyperextension
o Move each leg back behind the body.

• Abduction
o Move each leg out to the side.
• Adduction
o Move each leg back to the other leg and beyond in front of it.

• Circumduction
o Move each leg backward, up, to the side, and down in a circle
• Internal Rotation
o Turn each foot and leg inward so that the toes point as far
as possible toward the other leg.
• External Rotation
o Turn each foot and leg outward so that the toes point as
far as possible away from the other leg.

• Flexion
o Bend each leg, bringing the heel toward the back of
the thigh.
• Extension
o Straighten each leg, returning the foot to its position
beside the other foot.

• Flexion (dorsiflexion)
o Point the toes of each foot upward.
• Extension (plantar flexion)
o Point the toes of each foot downward.

• Eversion
o Turn the sole of each laterally
• Inversion
o Turn the sole of each foot medially
• Flexion
o Curl the toe joints of each foot
downward
• Extension
o Straighten the toes of each foot

• Flexion
o Bend the trunk toward the toes
• Extension
o Straighten the trunk from a flexed position
• Hyperextension
o Bend the trunk backward

• Lateral Flexion
o Bend the trunk to the right and to the left

• Rotation
o Turn the upper part of the body from side to side
Abnormalities Affecting the Wrist, Hands and Fingers
• Acute Rheumatoid Arthritis
o tender, painful, swollen, stiff joints
• Chronic Rheumatoid Arthritis
o chronic swelling and thickening of the metacarpophalangeal and proximal
interphalangeal joints, limited ROM, and finger deviation toward the ulnar side
• Boutonniere and Swan-neck Deformities
o flexion of the proximal interphalangeal joint and hyperextension of the distal
interphalangeal joint
o hyperextension of the proximal interphalangeal joint with flexion of the distal
interphalangeal joint
• Thenar Atrophy
o atrophy of the thenar prominence due to pressure on the median nerve is seen in
carpal tunnel syndrome
• Ganglion
o non-tender, round, enlarged, swollen, fluid- filled cyst and commonly seen at the
dorsum of the wrist
• Osteoarthritis
o hard, painless, nodule over the distal interphalangeal joints ( Heberden’s nodes) and
over the proximal interphalangeal joints (Bouchard’s nodes)
• Tenosynovitis
o painful flexion of a finger (infection of the flexor tendon sheathes)
Abnormalities of Feet and Toes
• Acute – Gouty Arthritis
o metatarsophalangeal joint of the great toe is tender, painful, reddened, hot and
swollen
• Callus
o are non-painful, thickened skin that occur at pressure points
• Corn
o are painful thickening of the skin that occur over the bony prominences and at
pressure points
• Plantar Wart
o are painful warts ( verruca vulgaris ) that often occur under a callus, appearing as
tiny dark spots
• Hallux Valgus
o the great toe is deviated laterally and may overlap the second toe
D’Amico, D., and Barbarito, C., (2019) Health & Physical Assessment in Nursing 3rd Edition,
Singapore: Pearson Education, Inc.
https://journals.lww.com/nursingmadeincrediblyeasy/fulltext/2010/03000
/simplifying_neurologic_assessment.5.aspx

Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing

6th Edition, Philadelphia: Wolters Kluwer