Subjective and objective data for musculoskeletal system
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This article is currently under review and may not be up to date. Please come back soon to see the finished work! (23/06/2022) Show Complex clinical reasoning decisions in real time and becoming competent in patient assessment takes practice, refinement and reflection. Patient assessment is an essential skill for every student and practicing physiotherapist.[1] A complete musculoskeletal examination of the patients gives an over view of patients body structure and function. Musculoskeletal/orthopaedic patient assessment is a process of appropriate subjective assessment with the understanding of particular joints , with use of specific tests at those particular joints and also appropriate subjective and objective markers along with understanding the need for continuous reassessment. [1][2] Human body is bi-laterally symmetrical. Hence during a musculoskeletal assessment each body part is compared not only to an ideal normal but also to symmetrical other side of the body in a sequential manner in order to determine abnormalities in alignment of bone/joint/muscle to other. [2][3] \( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}} } \) \( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash {#1}}} \)\(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\) \(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\)\(\newcommand{\AA}{\unicode[.8,0]{x212B}}\)
Now that you reviewed the anatomy of the musculoskeletal system and common musculoskeletal conditions, let’s discuss the components of a routine nursing assessment. Subjective AssessmentCollect subjective data from the patient and pay particular attention to what the patient is reporting about current symptoms, as well as past history of musculoskeletal injuries and disease. Information during the subjective assessment should be compared to expectations for the patient’s age group or that patient’s baseline. For example, an older client may have chronic limited range of motion in the knee due to osteoarthritis, whereas a child may have new, limited range of motion due to a knee sprain that occurred during a sports activity. If the patient reports a current symptom, use the PQRSTU method described in the “Health History” chapter to obtain more information about this chief complaint. If the patient is experiencing acute pain or recent injury, focus on providing pain relief and/or stabilization of the injury prior to proceeding with the interview. Use information obtained during the subjective assessment to guide your physical examination. Sample focused interview questions to include during a subjective assessment of the musculoskeletal system are contained in Table \(\PageIndex{1}\). The first question of the musculoskeletal interview is based on the six most common symptoms related to musculoskeletal disease.[1] Table \(\PageIndex{1}\): Focused Interview Questions Related to the Musculoskeletal SystemInterview QuestionsFollow-upAre you experiencing any current musculoskeletal symptoms such as muscle weakness, pain, swelling, redness, warmth, or stiffness?Describe your concern today.How is it affecting your ability to complete daily activities? P: Does anything bring on the symptom such as activity, weight-bearing, or rest? If activity brings on the symptom, how much activity is required to bring on the symptom(s)? Does it occur at a certain time of day? Is there anything that makes it better or go away? Q: Describe the characteristics of the pain (aching, throbbing, sharp, dull). R: Is the pain localized or does it radiate to another part or area of the body? S: How severe is the pain on a scale of 0-10? T: When did the pain first start? Is it constant or does it come and go? Have you taken anything to relieve the pain? Have you ever been diagnosed with a chronic musculoskeletal disease such as osteoporosis, osteoarthritis, or rheumatoid arthritis?Please describe the conditions and treatments.Have you ever been diagnosed with a neurological condition that affected the use of your muscles?Please describe.Have you had any previous surgeries on your bones or muscles, such as fracture repair or knee or hip surgery?Please describe.Are you currently taking any medications, herbs, or supplements for your muscles, bones, or the health of your musculoskeletal system?Please describe.Have you ever had a broken bone, strain, or other injury to a muscle, joint, tendon, or ligament?Please describe.Life Span ConsiderationsWhen conducting a subjective interview of children, additional information may be obtained from the parent or legal guardian. Newborn
Pediatric
Older AdultsWhen assessing older adults, it is important to assess their mobility and their ability to perform activities of daily living.
Objective AssessmentThe purpose of a routine physical exam of the musculoskeletal system by a registered nurse is to assess function and to screen for abnormalities. Most information about function and mobility is gathered during the patient interview, but the nurse also observes the patient’s posture, walking, and movement of their extremities during the physical exam. During a routine assessment of a patient during inpatient care, a registered nurse typically completes the following musculoskeletal assessments:
While assessing an older adult, keep in mind they may have limited mobility and range of motion due to age-related degeneration of joints and muscle weakness. Be considerate of these limitations and never examine any areas to the point of pain or discomfort. Support the joints and muscles as you assess them to avoid pain or muscle spasm. Compare bilateral sides simultaneously and expect symmetry of structure and function of the corresponding body area. InspectionGeneral inspection begins by observing the patient in the standing position for postural abnormalities. Observe their stance and note any abnormal curvature of the spine such as kyphosis, lordosis, or scoliosis. Ask the patient to walk away from you, turn, and walk back toward you while observing their gait and balance. Ask the patient to sit. Inspect the size and contour of the muscles and joints and if the corresponding parts are symmetrical. Notice the skin over the joints and muscles and observe if there is tenderness, swelling, erythema, deformity, or asymmetry. Observe how the patient moves their extremities and note if there is pain with movement or any limitations in active range of motion (ROM). Active range of motion is the degree of movement the patient can voluntarily achieve in a joint without assistance. See Figures 13.2.9 and 13.2.10 as resources for describing joint movement. PalpationPalpation is typically done simultaneously during inspection. As you observe, palpate each joint for warmth, swelling, or tenderness. If you observe decreased active range of motion, gently attempt passive range of motion by stabilizing the joint with one hand while using the other hand to gently move the joint to its limit of movement. Passive range of motion is the degree of range of motion demonstrated in a joint when the examiner is providing the movement. You may hear crepitus as the joint moves. Crepitus sounds like a crackling, popping noise that is considered normal as long as it is not associated with pain. As the joint moves, there should not be any reported pain or tenderness. Assess muscle strength. Muscle strength should be equal bilaterally, and the patient should be able to fully resist an opposing force. Muscle strength varies among people depending on their activity level, genetic predisposition, lifestyle, and history. A common method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing Scale.[3] This method involves testing key muscles from the upper and lower extremities against gravity and the examiner’s resistance and grading the patient’s strength on a 0 to 5 scale. See Box \(\PageIndex{1}\) for the muscle strength testing scale. Note \(\PageIndex{1}\): Muscle Strength Scale[4]0 – No muscle contraction 1 – Trace muscle contraction, such as a twitch 2 – Active movement only when gravity eliminated 3 – Active movement against gravity but not against resistance 4 – Active movement against gravity and some resistance 5 – Active movement against gravity and examiner’s full resistance To assess upper extremity strength, first begin by assessing bilateral hand grip strength. Extend your index and second fingers on each hand toward the patient and ask them to squeeze them as tightly as possible. Then, ask the patient to extend their arms with their palms up. As you provide resistance on their forearms, ask the patient to pull their arms towards them. Finally, ask the patient to place their palms against yours and press while you provide resistance. See Figure \(\PageIndex{1}\)[5] for images of a nurse assessing upper extremity strength. To assess lower extremity strength, perform the following maneuvers with a seated patient. Place your palms on the patient’s thighs and ask them to lift their legs while providing resistance. Secondly, place your hands behind their calves and ask them to pull their legs backwards while you provide resistance. Place your hands on the top of their feet and ask them to pull their feet upwards against your resistance. Finally, place your hands on the soles of their feet and ask them to press downwards while you provide resistance, instructing them to “press downwards like pressing the gas pedal on a car.” See Figure \(\PageIndex{2}\)[6] for images of a nurse assessing lower extremity strength.  NoteTo read additional details regarding a full range of motion assessment of the musculoskeletal system, visit the following chapter from Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition: An Overview of the Musculoskeletal System Video Review of Musculoskeletal Assessment[7]
See Table \(\PageIndex{2}\) for a comparison of expected versus unexpected findings when assessing the musculoskeletal system. Table \(\PageIndex{2}\): Expected Versus Unexpected Findings on Musculoskeletal AssessmentAssessmentExpected FindingsUnexpected Findings (document and notify provider if a new finding*)InspectionErect posture with good balance and normal gait while walking. Joints and muscles are symmetrical with no swelling, redness, or deformity. Active range of motion of all joints without difficulty. No spine curvature.Spinal curvature is present. Poor balance or unsteady gait while walking. Swelling, bruising, erythema, or tenderness over joints or muscles. Deformity of joints. Decreased active range of motion. Contracture or foot drop present.AuscultationNot applicableCrepitus associated with pain on movement.PalpationNo palpable tenderness or warmth of joints, bones, or muscles. Muscle strength 5/5 against resistance.Warmth or tenderness on palpation of joints, bones, or muscles. Decreased passive range of motion. Muscle strength of 3/5 or less.*CRITICAL CONDITIONS to report immediately Hot, swollen, painful joint. Suspected fracture, dislocation, sprain, or strain.
This page titled 13.4: Musculoskeletal Assessment is shared under a CC BY-SA 4.0 license and was authored, remixed, and/or curated by Ernstmeyer & Christman (Eds.) (OpenRN) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. What is the objective assessment of the musculoskeletal system?Objective Assessment. The purpose of a routine physical exam of the musculoskeletal system by a registered nurse is to assess function and to screen for abnormalities.
What should be included in a musculoskeletal assessment?To assess the musculoskeletal system, you carefully inspect your patient, examining the symmetry of the joints, muscles, and bones and checking for swelling, redness, and ease of movement. Then you palpate over the joints, noting any areas of warmth or tenderness.
What is a normal assessment finding of the musculoskeletal system?Normal or abnormal findings that could be elicited by observation and palpation include: symmetry/asymmetry - skin color and appearance, rash, ulcers, lack of sweating hair abnormalities - warmth and heat - Swelling including effusions, nodules, and inflammatory findings like synovial and periarticular thickening - ...
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