Health History: musculoskeletal disorders may be stable or progressive, characterized by symptom-free periods as well as fluctuations in symptoms.
Details about onset, character, severity, location, duration, and frequency of S/S.
Note its associated complaints: precipitating, aggravating, and relieving factors;
Progression, remission, and exacerbation.
Presence or absence of similar symptoms in family members.
Common Symptoms:
Pain and Tenderness: bone pain is typically described as a dull, deep ache that is “boring” in nature. It is not typically related to movement and may interfere with sleep. Rest relieves most musculoskeletal pain.
Muscular pain is described as soreness or aching, potentially referred to as “muscle cramps”.
Fracture pain is described as sharp, piercing, and relieved by immobilization.
Bone infection (osteomyelitis) may also result in sharp pain with muscle spasms or pressure on a sensory nerve.
Joint pain is felt around or in the joint and typically worsens with movement.
Pain that increases with activity indicates joint sprain, muscle strain, or compartment syndrome.
Steadily increasing pain points to progressing infection, a malignant tumor, or neurovascular complications.
Radiating pain is found in conditions that place pressure on a nerve root.
The time of day in which pain occurs may also be important: inflammatory rheumatic disorders experience worse pain in the morning, especially upon walking. Tendonitis worsens during the early morning and eases by midday. Osteoarthritis worsens as the day progresses.
Some assessment focuses include:
Is the body in alignment?
Are the joints symmetrical or are bony deformities present?
Is there any inflammation or arthritis, swelling, warmth, tenderness, or redness?
Is there pressure from traction, bed linens, a cast, or other appliances?
Is there tension on the skin at a pin site?
Altered Sensations: sensory disturbances are frequently associated with musculoskeletal problems. Paresthesias may be described as sensations of burning, tingling, or numbness. These may be caused by pressure on nerves or circulatory impairment. Assess the patient’s neurovascular status in the affected area.
Soft tissue swelling or direct trauma to neurovascular structures may impair their function.
Some assessment focuses include:
Is the patient experiencing abnormal sensations, such as burning, tingling, or numbness?
If the abnormal sensation involves an extremity, how does this feeling compare to sensation in the unaffected extremity?
When did the condition begin? Is it getting worse?
Concurrent health conditions: diabetes, heart disease, COPD, infection, preexisting disability
Related problems (familial or genetic abnormalities)
Any history of trauma, or injuries (e.g. falls)
Fracture Risk Assessment Tool (FRAX): a tool to predict a patient’s 10-year risk for fractures of the hip or other major bones (spine, forearm, shoulder). The data required includes age, gender, BMI, history, parental history of hip fractures, cigarette use, corticosteroid use, history of RA, alcohol intake of 3 or more drinks per day, and history of secondary causes/risks for osteoporosis. Bone Mineral Density (BMD) based on bone densitometry results may be used as risk assessment if hip-based.
Assess for osteoporosis if the patient is a postmenopausal woman over the age of 50, has low BMD, and those with secondary causes/risks for osteoporosis.
Physical Assessment
Posture: the normal curvature of the spine is convex through the thoracic portion and concave through the cervical and lumbar portions. Common deformities of the spine include:
Kyphosis: rounding of the back from increased forward curvature of the thoracic spine; hunchback. This may occur at any age from degenerative diseases of the spine (e.g. arthritis, disc degeneration, fractures r/t osteoporosis, and injury or trauma) or other neurovascular diseases.
Lordosis: exaggerated curvature of the lumbar spine. This may occur at any age. Common causes include tight low back muscles, excessive visceral fat, and pregnancy.
Scoliosis: lateral curving deviation of the spine. This may be congenital, idiopathic, or from damage to paraspinal muscles (e.g. muscular dystrophy).
During inspection, the spine, back, buttocks, and legs are exposed. Standing and trunk symmetry are noted from posterior and lateral views. Differences in the height of the shoulders or iliac crests are noted. Shoulder and hip symmetry, as well as the line of the vertebral column, is inspected twice with the patient erect, then while bending forward.
Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders are not level, the waistline is asymmetric, and a prominent scapula (especially noticeable when bent forward).
Inspection should also be done with the patient bending backwards with support from the nurse.
Gait: assess gait by having the patient walk away from the examiner for a short distance. Observe the gait for smoothness and rhythm. Any unsteadiness or irregular movements (frequently noted in older adult patients) are considered abnormal.
A limping motion is most frequently caused by painful weight bearing. In such instances, the patient can usually pinpoint the area of discomfort, thus guiding further examination.
A limp may be observed if one extremity is shorter than another, with the hip dropping downward on the affected side with each step.
In a normal gait, the knee should flex: limited joint motion may interrupt the smooth pattern of gait.
Other neurologic conditions are also associated with abnormal gaits, such as spastic hemiparesis gait (from a stroke), steppage gait (from lower motor neuron disease), and a shuffling gait (found in Parkinson’s Disease).
Bone Integrity: assess for deformities and alignment. Compare symmetries between parts of the body such as extremities. Abnormal bony growths due to tumors may be observed.
Shortened extremities, amputations, and abnormal alignment are noted.
Fracture findings may include abnormal angulation of long bones, motion found at points other than joints, and crepitus (grating/crackling sensation or sound) at the point of abnormal motion.
The nurse should assess the following:
If the affected part is an extremity, how does its overall appearance compare to the unaffected extremity?
Can the patient move the affect part? If an extremity is involved, does each toe or finger have normal sensation and motion, and is the skin warm or cool?
What is the color of the part distal to the affected area? Is it pale? Dusky? Mottled? Cyanotic?
Does rapid capillary refill occur? (The nurse can gently squeeze a nail until it blanches, then release the pressure. The amount of time for the color under the nail to return to normal is noted. Color normally returns within 3 seconds. The return of color is evidence of capillary refill.)
Is a pulse distal to the affected area palpable? If the affected area is an extremity, how does the pulse compare to the pulse of the unaffected extremity?
Is edema present?
Is any constrictive device or clothing causing nerve or vascular compression?
Does elevating the affected part or modifying its position affect the symptoms?
Joint Function: note the range of motion, deformity, stability, tenderness, and nodular formation.
ROM is evaluated actively and passively. The nurse should be familiar with the normal ROM of major joints. Precise measurements may be made using a goniometer.
Limitations may exist from skeletal deformity, joint pathology, or contractures (shortening of surrounding joint structures) of the muscle, tendons, or joint capsules.
If compromised, the joint is examined for effusion (suspected if swollen and normal bony landmarks are obscured), swelling, and increased temperature that may reflect active inflammation.
Patellar Joint Effusion may manifest as knee ballottement or the balloon sign. Consultation with a specialist is indicated.
Joint Deformity may be caused by contractures, dislocation, subluxation, or disruption of structures surrounding the joint.
Weakness may indicate the need for an external supporting appliance.
Palpation during passive movement provides information about integrity: motion is normally smooth. Snapping or cracking may indicate ligament slippage. Crepitus indicates a disorder that produces rough deformity of the articular surfaces.
Nodules may form, such as the characteristic nodules of rheumatoid arthritis, gout, and osteoarthritis
Rheumatoid Arthritis has characteristic soft subcutaneous nodules on the extensor tendons for the joint.
Gout nodules are hard and lie within and immediately adjacent to the joint capsule itself.
Osteoarthritic nodules are hard and painless, and represent bony overgrowth resulting from destruction of the cartilaginous surface of bone within the joint capsule.
Muscle Strength and Size: note muscular strength and coordination, size, and ability to change positions. Weakness can indicate a variety of conditions, such as polyneuropathy, electrolyte imbalances (particularly of potassium and calcium), myasthenia gravis, poliomyelitis, and muscular dystrophy.
Have the patient perform certain maneuvers with and without added resistance from the nurse. A simple handshake can provide an indication of grasp strength.
Clonus (rhythmic contractions) of the ankle or wrist may be elicited by sudden, forceful, sustained dorsiflexion of the foot or extension of the wrist.
Fasciculation (involuntary muscle twitching) may be observed.
Measure extremity girth (the maximum circumference) compared to the unaffected extremity to monitor for increases in size from rehabilitation, edema, or bleeding; or decreases in size from atrophy. Note location or landmark of measurement for consistency.
Skin: inspect the skin for edema, temperature, and color. Palpation of the skin may reveal warmer areas that suggest increased perfusion or inflammation, or cooler areas that suggest decreased perfusion, and wether edema is present.
Cuts, bruises, skin color, and evidence of decreased circulation or inflammation can influence nursing management of musculoskeletal disorders.
Neurovascular Status: obtained frequently in musculoskeletal disorders, especially for fractures because of the risk of tissue and nerve damage.
The nurse should be aware of the symptoms of compartment syndrome, a result of increased pressure in a muscle compartment, resulting in nerve and muscle anoxia and necrosis. Function can be permanently lost if uncorrected for 6 hours.
