Pengkajian Sistem Muskuloskeletal (Bandingkan dengan University of Melbourne’s Procedure- attached )

Perkenalkan diri pada klien Meminta “informal consent” dari klien Mencuci tangan dengan sabun atau “chemical agents” Pertahankan privasi klien tetap terjaga (tutup tirai) Menginspeksi penampilan umum klien, kebersihan dan kemampuan klien untuk berhias, postur, cara berjalan,

perubahan karena aktivitas. Inspeksi apakah ektremitas dan persendian simetris, adanya deformitas Kaji kekuatan otot (muscle strength) Kaji Rentang Pergerakan Sendi/ ROM Kaji Neuromuskular Deep Tendon Reflex Lakukan evaluasi obyektif dan subyektif Mencuci tangan Dokumentasi

Addition:

Objective Data Collection

• Inspection: general and specific Palpation (no percussion or auscultation)Special techniques: Range of motion & Muscle size, strength, tone, and involuntary movements

General Assessment

• Overall appearance

• Posture

• Gait and mobility

– Gait patterns

– Transfer ability

– Weight bearingGait:

Spastic hemiparesis- CVA, trauma. Arm is immobile against the body; shoulder, elbow, wrist, fingers flexed. The leg is stiff and extended and circumducts with each step )

Cerebellar ataxia – alcohol; cerebellar tumor; MS (staggering, wide-based; uncoordinated, positive Romberg)

Parkinsonian- stooped, trunk forward; elbows, hips, and knees are flexed. Steps are short and shuffling. Hesitation to begin walking. Body rigid

Steppage- looks like he’s walking up stairs, but no stairs there (polio, peripheral neuropathy)

Waddling- pregnant woman

Short leg

General Assessment

• Normal findings

– Height and weight are appropriate

– Ambulates independently

– No structural defects

– Shoulders and hips are level

– Head and torso are upright

– Stable gaitPresence of swelling at the joint is significant and signals joint irritation.

Swelling may be due to excess joint fluid, thickening of synovial lining, inflammation of surrounding tissue (bursae, tendons) or bony enlargement.

Inspection of muscles

• Muscle size and shape

– Symmetry--Muscle size and shape must be compared side to side.

– Hypertrophy

– Atrophy

– Involuntary muscle movements

– Limb circumference

Inspection

• Normal findings

– Symmetrical muscle contour

– No involuntary muscle movements

– Bilateral limb measurements are within 1–3 cm of each other

Inspection of joints

• Normal findings

– Joints are flat when extended, and smooth or rounded during flexion

– No joint enlargement or deformity

Palpation of joints

• Palpate each joint

– Temperature/ Muscles/ Bony articulations

– Area of joint capsuleJoints are not normally tender to palpation. If it is tender, try to idntfy where exactly. (skin, muscle, bursaw, ligaments, tendons, fat pads, joint capsule.)

Palpation of the muscles

• Tone is the normal degree of contraction in voluntary relaxed muscles• Flaccidity: decreased resistance• Spasticity: increased tone; increased resistance then suddenly may release• Rigidity: constant state of resistance

Range of Motion (ROM)

• Active ROM

– Stabilize proximal area

• Passive ROM if active ROM limited

– Be gentle, do not force

• Tenderness, pain, or crepitationCrepitation is an audible and palpable crunching or grating with movement. It is not the crack that you sometimes hear as ligaments or tendons slip over the bone during motion.

Muscle Testing

• Test the strength of the prime mover for each joint• Ask person to flex and hold while examiner uses opposing force.• Should be strong and equal bilaterally with full resistance• Always compare right and left sides of paired muscles groups• Note any involuntary movements

Assessing Muscle Strength There are several ways to document muscle strength. If you “grade” the muscle strength, you use 0-5 with 5 normal. Description uses words. Percentage of normal is another option.

• Muscle strength can be assessed directly by using the Muscle Strength Grading Scale

Techniques for Assessing Joints

• Temporomandibular Open and close mouth; Lateral jaw movement 3-6 cm Lateral movement: 1-2cm

– Protrude and retract jaw without deviation• Cervical spine– Flexion/ extension/ hyperextension: 55 degrees extension/ 45 degrees flexion– Rotation – Lateral bending 40 degrees right and left lateral bending• Thoracic/Lumbar Spine – Forward flexion/ hyperextension – Lateral bending Rotation 70 degrees each way

• Shoulders – Adduction/ abduction – Flexion/ extension/ hyperextension – External Rotation (place hands behind head)– Internal Rotation (place hands behind lower back)

Special Techniques for Assessing JointsElbows

– Flexion/ extension – Pronation/ supination • Wrists and hands – Wrist extension/ flexion/ hyperextension – Radial and ulnar motion – Thumb opposition – Finger abduction and adduction • Hips – Abduction/ adduction – Hip flexion and extension with knee straight – Hip flexion with knee bent – Internal and external rotation – Knees• Ankles and feet– Dorsiflexion and plantar flexion – Inversion/ eversion

Use of Assistive Devices The assessment is only to ask if the patient uses any of these devices. The students do not need to demonstrate that they know proper use of these devices.

• Crutches • Cane • Walker

• Brace, splint, immobilizer • Cast

Developmental Considerations

• Newborn• School Age• Adolescent• Pregnancy• Aging

Infant: Musculoskeletal

• Rapid bone growth during infancy• Trauma or infection at epiphyses puts infant at risk for impaired growth• Skull larger in comparison to body• Fontanelles• Skeletal contour changes• Assessment– Motor development– Positional deformities– Congenital dislocation– Gluteal foldsAt birth, infant has C shaped spine. 3-6 months, cervical neck curve arrives. Walking helps deveop the anterior curve of the lumbar spine

Were you told of any trauma to ifnat during L&D? head first? Forceps? Resuscitation? Any bone deformities? Normal spine? Unusual shape of feet or toes?

Motor developmen checked with Denver II

Preschool-School Age

• Observation of joints and muscles while at play• Lordosis common in childhood• Genu varum (bowlegged) common until 1 year after walking• Genu valgum (knock-knees) between age 2 ½ and 3 ½• Toeing in (pigon toes) usually self corrects by age 3-- The little boy on the bottom right is showing the “toeing in” or pigeon toes.

Adolescents

• Check spinal posture especially kyphosis• Scoliosis—important to assess for this in adolescents• Sports related injuries

Pregnancy

• Lordosis—common with pregnancy• Anterior cervical flexion• Kyphosis

• Slumped shoulders• “Waddling” gait

The Aging Adult: Musculoskeletal

• Osteoporosis• Decreased height• “Use it or lose it”—if we do not use our muscles, they atrophy. If we do not use our bones for weight bearing, they lose density.• Kyphosis—almost all older people will show kyphosis to some degree

Gerontological Variations

• Decrease in bone density• Weaker bones, increased risk of osteoporosis• Muscle atrophy• Decreased muscle strength• Decreased overall body mass• Increase in fat content• Deterioration of articulating cartilage• Vertebral inflexibility