BSN220 - Clinical Health Assessment Lab

Week 14
Sem 1 AY 2024-25
Musculoskeletal Assessment Checklist

Student name………………………...……. Student number…………...……

Date…….…………………... Assessor…………………………

Musculoskeletal Assessment Performed Comments

Criteria Yes No
Student introduces self to
1-Client interaction patient
Communication, identification, Identifies patient using at
etc. least two identifiers
Explains procedure and gets
verbal consent
Provides privacy i.e., curtains,
drapes
Gathers equipment (gloves,
2-Safe environment light, and centimeter ruler)
Handwashing, manual handling, Performs hand hygiene
environment safety etc. before, during and after.
Maintains comfort and safety
through appropriate side rails
and bed level position
Uses appropriate back
techniques
Call bell & other necessary
items & belongings are within
reach of the patient
1- Subjective & Objective Musculoskeletal
 Performed
A-Subjective Data
Yes No Comments
1. Joint Pain
a. Pain
b. Stiffness
c. Swelling, heat and redness
d. Limitation of movement
2. Muscles
a. Pain (cramps)
b. Weakness
3. Bones
a. Pain
b. Deformity
c. Trauma (fracture, sprains, and dislocations)
4. Functional assessment (activities of daily living [ADLs])
(bathing, toileting, dressing, grooming, eating, mobility)
5. Patient centered behavior.
a. Occupational hazards that could affect the muscles &
joints (heavy lifting, exercise)
b. Exercise program
c. Recent weight gain
d. Usual daily diet
e. Any medications (OTC)
f. Effects of disability on interaction with the family,
friends, and self-image
B- Objective Data
Performed Comments
Procedure
Yes No
1. Gather the appropriate equipment (Tape measure, Skin
marking pen)
2. Perform hand hygiene
Order of Examination
 Inspection: note the size & contour of the joint. Inspect the
skin & tissues over the joints for color, swelling, & any
masses or deformity.
 Palpation: palpate each joint noting any heat, tenderness,
swelling, or masses.
 Range of Motion (ROM): Ask for active ROM while stabilizing
 the body area proximal to that being moved. Joint motion
normally causes no tenderness, pain, or crepitation.
 Muscle testing: Ask the person to flex & hold as you apply
opposing force. Muscle strength should be equal bilaterally
& should fully resist your opposing force.

Grade Description %Normal Assessment

5 Full ROM against gravity, full 100 Normal
resistance
4 Full ROM against gravity, some 75 Good
resistance
3 Full ROM with gravity 50 Fair
2 Full ROM with gravity 25 Poor
eliminated (passive motion)
1 Slight contraction 10 Trace
0 No contraction 0 zero

Temporomandibular joint
 With the person seated, inspect the area just anterior to the
ear. Place the tips of your first two fingers in front of each
ear and ask the person to:
 open and close the mouth. Drop your fingers into the
depressed area over the joint and note smooth
motion of the mandible. An audible and palpable
snap or click occurs in many healthy people as the
mouth opens.

 Then ask the person to:

 Open mouth maximally - Vertical motion. You can
measure the space between the upper and lower
incisors. Normal is 3 to 6 cm or three fingers inserted
sideways.
  Partially open mouth, protrude lower jaw, and move
it side to side. - Lateral motion. Normal extent is 1 to
2 cm.

 Stick out lower jaw - Protrude without deviation.

 Palpate the contracted temporalis and masseter muscles as

the person clenches the teeth. Compare right and left sides
for size, firmness, and strength. Ask the person to move the
jaw forward and laterally against your resistance and open
mouth against resistance. This also tests the integrity of
cranial nerve V (trigeminal).
3. Cervical spine
 Inspect the size & contour, mass, or deformity.
 Palpate for spinous processes, sternomastoid, trapezius,
and paravertebral muscles for temperature, pain,
swelling or mass.
 Test active ROM:
- flexion: touch chin to chest
- hyperextension: lift the chin towards the ceiling.
- lateral bending right then left - touch each ear
toward shoulder
- right & left rotation: turn the chin towards each
shoulder.
 Muscle strength: Repeat the movements and apply
opposing force
4. Shoulders
 Inspect the size & contour, color, swelling, mass or
deformity.
 Palpate for temperature, pain, swelling or mass, note any
crepitation.
 Test active ROM:
- Forward flexion: arms on the side and elbows
extended move both arms up and down in wide arc.
- Internal rotation: rotate arms internally behind back
 - Abduction/Adduction: with arms on the side and
elbows extended move arms up in a wide arc in
coronal plane touch hands above head.
- external rotation: touch hands behind the head with
elbows flexed.

 Mus
cle

strength: shrug the shoulder, against your resistance.

5. Elbows
 Inspect the size & contour, color, swelling, mass or
deformity.
 Palpate for temperature, pain, swelling or mass, check
for synovial thickness. Palpate with the elbow flexed
about 70 degrees and as relaxed as possible. Use your
left hand to support the person's left forearm and
palpate the extensor surface of the elbow—the
olecranon process and the medial and lateral epicondyles
of the humerus—with your right thumb and fingers.
  Test
active ROM:
- flexion/extension: bend and straighten the elbow.
- pronation/supination: stabilize hand on a table move
hand back and ford.
 Muscle strength:
- Stabilize the person’s arm with one hand. Have the
person flex the elbow against your resistance applied
proximal to the wrist.
6. Wrists & hands
 Inspect the size & contour, color, swelling, shape,
position or deformity.
 Palpate the wrist and
metacarpophalangeal joints for temperature, pain,
swelling or mass.

 Test for active ROM:

- Hyperextension: bend hand up at wrist
 - Palmar flexion: bend hand down at wrist
- Flexion: bend fingers up and down
- Ulnar and radial deviation: palm flat on table turn
them out and in
- Abduction: fingers spread, make fist
- touch thumb to finger
 Muscle strength, position the person’s forearm supinated
(palm up) and resting on a table.
- Flex the wrist against your resistance at the palm.
 Perform Phalen’s Test and check for Tinel’s sign

7. Hips
 Inspect Symmetric levels of iliac crests.
Gluteal folds, Equally sized buttocks
 Palpate the hip joints while the person in supine position
for stability, symmetry, pain, swelling or mass.
 Test active ROM:
- Hip flexion: raise each leg with knee extended, bend
knee up on the chest with other leg straight.
- Internal/ external rotation: flex knee and hip to 90
degrees, swing the foot outward and inwards
- Abduction/ adduction: Swing leg laterally and
medially with leg straight
- Hyperextension: when standing, swing the leg back
8. Knees
 Inspect shape & contour, color, swelling, lesion, lower leg
alignment, quadriceps muscle.
 Palpate for temperature, pain, swelling or bulge sign,
palpate for Ballottement of the Patella.
Bulge Sign

For swelling in the suprapatellar pouch, the bulge sign confirms the
presence of small amounts of fluid as you try to move the fluid from
one side of the joint to the other. Firmly stroke up on the medial
aspect of the knee 2 or 3 times to displace any fluid ( A). Tap the
lateral aspect (B). Watch the medial side in the hollow for a distinct
bulge from a fluid wave. Normally none is present.
Ballottement of the Patella

 Continue palpation and explore the tibiofemoral joint (Fig.

23.34). Note smooth joint margins and absence of pain.
Palpate the infrapatellar fat pad and the patella. Check for
crepitus by holding your hand on the patella as the knee is
flexed and extended. Some crepitus in an otherwise
asymptomatic knee may occur.

 Test active ROM:

- Flexion/extension: bend each knee and straighten
again.
- Check knee ROM while walking.
 Muscle strength by asking the person to maintain knee
flexion while you oppose by trying to pull the leg
forward.
 Asking the person to rise from a seated position in a low
chair without using hand for support
9. Ankles & feet
 Inspect the position & contour of joints, skin
characteristics.
 Palpate for tenderness or swelling.
 
 T
e st
active
ROM:
- Dorsiflexion:
point toes towards the nose
- plantar flexion: point toes towards the floor
- Eversion/ inversion: turn soles of feet out and in
 Muscle strength by asking the person to maintain
dorsiflexion & plantar flexion against your resistance.
10. Spine
 Inspect for straightness, Knees and feet for proper
alignment from the side the normal convex thoracic
curve and the normal concave lumbar curve.
 Palpate spinous processes and paravertebral muscles.
 Test active ROM:
- lateral bending right & left bend sideways
- hyperextension: bend backwards
- rotation: twist shoulders to one side then the other
6. Post Assessment
Asks the patient:
 “Is there anything you would like to mention?”
(Or)
 “Are there any questions you like to ask?”
(Or)
 “We have covered several concerns today. What would you
most like to accomplish?”
 Informed relevant findings to the patient throughout the
assessment.
 Assists client into a comfortable position.
 Assists client into a comfortable position.
 Replaced & disinfected used equipment and disposed
materials (as appropriate).
 Removes gloves and performs hand hygiene.
 Documented relevant findings using principles of
documentation.
 7. Documentation: writes subjective and objective data findings, overall assessment/nursing
diagnoses.

Sample Charting
Subjective
States no joint pain, stiffness, swelling, or limitation. No muscle pain or weakness. No history of bone
trauma or deformity. Able to manage all usual daily activities with no physical limitations. Occupation
involves no musculoskeletal risk factors. Exercise pattern is brisk walk 1 mile 5×/week.
Objective
Joints and muscles symmetric; no swelling, masses, deformity; normal spinal curvature. No tenderness
to palpation of joints; no heat, swelling, or masses. Full ROM; movement smooth, no crepitus, no
tenderness. Muscle strength—able to maintain flexion against resistance and without tenderness.
Overall Assessment
Muscles and joints—healthy and functional