Assessment of the Musculoskeletal System and Pain


Jarvis, Carolyn. (2016). Physical examination & health assessment (7th ed.). St. Louis, MO: Elsevier.

Assessment of the Musculoskeletal System and Pain
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Fred is an 83-year-old male who is being admitted to the medical-surgical unit status post fall. He is alert and oriented and reports that while visiting a local casino with his wife Margaret earlier this evening, he tripped over a curb and fell landing on his right side. After receiving morphine in the emergency room prior to transfer to your unit, Fred is rating his pain at 6/10. He has multiple bruises from his jawbone to his knee as well as a slight rotation of his right leg.
Past medical history includes: myocardial infarction (MI) x 2, peripheral vascular disease (PVD) with bilateral iliac stents, non-insulin-dependent diabetes mellitus (NIDDM), sleep apnea, and degenerative joint disease.
Medications include: aspirin, Plavix, Lopressor, Lisinopril, and Metformin.
After reviewing the above scenario please answer the following questions.
1.    Based on the information provided, how will you prioritize your care, what assessments will you include and in what order? Please provide rationale for your response.
2.    Considering this patient's age, injury, past medical history, and list of current medications, what, if any, concerns do you have related to his potential need for surgery?
3.    Should surgery to repair his right femur be required; what type of clearance and pre-op orders would you anticipate receiving related to his diet, meds, lab work, and so on?

Introduction to the Musculoskeletal System
A thorough assessment of the musculoskeletal system provides vital information on the health status of the client such as exercise and metabolism. Bone density and curvatures of the musculoskeletal systems vary widely in different cultural groups. A change in bone density and injury to the skeletal system from working environments create risks for trauma and long-term disability.
Clients seeking care for musculoskeletal issues often complain of joint pain or muscular injury. We want to gain as much information as possible about the current condition or injury that has motivated them to seek care. Don't forget, when delving into the history of musculoskeletal injuries, to ask about any medications they are taking because many medications can affect the musculoskeletal system. Also inquire into their lifestyle habits. What kind of job do they have? What are their hobbies? Many of these activities have repetitive motions, which can lead to stress injuries. Previously you were taught this mnemonic device to inquire about chest pain. It is also a good tool to utilize any time you wish to obtain more information about other types of pain.
Precipitating or Palliative: What precipitates the symptom? Does stress, anger, or certain physical positions or factors trigger the symptom or make it worse? What makes the symptom lessen or subside?
Quality or Quantity: What does the symptom feel like, look like, or sound like? Are you having the symptom right now? If so, is it more or less severe than usual? To what degree does the symptom affect your normal activities?
Region or Radiation: Where in the body does the symptom occur? Does the symptom appear in other regions, and if so, where?
Severity: How severe is the symptom? How would you rate it on a scale of 1 to 10, with 10 being the most severe? Does the symptom seem to be diminishing, intensifying, or staying the same?
Timing or Temporal: When did the symptom begin? Was the onset sudden or gradual? How often does the symptom occur? How long does the symptom last?
The Physical Examination
The musculoskeletal examination begins when you first meet the patient. Notice how the patient walks, moves, and stands. These observations can provide cues for detecting musculoskeletal problems; they help make up your general physical assessment of the patient.
Follow this general assessment with an examination of specific muscles and joints using the techniques listed below. These techniques are performed simultaneously rather than sequentially, as is done in other physical assessments.
•    Inspection
•    Palpation
•    Range of motion (ROM)
•    Tests for muscle strength
Attention to health history taking is very important because patients will occasionally make general comments that suggest problems.
During your assessment for range of motion, be alert to age limitations because muscles tend to become weaker as clients age and adopt sedentary lifestyles. Older adults are more prone to falls due to loss of balance because of postural changes over their lifespan.
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