TISSUE INTEGRITY: MOBILITY ASSESSMENT Adele Thaxton-Coy MSN, RN

MUSCLE STRUCTURE & FUNCTION Assessment should include the following:  Diagnostic test results (labwork, bone density test, MRI, etc.)  Health assessment interview  Nurse’s physical assessment findings

PHYSICAL ASSESSMENT Can be performed as part of total head-to-toe assessment or independently. Techniques used:  Inspection  Palpation  Measurement of muscle mass  Range of Motion (ROM)

PROPER ORDER OF ASSESSMENT 1. Assess gait, posture, and change of positions. Find out if client uses any assistive device. 2. Inspect and palpate bones for deformities, size, shape, tenderness, or pain. 3. Measure length and circumference of extremities—comparing limbs bilaterally. 4. Assess and inspect muscle mass for increase or decrease in size. Assess muscle strength. 5. Assess joints for swelling, pain, redness, warmth, crepitus, and ROM.

ASSESSING MUSCLE STRENGTH  Assess bilaterally  Be aware of client’s history (certain diseases can affect mobility of muscle)  Find out which side is dominant (strength is expected to be greater on this side)  Provide resistance against muscle to test client’s strength

HEALTH ASSESSMENT INTERVIEW  Can help the nurse determine any issues or concerns with muscle function  Detailed and thorough  Can be done during a health screening, total head-to-toe assessment, or as a focused interview  May also need to assess neurological system during this interview  Ask specific, focused questions  Be familiar with the focused musculoskeletal assessment in Pearson Vol. I pgs

SOME ABNORMAL FINDINGS  Pain  Swelling or heat  Tendonitis – inflammation of the tendon  Limited ROM  Synovitis – inflammation of the synovial membrane  Bursitis – swelling of the bursa  Numbness or burning  Tingling  Fluid bulge  Crepitus/crepitation  Locking  Clicking noises

SOME SPECIFIC TESTS  The following tests my reveal abnormal findings:  Phalen’s test – to look for carpal tunnel  Ballottment test – to look for fluid of the knee  McMurray’s test – finds pain upon flexed knee turning to center of body while in supine position  Thomas test – client should be able to flex one knee to chest while other leg rests on surface in supine position

REHABILITATIVE NURSING To help restore one’s ability to live and/or work at their most optimum level Focus is on preventing and correcting any musculoskeletal alterations or injuries 1. Preservative methods – interventions used to help an individual maintain their regular mobility (i.e exercise) 2. Restorative methods – interventions specifically designed for those with decreased mobility (i.e. ambulation with assistive devices). Purpose is to assist client in obtaining level of mobility that was present prior to them getting ill

IMPORTANCE OF EXERCISE  Promotes proper alignment  Prevents contractures  Stimulates circulation  Prevents pressure ulcers  Prevents thrombophlebitis  Reduces joint pain and stiffness  Increases flexibility and endurance  Prevents edema and promotes lung expansion

REFERENCE North Carolina Concept-Based Learning Editorial Board. Nursing: A concept-based approach to learning. (Vol. I). North Carolina State: Pearson