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Chapter 8: Assessment and Observation of the Musculoskeletal and Integumentary Systems

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To describe the basic anatomy and physiology of the musculoskeletal and integumentary systems.

-To explain how to collect a focused health history related to the musculoskeletal and integumentary systems.

-To explain how to undertake a physical examination of the musculoskeletal and integumentary systems.

-To recognise the common problems / conditions related to the musculoskeletal and integumentary systems, and their typical clinical findings, to enable differential diagnosis.

-To describe the variety of special assessment techniques which may be used in the physical examination of the musculoskeletal and integumentary systems.

Fundamental anatomy and physiology of the musculoskeletal system

The musculoskeletal system is comprised of:

  • The skeleton, comprised of: (1) the axial skeleton; the central body structure, and (2) the appendicular skeleton; the bones of the appendages.
  • The muscles.

Joints are where bones meet; they allow movement. Joints are classified in two ways: (1) by the type of material between them, and (2) by the type of movement they allow.

The musculoskeletal system is supported by:

  • Ligaments - strong, flexible bands of connective tissue which hold bone to bone.
  • Tendons - strong, non-elastic cords of collagen which attach muscle to bones.

Other structures in the musculoskeletal system are cartilage and bursae. Cartilage is a smooth, avascular tissue that is highly flexible. Bursae are sacs adjacent to some joints, which contain synovial fluid.

Musculoskeletal system - focused health history

When assessing a patient's musculoskeletal system, the nurse must collect a health history. This involves collecting data about:

Component

Rationale

Present health status

Chronic illnesses, even if they are not related directly to the musculoskeletal system.

Current medications, which: (1) may be taken to treat pre-existing musculoskeletal problems, and / or (2) may affect the musculoskeletal system.

Exercise, as lack of exercise is a risk factor for musculoskeletal dysfunction.

Recent changes in movement / mobility, as this can provide important information about possible causes of dysfunction in the musculoskeletal system, and also issues to be aware of during the physical examination.

Past medical history

Injuries to, or illnesses of, the musculoskeletal system, as these may leave a client with deficits which a nurse can anticipate finding during the physical examination.

Surgery on the musculoskeletal system, as this can provide a nurse with additional information on possible musculoskeletal problems the client has or has had.

Family history

Family history of diseases affecting the musculoskeletal system, as this can provide important information about the types of disease for which a person may have a congenital risk.

A person may present with a specific problem related to their musculoskeletal system. Nurses assess a patient's symptoms using the 'OLD CARTS' mnemonic.

Musculoskeletal systems - physical examination

This should follow the health history. This process, with normal and common abnormal findings, is presented in the following table:

Component

Normal Findings

Abnormal Findings

Inspect the axial and appendicular skeletons for alignment, contour, symmetry, size, gross deformities.

The client should stand erect; the body is relatively symmetric; the spine is straight with normal curvatures; hips, knees and ankles in a straight line; the feet are flat on the floor.

Irregular posture; asymmetry; misalignment, etc.

Inspect the muscles for size and symmetry.

The muscles should be relatively symmetric bilaterally.

Atrophy; fasciculations; irregular posture; asymmetry; misalignment, etc.

Palpate the bones and muscles for tenderness, heat, oedema.

Bones and muscles should be non-tender; no oedema; tissues should feel firm; no temperature anomalies.

Tenderness; heat; oedema; atrophy, etc.

Assess the range of motion of each of the main joints.

There should be full range of motion of each joint without crepitus, deformity, contracture or pain.

Crepitus; deformity; contracture; pain; joint instability; weakness; increased / decreased range of motion, etc.

Test the muscles for strength bilaterally.

Normal strength for the muscle tested; bilaterally symmetric; full resistance to opposition.

Muscle weakness; muscle cramping / contracture.

Observe gait for conformity, symmetry, rhythm.

Conformity; regular smooth rhythm; symmetry of steps / arm swing; smooth swaying movements.

Unstable / exaggerated gait; limp / irregular stride; arm swing unrelated to gait; inability to maintain straight posture; asymmetry, etc.

Palpate the temporomandibular joint for movement, sounds, tenderness.

The mandible should move smoothly and painlessly; audible or palpable clicking without pain is normal.

Difficulty opening the mouth; pain or crepitus; locking of the jaw, etc.

Percuss the spine for tenderness.

No tenderness should be noted.

Tenderness; inflammation; heat; oedema; muscle spasm, etc.

Special assessment techniques for the musculoskeletal system

There are a number of special assessment techniques particular to the musculoskeletal system:

  • Range of motion: moving a joint through its full range of normal, expected movements.
  • Muscle strength: asking client to flex a muscle and resist when the nurse applies opposing force. Muscle strength is rated on a scale of 0 (no capacity to resist an opposing force) to 5 (full capacity to resist an opposing force).

Differential diagnosis in the musculoskeletal system

When assessing a patient's musculoskeletal system, there are a number of common problems and conditions a nurse may identify, outlined in the following table:

Integumentary Problem or Condition

Typical Clinical Findings

Fracture

Pain; muscle spasm; deformity; loss of function; shortening of the tissue around the affected bone; localised oedema, etc.

Osteoporosis - a condition involving osteopenia and decreased bone strength.

May occur without signs / symptoms; loss of height; spontaneous fracture; kyphosis, etc.

Arthritis - a condition involving chronic inflammation of the connective tissue.

Gradual onset joint pain; joint stiffness; joint inflammation; reduced range of motion; fatigue, etc.

Bursitis - an inflammation of the bursae.

Sudden onset joint pain; joint stiffness; joint inflammation; reduced range of motion; fatigue, etc.

Gout

Oedema, erythema of affected joint; reduced range of motion; tophi; nephrolithiasis, etc.

Scoliosis - an S-shaped deformity of the spine.

Uneven / asymmetric shoulders and hips; rotation; rib / shoulder hump; possible dysfunction of the lungs, pelvis, central nervous system, etc.

Carpal tunnel syndrome.

Burning, numbness, tingling of the affected hand, etc. Often follows a prolonged period of repetitive hand movements.

Fundamental anatomy and physiology of the integumentary system

The integumentary system is comprised of the skin and accessory structures. The skin is comprised of three layers:

  • The epidermis - the thin, avascular outer layer comprised of keratinised cells.
  • The dermis - comprised of highly vascular connective tissue and sensory nerve fibres.
  • The subcutaneous layer - the support structure for the dermis / epidermis, comprised of connective tissue and subcutaneous fat.

The integumentary system also includes a number of accessory structures:

  • The hair.
  • The nails.
  • The sweat and sebaceous glands. These include eccrine and apocrine sweat glands, and the sebaceous glands.

Integumentary system - focused health history

As always, when assessing a patient's integumentary system, the nurse must commence by collecting a health history. This involves collecting data about:

Component

Rationale

Present health status

Chronic illnesses, even if they are not related directly to the integumentary system. In particular, chronic illnesses can result in pruritus, skin lesions, dryness, etc.

Current medications, either prescribed or over-the-counter, which: (1) may be taken to treat pre-existing integumentary system problems, and / or (2) may cause relevant side effects.

Current skincare practices - including hygiene measures, use of lotions and sun protection strategies, etc.

Changes in the way the skin looks / feels; this provides a nurse with important information about possible underlying problems.

Past medical history

Injuries to, or illnesses of, the integumentary system, as these may cause deficits which a nurse can anticipate finding during the physical examination.

Family history

Family history of diseases affecting the integumentary systems, as this can provide important information about the types of disease for which a person may have a congenital risk.

Integumentary system - physical examination

Following the health history, a nurse may commence a physical examination of the patient's integumentary system. Normal and common abnormal findings are presented in the following table:

Component

Normal (Expected) Findings

Abnormal Findings

Inspect the skin for general colour.

The skin colour consistent with the person's ethnicity, and consistent over the body surface. Freckles, moles and striae are all normal findings.

Cyanosis; ecchymosis; erythema; jaundice; pallor; petechiae, etc.

Palpate the skin.

Skin texture should be smooth, soft and intact, with an even surface; some callouses are normal. Skin temperature should be consistent, and may be cooler at the extremities; skin is dry, with minimal perspiration or oiliness; skin is elastic; no lesions are present.

Excessive dryness; flaking / cracking / scaling; maceration; discolouration; rashes; excessively cool or hot skin; diaphoresis; excessively moist skin; oedema; poor skin turgor; excessively thick or thin skin; lesions, etc.

Inspect the hair on the head and the body for characteristics, distribution, quantity, colour, texture.

Hair should be shiny and soft; may be fine or coarse; symmetric distribution.

Dull / coarse / brittle hair; alopecia (hair loss); broken hair shafts, etc.

Inspect and palpate the nails for shape, contour, consistency, colour, thickness, cleanliness.

Nail edges should be smooth and rounded; nail surface should be flat in the centre and slightly curved at the edges; skin adjacent to the nails should be intact.

Inflammation / oedema / erythema of the nails / surrounding tissues; spooned nails; banding; pitting; leukonychia (white spots); clubbing.

It is important to inspect the skin for colour. There are a number of abnormal findings associated with skin colour:

Clinical Finding

Light-Skinned People

Dark-Skinned People

Cyanosis

Greyish-blue tone of the nail beds, earlobes, lips, mucous membranes, palms, soles of the feet, etc.

Ashen-grey colour in the conjunctive, oral mucous membranes, nail beds, etc.

Ecchymosis (bruising)

Dark red / purple / yellow / green colour.

Deeper purple / blue / black tone; may be difficult to see.

Erythema

Reddish tone; evidence of increased skin temperature; inflammation.

Deeper brown / purplish skin tone; increased skin temperature; inflammation.

Jaundice

Yellowish colour of the skin, sclera, fingernails, palms, soles of the feet, oral mucosa, etc.

Yellowish colour of the sclera, fingernails, oral mucosa, etc.

Pallor

Pale skin colour.

Skin tone will appear lighter than normal; ashen.

Petechiae

Small (pinpoint), reddish-purple lesions.

Very difficult to see - may be evident as small (pinpoint), reddish-purple lesions in the buccal mucosa or sclera.

Nurses should inspect the skin for lesions. There are a number of abnormal findings associated with lesions:

Lesion Type

Description

Macule

A flat, circular area of skin, less than 1 centimetre in diameter, where there is a change in skin colour.

Papule

An elevated, firm area less than 1 centimetre in diameter.

Patch

A flat, irregular-shaped macule of more than 1 centimetre in diameter.

Plaque

An elevated, rough lesion with a flat surface greater than 1 centimetre in diameter.

Wheal

An elevated, irregular-shaped area of cutaneous oedema.

Nodule

An elevated, firm lesion, deeper in the dermis than a papule, and 1-2 centimetres in diameter.

A tumour

An elevated, solid lesion, may or may not be clearly demarcated, deeper in the dermis, >2 centimetres in diameter.

A vesicle

An elevated, superficial lesion, not into the dermis, filled with serous fluid, <1 centimetre in diameter

Bulla

A vesicle >1 centimetre in diameter.

Pustule

An elevated, superficial lesion, similar to a vesicle but filled with purulent fluid.

Cyst

An elevated, encapsulated lesion, in the dermis or subcutaneous layer, filled with liquid / semisolid material.

Scale

An accumulation of keratinised cells, flaky skin, thick or thin, dry or oily and variable in size.

Lichenification

Roughened, thickened epidermis secondary to persistent rubbing / itching / skin irritation.

Keloid

An irregular, elevated, progressively enlarging scar which grows beyond the boundaries of the wound.

Scar

A fibrous band of tissue that replaces normal tissue following injury to the dermis.

Excoriation

Loss of the epidermis in a linear, hollowed-out area.

Fissure

A linear crack or break in the epidermis / dermis, which may be moist or dry.

Crust

Dried drainage or blood, slightly elevated and variable in size.

Erosion

A loss of part of the epidermis in a depressed, moist area, often due to rupture of a vesicle or bulla.

Ulcer

The loss of the epidermis and dermis in a concave area.

Atrophy

Thinning of the skin surface.

Angioma

A benign tumour, varying in size, consisting of a small mass of blood vessels.

Pressure ulcer

These are caused by unrelieved pressure on, and resulting hypoxia and necrosis of, the tissues overlying a bony prominence.

Special assessment techniques for the integumentary system

Assessing skin turgor is performed by gently pinching the skin on the forearm or under the clavicle, lifting it away from the underlying tissues, and releasing it; the skin should move easily when lifted and should return to its original place immediately when released. Skin turgor may be poor if 'tenting' occurs.

Differential diagnosis in the integumentary system

When assessing a patient's integumentary system, there are a number of common problems and conditions a nurse may identify, outlined in the following table:

Integumentary Problem or Condition

Typical Clinical Findings

Hyperkeratosis (a 'corn') - a lesion that develops due to chronic pressure on the foot from a shoe.

Flat or slightly raised, painful lesion with a smooth, hard surface; lesion may be soft or hard.

Dermatitis - a superficial inflammation of the skin.

Red, weeping, crusted lesions; usually localised to the hands / feet / face; erythema; oedema; wheals; scales; vesicles; pruritus; petechiae, etc.

Psoriasis - an inflammatory skin condition.

Slightly raised, erythematous plaques; scales; most often on the elbows / knees / buttocks / lower back / scalp; pruritus; burning; bleeding, etc.

Warts - a benign lesion caused by the human papilloma virus (HPV).

Round, irregular-shaped papular lesions; light grey, yellow, brownish-black skin discolouration; most common on the fingers, hands, elbows, knees, etc.

Herpes simplex virus (HSV) - a viral infection of the skin.

A group of vesicles on erythematous skin; HSV-1 lesions often on the upper lip / nose / skin around the mouth / tongue; HSV-2 lesions usually appear in the genitalia.

Herpes varicella virus - a viral infection, 'chicken pox' resulting in lesions on the skin.

Lesions progress from macules to papules to vesicles, which eventually erupt and crust; usually appear on the trunk and then on the extremities.

Herpes zoster virus - a viral infection, commonly referred to as 'shingles' resulting in lesions in the skin.

Linear vesicles which appear along a cutaneous sensory nerve; these become pustules and eventually crust; this is a very painful condition.

Tinea - an infection with one or more of the tinea funguses.

Appears as circular patches or vesicles on various parts of the body; accompanied by discomfort, itching, etc.

Candidiasis - an infection with the Candida albicans fungus.

Scaling red rash; sharply demarcated borders; large patch with some loose scales; commonly in the genitalia, inguinal areas, gluteal folds, etc.

Impetigo - an infection with staphylococcal / streptococcal bacteria.

An erythematous macule that becomes a vesicle / bullae and ruptures; commonly on the face / nose / mouth, though other skin areas may be involved.

Folliculitis - an inflammation of the hair follicles.

An acute lesion, with erythema and a pustule, surrounding a hair follicle; common on the scalp and extremities.

Furuncle, abscess or boil - a localised infection caused by staphylococcal bacteria.

A nodule surrounded by erythema, oedema; progresses to a pustule; surrounding skin is erythematous, hot, tender.

Skin carcinoma - a cancer of the skin cells.

A lesion which is unusual, which may present as a growth or a sore, which doesn't go away; may be associated with changes in the colour / texture of the skin; may or may not be painful, etc.

Conclusion

The musculoskeletal and integumentary systems are the last two systems a nurse considers during their observation and assessment of a patient. This chapter has explored the fundamental anatomy and physiology of the musculoskeletal and integumentary systems, and has also explained the processes involved in collecting a general health history for the musculoskeletal and integumentary systems, and in performing a physical examination of these systems. This chapter also considered a number of special observation and assessment techniques which may be used in the physical examination of the musculoskeletal and integumentary systems, and discussed performing differential diagnosis relevant to these systems.


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