Health Assessment: Musculoskeletal System- Nursing Skills

00:05:02
https://www.youtube.com/watch?v=88pzhqbF5K0

Zusammenfassung

TLDRVideoen gir en omfattende gjennomgang av hvordan man vurderer muskel- og skjelettsystemet hos pasienter. Den dekker inspeksjon, palpasjon og bevegelser for ryggraden, overekstremiteter og underekstremiteter, samt vurdering av muskelstyrke. Vurderingene inkluderer både aktive og passive bevegelser der det er nødvendig, og refleksvurderinger kan også inkluderes. Hensikten er å avdekke eventuelle abnormiteter, smerte og funksjonsnivå.

Mitbringsel

  • 🫂 Start med vurdering av ryggraden.
  • 🔍 Inkluder inspeksjon og palpasjon av ledd.
  • 🧘‍♂️ Utfør bevegelsesøvelser for ryggen.
  • 💪 Test styrken i overekstremitetene.
  • 🦵 Gjør det samme for underekstremitetene.
  • ⚖️ Vurder balansen og gangmønsteret.
  • 📋 Sjekk for abnormiteter som hevelse og rødhet.
  • 🚑 Husk å bruke passive bevegelser om nødvendig.
  • 🤝 Oppmuntre pasienten til å rapportere smerte.
  • 📈 Noter styrken på en skala fra 0 til 5.

Zeitleiste

  • 00:00:00 - 00:05:02

    Videoen gir en oversikt over vurdering av muskel- og skjelettsystemet, inkludert undersøkelse av muskler, bein og ledd i struktur og funksjon. Det er viktig å vurdere ryggsøyle, overekstremiteter og underekstremiteter ved inspeksjon, palpasjon og bevegelsesområde. For ryggsøylen skal pasienten stå med ryggen mot deg, hvor du vurderer for skjevheter som skoliose og unormale kurvaturer som kyfose og lordose. Ved vurdering av bevegelsesområdet for nakke og thorax utføres flere bevegelsestester, og for korsryggen må du være støttende. Det samme gjelder for overekstremiteter, der leddvurdering inkluderer inspeksjon av muskelstørrelse, tilstand på huden og bevegelse av skuldre, albuer og håndledd. Muskulær styrke testes også for både over- og underekstremiteter. I vurderingen dekkes også bevegelse og evne til å opprettholde balanse, spesielt når man tester hofter, knær og ankler. Reflekser kan også vurderes under denne prosessen. Til slutt oppfordres seerne til å se flere ressurser og lære mer på nursing.com.

Mind Map

Video-Fragen und Antworten

  • Hva er hovedområdene for muskel- og skjelettvurdering?

    Det er tre hovedområder: ryggraden, overekstremitetene og underekstremitetene.

  • Hvordan vurderer man bevegelsesområdet for ryggraden?

    Pasienten bør bøye og vri hodet, samt lene seg fra side til side og tilbake.

  • Hvilke tester brukes for å sjekke styrken i overekstremitetene?

    Pasienten skal presse, trekke, løfte og senke armene mot motstand.

  • Hvordan undersøker man underekstremitetene?

    Inspeksjon og palpasjon av hofter, knær, ankler og tær, samt testing av bevegelsesområde og styrke.

  • Hvilke tegn ser man etter under vurderingen?

    Se etter muskelatrofi, misfarging, hevelse, smerte og avvik i bevegelse.

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Untertitel
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Automatisches Blättern:
  • 00:00:01
    [Music]
  • 00:00:05
    so this video is going to be a review of
  • 00:00:06
    a musculoskeletal assessment remember
  • 00:00:08
    this involves assessing muscles bones
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    and joints both structure and function a
  • 00:00:13
    couple key points before we start if
  • 00:00:15
    your patient can't stand you can perform
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    active range of motion in the bed to the
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    best of your ability if they can't
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    perform active range of motion you can
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    use passive movements to help them
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    through those range of motion exercises
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    there's three main areas we need to
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    assess the spine the upper extremities
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    and the lower extremities and for each
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    one you'll inspect palpate and perform
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    range of motion
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    so to start assessing the spine
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    have the patient stand in front of you
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    with their back towards you
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    you want to inspect and palpate for the
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    spinous processes which should run
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    vertically and in alignment
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    you also want to look for any abnormal
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    lateral curvature which could indicate
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    scoliosis
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    then you want to look at the patient
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    from the side to assess for kyphosis or
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    lordosis which is just exaggerated
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    curvatures
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    next you want to do range of motion so
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    to check range of motion of the cervical
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    spine have the patient put their chin
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    up and down
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    turn their heads left
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    and right
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    and then put each ear to the
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    shoulder on that side
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    to test thoracic range of motion have
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    the patient lean side to side and twist
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    left and right
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    you can demonstrate these motions if it
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    helps
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    for lumbar have the patient lean back
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    slightly just make sure that you are
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    there to support them all of this should
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    be done smoothly and without pain
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    next we're going to move on to the
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    extremities so for each joint you assess
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    starting at the shoulders you want to
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    inspect for the muscle size and shape is
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    there any atrophy what's the skin color
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    and condition any redness swelling or
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    masses deformities
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    then range of motion for the shoulders
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    involves abduction adduction
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    forward motion backward motion rotation
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    and shrugging
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    you also want to palpate the joint
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    during range of motion is there any heat
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    any crepitus with movement and of course
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    ask if there's any pain
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    now you're going to repeat the same
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    inspection and palpation for the elbows
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    taking them through flexion extension
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    supination and pronation
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    then the wrists flexion extension
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    supination and pronation and of course
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    the hands through flexion and extension
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    all the while inspecting and palpating
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    the joints for any abnormalities and
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    asking for any pain
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    before you move on to the lower
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    extremities you want to check the
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    strength of the uppers we have the
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    patient push against you pull you
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    towards them lift their arms up and put
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    their arms down all against resistance
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    check your outline to see the grading
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    scale for strength it goes from zero to
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    five for this patient she's got full
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    strength full range of motion so we'd
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    say five out of five
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    on the lower extremities you're going to
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    inspect and palpate each joint just like
  • 00:02:58
    you did on the uppers looking for heat
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    deformity pain and swelling start at the
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    hips and work your way down the hips
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    should flex and extend
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    abduct and adduct and rotate internally
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    and externally
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    now if your patient has trouble with
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    balance you can do these motions in the
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    bed or just assist them with stability
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    and of course check both sides
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    then you're going to check the knees for
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    flexion and extension
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    make sure that you're feeling for
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    crepitus
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    while they're moving through that range
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    of motion
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    then you're checking the ankles they
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    should be able to dorsiflex plantar flex
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    supinate pronate and rotate
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    and finally they should be able to flex
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    and extend their toes as well
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    now we also will do strength for the
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    legs
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    these are often done best sitting or
  • 00:03:47
    sitting on the edge of a bed so have
  • 00:03:49
    them push against your hands
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    pull against your hands
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    lift and lower their legs
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    again all against resistance
  • 00:04:05
    so if they can perform all of these
  • 00:04:06
    things then they are five out of five
  • 00:04:08
    again remember if your patient can stand
  • 00:04:10
    balance and and stand on one leg they're
  • 00:04:12
    probably five out of five so you also
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    can assess gait during this assessment
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    if you'd like just make sure that they
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    have any assistive devices they need
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    when they're walking now we tested
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    reflexes in the neurological assessment
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    but you could also include them here in
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    musculoskeletal if you wanted
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    all right well that's it for this
  • 00:04:27
    assessment make sure you check out all
  • 00:04:29
    the resources attached to this lesson
  • 00:04:30
    and the rest of the health assessment
  • 00:04:32
    lessons now go out and be your best
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    selves today and as always happy nursing
  • 00:04:37
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Tags
  • vurdering
  • muskel
  • skjelett
  • bevegelsesområde
  • inspeksjon
  • palpasjon
  • styrketesting
  • reflekser
  • nursing
  • helse