GEORGIA BAPTIST COLLEGE OF NURSING

OF MERCER UNIVERSITY
NUR211
Musculoskeletal Assessment
SUBJECTIVE DATA:
Weakness, pain, swelling, stiffness, deformity, cramping, crepitus, twitching, gait,
limitation of movement, prostheses or braces.

OBJECTIVE DATA:
Inspection: (gait, coordination, muscle tone, involuntary movements, posture,
body alignment, skin, deformities)

Palpate:
Joints: (tenderness, swelling, temperature, crepitus, thickening,
nodules/cysts/fluid)

Muscles: (tone/spasm, masses, tenderness, temperature)

Range of Motion:
TMJ (clench teeth, open clothes mouth)
Neck: (flexion, extension, rotation, lateral bending)

Spine: (forward flexion, extension, rotation, lateral bending)

Shoulders: (forward flexion, backward extension, abduction, adduction, internal

rotation,
external rotation)

Elbows: (flexion, extension, pronation, supination)

Wrists: (extension, flexion, radial deviation, ulnar deviation)

Thumbs/fingers: (abduction, adduction, flexion, extension)

Hips: (flexion, extension, abduction, adduction, internal rotation, external

rotation)

Knees: (flexion, extension)

Ankles: (dorsiflexion, plantar flexion, inversion, eversion)

Toes: flexion, extension, adduction, abduction)

Muscle strength: (grade1, 2, 3, 4, 5 [normal])

Neck:
Arms (deltoid, biceps, triceps)

Wrists:

Fingers:

Hips:

Ankles/feet:

Instructions for Lab

Musculoskeletal
1.

Review relevant data from health history related to the musculoskeletal systems (review
of system and other needed data).

2.

Perform general inspection.

gait
coordination
muscle tone
involuntary movements
posture
body alignment
Inspect
skin
nails
hair
extremities
Symmetry (muscles, joints, limb, size, deformities)
Measure of muscle mass, length of extremity
Bone formation
Palpate
Joints
o swelling
o temperature
o crepitus
o tenderness/pain

3.

4.

5.

6.

o thickening
o nodules/cysts/fluid
Muscles

o tone/spasms
o masses
o tenderness
Range of motion
TMJ
Neck
Spine
Shoulder
Elbow
Wrist
Thumb
Hip
Knee
Ankle
Toes
Muscle strength

Documentation of Musculoskeletal System

Musculoskeletal - muscles developed without atrophy/hypertrophy. Arms & legs
symmetric. No edema, varicosity's, or tenderness. Joints non-tender, without
swelling, and with full ROM. Muscle tone & strength 5/5 bilaterally. Spine has full
ROM and is without tenderness or deformities.
Motor:
No involuntary movements of extremities noted. Gait coordinated. Able to
maintain balance with eyes closed (Romberg negative). Able to perform rapid
coordinated movements with upper and lower extremities. All movements
coordinated.