Assessing Musculoskeletal System

Physical Assessment Guide to Collect Objective Client Data

Questions Findings
1. Gather equipment (tape measure,
goniometer).
2. Explain the procedure to the client.
3. Ask the client to put on a gown.
Gait
1. Observe gait for base, weight-bearing stability,
feet position, stride, arm swing, and posture.
Temporomandibular Joint
1. Inspect, palpate, and test ROM.
Sternoclavicular Joint
1. Inspect and palpate for middle location, color,
swelling, and masses.
Spine
1. Inspect and palpate cervical, thoracic, and
lumbar spine for pain and tenderness.
2. Test ROM of cervical spine.
3. Test ROM of thoracic and lumbar spine.
4. Test for leg and back pain.
5. Measure leg length.
Shoulders
1. Inspect and palpate shoulders for symmetry,
color, swelling, and masses.
2. Test for ROM of shoulders.
Elbows
1. Inspect and palpate elbows for size, shape,
deformities, redness, or swelling.
2. Test ROM of elbows.
Wrists
1. Inspect and palpate wrists for size, shape,
symmetry, color, swelling, tenderness, and
nodules.
2. Test ROM of wrists.
3. Test for carpal tunnel syndrome.
Hands and Fingers
1. Inspect and palpate hands and fingers for
size, shape, symmetry, swelling, color,
tenderness, and nodules.
2. Test ROM of hands and fingers.
Hips
1. Inspect and palpate hips for shape and
symmetry.
2. Test ROM of hips.
Knees
1. Inspect and palpate knees for size, shape,
symmetry, deformities, pain, and alignment.
 2. Test knees for swelling. If small amount of
fluid present, do “bulge test.” If large amount
of fluid present, do “ballottement test.”
3. Test ROM of kness.
4. Perform McMurray test if client complains of
“clicking” in knee.
Ankles and Feet
1. Inspect and palpate ankles and feet for
position, alignment, shape, skin, tenderness,
temperature, swelling, or nodules.
2. Test ROM of ankles and toes.
Analysis of Data
1. Formulate nursing diagnoses ( health
promotion, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.