Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino de las Alas Campus
Indang, Cavite
(046) 415-0010 / (046) 415-0011
www.cvsu.edu.ph
cvsu.op206@gmail.com

COLLEGE OF NURSING

HEALTH ASSESSMENT – NURS 02 RELATED

LEARNING EXPERIENCES

Name: Date:
Year and Section: Group No.

Competency Performance Checklist Assessing the Musculoskeletal System

SCRIPT/FINDINGS
PROCEDURE

1. Gather equipment (tape measure,

goniometer).
2. Explain the procedure to 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 midline location,
color, swelling, and masses.
Spine
1. Inspect and palpate cervical, thoracic, and
lumbar spine for pain and tenderness.
● Today I’ll be performing the assessment of the
Musculoskeletal System.The purpose of this
assessment is to evaluate the health, function,
and structural integrity of the musculoskeletal
system, which includes bones, muscles, joints,
tendons, and ligaments. This assessment is
crucial for diagnosing conditions such as
arthritis, fractures, sprains, and muscular
disorders, and for identifying abnormalities in
posture, range of motion, and strength.
● Evenly distributed weight.
● Client able to stand on heels and toes.
● Toes point straight ahead. Equal on both
sides.
● Posture erect, movements coordinated and
rhythmic, arms swing in opposition, stride
length appropriate.
● The client’s mouth opens and closes smoothly.
● Jaw protrudes and retracts easily
● Jaw has full ROM against resistance.
● Contraction palpated with no pain or spasms.
● There is no visible bony overgrowth, swelling,
or redness; joint is nontender.
● Cervical and lumbar spines are concave;
thoracic spine is convex. Spine is straight
(when observed from behind)
 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 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
● Flexion of the cervical spine is 45 degrees.
Extension of the cervical spine is 45 degrees.
● Flexion of 75–90 degrees, smooth movement,
lumbar concavity flattens out, and the spinal
processes are in alignment.
● Measurements are equal or within 1 cm
● Shoulders are symmetrically round; no
redness, swelling, or deformity or heat.
Muscles are fully developed. Clavicles and
scapulae are even and symmetric. The client
reports no tenderness.
● The extent of forward flexion should be 180
degrees; hyperextension, 50 degrees;
adduction, 50 degrees; and abduction 180
degrees.
● Elbows are symmetric, without deformities,
redness, or swelling
● Normal ranges of motion are 160 degrees of
flexion, 180 degrees of extension, 90 degrees
of pronation, and 90 degrees of supination
● Wrists are symmetric, without redness, or
swelling. They are nontender and free of
nodules.
● Normal ranges of motion are 90 degrees of
flexion, 70 degrees of hyperextension, 55
degrees of ulnar deviation, and 20 degrees of
radial deviation. Client should have full ROM
against resistance
● No tingling, numbness, or pain result from
Phalen’s test or from Tinel’s test
● Hands and fingers are symmetric, nontender,
and without nodules. Fingers lie in straight line.
No swelling or deformities. Rounded
protuberance noted next to the thumb over the
thenar prominence. Smaller protuberance
seen adjacent to the small finger.
● Normal ranges are 20 degrees of abduction,
full adduction of fingers (touching), 90 degrees
of flexion, and 30 degrees of hyperextension.
The thumb should easily move away from
other fingers and 50 degrees of thumb flexion
is normal.
● Buttocks are equally sized; iliac crests are
symmetric in height. Hips are stable,
nontender, and without crepitus.
● Normal ROM: 90 degrees of hip flexion with
the knee straight and 120 degrees of hip
flexion with the knee bent and the other leg
remaining straight.
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 knees.
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.
● Knees symmetric, hollows present on both
sides of the patella, no swelling or deformities.
Lower leg in alignment with the upper leg.
● No bulge of fluid appears on medial side of
knee. (bulge test)
● No movement of the patella is noted. Patella
rests firmly over the femur. (ballottement test)
● Normal ranges: 120–130 degrees of flexion; 0
degrees of extension to 15 degrees of
hyperextension.
● No pain or clicking noted.
● Toes usually point forward and lie flat;
● Skin is smooth and free of corns and calluses
● No pain, heat, swelling, or nodules are noted.
● Normal range of motion of the feet and ankles

Perfect Score: 84
Total Score:
Passing Score: 59