Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.). • Wash hands before starting the exam, any time the hands or gloves become soiled,and upon completion of the exam. • Provide a quiet, well-lit, and private place for theexam. • Ensure that the examination room is warm since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about the presence or history of: o Muscle or joint pain: Include location, onset, associated signs or symptoms, factors that increase or decrease the pain, and limitations to ADL caused by the pain o Family history of musculoskeletal problems o Previous injuries • Assess the muscles. o Normal: The size of muscles on one side of the body and the same muscles on the other side are equal; no muscle or tendon contractures; no tremors; musclesat rest are firm with good tone; smooth coordinatedmovements o Deviations from normal: The size of muscles on one side of the body and the same muscles on the other side are not equal (atrophy or hypertrophy); muscle or tendon contractures causing poor positioning of a body part; tremors; muscles at rest are flaccid or spastic; atonic muscle tone • Assess muscle strength. o Testing: Test strength by having the patient move against your resistance;always compare one side to the other; grade strength on a scale from 0-5 § Sternocleidomastoid: The patient turns her head to one side against theresistance of the nurse's hand. § Shrug test: The patient shrugs his shoulders against the resistance of thenurse pressing down on the shoulders (trapezius). § Deltoid: The patient extends each arm and resists as the nurse attempts to push it down. § Flexion at the elbow: The patient extends each arm and tries to flex it as the nurse attempts to hold the arms in extension (biceps). § Extension at the elbow: The patient flexes each arm and tries to extend it as the nurse attempts to hold the arm in flexion (triceps). § Extension at the wrist: The patient flexes each wrist and resists as the nurse attempts to force the wrist into extension. § Grip: The patient squeezes two of nurse's fingers as the nurse attempts topull fingers out of the grip. § Finger abduction: The patient spreads fingers on each hand and resists as the nurse attempts to squeeze the fingers together.

©2018

Achieve

Page 29

of 134