Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide § Hip muscles: With patient supine and legs extended, the patient attempts to raise one leg against resistance by the nurse. § Adduction at the hips (adductors): With the patient supine and legs extended, the patient attempts to move legs together while the nurse provides resistance on the medial aspect of eachknee. § Abduction at the hips (gluteus medius and minimus): With the patient supine and legs extended, the patient attempts to move the legs apart while the nurse provides resistance on the lateral aspect of eachknee. § Extension at the knee: With the patient supine and the knee partially extended, the patient resists the attempts to flex the knee (quadriceps). § Flexion at the knee: With the patient supine and both knees bent, the patient resists attempts to straighten the knee (hamstrings). § Dorsiflexion/plantar flexion at the ankle: The patient resists as the nurseattempts to dorsiflex and flexes the foot.

Grading muscle strength: Grade

Description No muscle movement Visible muscle movement, but no movement at the joint Movement at the joint, but not against gravity Movement against gravity, but not against added resistance Movement against resistance, but less than normal Normal strength

0/5 1/5 2/5 3/5 4/5 5/5

• Assess the bones. o Normal: No skeletal deformities and no tenderness or swelling over any bone o Deviations from normal: Bones misaligned; tenderness or swelling noted • Assess the joints. o Normal: No swelling, tenderness, nodules, or crepitation (crackling sound); smooth movement of the joint with full range of motion(ROM) o Deviations from normal: Presence of swelling, tenderness, nodules, or crepitation (crackling sound); limited range of motion(ROM) Evaluation It is important to compare all the findings with previous findings to determine if there are changes to any abnormal musculoskeletal findings. Record and report any significant deviations from the normal. In many agencies, there may be diagrams for documenting areas of musculoskeletal abnormalities.

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