Master of Nursing Science Nursing Assessment & Care (NURS 50004)

Interactive Class Activity 1: Assessment of the Musculoskeletal System

ICA Preparation

Suggested Prior to attending this ICA, students are encouraged to watch the videos that are posted on the LMS,
Resources in the Simulated Clinical Laboratory tab.

The following articles, are excellent recourses in addition to, the listed must-read chapters from the
prescribed text books. These articles can be source via the University Library.

Limbert, E., & Santy-Tomlinson, J. (2017). Acute limb compartment syndrome in the lower leg
following trauma: Assessment in the intensive care unit. Nursing Standard (2014+), 31(34), 61.
doi:http://dx.doi.org.ezp.lib.unimelb.edu.au/10.7748/ns.2017.e10708

Walls, M. (2017). Compartment Syndrome: an Orthopaedic Emergency. Journal of Emergency

Nursing, 43(4), 303-307.

MUST READ MUST READ ARTICLE: Johnston‐Walker, E. and Hardcastle, J. (2011), Neurovascular assessment in
the critically ill patient. Nursing in Critical Care, 16: 170‐177. doi:10.1111/j.1478‐
5153.2011.00431.x
Lewis L., & Foley, D. (Eds.). (2014). Health assessment in nursing. (2nded.). Sydney: Wolters Kluwer.
Chapter 28.

Crisp, J., Taylor, C., Douglas, C., & Rebeiro, G. (Eds.). (2017). Potter & Perry’s fundamentals of nursing
/ Australian and New Zealand edition. (5 th ed.). Chatswood: Elsevier. Chapter 24, p. 603 -608.

Enquiry based learning is based on effective group work. It provides students with the opportunity to be an active learner.
The learning is largely self-directed driven by your own decisions about appropriate ways to prepare for your future role
as a graduate nurse. Working in groups you will carry out research into various topics as they relate to your future role
and develop appropriate responses to the enquiry.

Learning Outcomes
 Understand the importance of undertaking a systematic health assessment as the basis of nursing care
 Identify key considerations and patient preparations required before & during assessment of the musculoskeletal
system
 Apply core physical assessment skills relevant to the musculoskeletal system and reflect on the use of these skills
in nursing practice
 Differentiate normal from abnormal assessment findings
 Analyse assessment data to determine the patient health problems and clinical priorities
 Document and communicate a systematic health assessment

The Clinical Case A:

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Mrs Ester Goldman is a 75-year-old woman with a history of Osteoarthritis, Osteoporosis, type two diabetes and
ischemic heart disease. Mrs Goldman underwent a right knee arthroplasty yesterday morning. Mrs Goldman lives with
her two cats (Salt & Pepper) in her own two storey house in Caulfield North. Her husband Samuel passed away 6 months
ago. Mrs Goldman has no family in Australia. Her parents and her sister were killed in Belzec during the Second World
War. Rachael Goldman (step daughter) lives overseas in New York and has not had any contact with her step mother
since her father passed away. Emily Withers, Mrs Goldman’s next door neighbour has been Mrs Goldman’s only visitor
whilst she has been in hospital. Ms Withers has also been taking care of Mrs Goldman’s two cats.

Mrs Goldman’s post-operative observations include, 4/24 vital signs and 1/24 neurovascular observations of her right leg.
Currently Mrs Goldman’s pain in well controlled with IVI Patient Controlled Analgesia (PCA) (Morphine), ibuprofen
400mg 4/24, and paracetamol 1 g 4/24. The surgical wound on Mrs Goldman’s right leg is clean and dry with no excess
redness or swelling. The incision is well apposed. A Cutifilm* Plus ® waterproof dressing is insitu.

You and your buddy nurse Susan, have two other orthopaedic patients allocated to you for this shift. They are all
progressing well but require several regular nursing interventions. You are currently wating the arrival of Mr Cameron
Taylor from the Emergency Department.

Group One
1. In your group, discuss the anatomy of the musculoskeletal system. Please address the following points:
a. What are the functions of the musculoskeletal system?
b. What is the difference between a fibrous, cartilaginous and synovial joints? Provide an example of
each.
c. What is a bursa?
This group of questions will not be discussed in class, as it is covered in Nursing Science 1. Please ensure that you able
to link this science content with the nursing assessment and care of a patient.

2. The following questions will relate to the collection of subjective data.

a. What questions would the nurse ask Mrs Goldman related to the history of her present health concern?
Provide a rationale for your answer.

3. What is Osteoporosis?
a. What is the impact of Osteoporosis on Australians?
b. What is the impact of Osteoporosis on Indigenous Australians?
c. How would the nurse promote improved bone health in patients like Mrs Goldman? Provide a rationale
for your answer.
d. What is meant by modifiable and non-modifiable risk factors? What are the modifiable and non-
modifiable risk factors for Osteoporosis? Relate your answer to Mrs Goldman.

4. The following questions relates to the collection of objective data.

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 a. What equipment would the nurse require to undertake a musculoskeletal assessment?
b. How would the nurse prepare the environment and the patient for a musculoskeletal assessment?

5. The following questions relate to the assessment of a patient’s gait.

a. What would the nurse note about a patient’s gait as they mobilised to and from the bathroom?
i. What is a normal finding?
ii. What mobility aid do you think Mrs Goldman would use to mobilise after her operation? Which
health care professional would be of most assistance to you in assessing the suitability of
mobility aids?
b. How would the nurse assess Mrs Goldman’s risk of falling?

Clinical Case B:
The following questions relate to Mr Cameron Taylor who is one of the other patients allocated to yourself and Susan. Mr
Taylor has just been transferred to the ward from the Emergency Department. Mr Taylor is a 42-year-old solicitor who
sustained a fracture of his right distal tibia and fibula whilst skiing at Falls Creek. Mr Taylor is awaiting for an open
reduction and internal fixation (surgical repair) of his fracture. Your Buddy Nurse Susan, asks you to perform a complete
set of vital signs on Cameron, and to also carry out a neurovascular assessment of his right leg.
1. Discuss in your group how the nurse would undertake a neurovascular assessment of Mr Taylors right leg.
Provide a rationale for each step in the assessment process.

2. What clinical signs would indicate deterioration in Mr Taylors neurovascular status of his right leg? Provide a
rationale for your answer. What actions would the nurse take once these abnormal assessment data are
identified?

3. Identify one actual and one potential patient problems related to the musculoskeletal system. Relate your
nursing diagnosis to Mr Taylors ’s current health status.

MUST READ ARTICLE: Johnston‐Walker, E. and Hardcastle, J. (2011), Neurovascular assessment in the critically ill
patient. Nursing in Critical Care, 16: 170‐177. doi:10.1111/j.1478‐5153.2011.00431.x

Group Two
1. In your group discuss the anatomy of the musculoskeletal. Please address the following points;

3 NURS 50004 Nursing Assessment and Care Melbourne University © 2018

 a. How does compact bone differ from spongy bone?
b. Define the following terms; abduction, adduction, circumduction, inversion, eversion, extension,
flexion, pronation, supination, protraction, retraction, rotation.
This group of questions will not be discussed in class, as it is covered in Nursing Science 1. Please ensure that you able
to link this science content with the nursing assessment and care of a patient.

2. The following questions relate to the collection of subjective data

a. What questions would the nurse ask Mrs Goldman in relation to her past health history? Provide a
rationale for your answer. Diabetes-diet, medication. osteoarthritis-pain, daily activity limitation. Heart
disease-any previous episode of chest pain. Family history, angina. This will affect her current health-
diabetes slow healing, medication if she is taking another medication. Osteoarthritis- she will difficulty in
walking, smoking/alchol, menopause
b. Why is it important to ask patients about the immunisations e.g. tetanus and polio?

She might be immune compromised because of long hospital stay, open wound can contract tetanus. She is old so at her
age immunization might not been existed.
c. What information would concern you the most about Mrs Goldman’s past health history?
Heart disease and diabetes
d. Why is it important to ask middle-aged women if they are receiving estrogen replacement therapy?
e. Lack of estrogen can lead to less bone mineral density and ultimately osteoporosis

3. What is Osteoporosis?
a. What is the impact of Osteoporosis on Australians?
An estimated 720,000 Australians over 50 years have osteoporosis.
• Women accounted for the majority of cases. 15 % of women over 50 and 4 % of men.
b. What is the impact of Osteoporosis on Indigenous Australians?
Rates of osteoporosis among Indigenous Australians were similar to rate reported for total Australians
c. How would the nurse promote improved bone health in patients like Mrs Goldman? Provide a rationale
for your answer.
Calcium and vitamin d intake
Promote little activity,
d. What is meant by modifiable and non-modifiable risk factors? What are the modifiable and non-
modifiable risk factors for Osteoporosis? Relate your answer to Mrs Goldman.

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 Non Modifiable
– Gender 75 – 80 % (F)
– Age >70 yrs (F), >80yrs (M)
– Body size small bones / thin
– Ethnicity – Caucasian & Asian at
highest risk
– Family history or personal history of
bone fracture
• Modifiable
• Little or no physical activity
– Hormones - ↓ Estrogens ↓Testerone
– Low Ca and Vit D intake
– Anorexia Nervosa
– Smoking
– Excessive caffeine / alcohol consumption
– Medication intake e.g. corticosteroids

4. The following questions relates to the collection of objective data.

a. What equipment would the nurse require to undertake a musculoskeletal assessment of Mrs Goldman?-
not much just neurovascular.just simple inpection
b. How would the nurse prepare the environment and the patient for a musculoskeletal assessment? -nice
safe and well lit.clear the clatter

5. The following questions relate to inspection of a patient’s temporomandibular joint (TMJ).

a. Describe how the nurse would inspect and palpate the TMJ
Index & middle finger anterior to external
ear opening
– Pt to open mouth as wide as possible
– Move jaw from side to side
– Protrude jaw
• Test for range of movement.
b. Describe how the nurses would test the range of motion (ROM) of the TMJ.
i. What is a normal finding?
Normal findings

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 – Jaw moves laterally 1-2cm, mouth opens 3
– 5 cm, jaw protrudes and retracts, jaw has
full ROM
ii. Which cranial nerve is associated with assessment of the TMJ ? -mandibular branch of trigeminal
nerve

Clinical Case B:
The following questions relate to Mr Cameron Taylor who is one of the other patients allocated to yourself and Susan. Mr
Taylor has just been transferred to the ward from the Emergency Department. Mr Taylor is a 42-year-old solicitor who
sustained a fracture of his right distal tibia and fibula whilst skiing at Falls Creek. Mr Taylor is awaiting for an open
reduction and internal fixation (surgical repair) of his fracture. Your Buddy Nurse Susan, asks you to perform a complete
set of vital signs on Cameron, and to also carry out a neurovascular assessment of his right leg.

1. Discuss in your group, how the nurse would undertake a neurovascular assessment of Mr Taylors right leg.
Provide a rationale for each step in the assessment.

2. What clinical signs would indicate deterioration in Mr Taylors neurovascular status of his right leg? What actions
would the nurse take once these abnormal assessment data are identified?

3. Identify one actual and one potential patient problems related to the musculoskeletal system. Relate your
nursing diagnosis to Mr Taylors ’s current health status.

MUST READ ARTICLE: Johnston‐Walker, E. and Hardcastle, J. (2011), Neurovascular assessment in the critically ill
patient. Nursing in Critical Care, 16: 170‐177. doi:10.1111/j.1478‐5153.2011.00431.x

Group Three
1. In your group, discuss the anatomy of the musculoskeletal system. Please address the following points:
a. What are osteoblasts and osteoclasts?
b. Locate the following bones; phalanges, fibula, tibia, patella, femur, sacrum, ulna, radius, humerus,
sternum, mandible, calcaneus.
This group of questions will not be discussed in class, as it is covered in Nursing Science 1. Please ensure that you able
to link this science content with the nursing assessment and care of a patient.

6 NURS 50004 Nursing Assessment and Care Melbourne University © 2018

 2. In your group discuss the following related to the physical assessment of the musculoskeletal system. Please
address the following points;
a. Describe how the nurse would inspect and palpate the sternoclavicular joint.
b. Describe how the nurses would test the range of motion (ROM) of the sternoclavicular joint.
i. What is a normal finding?

3. What is Osteoporosis?
a. What is the impact of Osteoporosis on Australians?
b. What is the impact of Osteoporosis on Indigenous Australians?
c. How would the nurse promote improved bone health in patients like Mrs Goldman? Provide a rationale
for your answer.
d. What is meant by modifiable and non-modifiable risk factors? What are the modifiable and non-
modifiable risk factors for Osteoporosis? Relate your answer to Mrs Goldman.

4. The following questions relates to the collection of objective data.

a. What equipment would the nurse require to undertake a musculoskeletal assessment?
b. How would the nurse prepare the environment and the patient for a musculoskeletal assessment?

5. The following questions relate to the collection of subjective data.

c. What questions would the nurse ask Mrs Goldman related to her family history. Provide a rationale for
your answer. What information would concern you the most about Mrs Goldman’s family history?

6. The following question relate to assessment of a patient’s cervical, thoracic and lumbar spine.
a. Where are the cervical, thoracic, lumbar, sacral and coccygeal vertebrae located?
b. Describe how the nurse would inspect and palpate the cervical, thoracic and lumbar spine.
c. Describe how the nurses would test the range of motion (ROM) of the cervical, thoracic and lumbar
spine.
i. What would be a normal finding?
ii. Define the following terms: scoliosis, lumbar lordosis, & kyphosis.
Clinical Case B:
The following questions relate to Mr Cameron Taylor who is one of the other patients allocated to yourself and Susan. Mr
Taylor has just been transferred to the ward from the Emergency Department. Mr Taylor is a 42-year-old solicitor who
sustained a fracture of his right distal tibia and fibula whilst skiing at Falls Creek. Mr Taylor is awaiting for an open

7 NURS 50004 Nursing Assessment and Care Melbourne University © 2018

reduction and internal fixation (surgical repair) of his fracture. Your Buddy Nurse Susan, asks you to perform a complete
set of vital signs on Cameron, and to also carry out a neurovascular assessment of his right leg.

1. Discuss in your groups how the nurse would undertake a neurovascular assessment of Mr Taylors right leg.
Provide a rationale for each step in the assessment.

2. What clinical signs would indicate deterioration in Mr Taylors neurovascular status of his right leg? What actions
would the nurse take once these abnormal assessment data are identified?

3. Identify one actual and one potential patient problems related to the musculoskeletal system. Relate your
nursing diagnosis to Mr Taylors ’s current health status.

MUST READ ARTICLE: Johnston‐Walker, E. and Hardcastle, J. (2011), Neurovascular assessment in the critically ill
patient. Nursing in Critical Care, 16: 170‐177. doi:10.1111/j.1478‐5153.2011.00431.x

Group Four
1. In your group, discuss the following related to anatomy of the musculoskeletal system. Please address the
following points;
a. Give an example of the following bone types; short and long bones, flat bones, bones with irregular
shapes.
This group of questions will not be discussed in class, as it is covered in Nursing Science 1. Please ensure that you able
to link this science content with the nursing assessment and care of a patient.

2. The following questions relate to the collection of subjective data.

a. What questions would the nurse ask Mrs Goldman related to her lifestyle and health practices? Provide
a rationale for your answer.
b. What information would concern you the most about Mrs Goldman’s lifestyle and health practices?
Provide a rationale for your answer.

3. What is Osteoporosis?
a. What is the impact of Osteoporosis on Australians?
b. What is the impact of Osteoporosis on Indigenous Australians?
c. How would the nurse promote improved bone health in patients like Mrs Goldman? Provide a rationale
for your answer.

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 d. What is meant by modifiable and non-modifiable risk factors? What are the modifiable and non-
modifiable risk factors for Osteoporosis? Relate your answer to Mrs Goldman.

4. The following questions relates to the collection of objective data.

a. What equipment would the nurse require to undertake a musculoskeletal assessment of Mrs Goldman?
b. How would the nurse prepare the environment and the patient for a musculoskeletal assessment?

5. The following questions relate to the assessment of a patient’s shoulders and arms (including the elbow, wrist,
and fingers)

6. Describe how the nurse would test the range of motion (ROM) of the shoulders and arms (including the elbow,
wrist, and fingers)
i. What would be a normal finding?
b. What is a Phalen’s test?
c. In what clinical situation would the nurse utilise there rules?
d. What is Tinel’s sign?
e. Where is your anatomical snuff box? In what clinical situation would the nurse palpate this area?

Clinical Case B:
The following questions relate to Mr Cameron Taylor who is one of the other patients allocated to yourself and Susan. Mr
Taylor has just been transferred to the ward from the Emergency Department. Mr Taylor is a 42-year-old solicitor who
sustained a fracture of his right distal tibia and fibula whilst skiing at Falls Creek. Mr Taylor is awaiting for an open
reduction and internal fixation (surgical repair) of his fracture. Your Buddy Nurse Susan, asks you to perform a complete
set of vital signs on Cameron, and to also carry out a neurovascular assessment of his right leg.

1. Discuss in your groups how the nurse would undertake a neurovascular assessment of Mr Taylors right leg.
Provide a rationale for each step in the assessment.

2. What clinical signs would indicate deterioration in Mr Taylors neurovascular status of his right leg? What actions
would the nurse take once these abnormal assessment data are identified?

3. Identify one actual and one potential patient problems related to the musculoskeletal system. Relate your
nursing diagnosis to Mr Taylors ’s current health status.

MUST READ ARTICLE: Johnston‐Walker, E. and Hardcastle, J. (2011), Neurovascular assessment in the critically ill
patient. Nursing in Critical Care, 16: 170‐177. doi:10.1111/j.1478‐5153.2011.00431.x

9 NURS 50004 Nursing Assessment and Care Melbourne University © 2018

Group Five
1. In your group discuss the following related to the musculoskeletal system. Please address the following points;
a. How many muscles are there in the human body?
b. Name three different types of muscles in the body.
c. How do ligaments and tendons differ?
This group of questions will not be discussed in class, as it is covered in Nursing Science 1. Please ensure that you able
to link this science content with the nursing assessment and care of a patient.

2. The following questions relate to the collection of subjective data.

a. Outline the questions you would ask Mrs Goldman related to her pain in her right leg? Utilise either the
OLDCARTS or PQRSTUV framework.

3. What is Osteoporosis?
a. What is the impact of Osteoporosis on Australians?
b. What is the impact of Osteoporosis on Indigenous Australians?
c. How would the nurse promote improved bone health in patients like Mrs Goldman? Provide a rationale
for your answer.
d. What is meant by modifiable and non-modifiable risk factors? What are the modifiable and non-
modifiable risk factors for Osteoporosis? Relate your answer to Mrs Goldman.

4. The following questions relates to the collection of objective data.

a. What equipment would the nurse require to undertake a musculoskeletal assessment of Mrs Goldman?
b. How would the nurse prepare the environment and the patient for a musculoskeletal assessment?

5. The following questions relate to the assessment of a patient’s hips, knees, ankles and feet.

a. Describe how the nurses would test the range of motion (ROM) of the hips, knees, ankles and feet.
i. What would be a normal finding?
b. What are the Ottawa ankle and foot rules?
c. In what clinical situation would the nurse utilise these rules?
Clinical Case B:
The following questions relate to Mr Cameron Taylor who is one of the other patients allocated to yourself and Susan. Mr
Taylor has just been transferred to the ward from the Emergency Department. Mr Taylor is a 42-year-old solicitor who
sustained a fracture of his right distal tibia and fibula whilst skiing at Falls Creek. Mr Taylor is awaiting for an open

10 NURS 50004 Nursing Assessment and Care Melbourne University © 2018

reduction and internal fixation (surgical repair) of his fracture. Your Buddy Nurse Susan, asks you to perform a complete
set of vital signs on Cameron, and to also carry out a neurovascular assessment of his right leg.

1. Discuss in your groups how the nurse would undertake a neurovascular assessment of Mr Taylors right leg.
Provide a rationale for each step in the assessment.

2. What clinical signs would indicate deterioration in Mr Taylors neurovascular status of his right leg? What actions
would the nurse take once these abnormal assessment data are identified?

3. Identify one actual and one potential patient problems related to the musculoskeletal system. Relate your
nursing diagnosis to Mr Taylors ’s current health status.

MUST READ ARTICLE: Johnston‐Walker, E. and Hardcastle, J. (2011), Neurovascular assessment in the critically ill
patient. Nursing in Critical Care, 16: 170‐177. doi:10.1111/j.1478‐5153.2011.00431.x

11 NURS 50004 Nursing Assessment and Care Melbourne University © 2018