{"id":1154,"date":"2022-09-19T09:26:15","date_gmt":"2022-09-19T13:26:15","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/objective-assessment-2-2\/"},"modified":"2026-02-02T11:59:12","modified_gmt":"2026-02-02T16:59:12","slug":"objective-assessment-2-2","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/objective-assessment-2-2\/","title":{"raw":"Objective Assessment","rendered":"Objective Assessment"},"content":{"raw":"An objective MSK assessment is generally completed after the subjective assessment. If the client shows signs of clinical deterioration, such as respiratory distress, you should focus the interview portion on pertinent questions and proceed directly to the objective assessment and associated interventions. For example, a fractured rib or vertebral fracture or a fracture that has severed circulation requires urgent intervention.<\/span>\r\n\r\nBe aware of the environmental temperature in the room and the temperature of your hands. Room temperatures are not easily modified, so try to limit exposing the client\u2019s body parts and keep them covered with their clothes or sheet\/blanket until you need to assess that body part. This also follows a trauma-informed approach<\/strong> and maintains the client\u2019s dignity and limits exposing them unnecessarily. If a stethoscope is needed, warm your hands and stethoscope before placing them on the client\u2019s body.<\/span>\r\n\r\nThe objective assessment of the MSK system involves a brief scan and a focus on inspection<\/strong>, palpation<\/strong>, range of motion (ROM)<\/strong>, and manual muscle testing (MMT)<\/strong>, and sometimes auscultation<\/strong>, depending on the affected area (see Table 2<\/strong>). Compare the body bilaterally throughout the assessment. Assess the unaffected side first for comparison with the affected side, and when a joint is affected, at the minimum, assess above (proximal) and below (distal) the joint. However, it is important to note that some causes of joint pain can go beyond the joint above and joint below.<\/span>\r\n\r\nThe sequential order of the objective assessment<\/strong> is typically based on minimizing position changes and using a cephalocaudal (head to toe) or proximal to distal approach. Although certain positions are suggested, you may need to adapt the position if a client is not able to stand or sit up. Do not conduct ROM or muscle testing<\/strong> if the subjective assessment and\/or inspection and palpation suggest trauma to the neck or back, or a bone fracture<\/strong>.<\/span>\r\n\r\nTable 2:<\/strong> Brief overview of a MSK assessment.<\/span>\r\n
\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
 \r\n\r\nMSK Assessment<\/strong><\/span><\/td>\r\n \r\n\r\nClinical Tips<\/strong><\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nInspection<\/strong> involves systematic observation with a focus on muscles, bones, and joints. Depending on the areas inspected, this may include colour, swelling, masses, deformities, and asymmetry. Observed deformities may include subluxation (when a bone is partially dislocated within a joint) or a complete dislocation in which the articular surface of two bones are no longer aligned or connected. You also need to assess the surrounding skin condition and presence of bleeding with [pb_glossary id=\"1296\"]open fractures[\/pb_glossary] and whether you observe any involuntary muscle contractions (e.g., twitching, spasms).<\/span><\/td>\r\n \r\n\r\nRemember to compare findings bilaterally<\/strong> and further assess discrepancies, asking additional subjective questions when required.<\/span>\r\n\r\nAny abnormal findings<\/strong> noted upon inspection should be further assessed with palpation.<\/span>\r\n\r\nYou should assess for the presence of muscle atrophy\/wasting (loss of muscle mass and tone) in clients who have suspected musculoskeletal conditions and mobility issues. It is best evaluated by comparing the client's muscle mass and tone to their baseline (i.e., their normal composition).<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nPalpation<\/strong> involves applying your hands to assess temperature, pain, masses, swelling, deformities, palpable fluid, and size and contour of muscles. You can palpate the affected area if the client notes or you observe any involuntary muscle contractions (e.g., twitching, spasms).<\/span><\/td>\r\n \r\n\r\nAssess the unaffected side first<\/strong> to compare it to the affected side.<\/span>\r\n\r\nUse the dorsal aspect<\/strong> of your hands to assess for temperature, because it is most sensitive to temperature changes.<\/span>\r\n\r\nFor palpation, use your finger pads<\/strong> as they are densely innervated. Your thumb will often be used along with your fingertips when assessing joints.<\/span>\r\n\r\nA synovial joint does not normally have palpable fluid.<\/span>\r\n\r\nTo learn more details about palpation techniques, review the<\/span> Physical Examination Techniques: A Nurse's Guide<\/a> open educational resource.<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nRange of motion (ROM)<\/strong> refers to a joint\u2019s mobility: can it stretch to its fullest extent? You should become familiar with the normal ROM of each joint. A client\u2019s baseline also is important so that you can evaluate their progress over time.<\/span>\r\n\r\nWhen assessing, make note of:<\/span>\r\n
    \r\n \t
  • Range of motion<\/strong> of the joint (full ROM or limited ROM with the specific range, and the presence of any [pb_glossary id=\"1298\"]contractures[\/pb_glossary]).<\/span><\/li>\r\n \t
  • Quality of the movement<\/strong> (movements of joints should be smooth and symmetrical with no obvious misalignments).<\/span><\/li>\r\n \t
  • Presence of pain<\/strong> (ask the client if they have any pain).<\/span><\/li>\r\n \t
  • Presence of crepitus<\/strong> (crepitus is an abnormal grating or crunching sound or sensation felt and heard over joints at the location where bones meet. It occurs when the articular surface of bones grind together. It is different from the sounds that are made when a person cracks their fingers or joints, which are caused by the slipping of tendons\/ligaments over bony surfaces. Ask the client to move their joints through a range of motion and listen. If the client has pain or a limited range of motion, you may cup your hand over the joint or grasp the joint with your fingers and thumb.).<\/span><\/li>\r\n<\/ul>\r\nWhen performing ROM exercises, encourage the client to try to perform active ROM<\/strong> first, meaning that they move without assistance. If they are unable, help the client perform assisted active ROM, and then move to passive ROM as needed.<\/span>\r\n
      \r\n \t
    • Assisted active ROM is when you are providing some assistance to help the client with ROM.<\/span><\/li>\r\n \t
    • Passive ROM is when a healthcare provider or equipment\/machine moves the client\u2019s joints through ROM positions for a specific joint.<\/span><\/li>\r\n<\/ul>\r\nWith all ROM, ensure the joint is still <\/strong>and stabilized<\/strong>. When performing assisted active or passive ROM, always support the client\u2019s joint and maintain proper body alignment throughout the movement. It is appropriate to provide light pressure to fully test the full ROM of the joint, but you should never force a joint beyond its capacity<\/strong>, as this could cause damage.<\/span><\/td>\r\n
 \r\n\r\nIt is helpful to demonstrate the movement<\/strong> so that the client can mirror the motions you make. Before beginning, ensure the client\u2019s body is aligned<\/strong>. As the client moves through the motions, ensure stability of the body part proximal to the joints.<\/span>\r\n\r\nIdeally, the client would perform ROM bilaterally at the same time in order to make comparisons. However, this is not possible with all joints such as the hips. Additionally, it may not be possible with clients who have mobility limitations and pain.<\/span>\r\n\r\nThe guidelines for ROM angles vary across the literature. We recommend using the ROM guidelines set out by the American Academy of Orthopaedic Surgeons (1965) and Luttgens and Hamilton (1997), as they are most commonly used in practice.\u00a0<\/span>\r\n\r\nTypically, you will visually observe the angle of the joint. Note that this will be an estimate, which is an appropriate approach when doing a [pb_glossary id=\"1300\"]functional assessment of ROM[\/pb_glossary]. If a more accurate joint angle is needed (e.g., fitting for a wheelchair), you may require a goniometer, which is a tool that measures the angle of a joint.<\/span>\r\n\r\nROM can be affected by several factors including the person's typical use of the joint and their age. New onset of limited ROM is a concern and is a cue that requires further investigation.<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nManual muscle testing (MMT)<\/strong> evaluates the body\u2019s capacity to innervate muscle strength<\/strong>. This can reveal neurologic deficits and help you evaluate their response to treatment of neuromuscular conditions. Essentially, you are evaluating the muscle strength resistance against the force of the assessor (i.e., the nurse).<\/span>\r\n\r\nThe Medical Research Council (MRC) Manual Muscle Testing scale (1943) is a common tool used and accepted by healthcare providers (James, 2007). It uses a grading scale of 0\u20135<\/strong> to measure upper and lower extremities resistance against applied pressure by the healthcare provider in various ROM exercise movements (see Table 3<\/strong>).<\/span>\r\n\r\nAn alternative method to test muscle strength is to use a dynamometry, which is a kind of mechanical equipment. The tool can record a more precise measurement of the muscle strength. However, not all healthcare facilities have access to this equipment.<\/span>\r\n\r\nAnother method to assess a client\u2019s muscle strength is a functional test. This kind of test assesses performance during activities of daily living; examples include the\u00a030 Seconds Sit to Stand<\/a><\/span>\u00a0test or the<\/span> Timed Up, Go (TUG)<\/a> test.<\/span>\r\n\r\n <\/td>\r\n \r\n

MMT can be evaluated in several ways. Check with the unit policy to see if there is a preferred approach.<\/span><\/p>\r\n

The MRC tool is somewhat controversial in terms of grade breakdown, as the subjective nature of skill when performing MMT (Naqvi, 2019). You can minimize subjectivity by being consistent in how you perform these techniques.<\/span><\/p>\r\n

Keep these tips in mind when performing MMT:<\/span><\/p>\r\n\r\n