13.6 Checklist for Musculoskeletal Assessment
Use this checklist below to review the steps for completion of “Musculoskeletal Assessment.”
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: assistive device (i.e., walker, cane, crutches, brace, etc.) based on patient status.
- Check the patient chart for information prior to assessment regarding mobility status, fall risk, and use of assistive devices.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs.
- Perform inspection:
- Observe the patient using their arms, legs, gait, ability to sit and stand, and posture.
- Note symmetry; compare each side of the body.
- Inspect overall size, bony enlargement, and alignment of muscles and joints.
- Observe coordination and muscle function and note balance, limping, presence of deformity, or shuffling.
- Palpate and assess range of motion (ROM) and muscle strength:
- Gently palpate bones, joints, muscles, and surrounding tissue for heat, swelling, stiffness, tenderness, or crepitation.
- Ask the patient to move major joints (knees, shoulders, hips, and ankles) through the expected ROM movements. Observe the quality and equality of motion bilaterally with the same body parts. Note any limitation, pain, or crepitus with movement. Use passive ROM if indicated and appropriate.
- Assess muscle strength and tone in:
- Hand grips
- Upper extremities
- Lower extremities
- Compare strength of symmetrical muscle groups. Upper and lower extremities on the dominant side are usually stronger. Rate muscle strength on scale of 0 to 5.
- Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Perform hand hygiene.
- Document the assessment findings and report any concerns according to agency policy.