33
skill 2-9
Undertaking a musculoskeletal assessment
(continued)
Comments
Excellent
Satisfactory
Needs practice
Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
17.
Lower limbs.
Inspect the upper and lower legs, ankles and
feet for size, symmetry and colour.
18. Palpate the upper and lower legs, knees, feet and ankle
joints for tenderness, pain, oedema, heat, nodules or
crepitus. Mark any hot, reddened areas with a skin
marking pen.
19. Test strength and ROM. Have the patient perform the
straight leg test with one leg at a time.
20. Ask the patient to move one leg laterally with the knee
straight to test abduction of the hips and medially to test
adduction.
21. Ask the patient to raise their thigh against the opposing
resistance of your hand, then push outwards against the
opposing resistance of your hand. Repeat on the opposite
side.
22. Stroke the sole of the patient’s foot with the end of a reflex
hammer handle or other hard object such as a key; repeat
on the other side.
23. Ask the patient to dorsiflex and then plantar flex both feet
against opposing resistance.
24. Compare bilateral findings of all limbs.
25. Observe gait and posture. If needed, assist the patient to a
standing position. Observe the patient as they walk with a
regular gait, on the toes, on the heels and then heel to toe.
26. Assist the patient into a position of comfort.
27. Remove used PPE/equipment and dispose of them in the
appropriate receptacle.
28. Perform hand hygiene.
29. Document your assessment findings on the patient’s chart
and make any necessary referrals. Report any abnormal
results to a senior nurse, medical officer or endorsed
nurse practitioner immediately.
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