Checklists for Clinical Nursing Skills

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Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

skill 2-9 Undertaking a musculoskeletal assessment

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed accurately without causing the patient to experience anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation. 1. Identify the patient. 2. Check the medical order or clinical pathway/care plan. 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. Equipment: tape measure, goniometer (optional), skin marking pen. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), if indicated. 8. Ensure patient privacy is maintained and that interruptions are minimal. 9. Undertake a health history, as per Skill 2-1. 10. Help the patient to undress, if needed, and provide a patient gown. Assist the patient to a supine position. Use a blanket or drape to cover any exposed area other than the one being assessed. 11. Begin with a survey of the patient’s overall hygiene and physical appearance. 12. Assess the patient’s ability to move their neck. Ask them to touch their chin to the chest and to each shoulder, touch each ear to the corresponding shoulder and then tip the head back as far as possible. 13. Upper limbs. Inspect the upper and lower arms, wrists, elbows, hands and fingers for size, symmetry and colour. 14. Palpate the hands, fingers, wrists and elbow joints for tenderness, pain, oedema, heat, nodules or crepitus. Mark any hot, reddened areas with a skin marking pen. 15. Test strength and range of motion (ROM). Ask the patient to extend their arms forwards and then rapidly turn their palms up and down. 16. Ask the patient to flex their upper arm and to resist your opposing force. Repeat for the other arm.

Comments

Excellent

Satisfactory

Needs practice

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