Checklists for Clinical Nursing Skills

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skill 2-9 Undertaking a musculoskeletal assessment (continued)

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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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