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I. Introduction

“Osteoarthritis is a chronic degenerative disorder characterised by cartilage loss.

It is extremely prevalent in society and is a major cause of disability. It is important to

treat osteoarthritis effectively using a multidisciplinary approach tailored to the

patient’s needs.” (I Haq, 2003, p. 377)

There are two groups of osteoarthritis. Primary osteoarthritis can be located or

generalized with development of Heberden's nodes, the latter more commonly found

in postmenopausal women. The underlying cause of secondary osteoarthritis is trauma,

obesity, Paget's disease, or inflammatory arthritis. Patients are usually over 50 years

of age and complain about pain and rigidity in the affected joint / s, which is

exacerbated by activity and relieved by rest. Typically, if present, early morning

stiffness is less than 30 minutes.There may also be joint tenderness and movement

crepitus. Swelling can be caused by bony deformity such as formation of osteophytes

or by an effusion caused by accumulation of synovial fluids. There are no systemic

symptoms with a normal rate of erythrocyte sedimentation. Fever, weight loss,

anorexia, or abnormal blood testing should alert the doctor to other processes of

disease such as infection or malignancy.

In this study, the main focus is the assessment of the musculoskeletal system of

an elderly client. In an aim to do an in depth study of the current problem, and the
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system involve with the said issue, the student nurses conduct cephalo-caudal

assessment and health history taking focusing mainly on the client’s joint problem.

II. Objectives

During the case presentation, the students of BSN 1 - A will be able to:

1. Review suitably the musculoskeletal system's anatomy and physiology.

2. Identify accurately subjective and objective data taken from the client.

3. Discuss clearly the relevant information from the assessment of the systems of

the client.

4. Perform correctly the assessment techniques such as inspection, palpation,

percussion and auscultation in assessing the client.

III. Anatomy and Physiology

The main functions of the bones are to support the body, protect soft organs (ribs

protecting the organs in the thoracic cavity and the skull and vertebrae protecting

brain and spinal cord), allows movement to the attached skeletal muscles, store

minerals and fats and site of blood cell formation. The skeletal system includes the

bones (skeleton), joints, cartilages, and ligaments. Generally, the bone is made up of

diaphysis that makes up most of bone’s length, periosteum that covers the outside of

diaphysis, articular cartilage that covers the external surface of the epiphyses,

epiphyseal line which is a remnant of the epiphyseal plate that is commonly seen in
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adults, epiphyseal plate that causes lengthwise growth of long bone, endosteum which

lines the inner surface of the shaft, the medullary cavity which contains both yellow

and red marrow, bone markings which are the sites of attachments of muscles,

tendons, and ligaments. Bone is relatively lightweight and resists tension and other

forces. Organic parts (collagen fibers) of the bone make bone flexible and have great

tensile strength. Calcium salts deposited in the bone make bone hard to resist

compression.

The skeletal system also includes joints or articulations. Joints are the sites where

two or more bones meet. Joints have two main functions. They hold the bones

together securely, and give the rigid skeleton mobility. Joints are either classified

structurally or functionally. Functionally, joints are classified according to the amount

of movement the joint allows. Classifications are synarthroses (immovable joints),

amphiarthrosesn(slightly movable joint) and diarthroses (freely movable joints).

Structurally, joints are classified into fibrous, cartilaginous, and synovial. Joints

consist of cartilage- type of tissue that covers the surface of a bone at a joint. Cartilage

helps reduce the friction of movement within a joint, synovial membrane- tissue

called the synovial membrane lines the joint and seals it into a joint capsule. The

synovial membrane secretes a clear, sticky fluid (synovial fluid) around the joint to

lubricate it, ligaments- strong ligaments (tough, elastic bands of connective tissue)

surround the joint to give support and limit the joint's movement. Ligaments connect

bones together, tendons- attached to muscles that control movement of the joint.

Tendons connect muscles to bones, bursas- fluid-filled sacs, called bursas, between

bones, ligaments, or other nearby structures. They help cushion the friction in a joint,

synovial fluid- clear, sticky fluid secreted by the synovial membrane, femur or the
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thighbone, tibia or the shin bone, patella or the kneecap, meniscus- curved part of

cartilage in the knees and other joints.

When you have osteoarthritis, it affects the entire joint, including the bones,

cartilage, joint capsule, synovial membrane, synovial fluid, tendons, ligaments and

muscles. Osteoarthritis involves the breakdown of the cartilage protective cushion

around the ends of the bones where two bones meet to form a joint. A healthy joint

has a smooth cartilage lining and synovial fluid lubricates it. The cartilage becomes

flaky and rough in osteoarthritis, and small pieces break off to form loose bodies in

the synovial fluid. This causes the synovial membrane to be irritated and inflamed.

The cartilage loss leaves the bones unsafe and vulnerable to damage. The bone

underneath thickens and swells as the roughened cartilage becomes thinner. The

joint's smooth functioning is lost and the bone may lose shape and on the bone end

may form bony spurs (osteophytes). Micro-fractures can also occur at the ends of the

bones. The joint capsule and ligaments stretch and may slowly thicken to try to

stabilize the joint as the shape changes. It can also inflame the tissue around the joint.

OA can also cause the tendons, ligaments and muscles around the joint to deteriorate

and weak.

IV. Nursing Health History

A. Biographical Data

Name: J.D.A
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Address: Blk. 4, Lot B, Pinegrove Area, Camella Homes, Mandalagan, Bacolod

City

Gender: Male

Provider of History: Client himself

Birth date: January 2, 1940

Age: 79 years old

Place of Birth: Mambugsay, Cauayan. Negros Occidental, Philippines

Nationality: Filipino

Marital Status: Married

Religion: Roman Catholic

Educational Level: College Graduate

Occupation: Retired high school Teacher

B. Past Health History

In his childhood, the client acquired illnesses such as measles, pneumonia,

and the development of asthma. It is important to note that the asthma persisted

up until his adolescent years and the client mentioned that it disappeared around

his early thirties. As for the immunizations, the client was only able to verbalized

that he underwent small pox vaccination but was not able to show a vaccination

record book and was not able to remember any other vaccinations up to date.
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The client has illnesses in the physical aspects. First, the client expressed that

he is experiencing a problem with his joints specifically at the knee caps which

his doctor suggested to be a sign of osteoarthritis since he is mildly overweight,

had a right-sided mild stroke and had a problem with his left leg after a motor

vehicular accident. Likewise, the client is expressing problems in urination such

as incontinence and nocturia. Moreover, there is an on and off coughing. The

client is also experiencing blurred vision in OU. High blood pressure is also

prevailing in the client. In the mental aspect, there is instances of dysarthria and

intermittent memory lapses. In the emotional aspect, the client has a problem

controlling his emotions specifically anger. In addition, the client underwent

through eye surgery of OU. With the illnesses that the client is currently

experiencing, pain is present specially on both knee after performing activities

and chest pain that is triggered when overstretching of the chest.The individual is

also allergic to Simvastatin, a medication for cholesterol maintenance, which was

discovered after his initial intake of the aforementioned medication.

Another important characteristic is the physical aspect of the client. The

client is physically dilapidated and is experiencing slow progressive weakness in

the body affecting his ADLs. In terms of emotional aspect, the client has

problems with dealing and handling his anger. However, the client is extremely

extroverted and deals well with friends and relatives and engages himself in a

support group. Regarding the client’s spiritual aspect, he has a high spiritual

affinity and faith.

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C. Family Health History

The client’s parents are both deceased. His mother, while living was

experiencing asthma, died at the age of 93. While his father was hypertensive and

died at the age of 92. He then verbalized that he cannot remember the exact age of

his grandparents but he stated that his grandmother had asthma and his

grandfather was also hypertensive. The client stated that he cannot remember his

aunts and uncles. In addition, he had one living son and one deceased male child.

The first child died due to pregnancy problems. His second son is still living. The

second child is hypertensive, mildly overweight and is experiencing hair loss.

D. Lifestyle and Health Practices

The client usually wakes up around four o’clock in the morning and drinks

powdered milk with turmeric, with a side of sliced white bread and a glass of

water then proceeds back to sleep. He then wakes up again around six o’clock in

the morning to take his granddaughter to school and eats his breakfast afterwards.

Then he exercises for about five minutes and tends to his homegrown potted

plants once in a while. He spends his time in front of the television for the rest of

the morning. After having his lunch, consisting of vegetables and fishes, he takes

a rest for ten to fifteen minutes and goes back to sleep for over an hour or so. He

wakes around three in the afternoon to watch the television again until five

o’clock to have their daily rosary. He eats his dinner at six in the evening, also

consisting of fish, rice, cardaba banana, and a glass of water. The client then

proceeds to sleep but often wakes up to void or to have a midnight snack. The

client then stated that he only gets 3-4 hours of sleep but often wakes up in the
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middle of the night and after which he is then unable to readily go back to sleep.

It is also noted that the client does not prepare for his own food and is prepared by

a helper at their house. Likewise, household chores are also done by that same

helper.

Presently, the client has been taking the following medications: Telmisartan,

Clopidogrel, Amoddine, ISMN, Multi-vitamins, Simvastatin, Betahistine, and

Orphenadrine+Paracetamol.

The client has a check-up with a resident heart doctor every six months with

his wife. Often times the client refuses to comply with taking his medications and

would always resort to self or alternative medications or quack doctors. He also

refuses to do self-examination due to the fact that he believes it’s a taboo in his

age. The client would sometimes expose himself in hazards such as climbing the

stairs, complaining of feeling pain afterwards.

Regarding the client’s leisure time, often times he would isolate himself by

staying at home all day due to the fact that most of his friends are abroad or

deceased. Although the client is extremely extroverted, he is not vocal with his

family but is generally kind to his grandchildren. The client is devoted to the

church and has an unwavering belief in God. He currently lives with a pet. The

client used to work in the academe and was satisfied with his field of profession

but resigned due to old age. His stressors include pain with his illness. The client

cannot proceed with ADLs without guidance and he sits on a chair while bathing.
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Currently, he resides in a quite subdivision, with his wife and grandchildren. The

client is far from urban pollution and has a minimized environmental risk.

V. Review of The Systems for Current Health Problems

A. General Appearance

Upon entering the room, we have noticed that the room was clean from

clutter and the client which is a man of his 70’s, walking with assistance of his

crane and accompanied by his wife. The client was clean, and well groomed,

nails were of good color and even shaped and no odors were present, dressed in

his comfortable house clothes and his shoes appeared to be house sandals. The

client was about 5’6 in height and overweight at 80 kg. The client’s skin was not

out of the ordinary and there were no obvious lesions observed. The client exerts

more effort in walking while slightly dragging his right leg, as it is slightly

immobile as an effect of stroke history. As we introduced ourselves, the client

walked towards his chair and sat down then the client smiled and interacted. As

the client was sitting down, he placed both of his hands on his lap and his feet flat

on the floor. The client was alert, attentive and cooperative.

B. Skin, hair, and nails

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We assessed the client’s skin, hair, and nails through inspection and

palpation. The client’s over appearance is pleasant. He has a fair complexion,

smooth skin, and a good hygiene. He was wearing clean house clothes and

slippers. His body temperature was 36.7 °C which is generally accepted as the

normal body temperature. After inspecting his hair and skin, we have found no

evidence of rashes, discoloration, and dandruff although we have noticed skin

tags and hair loss which are normal signs of aging. In addition, we discovered a

scar on his left leg which was caused by a motorcycle accident. For the nails, we

have observed that the color was pale, brittle, and has lengthwise ridges.

C. Head and neck

We assessed the client’s head and neck through inspection, palpation, and by

asking the client a series of subjective questions. The client verbalized that he has

recently not experienced headaches, stiffness of the neck, and difficulty

swallowing. Furthermore, we palpated his neck and discovered that his lymph

nodes are non-palpable which indicates that there is no sign of enlarged lymph

nodes.

D. Eyes
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We assessed the client’s eyes through inspection, eye convergence test using

a ballpoint pen, visual acuity test and asking the client subjective questions. Upon

inspection, we observed that the client’s eyes particularly the edges of the iris had

some discoloration. When we asked the client regarding discharges from his eyes,

client verbalized that the only discharges were tears and rheum (“muta”). After

inspection and subjective questions, we proceeded with testing, we used a

ball-point pen instead of the penlight because of the discomfort that it could have

brought to the client. During testing, the client’s eyes had no convergence in

reaction to a pen directly pointed in front of him in a well-lit room. In terms of

visual acuity, we asked the client to read a short passage from the Bible, showed

signs of struggle in reading the passage as he was not able to read spontaneously

and we observed the client paused multiple times.

E. Mouth, throat, nose, and sinuses

We assessed the client’s mouth, throat, nose and sinuses through inspection,

palpation, smelling test, and asking a set of questions. At a glance, the client has

an incomplete set of teeth and has addressed them with dentures. He has

decreased strength in the mouth muscles during mastication or chewing when he

is eating. We also observed that he has no trouble smelling as he was able to

smell and able to differentiate menthol and perfume while eyes were closed.

When asked how often he has colds, the client verbalized that he doesn’t have

colds anymore. We then proceeded to palpate the sinuses for tenderness and at

the time of the assessment, we found that the client had non tender sinuses.
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F. Thorax and lungs

We assessed the client’s thorax and lungs through Inspection, Palpation,

Percussion and Auscultating the client. The client’s chest appeared Barrel-chested.

We took the client’s Respiratory Rate which was 20 cycles per minute (cpm) and

observed that he had a normal breathing pattern (eupnea). Upon palpation, there

were no masses or lesions present in the client. We then started with percussion,

we checked for the resonant sounds using a ladder approach. When auscultating

the client, we did not find any adventitious breath sounds in the lungs and thorax.

G. Breasts and regional lymphatics

We assessed the client’s breasts and regional lymphatic nodes through

inspection, palpation, breast self-examination, and asking the client subjective

questions. Through inspection, we noticed that both the areola and nipple were

dark but even in color. When questioned whether there were any nipple

discharges upon pressing the nipples, the client verbalized that there were none.

For testing and privacy purposes, we asked the client to conduct a breast

self-examination with the help of his spouse to assist him, we taught him the

vertical strip method, and evidently we found that there were no masses and no

palpable regional lymph.

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H. Heart and neck vessels

Upon assessment of the heart and neck vessels, the group of staff nurses

managed to acquire significant information about the client. The client verbalized

that he was experiencing chest pain if his chest was overstretched in long periods

of time. The client described that the pain was short term and said that it goes

away when he rests for a certain period of time. The client had a pulse rate of 60

beats per minute. In addition when the group assessed the jugular vein, there was

distention seen when the client was in a semi-fowler’s position. As for

palpitations, the client experienced it when he was still taking in caffeine but

since his doctor told him to stop there are no more signs of palpitations. Last

blood pressure that was taken from the client was 200/100. This is because the

client is hypertensive.

I. Ears

We assessed the client’s ears through inspection and a “ballpen clicking” test.

Through inspection, we have noticed that no discharges were visible on both

sides of the client’s ear and the right ear is lower compared to the left.

Furthermore, the client verbalized that there was no pain and swelling felt on both

side of ears although he experiences buzzing and ringing specifically in his left

ear. For the “ballpen clicking” test, we used a ballpen because of its availability,
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consistent sound production, inexpensiveness, and ease of utilization. We tested

the client’s hearing ability by clicking the ballpen near the client’s ear and by

gradually moving it away from his ears. In this test we measure the length

between the ballpen and the client’s ear and compare which side is affected. For

his left ear, he can only hear the clicking if the ballpen is 12 inches away from

him. For his right ear, he hears the clicking if the ballpen is 20 inches away from

his ear. Furthermore, the client said that he has difficulty hearing which is a

normal sign of aging .

J. Peripheral vascular

The client said that he was experiencing pain in both legs. It was brought

about by too much activity and usage of the legs. The pain is moderate and is

tolerable. It radiated around the legs and feet only. The students began to proceed

to the assessment part. Upon inspection the group saw that the legs were shiny

and hairless. This was due to venous insufficiency. There was swelling seen on

both legs of the patient. Color of feet and legs are brown and had a few bruises

around it. Then they began testing for pitting edema. The process was to push

down the leg with your thumb for 1 minute and then release. The results were

positive for 1+ edema since there was only slight pitting which was seen, no

visual distortion and it disappeared rapidly.

K. Abdomen
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The client verbalized that he did not have any pain in the abdomen. As the

student nurses inspected the abdomen, they we able to see that the color of the

abdomen was normal because it is usually paler than the general skin tone. Then

the group measured the abdominal girth of the client which was 41 inches. Next,

the student nurses auscultated the abdomen they were able to hear 20-30 bowel

sounds in each of the four quadrants which was the normal rate. Then they

palpated the abdomen and found no mass, lumps or tenderness in the area.

Indigestion was absent in this case. There was no difficulty in swallowing as said

by the client.

L. Male genitalia

There was no pain during urination but the client said that he usually would

wake up at night just to urinate. He also managed to tell us that his urine

sometimes was not consistent and that it sometimes stops during urinating and

then go out again. The client verbalized that the content of his urine was normal

and that there was no blood seen. The client also said that he was sure that he was

STI-free.

M. Anus, rectum, and prostate

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Through the review of the anus, rectum and prostate, the client was able to

state that hemorrhoids, defecation, and blood in stool were not present. However,

he stated that he has constipation the reason why he experiences pain in his bowel

movement which occurs 3-4 times in a week.

N. Musculoskeletal

Upon reviewing the musculoskeletal system of the client which has

osteoarthritis, the students have inspected that the posture of the client is slightly

hunched and since he has right-sided weakness from stroke, he had problem with

the acceleration portion of the swing phase and the mid-stance portion of the

stance phase which indicates that the client has a steppage type of gait the reason

why he was not able to walk in a straight line to maintain coordination and

balance when was asked to do such activity. Upon execution, redness were not

visible on both of his legs however both of his lower extremities retains a

dimpling effect after being pressed for several seconds. Upon assessing the

client’s cerebellar function, the students conducted Romberg’s Test and the client

was not able to maintain balance with evident swaying while eyes were closed

not finishing a full time minute. Activities in testing his range in motion (ROM)

was also conducted. The table below shows the results of the exercises:

Range of Motion Left Right

Activities
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Inversion of the ✓ ✓

Foot

Aversion of the × ×

Foot

Flexion of the ✓ ×

Foot

Extension of the ✓ ✓

Foot

The client also raised both feet alternately not reaching the 90 -degree angle and

experienced pain upon execution. The activity also indicated that he was able to raise

the left leg higher than of his right. The client also performed Phalen’s test and was

able to flex hands back to back at a 90-degree angle however, he was not able to hold

this position for a minute which indicates that he is positive for carpal tunnel

syndrome or the compression of the medial nerve of the hand. The tests that were

conducted were connected since he was diagnosed with a stroke on his right leg, the

client was able to conduct the exercises better when left leg is the one responsible for

the muscle movement.

Upon conduction of various tests, signs and symptoms of osteoarthritis were

evident which includes pain, tenderness, stiffness and loss of flexibility. The risk

factors that the client was positive of having includes old age, obesity, and certain

occupations such as industrial arts. People who live with joint pain, swelling, and
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damage to weight-bearing joints (i.e. hips, knees, ankles, feet) caused by osteoarthritis

have mobility issues which affect their ability to work and perform common daily

tasks such as taking a bath and carrying objects. In addition to facilitating accurate

pain assessment, the PQRST method was used. One of the palliative factors that affect

client’s osteoarthritis is the instances that he overuse his muscles or long period of

inactivity and being stressed. In return, muscles becomes tensed, the reason behind

the increasing throbbing and stretching pain. Pain as stated by the client is usually felt

on both of his knees and occasionally, in his elbows. On a pain scale of 0 to 10, with 0

being the lowest and 10 being the highest, the client graded it as 5 and the timing of

pain would usually start in the morning.

M .Neurologic

Testing the neurologic system includes the mood, behavior and the

responsiveness of the client. Throughout the assessment and interviews that were

conducted, the client was able to respond and cooperate to the activities given without

showing disrupted behavior or irritation. Addition to that, the client himself stated that

he has no problems when it comes to his mood and behavior regardless of the

situation of the external environment. Addition to the neurologic assessment, the

students tested the client’s ability to respond to sensation wherein a dot was drawn to

his skin and the client was asked to point where the dot was drawn while eyes were

closed. The client was able to point the dot correctly on his manus however loss of

sensation is present in client’s arm. Upon interview, the verbal response of the client

was oriented however, instances occur wherein the client may slightly talk with
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continued involuntary repetition of sounds. The client also verbalized that headaches

and anger with no apparent reason was nonexistent.

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VIII. Documentation
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Percussion
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From left to right (Aloro, Carmona, Cambell, Adarle, Casim, Cabañero, Bedrio, Abanilla)
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VII. References

Elaine Marieb, S. K. (2018). Essentials of Human Anatomy & Physiology.

England: Pearson Education Limited.

Hanrahan, J. H. (2019). Anatomy of a Joint. Retrieved from University

Rochester Medical Center:

https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&conte

ntid=P00044

I Haq, E. M. (2003). Postgraduate Medical Journal. Osteoarthritis, 377. Retrieved

from BMJ Journals: https://pmj.bmj.com/content/79/933/377

myDr. “Arthritis: How Osteoarthritis and Rheumatoid Arthritis Affect Joints.”

MyDr.com.au - Trusted Australian Health and Medicines Information, June 2017,

www.mydr.com.au/arthritis/arthritis-how-osteoarthritis-and-rheumatoid-arthritis-affec

t-joints.