3120 Midterm Study Guide

8/10/2019 3120 Midterm Study Guide

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Nursing 3120 Midterm

Course Intro, Health Hx, Communication, Assessment Techniques

Health Assessment

-systematic way of collecting data about a client/patient for purpose of determining the clients health status

-patient interviewsubjective

-physical examsubjective/objective

-lab/diagnostic testingobjective

Therapeutic Communication

-all about CONTEXT

-sender

-receiver

-message

-feedback

-context

Communication- no just words

-very dynamic process behavior is > words

-behaviors, verbal and nonverbal, intended or perceived

Personal variables

Age, gender, language, preferences, experiences, personality, self concept, values, cultural background, religion

Communication impacted by

-visual

-hearing

-tactile

Aspects to consider in a message

-What is in the mind of the sender?

-What does the sender chose to send?-How is the message sent?

-What is received by the receiver?

-What does the message bring to mind in the receiver?

Goals of effective communication

-send CLEAR, HELPFUL messages to our patients

-INTERPRET ACCURATELY what our patients are communicating

Verbal Communication

-Meaning

-denotation : concrete definition of a word-connotation: personal interpretation of word

Pacing

-speed or rate at which a message is delivered

-includes the use of pauses between important idea or concepts

Theurapeutic communication

-NURSE IS NOT SEEKING APPROVAL

-goal focused

-deliberate
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-different perspective

-planned

-needs of patient

-focus on problem solving

-encourage a patient to express feelings and concern

-nurse terminates

-genuineness: there for the patient, not about you

-respect: address patient by name and tone of voice

-empathy: recognize what patient is going through.. make connection, more willing to share info

Social communication

-spontaneous

-needs of both

-mutual sharing

-both parties express naturally

-reciprocal approval

-terminates spontaneously

Patient interview

-based on trust

-cant promise info patient shares is strictly confidential; only share w. people that need to know

-privacy

-confidentiality

-nonjudgemental

-do not react, use eye contact

-documentation

-writing; need to be aware how much time spent

-electronic health records

Stages of an interview

Stage 1-introduction

-purpose of interviewState 2-working

-collect data

Verbal techniques

-best way = open ended to allow patient to tell story in their own words

Closed question-

Facilitation

Silence-facilitate conversation

Reflection-pick up on emotion they are expressing and reflect back on patient

Summary-theurapeutic approach

Empathy-Clarification

Confrontation-

Interpretation-

Explanation-

Summary-

Non verbal techniques

Professional appearance

Posture-keep self open

Gestures and facial expression-

Eye contact-


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Voice-

Touch-need to first develop relationship

-theurapeutic

-do not tough psychiatric patient

-too touchy can cause patient to withdraw

Stage 3-closing

-thank and aknowledge; summarize what will do with info

Non therapeutic techniques

-requesting an explanation .. why?

-puts patient on defense

-probing

-If patient refuses need to provide why you are collecting information

-never leave a blank, interpreted as a health provider did not ask Q

-offering false reassurance

-if patient is stress, reflect back saying you would be stressed tootherapeutic approach

-defending

-advising

-if you were me, what would you do?response: pros and con from their stand point.. they need to make OWN decision

problematic questioning

-Posing leading questions

-you dont smoke, do you?

-Interrupting the patient

-Engaging in talkativeness

-Using multiple questions

-Using medical jargon

-talk at patient level

-Being authoritative-dont act as a boss, your there to help

Interviewing the patient with special needs

-Hearing Impaired

-Visually Impaired

-Speech Impaired

-Aphasic

-Non-English speaking

-Illiterate

-Low level of understanding

Tips for using an interpreter

-Use trained medical interpreternot family or significant other

-Allow time for the patient and interpreter to converse prior to interview

-Request sentence by sentence translation

-Allow extra time

-Use brief questions

-Maintain eye contact with the patient

-Observe patients nonverbal response

-Use preprinted questions if available


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Health History

*basis to use when you plan care

*need to judge how reliable the information given is

-Subjective information

-Database of persons health status including social, emotional, physical, cultural, and spiritual wellbeing

-Serves as a basis for planning care

-Reliability of informant

Types of Health HistoryComplete-only when general check up, not for a specific problem

-essential: co morbidity, medications, allergies, past health history

Episodic-

Interval or follow up-

Emergency-

Components of a health history

-Biographical Information

-Informant

-Patient or significant other

-Reliability of informant

-Reason for seeking health care- Chief Complaint

Characteristics of chief complaint

-Location

-Radiation:does it spread?

-Quality:what does it feel like .. open ended

-Quantity (severity): scale 1-10

-Associated symptoms

-aggravating factors:what makes it worse?

-alleviating factors:what makes it best?

-setting

-timing (when, duration)-meaning/impact

COLDSPAM

C- Character: how does it look, feel, sound, smell

OOnset

LLocation: where, ? Radiation

DDuration

SSeverity

PPattern: what makes it worse/better

AAssociated manifestations

MWhat Meaning does this have for you

PQRSTU

-Provokes/Palliative

-Quality/Quantity

-Region & Radiation

-Severity

-Timing

-Understanding Patients Perception


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Past health history

-Medical History

-Surgical History

-Psych/Mental Health History

-Medicationsprescribed, over the counter

-Communicable Diseases

-Allergiesdrug, food, allergensreaction

-true allergy: allergic responserash, throat close vs someone getting nauseas

**need to know exact reaction-Injuries/Accidents

-Childhood Illnesses

-Immunization History

Family Health History

-identify genetic patterns

-immediate blood relatives

-genogram

Social history

-Alcohol Use

-type, amount, frequency, CAGE

-Drug Use

-Type, amount, frequency

-Tobacco Usepack yr history

-higher pack yr= increased risk for pulmonary, cardiovascular and cancer

-1 pack a day for 20 yrs = 20 pack yr history

-Sexual practices

-Travel Historymilitary history

-important for ENDEMIC disease

-Education

-Roles and Responsibilities

-Domestic ViolenceCAGE!!!!

-ever felt need to cut down?

-are people around you annoyed with your drinking?

-ever felt guilty after drinking?

-ever need an eye opener to start day?

Health maintenance

-Sleep

-Diet

-Exercise

-Stress Management-Safety Devices

-Health Check-ups

-Traditional & Alternative Medicine

Review of systems

-subjective responses to series of body systems questions

-this is not the physical assessment; comes later

Purpose of physical assessment

-Screening of general well-being


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-Validation of complaints that caused the patient to seek health care

-Monitoring of current health problems

-Formulation of diagnoses and treatments

Assessment Technique

I- Inspection-sense of sight

-sense of smell

P-Palpation- act of touching the patient in a therapeutic manner

Light palpation- superficial, delicate, gentle-use finger pads or the back of your hand

-provides info on skin texture, moisture, temp, superficial pulsations and tenderness

Moderate palpation-superficial, delicate, gentle

-use finger pads

-depress 1 cm below surface

-provides info on skin texture, moisture, masses, fluid, muscle guarding, pulsations and tenderness

Deep palpation-provide info about position of organs, masses, size, shape, mobility and consistency

-use hands

-depress 4-5 cm below skin surface

-most commonly used for assessing abdominal and reproductive structures

Palpationtips

-Wash hands before and after the exam

-Wear gloves if indicated

-Warm hands

-Fingernails short and clean

-Inform the patient when, where, and how you will the touch will occur

Percussion

-Striking one object against another to cause vibrations that produce sound

-Analyze sounds by intensity, duration, pitch

-Any part of the body can be percussed

-Most commonly used for abdomen and thoraxDirect- feel sinuses

Indirect-place finger on chest and touch finger

Direct fist-slap finger place on kidney

Indirect fist-

Quality of sounds

Flatness- skull

Dullness- nose

Resonance-

Hyperresonance-

Tympany- over cheek or abdomen; gas filled

Auscultation

-Clean earpieces

-Point earpieces towards the nose

-Quiet room

-Diaphragmwith pressure

-Bellwithout pressure


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P- Percussion-

A-Auscultation-

-follow this order for most, except ABDOMEN, use IAPP

Nursing Process

Assessment- determine treatment

Diagnosis

Goal setting

PlanImplement

Evaluate

General survey, VS, Pain Assessment

General Survey

-Physical Appearance

-Assess patients:

-stated age. Vs apparent age

- health care issues aging to the person

-general appearance

-symmetry of findings via shoulders

-body fat-central obesity due to endocrine problem contribute to elevated BMI eg. cushing disease

-stature

-limbs proportional

-upright stature

-motor activity

-gait is smooth and stable

-able to bear own weight

-purposeful motor activity

-body and breath odors

-physically capable of proper hygiene-neglect for caring in older persons

-psychological presence

-observe the patients:

-dress grooming, personal hygiene

-mood and manner

-moody can indicate psychological issue

-speech

-slurring indicate toxicity or neurological impairment eg. stroke

-rapid indicate anxious or hyperthyroid

-expressive aphasia unable to articulate words indicate a neurological defecit

-facial expressions

-distress

-asses for:

-labored breathing, wheezing, cough and labored speech

-painful facial expressions, sweating, guarding,

-serious or life-threatening complication

-emotional distress or anxiety

***if distress, do not assess for patient history

Body Shape

Mesomorphic- average height, well develop muscle curvature


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Endomorphic- short and stalky, apple or pear shape

Pear- weight in hip and upper thigh

Apple- weight in chest/abdominal area .. risk for cardiovascular diease

Ectomorphic-taller, lanky and fat/muscular curvature distribution not well developed

Eg. marfan syndromepredispose for cardiovascular events

Vital SignsT-temperature

-Celcius

-equivalent to 5/9 x Temp in Farenheight32 degrees

-Routes:

-Oral

-Average: 37 C or 98.6 F

-Range: 36-38 C or 96.8-100.4 F

-Advantages: MOST COMMON

-convenient and accessible

-Disadvantages:

-safety, physical abilities, accuracy

-Rectal

-Average: 0.7 C or 0.4 F higher than oral

-Range: 36.7-38.5 C or 98.0101.6 F

-Advantages: MOST ACCURATE

-rounded bulb doesnt injur rectal mucosa

-Disadvantages: INVASE

-uncomfortable

-if immunesuppressed, not enough platelet and can rectally bleedco agulation

-axillary

-average: .6 C or 1 F lower than oral

-range: 35.4-37.4 C or 95.8 -99.4 F-advantages: safe, noninvasive

-under armpit child doesnt fight

-disadvantages: accuracy? Length of time to obtain measurement6-8 min

-tympanic

-average: calibrated to oral or rectal scales

-range: same as oral/rectal

-advantages: convenient, fast, safe

-calibrate to oral or rectal scale

-Disadvantages

-Accuracy? Technique affects reading-in adult; take pinna of ear and pull it up and back to straighten ear canal, place snuggly in ear

and hear beep

-in child; take pinna of ear and pull it up and back; need for infrared to hit tympanic

membrane to get an accurate temperature

**if hypothermic, may just be temp of ear canal; not tympanic membrane

-thermal artery thermometer

-As accurate as rectal and pulmonary artery temps

-More accurate than tympanic

-Press and run across forehead and temporal artery


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-helpful in pediatric client

-not good if person is sweaty

-variable affecting body temp

-Circadian rhythms

-Highest temperature in later afternoon and early evening

-Hormones

-temp difference in regard to menstrual cycle due to secretion of progesterone

-Age

-infants run higher temp; 99.6 rather than 98.6 for adult.. Elderly run temp of 96

-Exercise

-Stress

-patients immunosupressed due to steroids for inflam or arthritis will NOT see rise in

body temperature

-temperature variations

-Hyperthermia- above 101. 5 farenheight

-hypothermic- below 98.2 far

-induced into hypothermic to decrease oxygen in body so cellular activity goes down to

decrease basal metabolic rate

-A febrile- no temperature

P-pulse

-radial: thumb side

-4 point scale: absent to bounding

-normal range for adults: 60-100

Factors affecting heart rate:

-age, gender, activity, emotional status, pain, environmental factors, stimulants and medications

Age variations in heart rateNewborn: 100-170 bpm

1 yr: 80-160 bpm

3 yr: 80-120 bpm

6 yr: 70-115 bpm

10 yr: 70-110 bpm

14 yr: 60-110 bpm

Adult: 60-100 bpm

Apical Pulse:

-angle of Louis (2ndintercostals space) and move 3 down

-near nipple in men, under boob in women-listen to closure of AV valves

-s1 and s2 in cardiac cycle

Pulse deficit:

-apical pulse rate- peripheral (radial) pulse rate

-should equal ZERO

-cardiac dysrhythmias:people with irregular in conduction system will have extra beat in heart, but

volume of blood is minimal so doesnt reach radial pulse

R- respirations


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-rise and fall of chest indicating inspiration and expiration

-diaphragm movement of abdomen

-count for 1 full movement

-female and childrenthoracic movement

-maleabdomen movement

-higher than woman

-pain, anxiousness, heat and stimulants cause increased heart rate

-should be effortless and unconscious

Terms:

Eupnea- normal

Tachypnea- fast

Bradpnea- slow

Apnea- absence of

Dyspnea- difficulty breathing, labored or short of breat

Orthopnea- positional breathing problems

-seen in edema patients due to fluid ingested in pulmonary organs

Age Respiration rates:

Infat: 30-40/min

1 yr: 20-40/min

4 yr: 22-30/min

10 yr: 20-26/min

16 yr: 16-20/min

Adult: 10-20/min

B/P-blood pressure

-Force exerted by the flow of blood pumped into the large arteries

Korotkoff sounds

Phase 1- 1st

sound hear

-most accurate way: insert catheter into large artery; sense pressure and through transduceron outside; give digital read out

Phase 2- indicate highest systolic pressure.. Amount of force left ventricle have to resort to overcome

pressure from cuff wrapped around arm

-change in quality of sound

Phase 3- intense tapping

Phase 4- sound muffles

Phase 5- sound dissapears

Phase 6- recorded as diastolic pressure (bottom #)

99% of time see phase 1/phase 5

Factors that determine Blood Pressure-cardiac output: how strong is muscle to exert enough contract to push blood into larger arteries of

body

-PVr: how dilated/constricted arteries are influence pressure

-if dilate down; increase.. If dilate up; lower

-Volume: if hypovolemic (low volume; decrease volume)

-Viscosity: thicker blood; draw more fluid in vascular compartment cause BP to rise

-elasticity of wall: young; vessels are elastic and constrict rapidly and BP is maintained

-hardening of arties increase BP because no dilating out so pressure inside vessel will increase

Measuring Blood Pressure


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-SystoleContraction

-DiastoleRelaxation

-Pulse pressure

-difference between systolic and diastolic pressurev

-Equipment

-Mercury sphyg: eye needs to be eye level w. mercury because visual perception will change

-Aneroid manometer: measure in ml/mercury pressure

-Sphygmomanometer:

-Sites:-Brachial

-thigh **difficult to auscultate due to lots of movement and adipose tissue

-avoid AV shunts or fistulas, affect arm of postmastectomy patient

-Documentation

-position of patient

-location where taken

-Normal findings

-140/90

Pulse pressure-systolicdiastolic

-average = 40

-average < 40 indicate not profusing blood throughout body

-average > 40 indicate neurological damage in the brain

Common error in blood pressure measurements

-incorrect cuff size

-if too largefalsely low

-if too smallfalsely high

-unrecognized ausculatory gap

-not testing by palpation before auscultating

-common in people w. hypertension-incorrect cuff placement

Factors influencing B/P

-age: male > female

-race: African American high BP.. prone to cardio vascular

-weight: increase BMI, more force heart has to use to contract to spread blood throughout whole

body

-diurnal rhythm: BP decrease during sleep

-exercise

-emotion/stress

-white coat syndrome: when practioner come in, BP elevated because nervous-Hypervolemia: increase blood volume

-Hypovolemia: decrease in blood volume

Age variations in B/P

-newborn; 80/46

-infant: 90:61

6 yr: 100/56

14 yr: 118/61

Adult: 120/80

Elderly: 130/80


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P-pulse oximetry

-measurement of oxygen saturation of hemoglobin molecule

-normal: > 95%

-dark nail polish, ambient lighting will interfere w. reading, hypothermic or low BP

-interpert reading w. blood count and hemoglobin level

-indicate percent of oxygen breathing at a time: normal is 20.8%.. The other percentage is nitrogen

P-pain assessment

-subjective feeling and an individual response-need to asses, treat and evaluate pain

Pain Characteristics

-location

-radiation

-quality

-quantity/severity

-associated manifestation

-aggrevating factors

-alleviating factors

-timing/duration

-meaning and impact

What effect does pain have on vitals?

-BP, pulse rates, respiratory ratesincrease/breathing more shallow because deep breath may increase

pressure on area of pain

-not a normal affect in facial expression, begin to sweat

-mood becomes irritable or quiet and withdrawn

-position: keeled over, cluthing/protecting area of pain

Pain Scales

- Wong baker scale: 4-5 yr range understand scale of faces to communicate level of pain; severity scale --- -FLACC: used in infants and adults in ICU; look at behavioral cues indicating pain (face, legs, activity, cry and

consolability)

-PAINAD Scale: pain assessment in Advanced Dementia

Mrs. Samuels is admitted to the hospital with a diagnosis of Right Middle Lobe pneumonia. Her vital signs are

Temp 101.7 F, Apical pulse 112, radial pulse 104 BPM +2, Resp 28 and shallow; B/P 132/84; pulse ox on AA = 88%.

-Respiration: Tachypnea

-Apical pulse rate: tachycardia

-Pulse pressure: 48 (systolic/diastolic)

-Pulse defecit: 8 (apical/radial).. Indicates extra beats ..not enough contraction to push blood through

body-Pulse oximetry reading: need 95% or abovehypoxnea: low blood oxygen level

-AA: indicates use of ambiant air; source of aid

A 28 year old male is brought to the ED by a friend who found him outside on the sidewalk. He is unresponsive,

Temp 94F rectally; apical pulse 48 BPM & irregular; Resp 5 and shallow; B/P 82/42; pulse ox 74% on AA.

Vital signs:

-hypothermic, bradycardic, bradypnea, hypotensive, hypoxemic b/c < 95% on AA

Concerns:

-breathing!!!!!


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Skin, Hair, Nails Assessment

Importance as a System

-Largest organ system

-Guards from trauma, pathogens, and extreme temperature

-Barrier to keep fluids in and pathogens out

-Sensory contact with environment

-Vital organ system

Information from Assessing skin

-general health-presence of infection, fluid imbalance, and electrolye imbalance

-rashes/lesions indicate presence of lesions

-fluid overlead if skin is puffy; if skin is dry and sunken in, indicate fluid defecit

-pinkish tone reflective of oxygenation status

-tissue perfusion/oxygenation status

-activity, sleep/rest

-self care ability

-systemic disease manifestation

- reflective of problem within another organ system and show up in skin system

Structures of Skin

-epidermis: outer, highly differentiated avascular layer

-regenerative

-dermis: inner, supportive, vascular layer

-subcutaneous tissue: layer of adipose tissue

Structural of Epidermal Appendages

-nails: keratinized appendage of epidermis; hardened

-hair:

Vellus-short, fine, non pigmented

Terminal- thicker, coarse, pigmented.. develop as go through puberty

-sebaceous glands

-Sensory fibers- interpret outside worlds-Sebaceous glands- produce sebum which lubricates the skin and makes it soft and elastic

Sweat glands-

-eccine: control body temperature, if hot you will sweat

-apocrine: found in axilla and gentile area which function after puberty and are responsible for

body odor

Functions of Skin

-Sensory perception

-Synthesizes Vit. D

-Repair surface wounds

-Stores blood & fat-Identification of individuals

-Communicate emotions

-Protects internal structures

-older people lose adipose tissuelose cushioning, prone to injury

-Protects against heat/ultra violet rays

-Barrier to microorganisms

-Absorption of medication

Functions of the Glands

-Excrete metabolic waste
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-Regulate temperature through evaporation

-Softening/lubricating

-Resist water loss in low humidity

Health HistorySubjective Data

-Previous skin diseases

-Change in skin color or pigmentation

-indicate disease process

-Varies from person to person-Ask the person about their usual skin coloring

-Dependent on race

-Exposed vs. non exposed areas

-Change in a mole

-Change in feel of your skintemperature, moisture, texture, excess dryness

-feel hot or cold, excessive dryness or sweating, hard or leathery skin

-Itching - pruritis

-Excess bruising

-muscoskeletal problem; coagulation

-physchosocial issue- violence

-Rash or Lesion

-PQRST or COLDSPAM

-Impact and coping with

-Medications

-dermatological side effect

-rash or hives due to allergies to medicine

-Hair Loss

-Change in nails

-Environmental or occupational hazards

Transcultural Considerations

-Pigmentation

-Melanin located in epidermis, produced by melanocytes.-All people have same number of melanocytes; amount of melanin

produced varies with genetics, hormonal status, and environmental

influences.

-Melanin protects against ultraviolet rays

-When assessing dark skin, observe color changes in mucous membrane conjunctivae, earlobes,

nailbeds, palms & soles.

-Pallor can appear as greyish/dull tones or yellowish/brown tinges.

-Pallor is identified in dark skin as absence of underlying red tones.

-A normal Bluish tone of lips found in dark skinned Mediterranean population.

Skin Color changesCyanosis-oxygenation status and cardio respiration system.. Deoxygenated

blood in system?

Jaundice-biliary tract disease; something wrong with liver, gallbladder or

pancreas

-not allow of excretion of bile from liver and bile has yellow tint that is

reabsorb into circulatory system and enimate in skin

-normal for infants upon birth .. Too high can cause permanent

neurological problems but usually dissipates in a few days

-in adult; more of a path physiological issue


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Pallor-paleness to skin due to anemia, blood loss, not sufficient amount of RBC produced from bone

marrow

Erythema- redness of skin; reflect dermatitis or some inflammatory disorder

Ecchymosis-type of bruising of skin due to bleeding into subcutaneous layer

-body reabsorb bleeding skin changes yellow

Vitigo- complete absence of melanin

-patchy areas

-occurs in all races

-auto immune test: attacks own melanocytes-hypopituitary: lack of melanocytic stimulating hormone

-body image disturbance

Albinism-total body depigmentation; white cast to the skin

-congenital

-easily sunburned

-increase risk for skin cancer

Hyperpigmentation of skin

-sun exposure; tan lines

-over production of melanocytic stimulating from:

-pituitary tumor

-adrenal insufficiency

-renal disease

-birthmarkpink/purple markings

Lesions

Discrete- distinct; isolated

Confluent- run together

Annular- circular

Generalized- trunk or extremity where is located

Grouped- clustered together

Linear- scabies, creases of fingers

Target- bullseye rash

Zosterform- follow nervepath, very painful .. Herpes zoster-can develop shingles

-Macules and patches

-flat lesion w. a change in pigmentation

Eg. freckle or nevus

-Papules and Plaque

-solid, elevated lesion

-papules < .5 cm

-plaques > .5cm

-Blistersvesicles and bullae

-sharply delineated elevation filled w. clear fluid

-< 1 cm = vesicle-> 1 cm= bullae

Eg. chicken pox or small pox

-Pustules and Abscess

-vesicles or bullae filled with pus

Eg. acne or abcess in deeper layers

-Nodules and Tumor

-elevated lesion under the skincan be moved over the lesion

-0.5-2cm = nodule

-> 2cm = tumor

-Wheal


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-localized swelling in the epidermis

-irregular elevation

-red or pale

-antibody reaction to medication develop patches in skin

-treat w. bendaryl which is an ANTIHISTAMINE

eg. hives

-Scales

-patchy, flaking of the skin surface

Eg. dandruff, psoriasis-Crust

-dried serum, blood or pus on the skin surface of the skin

-eschar: black leathery scab on healing wound

-skin is attempting to repair and if infected, will see drainage

-Lichenification

-layer of skin becomes thickened and rough as a result of rubbing

-Erosion

-superficial wound with loss of epidermis or mucosa

-risk if deepens can cause infection

Skin Changes

-scar: lack melanocyte

-keloid formation: over production of scars

-staie: stretch marks pink initially then silvery white

Vascular Lesions

-capillary hemangiomas

-ecchymosis

-purpura

-petechiae

-spider angioma

-hormonal contraceptives

-pregnancy-liver disease: high levels of hormones due to lack of drainage

-venous star

-engorgement of veins: venous insufficiency due to circulatory problem manifesting self onto

Skin

Changes in skin w. aging

-Decreased skin elasticity, increased wrinkling

-Skin thinner, drier, more fragile

-Decreased sweat gland activity

-Fewer hair follicles

-Decreased vascularity in dermis (pale)-Medication based skin changes

-steroid causes skin to thin

-seborrheic keratosis

-skin tags: excess skin most commonly found under armpits

-senile lentigo: liver spots uneven pigmentation

-ability of melanocyte to produce even igmentation

-cherry angiomas: vascular arterial; benign

Danger Skins in pigmented lesions of the skin

AAsymmetry


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BBorder irregularcancer?

CColor variedcancer?

DDiameter larger than 6 mm

E - Elevation

Basal cell carincoma-waxy translucent appearance; sharply defined border

Squamous cell carcinoma- rough, elevated, irregular

-doesnt metastasize and spread cancer beyond lesion

Malignant melanoma-uneven surface, irregular outline, varying pigmentation-will metastasize can result in death

Palpation of the Skin

-Moisturedry, diaphoretic

-Influenced by environment, muscular activity, body temp., stress

-Temperaturewarm bilaterally

-Hands & Feet can be cooler but =

-Palpate using back of hands/fingers

-No Tenderness

-Texturesmooth, even, firm

-skin tugor; skin doesnt go back; not well hydrated or loss of adipose tissue

Edema

-Fluid build-up in intercellular spaces

- 0 - no pitting

-+1 - 0 - 1/4 (mild)

-+2 - (moderate)

-+3 - 1 (severe)

-+4 - > 1 (severe)

Alopecia; Hair loss

-male pattern baldness

-drug/radiation-trichotillomania

--loss 15 -40 hairs a day

-male patternbaldness assoc with genetics and testosterone

-known as alopecia.. Can develop to medical therapies as well

-hair will come back, with diff texture or color

-Trichotillomania- psych disorder manually pull hair out to scope w. stress

-Female baldness- hormonal imbalance often during pregnancy

-can reflect vitamin/defic or interraction w. medication

-inability for women to break down testerone into DHT

-develop hair follicle atrophy

-can be due to hot comb or traction (corn row)

Excess hair; Hirsutism

-drug induced

-over production of adrenal glands

-hormonal imbalance

Nails

-Nails should be pink, adherant to nail bed

-Surface of nail bed- smooth and flat

-Nail bed perfusion can reflect cardiovascular perfusion


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-blanch out nail bed and determine how long reperfussion takes (should be less

than 3 sec)

-160 degree angle .. If greater indicate systemic illness

-pigmented

-90% of black individuals

Nail Growth

-Infant/Children:

-Rapidevery 6-8 weeks-Softer

-Adult:

-12-16 weeks

-Elderly:

-26-32 weeks

-Thicker

Beau Lines- transverse growth arrest lines

-generalized serious illness

Clubbing

-Distal finger becomes roundeddrumstick

-Nail angle > 180

-Birds beak

-reflect pulmonary and cardiovascular

-diamond shape should form when nails together

Onychomycosis

-fungal infection of nail bed

-common in toenails

-dark, warm, most envioment

-common in people with diabetes

--difficult to treat; nails are keratinized so difficult to get medication down to where the infection is

-oral antifungal medications interact w. liver

-takes 6-8 months for complete resolution

Head & Neck Assessment

Head

Cranial bones- not fused to allow to engage in birth process

Sutures:

Posterior fontanele- close by 2ndmonth of life

Anterior fontanele- close at age of 2 yrs

**fontanele should be about same level of cranial bones; not depressed this incidates dehydration

-bulging indicates increases pressure of skull; for example meningitis produces increased fluid on brain

Facial bones:Facial Muscles:

Salivary Glands

Submandibular- jaw line and underneath chin

Parotid- along side of jaw

Sublingual-

Neck

-neck muscles:

-anterior and posterior triangle:


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-thyroid gland:

Lymph nodes of head and neck

-Preauricular

-Posterior auricular

-Occipital

-Submental

-Submandibular

-Jugulodigastric-Superficial cervical

-Deep cervical

-Posterior cervical

-Supraclavicular

Function***Fluid leaves vascular compartment, reabsorb in venous but extra fluid is picked up by lymp nodes

and return to circulatory system

-also, WBC pick up microorganism and lymph system reacts and enlarge to decompose

of organisms

Subjective DataHealth History Questions

1. Headache

2. Head injury

3. Dizziness

4. Neck pain, limitation of motion

5. Lumps or swelling

6. History of head or neck surgery

Head: inspect and palpate skull for size and shape

-normalcephalicin proportion to body

-Hydrocephalusin baby-no longer able to drain cerebral spinal fluid because sutures are not sealed upon birth

head will expand in size

-Acromeagaly- excessive growth hormone; facial features are thicker

Neck:

-Symmetry

-Range of Motion

-Lymph Nodes

-Trachea - midline

-Thyroid Gland

-Posterior Approach

-Anterior Approach

-Auscultate (if enlarged)

Inspect the fair: facial structures

Eyes:

-Transilluminationdarkened environment

-pen light under sinus; if clear sinus light will disperse

Lymphnodes

-Normally not palpable

-Can be small, discrete, moveable (1cm)

-inflammed will still be moveable

-Inflammation


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-enlarged, firm, tender, mobile

-Possible malignant

-hard, nontender, nonmobile

Thryroid Goiter-nodules can be benign or malignant

Musculoskeletal Assessment

Long Bones

-humerus, femur and tibia

Short bones

-carpals, tarsals

Flat bones

-ribs, sternum

Irregular bones

-pelvis and hip vertebrae

Skeletal muscles

Elongated muscle cells or fibers in striated bands

Mostly voluntary, under conscious control

Provide for movement

Maintain posture

Generate heat

>600 muscles in body

Ligaments

-attach bone to bone

-strong bands

-elastic

-maintain joint in normal ROM

Tendons

-attachs muscle to bone or muscle to muscle

-muscle contraction; tendon pulls on bone

-tendon sheath: tendonitisinflammed pain

-important in muscular move

-bursa are fatty pouches that facilitate movement of body to decrease frictions

Bursa

-fluid filled cavities located at tissue sites where tendons or muscles pass over bony prominences near joints

-facilitate movement-reduce friction

-bursitis: caused by overuse

Articulation:point where 2 bones meet

Fibrous-joined by fibrous tissues joints in head

Cartilaginous-cartilage to vertebrae

Synovial-bones separated by a fluid filled sac

-freely movable.. cushion that protect joint

Common chief complaints
https://learn.uconn.edu/bbcswebdav/pid-381021-dt-content-rid-980698_1/xid-980698_1?target=blankhttps://learn.uconn.edu/bbcswebdav/pid-381021-dt-content-rid-980698_1/xid-980698_1?target=blank


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-pain: most common complaint

-chronic vs acute

-where is it? Scale 0-10, what does it feel like, when does it occur? Assoc with other manifestations?

Alleviate/aggrevating?

Characteristics of chief complaint

-Location

-Radiation

-Quantity-Quality

-Timing

-Associated manifestations

-Aggravating factors

-alleviating factors

-Setting

-Meaning/Impact on ADLs and QOL

Medical History

-Musculoskeletal specific

-Joint disorders

-Bone or skeletal disorders - fractures

-Neuromuscular disorders

-Nonmusculoskeletal specific

-Infections: lyme disease

-Blood disorders: hemopheliablood into joint; limitation of motion

-Peripheral vascular disorders

**cancer may metastasize to bone

-Surgical History

-ArthroscopyJoint examination of

-ArthroplastyJoint repair/reconstruction

-Diskectomy or Laminectomysurgical fixation

-Internal fixation-External fixation

-Amputation

-Reattachment of a limb

-Common medications

-Anti-inflammatory agents - NSAIDS

-Analgesics: narcotic or non-narcotic

-Muscle relaxants

-Steroids

-Calcium supplements

-BiphosphonatesFosamax - Evista, Boniva - inhibit osteoclastic activity

-Protect bone-Hormone therapyused less for bone health

-Injuries/accidents

-Special needs

-Amputation

-Use of assistive devices

-Hemiplegia, quadriplegia, paraplegia

-Plegia = paralysis

-Childhood illnesses

-Poliopost polio syndrome

-Loss of muscular activity


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-Juvenile arthritis

-Auto immune body attack muscular skeletal system

-Family history

-Rheumatoid arthritis

-Pagets disease

-Unknown ediology

-Thickening of long bones; prone to fracture

-Osteoporosis

-Decrease in DENSITY of bone-Social history

-Alcohol or tobacco use

-Work environment: role of repetitious movements

-home environment: physical layout/barriers

-Hobbies/leisure activities

-ExerciseIs it F. I. T.?? (FREQUENCY, INTENSITY, TIME)

-Contact activitiesrisk of injury

-Weight-bearing activities

-Non-weight-bearing activities

-Aerobic activities

-Health maintenance activities

-Sleep

-Use of safety devices

-lumbar support

-Elbow/knee pads

-Health checkupsbone density tests

-Diet Intake

-24 recall

-Food frequency

-# of food items eaten

per day/week/month

-Food diaries3 days

-2 weekdays/1 weekend dayRecord after eating

-Direct observation

Assessment

-Equipment

-Goniometertest angle of joint

-Tape measure and felt tip marker

-Sphygmomanometer

-General approach

-Patient comfort

-Compare non-affected to affected - symmetry-Proceed in cephalocaudal (head to toe) order

-Overall appearance

-Posture

-Gait and mobility

-Weight-bearing status

-Gait patterns

-Transfer ability

-Sitting to standing

-Sitting to sitting

-Laying to sitting


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-Normal findings

-Height and weight are proportionate

-Full ROM

-Ambulate independently

-No structural defects

-Shoulders and hips are level

-Head and torso are upright

-Stable gait

-Transfers independently

Inspection

-Muscle size and shape

-Hypertrophymuscle size grows

-Atrophyloss of muscle size due to non use or paralysis of muscle; flaccid

-Involuntary muscle movements

-Tics, tremors

-Limb circumference

-Joint contour and peri-articular tissue

-Surround actual joint

-Normal findings

-Symmetrical muscle contour

-No involuntary muscle movements

-Bilateral limb circumference is within 13 cm of each other

-Joints are flat when extended, and smooth/rounded during flexion

-No joint enlargement or deformity

Palpation

-Muscle tone

-Slight resistance to passive stretch

-Hypotonity (flaccid)no resistance!

-Muscle strength

-SpasticityMuscle strengthmuch resistance, unable to extend muscle-Scale 0 to 5

Joints to Assess

-head to toe approach

-Check symmetry

-Do painful ones LAST

-Apply light pressure with fingerpads

-Start in the periphery of the joint and move to center of the joint

-Move it through the ROM

-Note swelling, pain, tenderness, warmth, nodules, erythema, ecchymosis

-ecchymosis: bleeding into tissue due to injuries

Range of Motion

-Active ROMperformed independently by the patient

-Passive ROMperformed by the examiner

Tempromandibular joint TMJ

-Articulation between mandible and temporal bone

-Open and close jaw

-Protraction and retraction

-Side to side movement


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-No crepitisbone on bone; not cushioned

Spine

-33 Irregular bones--vertebrae

-7 Cervical

-12 Thoracic articulate with ribs

-5 Lumbar

-Sacrum shapes the posterior wall of the pelvis

-Coccyx

Inspection and palpation of the spine

-Note curvature

-Check symmetry

-Check alinement by Palpating spinous processes

Kyphosis- increase convexity

-displace center of gravity

Lordosisconcave lumbar

-obesity; large abdomen; pregnant woman

Scoliosis- Screening is positive.. Refer to orthopedist

Range of Motion

Abduction-Arm over head

Adduction-Arm across body straight

Horizontal Flexion-Arms up like a dive

Horizontal Backward Flexion--Like on blocks for swim start

Circumduction

External Rotation--Hands behind head

Internal Rotation--Hands behind back

Inspection and palpation of shoulder

-Shoulders = in height

-No swelling-No tenderness

-No crepitus

-Full ROM

Rotator Cuff Tear

-Arm extended and abducted from the body

-Instruct patient to slowly lower the arm while maintaining arm extended

-Arm quickly drops

-Severe pain

-ask someone to extend out, abduct away from body, slowly lower to side of body

-if rip, will have pain trying to abduct

Palpation of elbow

-Palpate for warmth, swelling, tenderness, nodules, crepitus

-Tennis Elbow: Lateral epicondylitis

-Golfers Elbow: Medial epicondylitis

Wrist and Elbow

206 Bones in Body--1/2 in hands and feet

Extension flat out

Hyperextension--fingers


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Flexion--fold fingers

Radiocarpal Joint Radius Thumb Side and Row of Carpal Bones

MidcarpalTwo rows of carpal bones

Fingers and Hands

Abduction- tight fist

Opposition- touch thumb to each finger and be able to grasp

Grip Strength-Roll B/P cuff up

-Inflate to 20 mm Hg

-Have patient squeeze

-Normal: 150 mm Hg

-Check for symmetry

Carpal Tunnel Syndrome

2 tests:

Tinel- stimulate medial nerve by percussing it/tapping

-should haven no tingle or burn

Phalen-place hands at 90 degree angle for 60 seconds

Osteoarthritis

2 types:

Bouchard- proximal interphalangeal joint inflammation.. Closer to hand

Heberden- distal interphalangeal joint.. Tips of finger

Rheumatoid Arthritis

Develop swans neck, boutinere, severe ulnar deviation

Osteoarthritis- pain after actvity of joint

Rheumatoid- wake up in pain , more flexible as use joint

Fractured Hip-Pain

-Inability to bear weight

-Affected leg is shorter

-Affected leg:

-Internal rotation

-External rotation

-Any physical deformities in hip area?

-can measure affected and injured leg.. From ankle to hip

-should be no more than 3cm diff between 2 legs

-If fall forward- causes inward rotation and vise versa

Knee Joints

-Complex joint!!

-Patella, femur and tibia

-Extension

-Flexion - 130

Common Knee Disorders

-Younger adultLigament tears

-Traumatic

-Athletesfemale (?)


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Older adultsOsteoarthritis

-Wear and Tear

Hallux Valgus & Hammertoes

-shoe is too small, forces bone to be squished

-callous form and act as median for infection.. Osteomyolitis

Hammertoes- pronounce flexion of metatarsal

Anthropometric Measurements-Height/Weight

-best time is weight in morning and under same conditions

-Waist to Hip Ratio

-Body Proportions

-Growth Patterns in Children

-Changes in Nutritional Status in Adults

Ideal Body Weight

-Female: 100 Lb for 5 feet then add 5 Lb for every inch above 5 feet.

+ or10% for small or large frame

-Male: 106 Lb for 5 feet then add 6 Lb for every inch over 5 feet

+ or10% for small or large frame

-Actual Wt IBW x 100 = % IBW

-70-80% IBWmoderate malnutrition

-< 70% IBWsevere malnutrition

-110% IBWoverweight

->120 % IBWobesity

Waist to Hip ratio

-males are apple shape :thoracic and abdominal

-female are pare shape: weight aaaround hip and thigh

Risk for obesity related diseases-Waist to Hip Ratio

-Waist Circumference Divided by Hip Circumference

-Males

->1.0

-Females

-


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30.034.9 - Obesity Class I

35.039.9 - Obesity Class II

>40.0 - Obesity Class III

Skin Fold thickness

-Determines Body Fat Stores & Nutritional Status

-Triceps Skin Fold (TSF)

Midarm circumference-Skeletal Muscle Mass

-Measure in mm

-Normal: 5-95th% tile based on age/gender

-Used to calculate the Mid-Arm Muscle Circumference

Mid arm muscle circumference

-Measure of skeletal muscle mass and fat stores

-Calculated using the TSF & MAC

-MAMC (cm) = MAC (cm)(0.314 x TSF)

-Normal: 5-95th

tile for age & gender

Gerontological variations

-Bone density decreases

-Increased risk for osteoporosis

-Muscle atrophy

-Decreased muscle strength

-Deterioration of articulating cartilage

-Vertebral inflexibility

-Thoracic kyphosis

-Decrease in height

Neuro & mental Status Exam

CASE STUDY

-What would you ask mrs peters?

-Did you slip? Conscious? What made you fall? What pain do you feel?

-What assessments would you perform?

-Painradiating, quality, moving make it worse

-Set of vital signs

-Neurological assessmentpupils, hand grasps

-Basic inspection for wound, bruises, deformities

-Palpate neck, head, joints for fractures

-What possible risk factors might exist for this patient?

-Osteoporosis

-Post menopausal

-Caucasian female

-What would indicate to you a possible fracture?

-External rotation of fit indicate hip fracture

-Unable to bear weight

-Difference in leg length (shorter b/c femur bone rise up)

CASE STUDY

-Ms jones is 35 yr old

-5 foot 4, 162, bmi = 27.8, hip = 35 inches and waist = 40 inches


28/43

-Ideal weight?

-100 + 5 pounds per inch = 120 pounds

-What is hip to waist ratio?

-Waist circum/hip circum = 1.14 high because > .8 for woman

-% of Ideal body weight

-135%

-What is her BMI?

-Ideal = 19, hers is 27.8 so she is OVERWEIGHT

-Health risks?-diabete, cardiovascular, hypertension, lower back pain, at risk for osteoarthritis

-What would you ask about life style ?

-Ask her typical die, FIT test for fitness

Nervous System

-Central Nervous System

-brain

-spinal cord

-Peripheral Nervous System

-12 pairs of cranial nerves

-31 pairs of spinal nerves and their branches

Central Nervous System

-Cerebral Cortex-cerebrums outer layer of nerve cell bodies or which looks like gray matter because it lacks myelin

-The cerebral cortex is the center for humans highest function and governs thought, memory, reasoning,sensation

and voluntary movement

-Each half of the cerebrum is a hemisphere

-Each hemisphere is divided into four lobes

Hemisphere4 lobes

-Frontal braintumor- not able to make sense of world; cognitive issue

-Parietal- somatic body senses, make sense of sensory input

-Temporal-hearing, memory, speech perception and specialized wernike: auditory comprehension (listen towhat people say and articulate and make sense of itcould lead to receptive aphasia)

-expressive aphasiaable to process information, but cant clearly express themselve..make no sense

Occipital area-vision

Cerebrum

-ability to think and reason

-enclosed by 2 membrane layers called MENINGES

-Under dura meter there is cerebral spinal fluid

-under arachnoid mater is another space for fluid and place for blood to enter if there is trauma

-pia meter

Increased intracranial pressure (icp)

-If blood or fluid accumulates between these layers, pressure builds inside the skull and compromises brain

function.

-Can also occur with tumor growth or fluid build-up in brain tissue

-Increasing intercranial pressure only occurs in infant when fontanelle have closed

-may experience motor weaknesses depending upon where defecits are occuring

Damage to any of these specific cortical areas produces a corresponding loss of function

-such as motor weakness

-loss of sensation


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-impaired ability to understand and

process language

**due to loss of blood supply

-ASSESS FOR THE FOLLOWING:

-brains cant store o2 and glucose; needs a ready supply at all times for neurological functioning

-when blood supply is deminished, cells are oxygen deprived and cause neuorological defecits because can not

aerobic or cellular metabolism

Components of the CNSdivisions of the cerebrumBasal ganglia-coordinate automatic muscle movement of body

-involved in cognitive and emotional functioning in body

Thalamus- relay motor and sensory signals for processing

-regulate conciousness, sleep patterns, and how alert we are

Hypothalamus- connection between NS and endocrine

-regulated by pituitary gland

Cerebellum- involved in motor control and coordination

-how precise we are w. movement

-tested by police when suspected of DUI

Brainstem

-Central Core of the brain

-Consists of 3 areas

-Midbrain

-Pons

-Medulla oblongata

-Complex network of sensory fibers that control:

-Respiratory

-Cardiovascular

-Vegatative

-able to lose upper brain functions but still have heart working but the person may not be sane

Cross representation-Notable feature of nerve tracts

-Left side of body controlled by right side of the brain

-Right side of the body controlled by left side of brain

Peripheral Nervous System

-carries sensory messages to the CNS from sensory receptors, motor messages from the CNS out to muscles and glands,

as well as autonomic messages that govern the internal organs and blood vessels

-The peripheral nerves carry input to the CNS via sensory fibers (called afferent fibers)

- deliver output from the CNS via fibers (called efferent fibers).

-cranial nerves exit the BRAIN rather than the SPINAL CORD

-Spinal Nerves- 31 pairs of nerves which arise from the length of the spinal cord and supply the rest of the body.They

are named for the region of the spine from which they exit- they are:

-8 cervical

-12 thoracic

-5 lumbar

-5 sacral

-1 coccygeal

Subjective data

-headache


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-seizure

-syncopeloss of consciousness

-pain

-parasthesia: lack of feeling in body

-gait disturbance

-visual changes

-memory disorder

-difficulty with speech or swallowing

Neuro exam sequence

-mental status

-crainial nerve

-sensory system

-motor system

-reflexes

Mental status

-level of consciousness

-awake, alert and oriented x3

-place, person, time

-Who they are, where they are, general time of year

**first thing you lose is SENSE OF TIME, then PLACE, then WHO you are

Changes in loss of consciousness

-confusion

-lethargy.. require stimulus to be aroused

-stupor.. need vigorous stimulation

-coma

-varied responses to painful stimuli only

-thumb in notch between eyebrows or pinch trapezius muscle, pressure on mandible, sternal rub with knucles,

nail bed perfussion

-brain death-require 2 people to determine if withdraw life support

** LOC is the most sensitive indicator of a change in neurological status

-person who is confused, lethargic and start to deteriate

-test oxygen level, then glucose level (because brain cant store energy or oxygen)

Mental status

-Attentionability to repeat info or perform

-Memoryshort-term/long-term

-Judgmentsafety issues

-Insightrealistic perception of self

-Spatial perception - draw objects-Calculationability to calculate

-Abstract reasoningunderlying meaning

-Thought process & Contentlogical/coherent

-Suicidal ideation

Mini mental status screening

-Assesses cognitive functioning

-Assists in identification of delirium/dementia

-Score: 24-30 Normal

< 24impaired functioning


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Cranial nerves

-Olfactory- I

-Eyes closed

-Block one nostril

-Inhale deeply

-Present one odor at a time

-Compare both nares-Then introduce another scent

-Optic - II

-OculomotorIII

-Most eye movement, pupillary constriction, upper eye lid elevation

-TrochlearIV

-down and in eye movement

-TrigeminalV

-Sensory: Facial sensation

- ophthalmic

- maxillary

- mandibular

- corneal reflex

-Motor: Chewing

-Sense stimulation by whisp of cotton brush across face w. eyes closed

-Cornial reflex- see if person blink when rub cotton over side of cornea

-if lose, at risk for corneal abrasion

-Ability to chew food

-assess by having person frown

-AbducensVI

-lateral eye movement

-FacialVII

-Motor: Expressions frown, raise eyebrows, wrinkle forehead, smile show teeth, whistle, puff out cheeks,

close eyes tight against resistance-Bells Palsy

-Paralysis of the Facial Nerve

-Note the asymmetry of the palpebral fissures and the nasolabial folds

-unilateral paralyzation

-asymmetry in bindings

-if only in facial area and no weakness in side of body, this of bells palsy rather than stroke

-Chvosteks sign

-Neuro excitability of the facial nerve

-Normal: no twitching when it is stimulated

-If twitch/muscle spasm present hypocalcaemia or tetanus

-check stability of facial nerve-determine calcium balance determined by parathyroid gland

-low calcium level cause muscle twitching, externally stimulate 7th

cranial nerve by tapping on

side of head

-patient will twitch if not enough calcium to stabilize

-occurs after someone who has thryoid surgery

-calcium balance affects cardiac function as well as neurological function

-Sensorytaste

-Sweet/Saltytip of the tongue

-Sour - tip of tongue & borders

-Bitter - back of tongue


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-AcousticVIII

-hearing and balance

-GlosopharyngealIX

-swallowing, salivating and taste

-open mouth and place tongue stick on tongue.. Say ah and watch symmetric movement upward of uvula

-lose function and at risk for aspiration

-VagusX-Swallowing, gag reflex, talking, pharyngeal movement, activities of the thoracic and abdominal viscera, such as

heart rate and peristalsis

-say ah

-gag reflex.. Tongue blade to back of pharynx

-during anesthesia, loose gag reflex and cant feed until gag reflex has returned

-Spinal AccessoryXI

-shoulder movement and head rotation

-place hand on side of face and ask to laterally rotate head against resistance

-shrug shoulder against resistance

-Hypoglossal - XII

-tongue movement

-tongue is midline and not deviated to one side

-articulate words light, tight and dynamite

-Cranial Nerve Names

-On Old Olympus Towering Tops A Fin and German Viewed Some Hops

-Cranial Nerve Function (sensory, motor, both)

-Some Say Marry Money But My Brother Says Bad Business Marry Money

Dermatomes

-spinal nerves innervate different part of body

-spinal cord injury may impact person to feel diff parts of body

SensationPain & temp- tells us later spinal thalmic tract is sending senses to thalamus and connecting over to cerebral cortex and

able to respond to sensations

Discrimination- test integrity of dorsal column, thalamus and into sensory cortex

Exteroceptive sensation

-Light Touch - wisp of cotton

-Patients eyes closed

-Distal to proximal

-Check for symmetry

-Superficial painsafety pin

-Dull vs sharp-Temperaturehot/cold

**people with diabetes have nerve endings not sensitive to fine touches

Proprioceptive sensation

-motion and position

-vibration sense (distal to proximal)

-stike in palm of hand and then place on bony prominance (hand or foot)

-feel when vibration begins and ends

-neuropathy and diabetes may lose sensation


33/43

Cortical sensation

-Stereognosis

--feel something in environment and with eyes closed, actually identify common object

-graphesthesia

-Asterophoresis- absense of feeling

-Graphesthesisa- draw something in palm of hand and person will identify .. draw number 8.. Need to be

orientation to person-Two-Point Discrimination

-Lips/finger tips = 2-4 mm

-Palms- 8-15mm

-Shin, back = 30-40 mm

-Extinctionability to feel two points simultaneously and feel when one was removed

-Extinction- When stimulus is removed

Decerebrate rigidity (positioning)

-Ominous Signbrainstem, midbrain, upper pons lesion

-Armsstiffly extended, adducted, internal rotation, palms pronated

-Legsstiffly extended, plantar flexion

-Teeth clenched, back hyperextended

-lower portion of brainstem involved in trauma so person is in position that arms are stiff, extended and abducted into

body

-palms pronation

-feet are plantar flexion

-teeth clenched tight and hyperextended neck

-can start unilateral and move bilateral as pressure increases inside head

-Cerebral Cortex hemisphere lesion

-Flexion of Arms, Wrist, Fingers

-Adduction of arms

-Legsextension, internal rotation, plantar flexion

-can survive because vegetative functions are preserved in lower area of brain stem..-arms abduct into body and elbows flex

Pronator drift

-weakened side falls down and palm rotates up

Coordination

-Test of the integration of the pre-motor cortex, basal ganglia, cerebellum, vestibular system (ear), posterior column,

and peripheral nerves

Romberg test

-Patient stands erect w/ feet together, hands at side, and eyes open-Then patient closes their eyes

-Note ability to maintain balance

-Normal: Maintains balance with minimal swaying for 20 seconds

Reflexes

-Reflex action

-Automatic response to an adequate stimuli

-Types:

-Muscle stretch

-Deep tendon


34/43

-Superficial

-Pathological

Deep tendon reflex

-Biceps

-C 5 & C 6

-Contraction of biceps

-Flexion of elbow

-biceps contraction and cause arm to flex a tiny bit telling us deep tendon reflex is intact.. Test this with

someone who has neck pain or trauma-Brachioradialis

-C 5 & C 6

-Flexion and supination of forearm

-Triceps

-C 7 & C 8

-Contraction of triceps and extension of arm

-striking back of elbow and feel contraction of biceps and arm will extend a bit

-Patellar

-L 2, L 3, L4

-Contraction of quadriceps and extension of leg

-Achilles

-L 5, S 1, S 2

-Contraction of calf muscles and plantar flexion of foot

-Magnesium sulfate given to pregnant women can cause person to loose deep tendon relfex

Plantar vs babinski

Babinski- Pathological Upper neuron disease condition in adults.. Okay in infants up to age 2

Normal- big toe curves in toward stimulus

Babinski- big toe dorsiflex upward

Superficial reflexes

Abdominal-contraction of umbilical area.. Demonstrate innervation of t2-t12

Cremastic- spinal cord injury.. Take stimulus and stroke inside of thigh and watch for testicle to rise away from stimulusbulbocavernosus-squeeze glands on top of penis and they will contract

plantar

meningeal irritation

-Nuchal Rigidityresistance w/ neck flexion

-Kernigs Signresistance to leg extension and pain after the knee was flexed

-Brudzinski Signlegs flex with deliberate neck flexion

Increased intracranial pressure (ICP)

-Change in LOC - **initial sign**

-Cushings Reflex(late signs):-Elevated systolic pressure

-Widening Pulse pressure

-Bradycardia

-Apnea Spells

-= impending brain stem herniation

-Change in level of conciousness is most important indicator of neuorlogical problem

-increase pressure in head so heart has sytolic pressure increasing while diastolic remain same

-stimulate parasymp and heart rate drops

Glasgow coma scale


35/43

-Eye Opening 1-4

-Eyes Open

-4Spontaneous

-3To speech

-2To pain

-1Absent

-Best Verbal Response 1-5

-Verbal Response-5 - Converses/oriented

-4Converses/disorient

-3Inappropriate

-2Incomprehensible

-1 - Absent

-Best Motor Response 1-6

-Motor Response

-6Obeys Commands

-Response to pain

-5Localizes pain

-4Withdraws(flexion)

-3Decorticate

-2Decerebrate

-1 - Absent

-Normal: Score 15

-Below 8: Coma

Eye/Ear

-External structures

-Conjunctiva

-Palpebral:pink, moist mucous membrane seen when pull skin below eye down

-reflective of HCT, will be pale if anemic-Bulbar:clear transparent over entire eye

-vessels should not be engorged

-Canthus

-Inner:inside of eye (where eye goop is)

-Outer

-Lacrimal apparatus:upper outer quadrant for TEARS.. Clense front of eye to prevent microorganism enter

mucous membrane

-Extraocular muscles

-Internal structures

-Outer layer-Sclera:white with few small superficial vessels

-moist and shiny

-in Arican American, can see yellow streaking as normal variant

-if YELLOWjaundice due to biliary tract malfunction

-Cornea:should be clear, moist and shiny

-NO discharge, cloudiness, opacities

1. corneal laceration-foreign object that cuts cornea

2. acrus senilis- loss of pigmentation in IRIS, if in younger personcan be due to high lipid level


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-Middle layer

-Choroid

-Lens

-Iris

-Pupil

-Inner Layer

-retina

-optic disc-macula

-fovea centralis

-cones

-rods

-Visual pathway

-Sensory neurons in the retina

-Optic disc

-Optic nerve

-Optic chiasm

History of eye problems

-Age

-Children

-Amblyopia- brain partially or entirely ignores input from eye due to srabismus (lazy eye) and eye will

wander when not focusedneed to strengthen extraocular muscles

-Middle age

-Presbyopiaimpaired near visionage 45

-RetinopathyHTN, Diabetes Mellitusdue to intraocular pressure.. Deteriation of arterial beds, can

lead to blindness

-Elderly

-Cataract - with UV light exposure

-Glaucoma- IOP destroy optic nerve; result in blindness-Macular degeneration- central vision

Macular degeneration

-loss of central vision

-tested by Ampsler grid.. see if distortion within lines

Health History of Eye

-Common chief complaints

-Changes in visual acuity

-Blurred vision

-DiplopiaDouble vision-Visual field loss

-Blindness

-Floatersclumps of vitreous humor

-clump if vitreous humor can become aggitated with quick movement and float up into field of

visionsee bright sparkly lights

-Drainage

-Itching

-Dryness

-Medicalwill discuss common ones

-Eye Surgeries


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-Medicationseye drops

-Allergies

-Injuriesforeign bodies, trauma

-Family History of eye disease

-genetic predisposition for development of cataracts

-Social

-Work environment-exposure to toxins, chemicals, infections, allergens

-Health maintenance activities

-Use of safety devices - goggles-Eye exams, Glaucoma check

Visual Acuity

-Cranial nerve II

-Distance vision

-Myopianear sighted, can be corrected

-Near vision

-Hyperopia - far sighted

Eye Tests

-Snellen Eye chart: distant vision

-standing 20 ft away

-test each eye individually

-which eye read completely correct is recorded

-if visual acuity is 20/30 or >, referred

-green and red line is screening for color blindness

-E chart: distant vision

-Used with individuals who do not know the alphabet

-Note the green and red line for gross check of color vision

-Rosenbaum Card: near vision

-handheld card

-14 inches away

-results:-20/20 vision is NORMAL

-20/80 vision means a patient can read at 20 feet away what a patient with 20/20 can read at 80 feet

-blindness

-blindno light perception

-legally blindvaries state to state

-corrected vision is 20/200 or worse

-color blindness

-inheritred recessively x linked trait

Males: 8% white; 4% black

Females: .4% *RARE*

-test with Ishihara Plates

Visual fields

-Confrontation technique

-Assess all fields

-Types of defects

-determine if any problems with visual field

Hemianopsia-lose peripheral vision on sides, top or bottom of eye

Circumferential blindness-see in center, not peripheral

Unilateral blindness-blind in 1 eye, no visual field perception


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External eye and lacrimal apparatus

-eyelids

-abornmal:

-ptsosis:uneven eyelids.. can be reflection of cranial nerve #3 disfunction

-exophthalmos:can be due to hyperthyroid

-bulging of eye, bilateral in nature

-entropion

-hordeolum (stye)- infected hair follicle mostly due to staph aureus

-treat with warm, moist soaps-chalazion:infection of the eye lid

-warm water will treat, otherwise will need to be everted with staph aureus

-lacrimal apparatus:

-check for swelling, drainage, erythema (redness), excessive tearing

Extraocular muscle function

-Corneal Light Reflex (Hirschberg test)

-Focus penlight 12-15 inches away from eyes

-Note the reflected lightit should be symmetrical

-Cardinal Fields of Gaze - Cranial nerves III, IV, VI

-tested in DUI; unable to control extraocular muscles while intoxicated to keep focus

-Cover/Uncover Test (remain focus, or start to deviate?)

-Focus in distance

-Cover one eye

-Note any movement in uncovered eye

-Remove the cover

-Note any movement in the eye being uncovered

Pupil Check

-Cranial Nerve III

-Normal Size 2mm6 mm

-Note speed of constrictionwith light

-darken room, shine light, pupil constrict should be BRISK.. but can be sluggish or absent-Note consensual responsein other eye

-when one pupil constrict, the other will constrict

-accommodation: focus on object in distance, pupils will dilate and when object gets closer, pupils will bilaterally

constrict and converge

-PERRLA- pupils are equal, round, reactive to light and accommodation

Change in pupil response

-Pinpointsmall and fixed

-Opiates

-Miotic drops

-Brain Lesion-Dilated

-Mydriatric drops

-Head trauma

-Brain Stem infarct

-Cardiac Arrest after 4-6 minutes

Cranial Nerve III intact?

-Check Dolls Eyesvestibular ocular reflex

-Hold eyes open

-Briskly turn head to one side


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-if intact,maintain image on back of retina-if damage, eyes follow in same direction of turning

-Note movement of the eyes

-Positive = intact

-Negative = brain Stem injury

Clinical case

18 yr old with 2 day history of malaise(depression), loss of appetite, fever and aching muscle

-subjective info?-self diagnose self (exposures, congregate housing)

-what has she been doing to treat self

-life style behaviors (decrease in frequency in eating and pain)

-location of achy muscles

-key physical assessments

-vital signs

-palpate lymph nodes (movable, enlarged, tenderness)if tender and non movable, indicate cancer

-past medical history (co morbities)

-on medication.. esp steroid

-dizzy, lighthead, headache, signs of rash, photophobia (bright lights), vomiting,drowsiness

Vital signs:

-temp = 102.7 (every degree of farenheight above normal, see cardio vascular response increase by 10

beats per minute)

=pulse 128 bpm 3+

-respiration 28/minute

-bp = 118/72

Clinical case

-82 yr old, fall on ice and strike side of head 6 hras ago, slurred speech, difficulty swallowing and right arm/leg weakness

-cranial nerve

-visual inspection-loss of consciousness (lose time first because most abstract)

-vital signs

-range of motion

-examine hip fracture for muskoskeltal

-assess strength.. squeeze hand, push against hand

-as more pressure inside of head, heart needs to pump more forcefully to get blood into cranial.. systolic

increase, diastolic stay same and as pressure increase, baroreceptors in carotid arteries recognize this and increase

parasympathetic stimulation

Assessment of ear

Subjective data-change or loss of hearing

-drainagewhat type?

Blood- rupture ear drum

Clear- make sure not cerebral spinal fluid; test by glucose dipstick

-pain

-tinnitus; ringing in the ears

-indicate fluid behind tympanic membrane

-vertigo, dizziness indicate vestibular problems

-frequent ear infections common in pediatric because eutheschian tube is shorter and horizontal; easy for

microorganisms from back of pharynx is easily travel because direct pathway and close


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Inspection

-position

-if ear displace on head; diagnose with chromosomal abnormality

-coloreven tone

-size

-shape

-inflammation

-indicate rheumatoid arthritis on inner helix of ear due to gout

-pain/tenderness-drainage

Auditory screening

-whisper test

-Patient occludes on ear

-Examiner stands 2 ft. behind patient

-Examiner whispers 2 syllable word

-Have patient repeat it

-weber test

-Place vibratory Tuning Fork on center of head

-Sound lateralizes to both ears equally

-rinne test

-Place vibrating tuning fork on mastoid process

-When patient no longer hears it, place in in front of the ear

-Normal: AC > BC

-Air conduction 2 x bone

-tuning fork used to detect tone

Conductive hearing loss

-dysfunction of sound transmission

-unable to oscilate bones in middle ear or external ear and communicate to inner ear-can be result of serumen (ear wax)

-otitis media-- inflammation of middle ear

- injury of tympanic membrane

- oto sclerosis-- bone in middle ear fuse together so dont oscilate

-foreign object in ear canal

-Weber test on center of head will lateralize to fore ear

-Rene test air conduction time will = bone conduction time

-complete occlusion of ear canal there is no air conduction

Sensorineural hearing loss

-inner ear problem in vesibu cochlear ear

-Weber test in center of forehead will lateralize to good ear

-Rene test is normal finding: air conduction > bone conductions


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Opthalmoscopic and otoscopic examinations

-Diopter:Unit that measures power of lens to converge or diverge light

-0 lens clear for perfect or corrected vision

-20/20 vision

-Red: Myopic (nearsighted) Minus numbers

-Black: Hyperopic (farsighted) Plus numbers

Lens: get largest diameter of light in order to look through the pupil

-3 different lights of different size depending on size of pupil to maximize light

How do you see through iris?

-need to dilate pupils as much as possible

-darken room

-relax eyes as if gazing into distance

-patient looks in the distance

Medicine

-Mydriatic Drugsdilate the pupil

-Contraindications

-Head injury and coma

-Essential to observe pupillary reactions

-Suspicion of narrow-angle glaucoma

Getting ready

-Examiner removes glasses

-Leave contact lenses in place

-Darken room

-Switch on ophthalmoscope

-Set lens disc to 0 diopters

-Adjust to large round beam of white light

-Keep index finger on lens disc

*LEFT arm, LEFT eye of practitioner and place right arm on shoulder

Opthalmoscopic exam

-Relax eyes as if gazing into distance

-Place your left hand on patients forehead

-Examine right eye

-Right hand holds ophthalmoscope

-Right index finger on diopter adjuster

-Focus light on patients right eye

Method

-Left hand and left eye for patients left eye

- Patient gazes at a specific distant point-Tilt handle of ophthalmoscope ~ 20 degrees

-Begin 15 inches away, 15 degrees lateral to patients line of vision

-Shine light on pupil: Look for Red Reflex

-Place thumb of other hand on patients eyebrow

-Try to keep both eyes open

-RELAX, gaze into distance

-Move in on 15 degree line toward pupil

-Ophthalmoscope almost touches eyelashes


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Anterior structures

-Look for opacities in vitreous or lens

-Vitreous floaters: dark specks or strands

-Cataracts: densities in lens

-Optic Disc: observe

-Border: blurred nasally

-Color: yellowish orange to creamy pink

-look at this area for integrity of vessels

-lesions-fovea and macula

-Rings or crescents:

-Physiologic cup

-yellow-white

-< diameter of disc

-Symmetry

Arteries and veins

-Arteries

-Color: Light red

-Size: smaller (2/3 to 4/5 of veins)

-Light reflex: Bright

-Veins

-Color: Dark red

-Size: Larger

-Light reflex: absent

Macula and foveatoward nasal side

-Very last step

-Direct light laterally or ask patient to look at light

-Inspect Fovea

-High concentration of cones for central vision and high resolution vision-very painful for light to be shined at fovea

-Inspect Maculadistinct darker pigmentation

-macular degeneration common in people over 50


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Documents

3120 Midterm Study Guide