NUR 230 Test 2 Notes Bundle
NUR 230 Test 2 Notes Bundle NUR 230
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This 47 page Bundle was uploaded by Issy Notetaker on Sunday September 27, 2015. The Bundle belongs to NUR 230 at Ball State University taught by Marjorie Pyron in Fall 2015. Since its upload, it has received 153 views. For similar materials see Health Appraisal Across the Lifespan in Nursing and Health Sciences at Ball State University.
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Date Created: 09/27/15
Chapter 11 Nutritional Status 0 Balance bw nutrient intake an requirements 0 Optimal Suf cient nutrients are consumed to support activities and metabolic needs 0 Over nutrition Consumption is over body needs and can cause obesity diabetes hypertension ect 13 children are overweight and 16 are obese 23 adults are overweight w13 obese Needed nutrients the body must have for daytoday needs and an increased metabolic demands on growth pregnancy and iHness Leads to a more active lifestyle less illness and a longer life 0 Identify those who are malnourished or at risk 0 Obtain baseline nutritional data 0 Affected by psychological psychosocial developmental cultural and economic factors 0 Plate should be 12 fruits and veges 12 whole grains and protein lean meats sh beans eggs nuts with little amounts of sodium sat and trans fats cholesterol 0 Vitamins water soluble C and B and fat soluble ADEK 0 Minerals MgClCaPKNa Developmental Competence 0 Infants and Children 04 months is fastest growth period double weight I this period and triple it by 1 Length increases Lose 10 in rst day but gain back quickly Double weight at 4 months and triple at 1 year Breast feeding 5 recommended Age 2 brain is 50 of adult size and 100 by 8 gt2 should not have low fat or skim milk or be on low fat diets o Adolescence Rapid growth Increased need for protein and calories Nutritional snacks are important to meet the needs that 3 meals a day can39t reach Girls will double body fat earlier than boys Inactivity increases increasing risk for obesity 0 Pregnancy and Lactation Increased nutritional demands Weight should increase a predetermined amount based on mother weight 0 Adult Nutritional demands stabilize Education to preserve health is required Increased risk for Metabolic syndrome 0 Increased BP increased fasting glucose increased triglycerides increase waist circumference low HDL 0 Aging Adult Decreased energy requirements Increased need for nutrient dense foods Lose mm mass Sarcopenia Increase body fat Sarcopenic Obesity is when there is also a decrease in mm mass Change in taste and smell Dif culty swallowing and chewing Ability Polypharmacy poverty alcoholism 0 Know caloric intake for each age groups 0 Culture and Genetics Food customs are usually kept the same even after moving Under nutrition is common when moving to a new country Consider Frequency Number Form Content Amount Regularity and O O O 0 Types Dietary Practices of Groups Food preferences go w religious practices Keep fasting in mind 0 Types of Nutritional Assessment 0 Nutritional Screening is the rst step and contains easily obtained data identi es if at risk for nutritional risk 0 Assess Weight weight history conditions diet information lab data Tools include Malnutrition screening tool and Mini Nutritional Assessment Malnutrition costs money in complications If at nutritional risk more in depth screening occurs Comprehensive Nutrition Assessment dietary history clinical information physical measurements lab tests Methods 24hr Recall easiest and most popular 0 Everything in past 24 hours 0 Complete interview or questionnaire 0 Food Frequency Questionnaire will counter the items left out in 24 hour recall 0 Food diary is most accurate 0 Everything for a week is written down 0 Can be selfaltered Direct Observations will detect problems w eating Identi es at risk pt Subjective Data collected 0 Eating Patterns Normal and changes 0 Weight Normal 0 Changes in appetite taste smell chewing swallowing 0 Recent surgery trauma burn infection 0 Chronic illness 0 Nausea Vomiting Diarrhea Constipation 0 Food Allergies o Medications and Supplements 0 Patient Centered Care 0 Alcohol or Drug use 0 Exercise 0 History Additional Data for Infants and Children 0 Gestational Nutrition 0 Breastfed vs Bottle Fed o Willingness to eat what was prepared 0 Overweight or obesity factors Additional For Adolescents 0 Present weight 0 Use of steroids or others to increase mm mass 0 Overweight and Obesity risk factors 0 Age of Menarche Additional for pregnant women 0 of Pregnancies 0 Food Preferences Additional for Aging Adult 0 Differences in diet from when 405 and 505 Objective Data 0 General appearance provides cues 0 Lab testing is needed for accurate diagnosis Hemoglobin Males 1418 gdL Females 1216 gdL Hematocrit Males 3749 Female 3646 Blood Sugar lt100 mgdL Cholesterol 120200 mgdL o Derived Weight Measures Percent usua body weight currentusua100 lt95 indicates a form of malnutrition Recent UsuacurrentUsusa100 Unintentional loss of gt5 is signi cant BMI and of ideal 0 Recent change in weight 0 Waist to Hip Waist circumferenceHip circumference gt1 in men or 8 in women indicates android obesity Waist circumference gt35 inches in women or 40 inches in men increases risks 0 Skinfold Thickness Estimate of fat Stores 10 gt OR lt is over or under nutrition 0 Arm Span Height 0 Look at skin hair nai eyes ips gums tongue MS and neurological O Developmental Competence 0 Infant Child Adolescent BMI and skinfold thickness to determine obes y Pregnant Women Weight measured monthly until 30 weeks and then bimonthly last month weekly Increase calories protein vitamins minerals mainly iron folate and zinc Gain weight at a certain rate Aging Adult Height will decrease and arm span is a better measurement TSF is dif cult to get so BMI and Waist to Hip are better indicators Serial Assessment 0 Monitors nutritional status of those malnourished Malnutrition types include obesity marasmus kwashiorkor and a mix of the two last ones Approaches to each must be individualized Features of good plan Regular exercise Eating low cal diet and low fat Monitoring daily intake Teaching moment Enjoy food but eat less Monitor portions Smaller Read labels Increase activity Avoid empty calories Purpose of nutritional assessment is to determine is person is optimal over or under nutrition Abnormal O O 0 00000 Obesity excess caloric intake Weight 20 above ideal or BMI of 30399 Marasmus protein and caloric malnutrition inadequate intake due to starvation Weight lt80 normal Kwashiorkor protein malnutrition diets high in calories but low in protein Normal weight and appear nourished but lab ndings are low M and K mix Prolonged low intake of protein due to starvation lt80 weight low lab ndings Scorbutic Gums Vitamin C de ciency Rickets Vitamin D de ciency Bitot Spots Foamy plaques from Vitamin A de ciency Pellagra Skin condition of Niacin de ciency Follicular Hyperkeratosis Vitamin A or Iinoleic acid de ciency causing dry bumpy skin Magenta Tongue Ribo avin de ciency 0 Under nutrition where all reserves are depleted More vulnerable Infant and children pregnant immigrants lower income hospitalized aging 0 Over nutrition excess consumption calories fats sodium and increases risk for obesity heart disease and diabetes Chapter 12 0 Purpose 0 Protection lgA Perception of touch pain temp pressure Regulation of temperature and hydration Communication Absorbing Produce Vitamin D Support circulatory system Notes status of vascular system nutrition 02 stats hygiene and chronic disease OOOOOOO Skin 0 Largestorgan 20ftquot2 6pounds o Guards and Adapts Epidermis 0 Thin Tough Tightly bound cells Protective of underlying layers and organs lnner Basal Cell layer New cells formed Keratin Melanocytes Melanin Same amount of cells different production rates 0 Horny Cell Layer Dead keratin cells Constantly shed and replaced 0 Completely every 4 weeks 0 Avascular Nourished by dermis 0 Color Melanin Carotene and Vascular bed Dermis o Supportive Layer 0 Collagen o Resist tearing o Tough o Nerves sensory receptors blood vessels and lymphatic system Subcutaneous o Adipose tissue OOOO Hair 0000 O O 0 Stores fat for energy Cushioning Increased mobility 125000 on scalp w loss of 45 a day ability to grow 30 feet Keratin Shaft Root Bulb matrix Cyclic growth pattern Arrector Pili mm Creates goose esh or raising hairs on neck Vellus Fine and Faint Terminal Darker and Thicker on scalp and eyebrows other grows in after pube y Not needed for protection Consider culture Color style and design Sebaceous Gland O O O Sebum through hair follicles Lubricates w oil to prevent water loss Everywhere hair is Sweat Glands O O Nails 0 o o o Eccrine Coiled tubules opening directly on skin surface Dilute saline is produced Apocrine Thick milky secretion Open on hair follicles Activate during puberty Emotional and sexual stimulation Muslq odor Decrease w age Hard plates of keratin Clear Longitudinal Ridges Pink and clear at cuticle Function of Skin 0 0000000 0 Protection Prevents Penetration Perception Temperature regulation ldenU cann Communication Wound Repair Absorption and Secretion Produces Vitamin D Developmental Considerations 0 Infants and Children O Hair follicle develop after 3 months in womb Lanugo Fine downy After birth Ianugo is replaced w veIIus Vernix Caseosa is present at birth 0 Thick cheesy sebum and shed epithelial cells Helps w hydrating the skin Newborn skin smooth thin elastic More permeable Temperature regulation is ineffective Growth causes thickening Puberty Changes 0 Hair growth 0 Increased oil production 0 Increased fat deposits Pregnant Women Increased pigment in nipple and vulva Linea Nigra develops in many women Stretch marks develop Striae Gravidarum Fat deposits are created 0 Aging Adult Lose in elasticity Thins and attens Wrinkling occurs Lose in fat Shearing and tearing occur more frequently 0 Increased risk for skin breakdown Glands decrease in number Less temperature regulation Decrease in vascuIarity Hair thins and decreases Loss of selfesteem occurs Decrease mm tone Decrease in subcutaneous fat SeniIe Purpura discoloration caused by trauma looks like a bruise CultureGenetics O O O O O Melanin production rates produce different skin tones Skin cancer risk increases w age and is highest among whites Gene can UV exposure is important Tanning bed and sunburns increase risk Skin conditions among African Americans Keloids Post in ammatory Hypopigmentation or hyperpigmentation PseudofoIIicuIitis Melasma SLE is higher in African American Women and have more severe eves 0 Hair of African Americans is in a wide variety of textures Subjective 0 Past History of Skin disease Treatments Allergies Birthmarks Tattoos Ask if dryness irritation itching or rashes Change in Pigmentation Overall or Localized Change in Mole Color Size Shape Sudden Appearance tenderness Bleeding Excessive Dryness or Moisture Pruritus Skin itching Excessive Bruising Rash or Lesion SOLDCART Did it spread Associated Symptoms Coping Stress Medications some cause side effects that show up in skin rashes or dryness Some make sunburn more likely to occur Hair Loss Gradual vs Sudden Change in nails Shape Color Brittleness Environmental or Occupational Hazards Dyes toxic Substances Patient Centered Care What does pt do to care for skin hair and nails Additional for InfantsChildren Birthmarks Change in color as a newborn Rashes or Sores Diaper Rash Burns or Bruises Exposure to contagious skin diseases Communicable diseases Habits Nail biting Protection steps 0 Additional for Adolescent Skin problems OLDCARTS 0 Additional for Aging Changes in past few years Delay in healing Pain Change in feet Falls History of chronic illness How do you care for skin Objective Conscioust attend to characteristics Know normal coloring Incorporate into the Complete Physical Assessment Regional is when looking into one area Try to control external variables 0 Inspect and Palpate Skin Color 0 General Pigmentation even and Consistent o Darker in sun exposed areas 0 Common abnormalities Freckles Mole Junctional Nevus and Compound Nevus Birthmarks Reliable areas under tongue buccal mucosa palpebral conjunctive sclera Widespread Color Change 0 Pallor RedPink tones are lost White color Peripheral Vascular constriction Yellowish brown ashen grey Inspect nail beds 0 Erythema Intense Red Expected w fever in ammation emotional reactions 0 Cyanosis Blueish Color Lips Nose Cheeks and Ears Nonspeci c Dif cult to observe in dark skinned people 0 Jaundice Yellowish color Not normal First noted in hard and soft palate junction and sclera Temperature Hypothermia Hyperthermia Moisture Diaphoresis Profuse perspiration Dehydration Texture Firm smooth even surface Thickness Thin but thick of callus areas Edema Fluid accumulating in interstitial space o Press thumb into skin and if pit stays present grade 1 4 0 Normal skin color Mobility and Turgor Pinch under clavicle Shows elasticity Vascularity and Bruisingquot Charry Angiomes commonly appear 0 Normally no venous dilations Note tattoos Lesions Color Past and present Elevation Flat raised indented Pattern distinct grouped Annular Con uent Shape Size In cm Exudate color oder Papate blanch or stretch w pressure Use Woods Light Discrete Distinct individual lesions Grouped Cluster of lesions Annular circular Begins in middle and spreads outward Con uent Lesions run together Primary Lesions De ne o Macule Patch Papule Plaque Nodule Wheal Urticaria Vesicle Bulla Pustule o Cyst 0 Inspect and Papate Hair Color Varies Graying begins around 305 and is genetic Quantity of hair Texture Fine Thick Straight Curly Kinky SHINEY Distribution Vellus coats body 0 Terminal is colored Is balding occurring Hirsutism Hair growth on facial area in women or increase in body hair Lesions Separate an lift hair 0 Inspect and Papate Nails Shape and Contour Slightly curved or at smooth an rounded folds and edges 0 Pro le Sign Angle of nail base 160 degrees base is rm OOOOOOOOO o Clubbing is an angle of 180 degrees determined by diamond sign Consistency Smooth and regular uniform thickness rmly adheres to base and bed Color See trough plate and pink bed Cap Re ll Depress nail edge and release 0 Note time to regain all color should be 12 seconds Note if pitting peeling or ridges are present or redness swelling or exudate Vertical Ridges rt aging kidney disease iron de ciency anemia Beau39s Lines Pitting w psoriasis Spoon Shaped Ironde ciency anemia Fungal infection is under the nail and hard to treat turn nail yellow hard and thick lngrown toenails 0 Promoting Health and Self Care Teach SelfExam ABCDE Rule 0 Asymmetry 0 Border Irregular 0 Color Variations 0 Diameter Larger than 6mm 0 Elevation Enlargement Welllit room Full length mirror Educate about harmful effects of tanning and excessive sun exposureburns Avoid 10am2pm sun exposure prime times Use SPF 15 AT LEAST Use sunscreen when overcast Some meds increase sunlight sensitivity Fluids maintain hydration to help keep skin intact Moisturizer should be applied 0 Developmental 0 Infants Skin Color and General Pigmentation Black babies might develop a darker tone later Mongolian Spot Hyperpigmentation in Asian Black American Indian and Hispanic Newborns Caf Au Lait Spot Round patch of light brown pigmentation Skin Color Change Erythematous o Beefy red ush for rst 24 hours o Harlequin Color change When laying on side half red and top is white 0 Erythema Toxicum Rash Cyanotic Conditions 0 Acrocyanosis bluish around lips hands and ngernails o Cutis Marmorata Mottling in trunk in response to cooler temperatures Physiologic Jaundice common developing after 34 day Carotenemia YellowOrange in light skinned people Moisture Perspiration occur after 1 month Texture Milia or tiny papules on cheeks and forehead Thickness Thin and thicker layers of subcutaneous fat Mobility and Turgor Test over abdomen Vascularity and Bruising Stroke Bite is normal and fades Hair Newborn is covered Nails May be blue but will turn pink 0 Adolescents Acne is common 0 Pregnant Women 0 Aging Striae appear Linea Nigra BrownBlack line midline Chloasma Irregular hyperpigmentation Vascular Spiders Lesions w tiny red centers Adult Color and Pigmentation Senile lentigines Liver Spots Keratoses Seborrheic Keratosis thickened pigmentation areas Actinic Kertosis redtan scaly plaques Moisture Dry Skin is common Texture Acrochordons Skin Tags Sebaceous Hyperplasia Thickness Thins and fat diminishes Hair Growth rate decreases Nails Growth rate Decreases and nails may thicken Mobility and Turgor Decreased and Elasticity is less Abnormalities Freckles Note how they are and amount Junctional Nevus MOLE Size Elevation Color Compound Nevus Vitilago Educate about sunburns risk and sunscreen use education to coverup Jaundice Late stage will show in eyes common in newborns bc immature liver liver damage is usual cause yellowing of skin Xerosis Excessively dry skin Need prescription of super strength lotion O O O O o Edema Mostly in low extermities Found commonly in people who stand on their feet all day o If healthy the swelling will go down in an hour Pitting is serious and causes complications w circulation Lymph node removal and cardiac surgery put a person at a higher risk 0 Osteomyleitis Infection of the bone started as edema and swelling in the ankle 0 Children Mongolian Spots Common and go away with age more common in African American Milia Like pimples should be taught to not pop Caf au Lait Birthmarks Erythema Toxicum Will go away education should be toward maintaining good hygiene 0 Aging Adult Chapter 20 Cherry Angiomas Skin Tags Senile Lentigines Liver Spots Keratosis Not cancerous Should monitor for measurement elevation Actinic Petechiae Broken blood vessels Purpura Look like bruises common on hands 0 Any disease impairing vascular system impairs 02 and nutrient delivery along with removal of wastes Arteries Carry blood to tissues contains 02 0 High Pressure 0 Heart beats cause expanding and recoiing to pulse blood through and arefeltat Temporal Carotid Arm Brachial Radial Ulnar Leg Femoral Popliteal Dorsalis Pedis PosteriorTibial 0 Supply 02 and nutrients to tissues 0 lschemia l de cient supply O Veins O O O Obstruction is the cause Peripheral Artery Disease Noncoronary arteries arteries in limbs Absorb C02 and Waste More Closer to skin and accessible Jugular Arm Super cial and Deep Leg Flow from super cial into deep 0 Deep 0 Femoral and popliteal Super cial 0 Great and Small Saphenous Perforators Venous Flow 0 O O O 0 Low Pressure Pumped by Contraction of Skeletal MM Pressure gradient from breathing Intraluminal Valves Larger and hold more of blood volume 60 Capacitance Vessels Problems w Elements of pumping cause risk for venous disease Varicose Veins cause valves to stop working properly and lead to pooHng Lymphatic Carries lymph uid Clear containing water and blood cells 0 O 0 Separate Vessel System Retrieves interstitial uid and pumps into venous system Collect in R and Thoracic Duct and empty into subclavian veins Func ons Conserve Fluid and plasma proteins Part of immune system Absorb lipids from small intestines Lymph Nodes Clumps of lymphatic tissues that lter uid Exposing uid to B and T lymphocytes Super cal Nodes Cervical Head and Neck Axillary Nodes Breast and Upper Arm Epitrochlear Node Hand and Lower Arm lnguinal Node Groin Related Organs Spleen Destroy old RBCs Produce Antibodies Store RBCs Filter microbes Tonsils Thymus Develops T Cells in children 0 Developmental O 0 Infants and Children By 6 system is fully developed Surpasses adults and then atrophies Nodes are large in children Pregnant Low BP increases venous pressure Edema results 0 Aging Adult Arteriosclerosis Hardening of vessels 0 Rise in systolic BP Atherosclerosis Fatty build up PAD Underdiagnosed Large cause of morbitiy and mortality 0 Women develop later than men 0 Associated w CAD only 7080 Diagnosed are treated Enlargement of calf vein 0 Risk for DVT o DVT risks Bed rest Sitting for large amount of time Heart failure 0 Results in PE is not treated Ml treatment 0 Early mobilization Low dose anticoagulant Fewer number of Lymph tissue CultureGenetics O PAD is a CAD risk Screening and treatment are key Smoking and obesity increases risk NonHispanic black have highest risk factors Subjective O O O Leg painCramps SOLDCART Skin Changes in Arms or Legs Swelling in Arms or Legs When Lymph Node Enlargement Chest pain SOB Coughing Where when and what activities induce these Fatigue O O O O Medications Smoking History Family note what side of family Diabetes HD Hyperlipidemia Hypertension Personal these affect circulation Objective 0 O 0 Prep Exercise eating habits caffeine alcoholdrug use Examine arms at the beginning during vital signs Legs after abdominal in supine and standing Inspect and Papate Arms Hold in hands and inspect color temp texture ect Look for clubbing by pro ling nger Check Cap re ll Note scars on hands and arms Papate Radial and Brachial Pulse Check Epitrochlear lymph nodes Modi ed Allen Test is used to evaluate adequacy of collateral circulation Inspect and Papate Legs Note color texture temperature Hair on toes indicated proper swelling Bend knee and assess for tenderness Papate Femoral Popliteal Dorsalis Pedis and Posterior tibial arteries 0 Grade force Check for edema by pressing on tibia or medial malleolus for 5 seconds o If pitting occurs grade it Color Changes Raise legs 30 cm an have pt shake feet to rid of venous blood and check color o If really paleD Problem 0 Have person sit and dangle feet over edge count time to re ll color 0 Test leg strength and sensation Doppler Ultrasonic Probe Detects weak peripheral pulse Ankle Brachial Index 0 R Highest R ankle pressureHighest Arm Pressure 0 L Same but for left Wells Score for DVT Development InfantsChildren 0 Pulse should be Bilaterally Nodes can be palpated 0 Pregnant Women Expect bilat pitting in lower extremities 0 Aging DP and PT pulses are harder to nd Edema Pitting 04 0 0 No pitting o 1 Mild pitting 2 mm disappears rapidly o 2 Moderate pitting 4mm Disappears in 1015 seconds 0 3 Moderately severe pitting 6 mm lasts 1 minute leg looks swollen o 4 Severe Pitting 8mm lasts 2 minutes leg looks veryy swollen Expected nding immediate rebound Arterial Insuf ciency 0 Normal Transports 02 lled blood 0 Caused by 02 De cit 0 55 Lower legFoot pain 0 1 hour onset Numbness tingling quotCrampingquot quotFeeling Coldquot 0 Relievers Rest Dangling o Aggravators Activity Elevation Venous Insuf ciency 0 Normal Transports de02 blood an wastes o Caused by metabolic waste build up 0 55 Lowerleg pain 0 Intense Sharp 0 1 hour onset Red swollen warm Aching feeling of fullness o Relievers Elevation Lying Walking 0 Aggravating Prolonged sittingstanding lschemia De cient 02 suppled blood to tissues 0 Apparent in exercise bc body needs more 02 ODVT o Occluded vessel from thrombus In ammation Blocked venous return Cyanosis Edema 0 Treatment is urgent or PE will occur 0 Causes Bed rest Varicose Veins Trauma Infection Cancer Oral contraceptives Cyanosis Edema 0 55 Increased Warmth and Swelling Redness Cyanosis Tender palpation Intense sharp mm pain Homan Sign Chapter 21 0 Surface Landmarks o Abdomen Large oval cavity Diaphragm to pelvis Four layers of at mm joined by linea alba Internal Anatomy 0 Viscera is internal organ cavity 0 Visualize each organ 0 Solid viscera maintain shape liver pancreas spleen adrenal glands kidneys ovaries and uterus Liver is in RUQ and extends to MCL lower edge and kidney are normally palpable Ovaries can only be palpated bimanually during pelvic exam Spleen is soft mass on posterolateral wall just under diaphragm Pancreas is soft and lobulated behind stomach in ULQ Kidneys RETROPERITONEAL protected by ribs 0 Left lies at 11th and 12 ribs Costovertebral angle 0 Right is 12cm lower than left 0 Hollow viscera change shape depending on content Stomach gallbladder small intestine colon and bladder Usually not palpable but may feel bladder or colon if containing excrement Small intestine is in all four quadrants o Belly Button is the Center of the four quadrants Note for redness and drainage or piercings o KNOW THIS CHART Upper Right Quadrant Upper Left Quadrant Liver and Gallbladder Stomach Duodenum Spleen Head of Pancreas Right kidney w adrenal gland Hepatic exure Part of ascending and transverse Colon Left Lobe of Liver Body of Pancreas Left kidney and adrenal Splenic Flexure Transverse and descending colon parts Lower Right Quadrant Cecum Appendix Ascending Colon Right ovary tube ureter Right spermatic cord Lower Left Quadrant Descending colon Sigmoid Colon Left ovary tube ureter Left Spermatic cord Midline Aorta Uterus Bladder Know Epigastric Stomach Transverse Colon NG tube placement Umbilical Hernia TlO Aortic Aneurysm and Suprapubic right above pubic bone and on bladder and rectum Regions Each is 13 of abdomen Developmental Competence 0 Infants and Children Newborn umbilical cord shows Liver takes up more space Bladder is higher Abdominal wall is less mm 0 Pregnancy Morning Sickness and Acid Indigestion are common causing constipation causing hemorrhoids Uterus pushes intestines up and backward Bowel sounds are less 0 Aging Adult More fat accumulates in suprapubic area Salivation decreases Esophageal emptying is delayed Gastric acid secretion decreases Increase in gallstone possibility Liver shrinks Increased chance of constipation Culture and Genetics 0 Lactose intolerance increases abdominal pain bloating and atulence Different rates among racial groups however not as much as once thought 0 Obesity Higher rates in blacks Subjective Data 0000000000 0 Appetite Note changes Dysphagia and Dysarthria Food intolerance Abdominal Pain Nausea and Vomiting Constipation and Diarrhea Bowel Habits Past Abdominal History Medications Nutritional Assessment Blood and vomit in stool Flatus ad Borborygmus Additional For Infants and Children 0 00000 O Breastfeeding or Bottle feeding Which table foods have been introduced How often do they eat Is there abdominal pain If there is a weight problem how long ls constipation present BMI Additional for Adolescents O O O 0 Eat regular meals Exercise pattern How much has been lost and how Amount ofjunk food BMI Additional for Aging Adult O 0000 0 How are groceries obtained and made Eat alone or share What was eaten yesterday How often are bowel movements BMI Dif culty swallowing Objective Data 0 Expose abdomen fully in supine position w knees on pillow 0 Ask about painful areas 0 Have relax abdomen mm w breathing soft voice conversation Inspect the Abdomen O O O Contour Determine rib pro le to pubic bone Have pt prop up on elbows and look at contour for bumps or masses Know if distended protuberant at or scaphoid Symmetry Should be bilaterally Ask to breath deep to check for nonsymmetry Ask to sit up wout using hands Umbilicus Should not be red or crusted Note if In or out Smooth Stroke w back of hand and even in color Color should match raceethnicity Note temp moisture diaphoretic or sweaty and texture Tugor Pinch Test Look for lesions anything abnormal describe and if unusual measure Note stretch marks pink of white old Look for venous pattern 0 Pulsation or Movement Pulsation from aorta 0 Hair Distribution Male pubic is diamond and female is triangle Consistent and even for male or female of the age 0 Demeanor Relaxed w normal breathing Ask if in pain or for any tenderness BEFORE palpation Auscultate Bowel and Vascular Sounds 0 Use diaphragm and hold lightly against skin beginning in RLQ at ileocecal valve area Bowel sounds are air passing through intestines o Bowel Sounds Character and Frequency High pitched gurgling cascading Judge is hyper or hypoactive hyper can be caused by u or hungen As soon as hearing in that quad move to the next one If no sounds listen for min to declare hypoactive Have another listen and call physician Report as normal active hyperactive or hypoactive 0 Vascular Sounds Bruits Use rm pressure to check over the aorta renal arteries iliac and femoral arties Usually no sound but if one occurs it is medium to low pitch Percuss Genera lTympany Liver Span Splenic Dullness 0 General Tympany Lightly in all 4 quadrants moving clockwise Tympany should predominate dullness is not normal Resonance Hyperresonance Flat Dullness 0 Liver Span Mapping out organs Measure height of liver in RMCL Start at lung and move down inti dull sound 5th intercostal space then move down and percuss up until dull again R costal Margin should be 612cm distance 0 Splenic Dullness O Dull note bw 9th and 11th intercostal space and normally lt7 cm wide 0 Costovertebral Angle Tenderness Kidney hand over 12th rib and thump w ulnar edge of other st Thud but no pain 0 Special Procedures Ascites Free uid is peritoneal cavity Distended abdomen bulging anks protruding umbilicus Differentiate from gaseous distention by 0 Fluid Wave Place one hand on left ank and tap other ank with other hand this will create uid ow in abdomen if ascites o Shifting Dullness Here tympanic note as percussing if uid it will turn dull Ask to turn on side and repeat dull sound will be heard higher up Palpate Surface and Deeper areas 0 Have person relax and lay down w knees bent up 0 DO NOT palpitate if organ transplant suspected aortic aneurysm painful rst 0 Judge size location and consistency 0 Look for mass or tenderness 0 Light and Deep 0 Liver Begin w light using 4 ngers and depressing lightly Use rotary motion moving skin and ngers then pick up ngers and move Notice Voluntary Guarding happens to cold tense or ticklish areas involuntary is constant hardness Do in all 4 quad and over bladder Note tenderness or masses Deep uses same technique but depress greater than 1 cm 5 8cm 0 Nurses don39t normally do this Bimanual can be used for obese or a large abdomen Separate masses from organs Then move on to particular organs RUQ place L hand under back and use R nger parallel to midline Push deep down and under W each breath move had up 12 cm You can try hooking technique too 0 Spleen Normally not palpable unless enlarge 3x Place hand like for liver but on LUQ and have L at an angle Nothing rm should be felt o Kidneys Make a duck bill w hands at R ank and press rmly Either feel nothing or a round smooth sliding mass L is not normally palpable bc it sits higher but place hands like for liver w R hand perpendicular and press deep and no change should be felt o Aorta Palpate pulse L of midline Aneurysm causes ngers to be spread apart 0 Special Procedures Rebound Tenderness When pain hold hand at 90 degrees and press down in area away from pain 0 Normal or negative is no pain 0 Pain on release con rms lnspiratory Arrest Place ngers under liver border and if pt can t take a deep breath wout pain test is positive lliopsoas MM Test 0 When acute abdominal pain hold R leg up and push down on lowest part of thigh is RLQ is in pain test is positive Alvarado Score for appendicitis MANTRELS score 0 000000 0 Migration Anorexia Nausea and vomiting Tenderness RLQ Rebound Tenderness Elevated Temp Leukocytosis Shift to the left 0 Developmental Competence 0 Infant Inspection Abdomen will be protruding Umbilical hernia and Diastasis Recti are common but disappear by childhood Auscultation Only bowel sounds Percussion Spleen is not Palpation Offer paci er and hold leg in one hand and palpitate with other 0 Note rst bowel movement as sticlq greenish black Bladder and Liver are different size and location 0 Child 4 Potbelly when standing 0 Aging Adult Increased subcutaneous fat Organs are easier to palpitate Decreased salivation Esophageal emptying is delayed Decreased gastric secretions O Increased in constipation Increased risk of gall stones Liver decreases in size and drug metabolism is decreased Pregnant Morning Sickness decrease in gastric motility displacement of organ reabsorbed H20 constipation and hemorrhoids painless abby papules caused by vascular pressure Abnormal Findings 0 000000 0000 Obesity uniform round umbilicus is sunken in percussion and palpitation is normal Air or Gas Single Round Curve Auscultation depends on gas Pal and Percussion are abnormal Ascites Bulging anks Aus is normal Percus is dull over uid Pal is taught skin Ovarian Cysts Curve on lower 12 of abdomen normal Aus Percus is dull Pal aortic pulse Pregnancy Single Curve engorged breasts Aus Fetal heart sounds Percus dull over uterus Pal fetus Feces Localized distension Aus normal Percus scatter dullness over mass Pal rope like Tumor localized distension Aus is normal Percus is dull over mass Pal de ne borders Intestinal Obstruction Vomiting absence of voidinggas distended ab hyperactive bowel sounds dehydration fever hypovolemic shock ect Umbilical Hernia Soft skin covered mass common in premature an usually resolve by 1 year of age Hernia Protrusion of organ Epigastric Hernia Abdominal protrusion Incisional Hernia bulge near operative scar Diastasis Recti Midline ridge Succession Splash Loud splash in Aus over UQs Hypoactive Bowel diminished bowel sounds Hyperactive Bowel Loud and gurgling Peritoneal Friction Rub Rough grating sound peritoneal in ammation Vascular Sounds Arterial bruit turbulent ow Aortic aneuy Renal artery stenosis partial occlusion of femoral arteries Venous Hum Rare and hear in umbilical region Enlarged Liver Enlarged smooth not tender Enlarged Nodular Liver Enlarged Gallbladder tender Enlarged Spleen Toward midline and can extend to left pelvis and usually not tender Enlarged Kidneys Similar shape as enlarged spleen no notch tympanitic percussion o Aortic Aneurysm Most below renal arteries will hear bruit femoral pulses are decreased 0 Ostomies Intestine is turned inside out on surface of skin when intestine or bladder function is lost Needed in colorectal cancer diverticulitis ln amed bowel Cohn39s disease removal of bladder o Appendicitis tenderness in RLQ and migrating pain w rebound tenderness Needs surgical removal 0 ln amed Gallbladder is cholelithiasis Flu like no pain Murphey and Blumberg sign Jaundice Pruritus Pain is intermittent and radiate to R shoulder tender abdomen Chapter 22 Musculoskeletal Bones Joints mm 0 Support movement protection production RBCs WBCs platelets storage minerals Components 0 Bones skeleton 206 Connective tissue Hard and very dense Continuous turn over 0 Joints Union of 2 bones Functional unit Needed for ADL Nonsynovial or Synovial Non Fibrous tissue and immovable or slightly moveable Synovial move freely bones are separated from each other and enclosed cavity 0 Cavity is lled w uid to grease movement sliding 0 Layer of cartilage covering surface Receives nourishment from uid Stable Slow turn over Flexible Cushions bones Surrounded by capsule Capsule is supported by ligaments Fibrous bands 0 Strengthen joint Prevent movement in wrong direction Bursa Sac lled w uid In areas of friction Help mm and tendons to gluide 0 MM 4050 body weight Produce movement Skeletal voluntary Bundle of fasciculi Attached to bone w tendon Flexion Extension Adduction Abduction Pronation Supination Circumduction Inversion Eversion Rotation Protraction Retraction Elevation Depression 0 TemporomandibularJoint TMJ Chewing and Speaking Hinge and slidinggliding protrusion and retraction and side to side actions Mandible and temporal bone Vertebra 33 7C 12T 5L SS 34C Landmarks Spinous Process C7 and T1 Inferior angle of Scapula T7 and T8 0 Line cross iliac crest L4 Dimples overlaying sacrum C and L are Concave T and S are convex Curves allow for shock absorption lntervertebral Disks Elastic brocartilaginous plates Center is made of soft semi uid mucoid Provide shock absorption When pressure is too great slipped disk occur Allow for turning o Shoulder GlenohumeralJoint Ball in socket Four mm make up rotator cuff Subacromial Bursa Abduction Landmarks Acromion Process Clavicle and Scapula Greater Tubercle On Humorous lateral to Acromion Coracoid Process is medial o Elbow 3 bones Hinge Landmarks Medial and Lateral Epicondyles humorous Olecranon Process Ulna bw epicondyles 0 Wrist and Carpals WristRadiocarpajoint Radius and carpals Movement is side to side and exionextension Midcarpal Two rows of carpals Flexion extension rotation Metacarpophalangeal and interphalangeal nger exion and extension Acetabulum and Femur Ball in socket Less ROM than shoulder More stability Landmarks lliac Crest lschial Tuberosity When hip is exed under glut max 0 Greater Trochanter 3 Bones Femur Tib patella Largest and most complex Hinge Largest synovial membrane Menisci Cruciate and Collateral ligaments Numerous Bursa Landmarks Quadriceps 0 Four mm heads merge at tendon to knee Tibial Tuberosity Boney protrusion Lateral and Medial condyles of Tibia Medial and Lateral Epicondyles of Femur o Ankle and Foot AnkleTibiotalarJoint Tib Fib Talus Hinge Landmarks o Medial Malleolus and Lateral Malleolus Ligaments extend for stability Joints distal give additional mobility Subtalar Longitudinal Arch 0 Heel and Ball of foot 0 Calcaneus and heads of metacarpals Developmental Competence 0 Infants and Children Skeleton formed by 3 months cartilage 0 Bone is formed through rest of development and after birth 0 Rapid in infancy and adolescence Long bones increase width and length epiphyses closes around 20 years of age Spine Curves Birth spine is C shaped 34 months w raising of head Cervical neck region is developed 0 1 year 18 months w standing Lumbar curve is developed MM 0 Weight increase 0 Most growth is during adolescent spurt Depend on genetic programming nutrition and exercise 0 Pregnant Women Increased hormone levels increase mobility in joints Progressive Lordosis to compensate for fetus Creates low back pain Anterior neck exion and shoulder slumping occur 0 Aging Adult After 40 bone loss occurs 0 Loss of density in bones osteoporosis Women more than men Decreased height Shortening of vertebral column in intervertebral disks 0 Progressive Can begin as early as 40 0 Greatest decrease is in 705 and 805 Kyphosis is curvature change hump back Less fat in extremities and more in center MM decrease in size and atrophy Physical activity decreases risks for all of the above 0 Culture and Genetics 0 RaceEthnic differences in bone mineral density occur Higher BMDDense bone Higher in AfroCaribbean Earlier peak in White women Earlier peak faster decline Subjective Data 0 Joints Pain 0 Pain and loss of function are common 0 Location 0 Quality Severity Onset Timing 0 Some forms are worse at different times RA in morning OA afternoon AggravatorsRelievers 0 Movement can increase or decrease Associated w anything Stiffness swelling heat redness limitation of movement Knee if injured How did injury occur Was there a pop can stand or ex MM Pain or cramping Myalgia Mm Aches Weakness Location Symmetry bilat Bones Pain Affected by movement Deformity caused by ROM Accidentstrauma ever affected bonesjoints Onsettime occurred treatment problemslimitations Back Pain Numbness tingling Functional Assessment Safety of independent living need for services and QOL screening Do problems create limits on ADLs Which ones Pt Centered Care Occupational hazards or safety risks Exercise program 0 Pain during Weight gainloss Medicationsupplements Chronic illness and effects Smoking Drinking Additional for Infants and Children Trauma to infant during labor head rst forceps resuscitation Milestones at right age Broken bones dislocations treatment Deformities age treatment Additional for Adolescents After school activities frequency Special equipment training program What happens if get hurt Additional for Aging Adult 0 Prep Change in weakness over past months or years increase in fallsstumbling Mobility aids screening for osteoporosis Objective Data Assess for function of ADL and screen for abnormalities Head to toe manner Flexion is bending Extension is straightening Adduction is moving towards body Abduction is moving away Additional data is gained from general survey Screening Inspection and palpitation Observation of ROM Age speci c screenings Complete For particular disease history of symptoms or ADL problems Make comfortable throughout exam Head to toe proximal to distal Support joints at rest 0 Gentle support and movement Compare joints elbow w elbow Symmetry bilat And normal measurements 0 Order of Examination lnspec on Size and contour of every joint Color Swelling masses deformities o Swellingirritation excess uid thickening of lining bone enlargement in ammation 0 Deformities Dislocation subluxation Contracture Ankylosis Palpation Each joint Note skin temp mm boney artics area of capsule Note heat tenderness swelling masses 0 Localize tenderness o Warmth and tendernessin ammation Palpable uid is NOT normal Active ROM while modeling movements Gently attempt passive ROM on limited mm Note pain tenderness or crepitation audible and palpable crunching MM Testing 0 Test strength of prime mover mm for each joint 0 Repeat ROM motions but asking to ex while applying force 0 Should be equal bilat and opposing to force TM 0 Seat person 0 Inspect area anterior to ear 0 Place ngers in front of ears and ask to open and close mouth and slide ngers into groove that is created Palpable and audible crack should occur Ask to open moth fully Open mouth slightly and move jaw side to side Stick out lower jaw o Clench teeth and palpate mm Note bilat strength size rmness 0 Ask to move jaw forward and lat against resistance and open mouth against resistance Test CN V Cervical Spine 0 Inspect alignment straight and erect o Palpate spinous process sternomastiod trapezius and paravertebral mm Firm wout spasm 0 Ask to move head forward and back quotYesquot Left and right quotNoquot movement Repeat w opposing force Test CN XI 0 Upper Extremity o Shoulder Inspect and compare both 0 Size and contour equal landmarks Redness atrophy deformity swelling Palpate both noting spasm atrophy pain swelling heat tenderness Start at clavicle Test ROM 0 Cup hand over should to note crepitation Hyperextend back forward exion arms straight to above head clasp wrist behind back and above head jumping jack arm movement Ad and Abduction Test Strength Shrug shoulders ex forward and up abduct o resistance 0 CNXI o Elbow Inspect size and contour in relaxed and exed position 0 Note abnormality Check hollows on each side of olecranon process Palpate w exed at 70 degrees and relaxed Heck for swelling thickening nodules tenderness ROM 0 Bend and straighten elbow Pronate and Supinate Strength Stabilize ex elbow against pulling opposition force at wrist Extend against resistance 0 Wrist and Hand lnspect both sides for size contour shape 0 Note abnormalities Palpate each joint w thumb and making sure pt hand is relaxed and straight in alignment Gentle but rm 0 Use pointer an thumb to palpate sides of ngers for swelling or tenderness c From at Bend up at wrist extension and down exion From at Bend ngers down and on surface up 0 Spread ngers apart and make a st Move wrist side to side 0 Touch thumb to each nger Strength 0 Flex wrist against opposition Phalen Test 0 Hold hands back to back while exing wrists at 90 degrees 0 No pain unless Carpal tunnel Tinel Sign o Percussion of median nerve o No movement in normal 0 Lower Extremity 0 Hip o Knee Inspect w spine when standing Note symmetry of iliac crests gluteal folds and equal size Smooth Even gait Palpate o 0 ROM 0 In supine Stable and symmetric Raise w knee extended exion Bend knee at chest and keep other leg straight exion Knee at 90 move ankle in and out while holding at thigh and ankle feel opposite movement Leg laterally and medially Ad and Abduction When standing swing leg back Hyperextension Inspect Supine or sitting dangling Lower leg on same axis as upper Hollow areas should be present on either side Check mm of atrophy Palpation ROM Start on thigh 10 cm above and move down Note soft from swelling tissue or increased uid in the joint 0 Bulge Sign Swelling in suprapatellar pouch Move uid from one side ofjoint to another Small amounts of uid 0 Ballottement Larger amount of uid Hold thig above patellar and push up on patellar It will move if there is uid Bend and extend and hyperextend Check during walking Squat and duck walk O Spine O Strength 0 Maintain exion while pull leg forward and pushing back Tests for meniscal tears o McMurray Test Supine stand on affected side Hold heel and knee ex at knee and hip rotate leg in and out rotate externally and push inward on knee straighten Normal is no pain Ankle and Foot lnspect while sitting and nonweight bearing 0 Note locations of calluses or bursal reactions Palpate w thumb feeling grooves and spaces 0 Use pinching motion with whole hand to move up foot ROM 0 Point toes at oor toward nose turn soles of feet in and out ex and straighten toes Strength 0 Maintain dorsal and plantar exion against force Standing in open back gown Inspect Straight vertical and horizontal Knees and feet should be aligned Note curvatures by standing at side Palpate spinous process and paravertebral mm ROM Bend forward and touch toes Note smoothness and symmetry on way down Note single C curve of spine Stabilize pelvis and Bend sideways back and twist shoulders from side to side Walk on toes away and on heels back Straight Leg Raising or Lasegue Test Reproduce back and leg pain O Keep leg and knee straight while raising leg normal is no pain The dorsi ex foot Measure Leg Length Discrepancy Measure from anterior iiac spine to medial malleolus for true leg length Measure from umbilicus to medial malleolus for apparent leg length 0 Developmental Competence Know milestones Use Denver ll Test for ne and gross motor skills Infants 0 Fully undressed and lying on back 0 Feet and Legs 0 Note positional deformities Fixed or selfcorrected posture scratch bottom of foot to tell if leg moves to 90 degree angle Check for tibial torsion twisting of tib Check for developmental congenital dislocation dysplasia Flex knees and abduct moving knees apart to touch table Ortolani Maneuver Place baby s feet at and ex knees up note gluteal folds Allis test 0 Hands and Arms Palpate and inspect for the normal shape number and position Feel clavicle for smoothness and free of fracture Perform ROM Note normal C curve or curve for age Inspect for air dimples cyst or mass where none should be present 0 Observe ROM w normal movements 0 Strength is tested by holding up infant and having them wedge securely into place 0 Slipping shows weakness Preschool and School age 0 Back 0 Note posture plum line lordosis is common Legs and Feet 0 Note position Bowlegged stance is normal for 1 year after walking and is xed by growth Genu varum Knock knees occur bw 2 and 35 years Genu valgum 0 Check gait Wider from 12 and narrows w age 0 Sit for remaining bit and go through like normal 0 Make sure to check for arm full ROM Adolescents 0 Same as adult but note spinal posture 0 Screen for scoliosis w the forward bend test 0 Pregnant Women 0 Same as adult 0 Remember waddling gait ordosis slumped shoulders and kyphosis are normal 0 Aging Adult 0 Decrease in height shortening of trunk o Kyphosis is common with back bend of neck slight o Flexion of hips is common 0 Decrease in periphery fat and more showing boney prominences 0 ROM is tested the normal ways 0 Get up and Go test Stand up walk ten feet walk back sit down 0 Under 10 seconds means decreased risk of falling 0 Functional Assessment ROM and strength to activities Walk climb up down stairs pick up object from oor rise up for chair or lying in bed Abnormal Findings 0 In ammatory Conditions Rheumatoid Arthritis RA Chronic Autoimmune in ammation of synovial tissues Ankyosing Spondyitis AS Fusion of in amed vertebrae o Degenerative Osteoarthritis OA Nonin ammatory localized deterioration of articular cartiages Common Stiffness pain loss of ROM Aduts over 60 are at risk 0 Weight 0 Women 0 Previous injury to the jointoverusing 0 Weak thigh mm 0 Chronic progressive New bone forms at joints 0 Hard nodules atjoints Osteoporosis 0 Loss of bone density 0 Due to low estrogen level Prevent w diet weight bearing exercise and calciumVitamin D o Shoulder Abnormalities Atrophy Dislocation Joint Effusion Swelling from excess uid in capsule Rotator Cuff Tear Frozen Shoulder Adhesive Capsulitis Subacromial Bursitis o Elbow Abnormalities Olecranon Buritis Gouty Arthritis Subcutaneous Nodules Epicondylitis Tennis Elbow 0 Wrist and Hand Abnormalities Ganglion Cyst Colles Fracture Carpal Tunnel w Atrophy of Thenar Eminence Synovial uid become edematous Repetitive motion Younger adults 0 More in females An kylosis Dupuytren Contrancture OA Acute RA Polydactyly Syndactyly Gout in Thumb 0 Conditions Caused by Chronic RA Swan Neck and Boutonniere Deformity Ulnar Deviation Drift o Knee Osgood Schlatter Disease PostPolio Atrophy Mild Synovitis Perpatellar Bursitis Swelling of Menisci o Ankle and Foot Achilles Tenosynovitis Tophi w Chronic Gout Acute Gout Hallux Valgus w Bunion and Hammertoes Callus lngrown Toenail Plantar Wart o Spine Scoliosis S or C curvature Mainly identi able in younger children 0 Females are more common 0 Assess by bending forward and watching spine curve Brace is usually treatment and surgery is a LAST resort Herniated Nucleus Pulpous o Congenital or Pediatric Congenital Dislocated Hip Talipes Equinvarus Spina Bi da Coxa Pana o Fibromyalgia Syndrome Chapter 23 CNS brain and spinal cord PNS CN 12 Spinal nerves 31 and branches Sensory to CNS Afferent Motor from CNS Efferent Dysphasia dif culty understanding language Dysarthria Speech mm control CNS 0 Cerebral Cortex Outer layer of brain Gray not myeinated highest functions thought memory reasoning sensation voluntary movement Left Hemi is dominant in most people Frontal Personality behavior emotions intelligence Parietal Sensation Occipital Vision Temporal Auditory taste smell Wernck39s area Language comprehension in temporal lobe Broca39s Area mediate motor speech frontal lobe Basal Ganglia Initiate and coordinate movement Thalamus Rely station Hypothalamus Life functions Cerebellum Coordination mm tone balance Brain Stem Central Core CN lllXll originate from Midbrain Motor neurons and tracts Pons Respiratory centers Medulla Vitals and CN crossing of nerves 0 Spinal Cord upper 23 of column white matter myeinated Posture urination pain response 0 Pathways of CNS Cross representation Sensory Pathways OOOOO Spinothalamic Tract o Sensations od pain temp crude lighttouch Posterior Columns 0 Position Vibration nely localized touch 0 Position Proprioception 0 Travel to thalamus Motor Pathways CorticospinalPyramidal Tract motor cortex brainstem Cross D lat Column of spinal cord 0 Skilled purposeful movements Extrapyramidal Tracts All motor bers outside pyramidal tract Cerebellar System receive info from joint position and mm all subconscious 0 Upper and Lower Motor Neurons Upper all descending motor neurons that in uence or modify lower motor neurons Lower Mainly in PNS Translates movements into actions CN and spinal nerves 0 PNS o Re ex Arc Re ex is defense mechanism involuntary quick Fourtypes oCN Arc Deep tendon knee jerk Super cial corneal Visceral Pupillary Pathologic Abnormal Babinski Hit tendon Tendon stretches Sensory afferent nerve is activated Sensory afferent bers carry message to spinal cord synapsing directly w motor neuron Motor efferent leaves traveling to mm Stimulation of sudden contraction LMN entering and leaving brain I and II are from cerebrum lllXll are from lower brain stem 0 Spinal Nerves Length of spinal cord 8C 12T 5L SS 1C Sensory and motor Exit in dermal segmentation Dermatome is skin are supplied by one nerve 0 Important in epidural and spinal pain killers O 0 Be prepared to know where the pt won39t have feeHng Overlap ANS Smooth involuntary mm cardia mm glands Maintains homeostasis Developmental Competence O 0 Infants NS is not fully developed at birth Spinal cord and medulla control activity Primitive re exes Presence of these after cerebral cortex should have developed is a sign of dysfunction Milestones occur in an orderly manner Strong stimulus is needed bc infant cannot localize yet Aging Adult General atrophy Steady loss of neurological function Strength and agility decrease Culture and Genetics 0 0 Age related memory loss Alzheimer39s Stroke is common in the US Most common in AlAN Burden is higher among African Americans Subjective Data 0 OOO OOOOOOOOO Headache Frequency Head Injury EVER had one and describe DizzinessVertigo Seizures Ever had and describe Age Times How Many Types Frequency Triggers Tremors Weakness lncoordination NumbnessTingling Dif culty Swallowing Dif culty Speaking Pt Centered Care Past History EnvironmentalOccupational Hazard Additional for Infants and children Health problems during pregnancy Birth information Re exes Balance Seizures and describe Milestones came in correct order and age Lead exposure Learning problems Fam history of neurological disorders Teen play sports Screened for concussion 0 Additional for Aging Adult Dizziness problems Decrease in mental function or memory Noticed a tremor Sudden vision changes 0 Objective Data 0 Prep Screening neurological exam is when there is no signi cant data from subjective history 0 Mental Status Cranial Nerves Motor Function Sensa on Re exes Complete exam is done when there are concerns Neurological recheck s done when there are de cits Sitting up w head at eye level 0 Test Cranial Nerves CN Olfactory Don t do routinely Test both nostril with wellknown scent CN Optic Nerve acuity and elds by confrontation Ophthalmoscope is sued to see ocuar fundus 0 Determine size shape and color of optic disc 0 Show pt object and have them tell coor CN III IV VI Ocuomotor Trochear Abducens Papebra ssures are equal in width Pupil size regularity equality direct and light reaction Asses position of gaze Hold head steady foow movement of penci w eye and report parallel tracking CN V Trigeminal Motor Function Mastication mm when clenching teeth and try to separate jaw by pressing on chin you can39t Sensory Function Cose eyes and lightly touch cotton swab on face and have pt say now when they are touched CN V Facial Mobility and symmetry Smile frown cose eyes tightly eft eyebrows show teeth puff cheeks o Press on cheeks and air shoud escape equally CN V Acoustic Whispered voice test 0 2 syabus word CN IX and X Glossopharyngeal and Vagus 0 Motor Function 0 Depress tongue and say ahh o Uvula should rise and pillars should move 0 Note gag re ex by touching wall w tongue blade 0 Stick out tongue say ahh CN XI Spinal Accessory Examine sternomastoid and Trapezius for equal size Rotate head against hand Shrug shoulders while pushing down CN XII Hypoglossal Inspect tongue 0 Move tongue left and right 0 Inspect and Palpate Motor System MM 0 Size Compare R and L mm groups based on age and size symmetric bilat Strength Test mm groups 0 Tone Normal degree of tension in voluntary relaxed mm 0 Move extremities through passive ROM 0 Mild even resistance Involuntary movements location frequency rate amplitude Cerebellar Function 0 Coordination and Skilled Movements 0 Rapid Alternating Movements Pat knees with front and back of hands and pick up speed Touch thumb to each nger and then reverse the order 0 Finger to Finger Ask person to touch your nger and then their nose move nger after several times 0 Finger to Nose Touch tip of nose w eyes closed 0 Heel to Shin Supine touch heel to shin and run heel down leg to ankle Balance Tests 0 Gait Observe walking 10 ft there and back Heel toe walk 0 Romberg Test Stand w feet together and arms at sides close eyes and hold position wait 20 seconds Hop on one leg or the other 0 Assess Sensory System Identify stimuli Only in those w symptoms for complete testing Avoid leading questions Use quottell me what you feelquot Spinothalamic Tract Pain Ability to perceive pinprick 0 Break depressor in half and alternate randomly bw dull and prickly part asking pt which they feel 0 Light Touch Wisp of cotton on skin say yes when feel Posterior Column Tract Vibration Tuning fork lace on skin and strike pt identi es when starts and stops 0 Position Passive movements of extremities move extremities w pt eyes closed and have them say which direction movement is in Tactile Discrimination o Stereognosis Recognize object by feeling it o Graphesthesia Read number when it is traced on skin 0 Two Point Discrimination Separate two points on the skin 0 Extinction Touch both sides of body at same point and time ask how many and where sensations are 0 Point Location Touch and withdraw have pt point where they were touched 0 Test Re exes Stretch or Deep Tendon Relaxed limb w mm partially stretched Stimulate w short snappy blow Reinforcement is needed when pt I focusing on re ex ask to perform isometric exercise grasp forearms and pull Biceps C5 and C6 Contraction of bicep occurs when striking the tendon through your thumb when arm is resting on table Triceps C7 to C8 Let arm go dead as suspended and strike just above elbow arm should extend Brachioradialis C5 to C6 hold thumb suspending forearm strike above styloid process 0 Quad or knee jerk L2 to L4 Let leg dangle and strike just below patellar Achilles L5 to SZ Knee exed hip rotated eternally foot in dorsi exion and strike Achilles tendon Clonus Support leg in one hand move foot up and down and dorsi exion foot quickly Super cial Re exes Abdominal T8 to T10 T10T12 Supine w knees bent and scrape handle of hammer across and see exion of mm Cremasteric L1 to L2 stroke inner thigh to note contraction of testicle Plantar L4 to 52 Thigh on external rotation stroke lat side of foot to ball and around for shape of upside down 0 Developmental Competence Infants 01 year Dramatic growth 0 Note milestones 0 000 0M0 Fl 0 000000 00000 Newborn alter eye open sucking loud angry lusty cry Note waking behaviors and responses to stimuli ad social interaction 2 months Smiles response and know parent face 4 Months Babbling 9 months one or two words used r System Spontaneous activity for smooth and symmetry Assess mm tone Use Denver ll test 2 months gradual exion 3 months sts begin opening 4 months is purposeful reach head can be held in straight line 7 months transfer hand to hand 9 months grasp 10 months purposeful release 18 months ambidextrous Strength is noted by sucking and spontaneous activity Sensory System little is done 0 79 months pt can wdraw from pain stimulus Re exes O O Infantile automatisms Rooting brush cheek near mouth and note if head turns Disappears around month 34 Sucking Touch lips w gloved nger Disappears at 1012 months Pamar Grasp Offer nger and note grab Disappears 34 months Plantar grasp Touch thumb to foot note toe curl O O Disappears 810 months 0 Babinski Stroke nger up lateral edge of foot and note fanning of toes Disappears at 24 months 0 Tonic Neck Turn head and watch arm and leg of opposite side ex Disappears 46 months 0 Moro Stratle and see if baby looks like it is hugging a tree Disappears 14 months 0 Placing Re ex Hold upright and let top part of foot touch able 0 Note exing of hip o Stepping Use position from placing and note walking movements Disappears before walking Preschool and School Age Asses behaviors Ask to imitate funny faces Assess balance gait and posture Assess ne and gross motor using Denver ll test Don t perform DTRs Aging Adult Same exam as w adult Slower responses Senile tremor occur Sensation may be impaired Decrease in ne motor skills Neurologic Recheck O O O 0 Those w injury or de cit that must be checked and monitored closely Level of conscious CHANGE in level is important ask person place time Motor Function Voluntary by giving commands Pupillary Response Size shape symmetry of both in the presence of bright light constrict Vital Signs T P R BP Glasgow coma Test Standardized objective assessment by giving number value Abnormalities 0 Alzheimer39s Neuron Cote and hippocampus degeneration Cholinergic neuron loss Loss of neurotranmitters Better long term memory 0 Mm Tone Flaccidity Spasticity Rigidity Cogwheel rigidity Small regularjerks 0 MM movement 0 Stroke 0 Gaits Paraylsis Fasciculation Myoclonus Tic Chorea Athetosis Seizure Disorder Uncontrolled discharge of electrical impulses Types 0 Generalized 0 Partial 0 Simple 0 Complex Phases 0 Prodromal Aural Ictal and Postictal What to do 0 Remove pillows 0 Position on side 0 Loosen clothing 0 Safety measures protecting head Tremor Rest Tremor Intention Tremor schemic Interruption of blood ow Hemorrhagic Acute rupture and bleeding Spastic Hemiparesis Cerebellar taxia Parkinson Degeneration of basal ganglion Imbalance in dopamine Increased involuntary movement SS Tremor Rigidity Dysphagia UnparaIIeI Gait No postural control Mask face expressinon OOOOO 0 Wide open eyes Scissors Steppage or Footdrop Waddling Short Leg 0 Patterns of Motor Dysfunction Cerebral Plasy Bell s Palsy CN VII In ammatory response Unilateral paralysis Muscular Dystrophy Hemiplegia Parkinsonism Cerebellar Paraplegia MS Damage to myelin sheath leading to in ammation and permanent loss of nerve function SS Weakness stiffness Spastic mm Hyperactive DTR Clonus No abdominal re exes Intention tremor clumsy loos of balance Decreased pain sensation or abnormal sensation facial pain 0 Tinnitus facial weakness vision changes 0000000 0 Postures Decorticate Rigidity Flaccid Quadriplegia Decerebrate Rigidity Opisthotonos
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