Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nursing IAC Modules > Week 2 > Flashcards

Week 2 Flashcards

1
Q

Range core body temperature

A

36.0-37.0

97-99.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What regulates body temperature

A

Homeostasis+ set point
Heat production
Heat loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

3 factors that affect body temp

A

Age babies+ old people < temp
Gender: women have high temp variations
Circadian rhythm- highest 4-7 pm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Temperature extremes affect body temp

A

Environmental temp

> metabolic rate in body > temp

So exercise, stress + illness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Febrile

Afebrile

A

Temp above normal

Afebrile= normal temp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Hypothermia

A

<97.0c

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Fever

A

101> is natural disease fighting, not too harmful

Above 104 is very harmful

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

In older adults fever

A

Is a sign you’re in the later stage of a Disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Older adults and infants

A

Small change is important. Takes a lot on their metabolize to > temp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Core body temps

A

Rectal or tympanic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Interventions for fevers

A 
Monitor VS
FLUID
SEIZURES (in extreme cases)
Administer antipyretic meds
Administer IV fluids 
Apply ice (extreme)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Don’t use rectal

A

Diarrhea, bowel surgery, diseases of the rectum, nutripenic (immunocomprimised), quadriplegics, no CV surgeries
Stimulate vagus nerve= fainting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

> age pulse

A

<

Women have slightly higher pulse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Infancy pulse range

A

100-160

Adult 60-100

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

The vagus nerve

> temp pulse?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Tachycardia

A

Ventricle strokes a lot, so less blood is getting out so higher pulse. Stroke volume is less

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

< BP

A

> temp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Bradycardia

A

<60 bpm
Men have lower HR so elderly + adults
Hypothermia < pulse rate
Vagostimulaiton/ bradycardia < Pulse

SEVERE CHRONIC PAIN < pulse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Dysrhythmias

A

Regular irregular (same irregular pattern)

Irregular irregular (no predictability)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Ventral ejection is the same as

A

Pulse= pulse generation= pulse wave= ventricular opening

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Characteristics of pulse

A

Rate, quality, Rhythm

Indicate effectiveness of system & quality of blood flow

Quality of pulse rate determined by the force of the blood flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Quality of pulse

A 
0=absent
1= threats
2=weak
3= normal
4= bounding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Cardiac output is calculated as

A

Heart rate* stroke volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Temporal artery

A

Front of upper part of ear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Carotid artery

A

Under the chin towards the neck

Best representative of the quality of the pulse rate directly front he heart or aorta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Brachial artery

Radical artery

A

Need to accurate put the BP cuff on it
Bend arm, pulse is at the antecubitol space locate medically

Anywhere within a 2in range above where the arm flexes

Radial you know this

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Femoral artery

A

Have person bend their thigh up

Located in the medial aspect of thigh, halfway btn the anterior superior iliac spine & the synthesis pubis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Popliteal

A

Patient flexes their knee, reach behind and palpate the lateral aspect of the fossa

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Dorsalis pedis

A

Top of foot

Wiggle their great toe. Tenden goes towards ankle, palpate the lateral side of that

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Posterior tibial

A

Behind medial malleolus in each side

Always palpate both sides of parallel pulse except temporal and carotid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

If the stroke volume is decreased

A

The pulse amplitude decreases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Doppler monitors

A

Feel for skin temp and capillary refill. They’re getting good pulses but you can use the Doppler to hear that artery

Knee surgery on L side. Lower leg really swelled. You wanna assess those pedal pulses on that Left leg for circulation . Or edema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Difficult pulses

A

Doppler monitor

Check both sides

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Pulse documentation

A

Rate
Rhythm
Quality

68 regular, even

72 regularly irregular, and bounding

52 right dorsalis pedis via Doppler

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

NANDA Diagnosis regarding tissue perfusion

A

Decreased cardiac output

Ineffective tissue perfusion- peripheral

Deficient fluid volume

Acute pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Factors that affect respirations

A 
Age lungs get bigger resp. <
Gender females breathe more
Stress, anxiety
Exercise balance breathe faster
Acid-base inbalance will change respirations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Factors that affect respirations

A

Meds.
Altitude
Pain
Anemia < in O2 so increase is respirations
Fever
Respiratory diseases
-body position will affect ability of your lungs to expand. Tripod position is common with COPD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Eupnea

A

Normal rate (12-20)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Tachypnea and Bradypnea

A

You know

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Apnea

A

Period of no breathing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Note quality of respirations

A

Unlabored, quiet, effortless

Labored, shallow, deep, gasping, painful

Note Rhythym

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

NANDA NURSING DIAGNOSES

A

Ineffective breathing patterns

Impaired gas exchange

Risk for activity intolerance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

AnEroid
Digital

BP cuff

A

Aneroid- sphyg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Factors affecting BP

A

Age, older adults higher BP. Have a < in vascular existence (> plasticity of blood vessels) esp. systolic

Circadian Rhythm lowest in morning highest in later afternoon
Gender. Women are lower than men until menopause
Food intake
Exercise

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Other factors that affect BP

A 
Overweight people 
Emotional state activate autonomic system > stress, > BP
Body position
Race: HTN prevalent in AA
Medication
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

BP cuff sizes

A

Cuff to big, low reading
Cuff to narrow, false high
Bladder width should be 40 of curcumference

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Preparation for patient’s

A 
Rested for 5 minutes
Has not consumed coffee
Has not smoked for 30 min.
Sitting in a straight back chair 
Feet resting on ground
Arm at heart level
Patient is quiet
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

BP measurement

A

5 separate phases
Phase 1 systolic

Phase 5: diastolic

3 numbers in pediatric
1st, 4th, & 5th

Also in exculpatory gap

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

To put a Bp cuff

A

Medial aspect of antecubital foss

1-2 inchesfossa, same

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Deflate cuff at

A

2-3 mm per second

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Can you use a pipliteal artery for BP?

A

The systolic number is 10-40 mmHg higher. Diastolic the same

Use thigh cuff or large regular cuff.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Auscultatory Gap

A

See them in patients with HTN
Important bc common in people with atherosclerosis (plaque)& > arterial stiffness
Identify these gaps. Too high to have gone away and then it picks up again.
Top #, second number # whenyou reheard the best, 3# last beat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Causes of false readings

A 
Mono meter not calibrated to “0”
Viewing the needle below eye level
Releasing the valve too slowly
Reinflating the bladder during auscultation 
missing an ausculatory gap
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Causes of false low readings

A 
Viewing the needle above eye level
Releasing valve too rapidly
Not placing the stethoscope over the artery
Not pumping 30mmHg above the Sbp
Missing an auscukatory gap
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

What BO reading will you get with a Doppler monoter

A

The systolic reading

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Moderate HTN

SEVERE
CRISIS

A

160-178. /100-109

180-209. / 110-119

>

  1. / 120
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

What organs are at risk for damage in BP

A

Brain
Heart
Kidney

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Pulse pressure

A

A mathematical equation

Systolic-diastolic
Larger someone’s PP means their arteries are not compliant

Complaint arteries have elasticity
Non complaint/ resistance are tight

PP determined by how compliant ur arteries are & ur stroke volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

For a given stroke volume

A

Increased complaint= smaller pulse pressure
Decreased compliance= higher pulse pressure
A larger stroke volume fives a large pulse pressure at any compliance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Why do non compliant arteries take more time and pressure

A

Dump a lotta blood into artery at one time, that opens a bit, as blood flows through it’ll close again, how wide it gets vs how small it gets (systolic versus diastolic) is bigger than normal then it’ll flex smaller than normal

Boncomplaint aretiers do not open very wide and cause more pressure and it’ll take more time for the blood to pass

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Pulse pressure is going to be higher

A

With higher volume
It’ll be much higher for someone who has arteries that are not complitany

Artery that is stiff will take longer to pass blood through

Arterial resistance increases with age

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Orthostatic hypotension

AKA Postural hypotension

A 
When you stand up and your Bp drops 
Lying to sitting
Vasodilated arteries then quickly have to vasocstrict to stand up
< O2 to the brain 
People at risk
Older adults
Prolonged bed rest like 3 days
Dehydrated people
Significant blood loss
Analgesic and diuretic meds
63
Q

Orthostatic hypotension interventions

A

Slow risk for lying position. Then dangle feet off side of bed
Get body moving again

64
Q

What happens when you make a change in position

A

you have a < in your glomerular filtration rate. A < in the blood going into your kidneys which causes an increase in sodium which causes the distal tubules to absorb water to > circulating blood flow. Also have < in the pressure sensors in your carotid arteries that tell you that the circulating blood flow isn’t as high as it needs to be which stimulates the sympathetic NS which causes vasoconstriction, > cardiac output, BP >, pulse>, feel better and your symptoms go away so you can stand

65
Q

How do you take measurements for someone with orthostatic hypotension.

A

Lay flat for 4-5 min
Sit 1
Stand up for a minute take their Bp
If there’s an increase of 40 bpm or 30 mmHg the in systolic BP

66
Q

Pulse oximetry

A

Determines % of hemoglobin combined with O2 in the blood

96> normal
93< need for oxygen
At least =93

67
Q

Where do pulse ox sensors go?

A

Finger, toe, ear, nose

Very small changes in oxygen levels are significant

SA o2 of 90means your actual ox in your blood is like 20 points lower than that

68
Q

Patient has anemia at sa02 of 98

What does this mean?

A

It’s a false high bc it’s indicating that 98% of the hemoglobin in this patient’s blood is supposedly bound to an O2 molecule

This patient doesn’t have enough oxyhemoglobin receptors bc they have anemia

Does it look like they’re having difficult with profusion?

69
Q

NANDA NURSING DIAGNOSES FOR BP

A

Decreased cardiac output

Ineffective health maintenance

Effective therapeutic regimen management

Risk for falls

70
Q

Height and weight

A 
You need both
Ratio is a good indicator of 
Nutrition
Hydration status
General health

Provide sensitive care

71
Q

Measuring weight

A

Calibrate scale to 0
Remove shoes and heavy clothing
If patient is barefoot-place paper towel on plate form
Balance scale and read the weight to the neardt 1/4 pound

Monitor daily of weekly weights
Same time each day
Similar clothing
Same scale

72
Q

Stadiometer

A

How to measure height

Go to nearest half inch

73
Q

Sternum

A

Sternal botch
Manubrihn
Angle of Louis:
Xiphoid process

Ribs-intercostal spaces

Landmarks
Costal margins
Sternal borders
Midclavicular arch

74
Q

Know heart anatomy

A

D

75
Q

Diastolic

A

Diastoli period inthe heart where he ventricular are possibly filling

A heart beat is lub-dub, s1-s2

The period of time between the last s2 and the next s1 is diastli

76
Q

Systoli

A

Ventricles contracting, left and right atrium are passively filling with blood

So two things happen systoli happens btn s1 and s2
S1 systole s2. Diastoli s1. Systole s2

77
Q

What opens and closes during systole and diastole

A

Contraction of ventricles (s1-s2)
Valves closing in s1 (bicuspid and mitral)

After s2 is pulmonic and semilunar (aorta)

Systole ventricles contracting

QRS= systoli

78
Q

Cardiovascular assessment

Important for prevention

A

General state of health: fatigue, signs of distress (does the patient appear to be SOB? Palapatations?) , chest pain (angina)
Family history: HTN, DB, CVD, Hyperlipidemia
Most patients with diabetes die of CVD
Med history: prescription, OTC
Activity level: need 30 min. A day
Weight + dietary habits:Na+ fat, Cholesterol
Personality, stress, and work
Smoking alcohol, habits

79
Q

Cardiovascular assessment

A

Survey the patient for general signs of CVD Restlessness? Anxiety?? Might be SOB

80
Q

Cyanosis

A

Not enough o2 in blood
Can be bluish hue to them
Want to know if it’s central cyanosis, true hypoxia?

81
Q

Central cyanosis

A

True hypoxia
Circumoral palor. Area around lips very pale.
Open their mouth and mucus membranes are pale, or Greyish look to them. Conguntival sacs in eye

Fingers might not be a sign of central cyanosis. Could be peripheral vascular disease

82
Q

What to else to asses in CV assessment

A

Tripod position help? Flaring nose?

Breathing pattern

83
Q

Breathing pattern in CVD

A

Are they using accessory muscles
Purse lip breathsing. In through their nose, lips pursed out
-when they do that, they don’t let enough air escape
Rate, rhythym, depth, and effort of breathing

84
Q

Late sign of CVD

A

Long-standing hypoxia. Will have clubbed fingers

Schamroth test. Fingers aren’t touching parallel
Soft and spungy feeling

If angle is 160, 180 and up your patient has clubbed fingers

85
Q

Accessory muscles for breathing

A

Sternocleidomastoid muscle

Connects to sternum and clavical. Pulls up on those to help people with CVD breathe. The sternocleidomastoid bulges out

Trapezious pulls up on clavical to help breathing shoulder pushed up a little

Use intercostal muscles retractions

86
Q

Apical pulse

A

Look at slide she explains how to count ribs

87
Q

What’s is the apical pulse also called

A

Point of maximal impulse
Left ventricular recoiling the most
Mitral valve the loudest

We want the peripheral pulse to be the same as the heartbeat. If there’s a difference there’s a pulse deficit

88
Q

What would alert you to check for a pulse deficet?

A

The pulse rate is irregular. Are all the beats making it there?

89
Q

Sinus bradycardia

A

Results when the SA nods generates slower than normal impulse rate.

Active during sleep, in hypothermia, beta blockers, Vagal stimulation, severe pain, > intracranial pressure, and MI

report difficulty breathing, changes in level of consciousness, < BP, ECG changes, & angina

90
Q

When to use the bell of the stethoscope

A

When listening to low frequency sounds like those in the heart.

It screens out high frequency sounds

91
Q

Respiratory rate

A 
< with age
Changes in acid base 
Brain lesions
> altitude
Respiratory diseases: difficulty breathing, using accessory muscles to breathe
Anemia >?O2
Anxiety 
Medications 
Acute pain: > respiratory rate, < respiratory depth
92
Q

Cheyenne-stokes

A

Respiration pattern that’s tachypnea then apnea

93
Q

Biot’s respirations

A

Completely irregular respirations

meningitis, severe brain damage

94
Q

How does the cardiovascular center transmits parasympathetic and sympathetic impulses

A

Transmits sympathetic impulses via three spinal cord and peripheral sympathetic nerves

Parasympathetic via the vagus nerve

95
Q

Epinephrine is released from the adrenal cortex to increase heart rate

A

Activates the renin-Angiotensin- aldosterone system through angiotensin 2

Causes vasoconstriction of the arteriole

Increased peripheral resistance, and > sodium AND water retention to increase circulatory fluid volume

> total volume of water+ Na+

96
Q

Vasopressin

Antidiuretic hormone

A

Released form the posterior pituitary when stimulated to act by < blood volume and < BP or
> osmolality of fluid

It causes vasoconstriction of blood vessels, increasing peripheral resistance

IT REUPTAKES WATER DIRECTLY FROM COLLECTING DUCTS ONLY WATER

97
Q

What is a significant increase in Bp?

A

20-30mmHg

5-10mmHg can be attributed to metabolism > by late afternoon

98
Q

High blood pressure

A

Starts at 140/90

99
Q

BP cuff should have bladder

A

That is 40% of the width and 80% of the length

100
Q

What is the most primary sign of a Musculoskeletal issue?

A

The diminished use or loss of use to move as they did before.

101
Q

wheenever we proform a skeletal muscle assessment, we’re always

A

thinking about the potential for there to be a neurological source of the problem. Always consider the impact of a neurological assessment

102
Q

pain inthe elbow due to?

A

True musculoskeletal issue? Like with the ligament or muscles r does it hae to do with the pain receptors in the elbow?

103
Q

What two basic thins will you do in a musculoskeletal assessment

A

We do inspection and palpation. We don’t do percussion or ascultation in an MS situation

104
Q

What do you want to inspect for in an MS assessment

A

1) the alignment of the body &always compare the contralateral side
2) level of the iliac crest scapula
4)look at the head and the spine. Is the head directly over the head? Is it in a straight line?
5) symmetry of the arms as they hand from the body. One arm hanging further away from the body than the other?
6) Any discoloration in their joints or swelling
&) are they hypertrophied or atrophied, spasticity or rigidity
8)Fasciculations- very small spasms of muscles

105
Q

Fasciculations

A

spasms of muscles, very small, usually on the face

106
Q

How do you palpate during an MS Assessment

A
  1. Is it tender? Hot? Swelling?
  2. Crepitus (crunchiness- indicates air buildup)
  3. Range of Motion-compare with contralateral side.
  4. Test strength of the muscle group as a whole
107
Q

Active Range of Motion Assessment

A

Have patient exihbit their best ROM on limb
Note any limitations, weakness, pain, tremors
Note an > or < ROM or instability
Compare with contralateral side

108
Q

Muscle Strength test

A

0/5 No muscle contraction
1/5 Can palpate muscle & notice trace contraction
2/5 Patient can move muscle with help
3/5 Muscle motile BUT NOT AGAINST RESISTANCE
4/5 Muscle motile against weak resistance
5/5 Muscle motile even against muscle resistance Normal muscle movement

109
Q

In older patients, is 4/5 muscle strength normal?

A

Yes, they’re old people

110
Q

Cervical Spine

A 
Note alignment and symmetry. 
Palpate posterior neck, cervical spine, &amp; area muscles
ROM: flexion/extension; 
lateral bending; 
right/left rotation
111
Q

Abduction

A

away from the body.
Adduction is back towards it
can test bot legs at the same time.

112
Q

Thoracic & Lumbar Spine assessment

A

stand behind them
• Symmetry of scapulae, iliac crests, 7 paravertebral muscles
• Palpate for spinal tenderness
• Note spine curvature (scoliosis, lordosis, kyphosis, gibbus)
• ROM: flexion, extension; lateral bending, right/left rotation

113
Q

What range of miton will you do for assessment of thi=oracic & lumbar spine?

A

Flexion
Hyperextension
Lateral bending (both sides)
Rotation to Left and Right

114
Q

Kyphosis

A

Hunching of the back

Gibbus is an extreme kyphosis

115
Q

Scoliosis

A

Sideways curvature of the spine “S” shaped

116
Q

Lordosis

A

exaggerated lumbar curvature
Poor abdominal muscles
during pregnancy, & Obesity

117
Q

Scoliosis

A

ages 10-15
Use scoliometer & look for reading. Symmetrical on each side=0
6-7 degrees greater then surgery
Look for uneven shoulder blades and scapula, one arm further away from body

118
Q

MS assessment of the hips

A
  • Inspect while patient stands: symmetry of iliac crests, greater trochanter of femur level of gluteal fold
  • Palpate for instability, tenderness, crepitus
  • ROM: flexion/hyperextension (knees extended); flexion (knee flexed); abduction/adduction; internal/external rotation
  • Test strength: flexion (knee extended & flexed); adduction/abduction
119
Q

MS assessment of the hips

A
  • Inspect while patient stands: symmetry of iliac crests, greater trochanter of femur level of gluteal fold
  • Palpate for instability, tenderness, crepitus
  • ROM: flexion/hyperextension (knees extended); flexion (knee flexed); abduction/adduction; internal/external rotation
  • Test strength: flexion (knee extended & flexed); adduction/abduction
120
Q

wheenever we proform a skletal uscle assessment, we’re always

A

thinking about the potential for there to be a neurological source of the problem. Always consider the impact of a neurological assessment

121
Q

pain inthe elbow due to?

A

True musculoskeletal issue? Like with the ligament or muscles r does it hae to do with the pain receptors in the elbow?

122
Q

What two basic thins will you do in a musculoskeletal assessment

A

We do inspection and palpation. We don’t do percussion or ascultation in an MS situation

123
Q

What do you want to inspect for in an MS assessment

A

1) the alignment of the body &always compare the contralateral side
2) level of the iliac crest scapula
4)look at the head and the spine. Is the head directly over the head? Is it in a straight line?
5) symmetry of the arms as they hand from the body. One arm hanging further away from the body than the other?
6) Any discoloration in their joints or swelling
&) are they hypertrophied or atrophied, spasticity or rigidity
8)Fasciculations- very small spasms of muscles

124
Q

Fasciculations

A

spasms of muscles, very small, usually on the face

125
Q

Ankles MS assessment

A

ROM: plantar flexion (down), dorsiflexion, inversion (arch inward), eversion (arch outward), rotation
Test strength: dorsiflexion/plantar flexion

126
Q

Active Range of Motion Assessment

A

Have patient exihbit their best ROM on limb
Note any limitations, weakness, pain, tremors
Note an > or < ROM or instability
Compare with contralateral side

127
Q

Muscle Strength test

A

0/5 No muscle contraction
1/5 Can palpate muscle & notice trace contraction
2/5 Patient can move muscle with help
3/5 Muscle motile BUT NOT AGAINST RESISTANCE
4/5 Muscle motile against weak resistance
5/5 Muscle motile even against muscle resistance Normal muscle movement

128
Q

In older patients, is 4/5 muscle strength normal?

A

Yes, they’re old people

129
Q

Elbow Assessment

A
  • Inspect contours
  • Note subcutaneous nodules along pressure points (sign of arthritis)
  • Palpate olecranon process & adjacent grooves; medial & lateral epicondyles
  • ROM: flexion/extension, supination/pronation
  • Test strength: flexion & extension
130
Q

Abduction

A

away from the body.
Adduction is back towards it
can test bot legs at the same time.

131
Q

Thoracic & Lumbar Spine assessment

A

stand behind them
• Symmetry of scapulae, iliac crests, 7 paravertebral muscles
• Palpate for spinal tenderness
• Note spine curvature (scoliosis, lordosis, kyphosis, gibbus)
• ROM: flexion, extension; lateral bending, right/left rotation

132
Q

What range of miton will you do for assessment of thi=oracic & lumbar spine?

A

Flexion
Hyperextension
Lateral bending (both sides)
Rotation to Left and Right

133
Q

Kyphosis

A

Hunching of the back

Gibbus is an extreme kyphosis

134
Q

Test strength or wrist

A

wrist flexion, hyperextension, finger grips, extension, abduction (turkey hand), adduction (fist)
Radial and ulnar deviation

135
Q

Lordosis

A

exaggerated lumbar curvature
Poor abdominal muscles
during pregnancy, & Obesity

136
Q

Scoliosis

A

ages 10-15
Use scoliometer & look for reading. Symmetrical on each side=0
6-7 degrees greater then surgery
Look for uneven shoulder blades and scapula, one arm further away from body

137
Q

MS assessment of the hips

A
  • Inspect while patient stands: symmetry of iliac crests, greater trochanter of femur level of gluteal fold
  • Palpate for instability, tenderness, crepitus
  • ROM: flexion/hyperextension (knees extended); flexion (knee flexed); abduction/adduction; internal/external rotation
  • Test strength: flexion (knee extended & flexed); adduction/abduction
138
Q

How to test hip strength

A

flexion (knee extended & flexed); adduction/abduction

139
Q

ROM of the hip

A 
Extended
flexion, knee extended
flexion with the knee flexed
Abduction, adduction
Internal rotation (knee flexed), &amp; extenal
140
Q

MS Assessment of the knee

A

• Inspect patella & alignment
o Genu valgum (knock knees)
o Genu varum (bowlegs)
• Palpate the popliteal space
• ROM: flexion, extension, hyperextension
• Test strength: flexion/extension. Support the joint, ask them to push up or down on your hand to assess

141
Q

Should people be able to hyperextend their knee?

A

No, it means that they have weak ligaments & they’re at risk for knee injury, particularly happens in younger children. Need knee strengthening exercises

142
Q

When do you inspect a person’s ankles

A
  • Want to look at them while they’re weight bearing. Inspect medial and lateral malleolus; Achilles tendon, contour of feet
  • Palpate Achilles tendon & metatarsophalangeal and interphalangeal joints
  • Heel pronation, indication of weak muscles
  • Palpate for swelling or tenderness of crepitus
143
Q

Ankles MS assessment

A

ROM: plantar flexion (down), dorsiflexion, inversion, eversion, rotation
Test strength: dorsiflexion/plantar flexion

144
Q

Assessing gait

A

Balance, ease of movement, width of steps, should have even steps,
Tandem gait- heel to toe in straight line (drinking & driving), sensitive indicator of balance
Walk on toe in straight line (plantar flexion weakness)
Heels in straight line (dorsiflexion weakness)
sit down and standup from a sitting position. If you can do that w/o your hands you have balance and strength

145
Q

MS assessment of Shoulders

A

• Clavicle and scapulae are symmetrical?
• Palpate sternoclavicular & acromioclavicular joints
o Greater tubercle of the humorous as well
• ROM: shrug shoulders (CN XI), forward flexion & hyperextension; internal/external rotation; abduction/adduction
• Test strength: shrug shoulders. Forward flexion, abduction

146
Q

Normal shoulder flexibility

A

shoulder shrug
forward flexion, and hyperextension
internal & external rotation
abduction and adduction

147
Q

Elbow assessment pitchers elbow vs tennis elbow

A

If medial epicondyle is inflamed its pitchers elbow

lateral epicondyle= tennis elbow

148
Q

ROM of the elbow

A

Should test flexion & extension

Supination & pronation

149
Q

MS Assessment on hands and wrists

A
  • Inspect dorsal & palmar aspects of hands, Note palmar and phalangeal creases; thenar & hypothenar eminences
  • Palpate metacarpophalangeal & Interphalangeal joints, wrist & radiocarpal groove
  • ROM: Wrist Flexion/hyperextension; radial/ulnar deviation, metacarpophalangeal flexion/hyperextension; abduction/adduction, thumb opposition
150
Q

thenar & hypothenar eminences

A

Muscles on your hands
Thenar- group of muscles at the base of the thumb
Hypothenar- opposite thenar, meaty muscles below pinky

151
Q

Test strength or wrist

A

wrist flexion, hyperextension, finger grips, extension, abduciton (turkey hand), adduction (fist)
Radial and ulnar deviation

152
Q

Pulmonary arteries contain

A

Deoxygenated blood

153
Q

If you have an irregular apical pulse

A

You should check for a pulse deficit

154
Q

Glasgow coma scale

A

Eyes-open to pain
Verbal- moan to pain
Motor-withdraw to pain?

Nursing IAC Modules (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions