Final Flashcards
(183 cards)
1
Q
Structure of the Bones
A
- 206 bones
- Axial (head and trunk) and appendicular (extremities, shoulders, and hips) skeleton
- Compact bone: Hard and dense and makes up the shaft and outer layers.
- Spongy bone: Numerous spaces and makes up the ends and centers of the bones.
- Osteoblasts and osteoclasts are the cells that make up the bones.
2
Q
Skeletal Muscles
A
Three types: Skeletal voluntary (650), smooth, cardiac
3
Q
Movements of Skeletal Muscles
A
- Abduction: Moving away from midline of the body
- Adduction: Moving toward midline of the body
- Circumduction: Circular motion
- Inversion: Moving inward
- Eversion: Moving outward
- Extension: Straightening the extremity at the joint and increasing the angle of the joint
- Hyperextension: Joint bends greater than 180 degrees
- Flexion: Bending the extremity at the joint and decreasing the angle of the joint
- Dorsiflexion: Toes draw upward to ankle
- Plantar flexion: Toes point away from ankle
- Pronation: Turning or facing downward
- Supination: Turning or facing upward
- Protraction: Moving forward
- Retraction: Moving backward
- Rotation: Turning of a bone on its own long axis
- Internal rotation: Turning of a bone toward the center of the body
- External rotation: Turning of a bone away from the center of the body
4
Q
Structure of the Joints
A
- Fibrous joints are joined by fibrous connective tissue and are immovable. Sutures between the skull bones.
- Cartilaginous joints: Joined by cartilage (joints between vertebrae)
- Synovial: Shoulders, wrists, hips, knees, ankles, contains a space between bones filled with synovial fluid: acts as a lubricant. Bones in these joints are joined by ligaments. Some contain bursae: small sacs filled with synovial fluid that cushion the joints, a knee joint.
-Ligaments: Strong dense bands of fibrous connective tissue.
5
Q
Osteoporosis
A
- One in three women and one in five men will have a fractured bone, with hip, forearm, and vertebral fractures predominating.
- Europeans and Americans accounted for 51% of osteoporosis-related fractures in the year 2000, followed by people from the Western Pacific and Southeast Asia.
- Osteoporosis is lowest in black males and highest in white females.
6
Q
Osteoporosis Risk Factors
A
-Uncontrollable risk factors:
Age, gender, family history, previous fracture, ethnicity, menopause/hysterectomy, long-term glucocorticoid therapy, rheumatoid arthritis, primary/secondary hypogonadism in men
-Modifiable risk factors:
Alcohol, smoking, low body mass index, poor nutrition, vitamin D deficiency, eating disorders, low dietary calcium intake, insufficient exercise (sedentary lifestyle), frequent falls
7
Q
Risk Reduction: Osteoporosis
A
- Ensure a nutritious diet with adequate calcium intake.
- Avoid protein malnutrition and undernutrition.
- Maintain an adequate supply of vitamin D.
- Participate in regular physical activity.
- Avoid the effects of second-hand smoke.
8
Q
Collection of Subjective Data: Musculoskeletal System
A
- History of present health concern: Have you had any recent weight gain? Describe any difficulty chewing. Describe any joint, muscle, or bone pain you have. Do a pain assessment.
- Past health history: Describe any problems or injuries you have had to your joints, muscles, or bones. Diagnoses of diabetes, sickle cell anemia, systemic lupus, osteoporosis.
- Family History: Any history of rheumatoid arthritis, gout, or osteoporosis.
- Lifestyle and Health Practices: What activities do you engage in to promote the health of your muscles and bones. What medications do you take? Do you smoke?
9
Q
Collection of Objective Data : Musculoskeletal System
A
-Preparing the client
-Equipment required:
Tape measure
Skin marking pencil
10
Q
Musculoskeletal System: Gait
A
- Gait: Note the base of support, weight bearing stability, foot position, arm swing, and posture.
- Normal gait: Feet pointing forward, parallel to each other, bear weight evenly. Arm swing should be in opposition from the feet. Posture should be erect: stand up straight.
- Overall risk for falling: walker, Cain, assistive device. Are they steady on their feet.
11
Q
Musculoskeletal System: Temporomandibular Joint
A
- Temporomandibular Joint: Inspect and palpate TMJ, put index and middle fingers anterior to the external ear opening and have client open their mouth. Have them move their jaw from side to side. Finally protrude and retract the jaw.
- ROM of the TMJ: Ask the client to open the mouth and move the jaw laterally against resistance. Next, as the client clenches the teeth, feel for the contraction of the temporal and masseter muscles to test the integrity of cranial nerve V (trigeminal nerve).
12
Q
Musculoskeletal System: Sternoclavicular Joint
A
Sternoclavicular joint: Observe it for midline location, color, swelling, and masses. Where the clavicle meets the sternum. Palpate to look for swelling, masses, crepitus, make sure where it joins on each side is symmetrical.
13
Q
Musculoskeletal System: Cervical, thoracic, and lumbar spine
A
- Observe the cervical, thoracic, and lumbar curvesfrom the side, then from behind. Have the client standing erect with the gown positioned to allow an adequate view of the spine. Observe for symmetry, noting differences in height of the shoulders, iliac crests, and buttock creases.
- Palpate the spinous processes and the paravertebral muscleson both sides of the spine for tenderness or pain.
- Test ROM of the cervical, thoracic, lumbar spine.
- Test for back and leg pain.
- Measure leg length.
14
Q
Musculoskeletal System: Shoulders, arms, and elbows.
A
-Shoulders, arms, and elbows; inspection, palpation, ROM
-Elbows:
Inspect for size, shape, deformities, redness, or swelling.
Test ROM.
15
Q
Musculoskeletal System: Wrists, Hands and Fingers, Hips
A
- Wrists: inspection, palpation, test ROM
- Hands and fingers: inspection, palpation, test ROM
- Hips: inspection, palpation, test ROM
16
Q
Musculoskeletal System: Knees
A
- Knees: inspection, palpation
- Assess for swelling.
- Test for ROM.
- Assess for pain and injury.
17
Q
Musculoskeletal System: Ankles and Feet
A
-Ankles and feet:
Inspect position, alignment, shape, and skin.
Palpate ankles and feet for tenderness, heat, swelling, or nodules.
Test ROM.
18
Q
Abnormal Spinal Curvatures
A
- Kyphosis: A rounded thoracic convexity (kyphosis). older adults as the spine breaks down, kyphotic curve in the thoracic spine.
- Scoliosis: A lateral curvature of the spine with an increase in convexity on the side that is curved is seen in scoliosis.
- Normal: Mild S curve.
19
Q
Wrist Abnormalities
A
-Acute rheumatoid arthritis: Tender, painful, swollen, stiff joints are seen in acute rheumatoid arthritis.
-CHRONIC RHEUMATOID ARTHRITIS:
Chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints, limited range of motion, and finger deviation toward the ulnar side are seen in chronic rheumatoid arthritis.
-BOUTONNIÈRE AND SWAN-NECK DEFORMITIES:
Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint (boutonnière deformity) and hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint (swan-neck deformity) are also common in chronic rheumatoid arthritis.
-GANGLION:
Nontender, round, enlarged, swollen, fluid-filled cyst (ganglion) is commonly seen at the dorsum of the wrist.
-OSTEOARTHRITIS:
Osteoarthritis (degenerative joint disease) nodules on the dorsolateral aspects of the distal interphalangeal joints (Heberden nodes) are due to the bony overgrowth of osteoarthritis. Usually hard and painless, they may affect middle-aged or older adults and often, although not always, are associated with arthritic changes in other joints. Flexion and deviation deformities may develop.
-TENOSYNOVITIS:
Painful extension of a finger may be seen in acute tenosynovitis (infection of the flexor tendon sheaths).
-THENAR ATROPHY:
Atrophy of the thenar prominence due to pressure on the median nerve is seen in carpal tunnel syndrome.
20
Q
Feet and Toes Abnormalities
A
-ACUTE GOUTY ARTHRITIS:
In gouty arthritis, the metatarsophalangeal joint of the great toe is tender, painful, reddened, hot, and swollen.
-FLAT FEET:
A flat foot (pes planus) has no arch and may cause pain and swelling of the foot surface.
-CALLUS:
Calluses are nonpainful, thickened skin that occurs at pressure points.
-HALLUX VALGUS:
Hallux valgus is an abnormality in which the great toe is deviated laterally and may overlap the second toe. An enlarged, painful, inflamed bursa (bunion) may form on the medial side.
-CORN:
Corns are painful thickenings of the skin that occur over bony prominences and at pressure points. The circular, central, translucent core resembles a kernel of corn.
-HAMMER TOE:
Hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint (hammer toe) commonly occurs with the second toe.
-PLANTAR WART:
Plantar warts are painful warts (verruca vulgaris) that often occur under a callus, appearing as tiny dark spots.
21
Q
Older Clients: Musculoskeletal System
A
- Older clients usually have slower movements, reduced flexibility, and decreased muscle strength because of age-related muscle fiber and joint degeneration, reduced elasticity of the tendons, and joint capsule calcification.
- An exaggerated thoracic curve (kyphosis) is common with aging.
22
Q
Older Client Frequent Findings: Musculoskeletal System
A
- Bones lose their density with age, putting the older client at risk for bone fractures, especially of the wrists, hips, and vertebrae. Older clients who have osteomalacia or osteoporosis are at an even greater risk for fractures.
- Joint-stiffening conditions may be misdiagnosed as arthritis, especially in the older adult.
- Osteoporosis is more common as a person ages because bone resorption increases, calcium absorption decreases, and production of osteoblasts decreases as well.
- Some older clients have an impaired sense of position in space, which may contribute to the risks of falling.
23
Q
Analysis of Data: Musculoskeletal System
A
Analyze the data from the interview and physical assessment of the musculoskeletal system to formulate valid nursing diagnoses, collaborative problems, and/or referrals.
24
Q
General Routine Screening vs Focused Assessment of the Musculoskeletal System
A
- The nurse routinely observes the client’s posture, gait, and movements, along with activities of daily living.
- If the client describes the inability or limited ability to move a joint or extremity or describes pain in a joint or muscle, a more complete assessment is required. This would include inspection of symmetry, color, range of motion, and strength. In addition, the nurse would palpate the joint, bone, or muscles for tenderness, heat, swelling, or nodules.
- More advanced or specialty tests include testing for carpal tunnel, the bulge test, and the ballottement test.
- A total head-to-toe musculoskeletal examination would more likely be performed by a physical therapist or a primary care provider.
25
Which skeletal muscle movement means “to move forward”?
Protraction
26
Is the following statement true or false?
| Decreased estrogen levels after menopause increase the risk of osteoporosis.
True
27
Is the following statement true or false?
| Calluses are painful thickenings of the skin that occur over bony prominences and at pressure points.
False, they are nonpainful
28
Muscle strength grading scale:
- 0/5= No muscular contraction. Paralysis
- 1/5= Slight flicker of contraction. Severe weakness
- 2/5= Passive ROM (gravity removed and assisted by examiner) Poor ROM
- 3/5= Active motion against gravity. Average weakness
- 4/5= Active motion against some resistance. Slight weakness
- 5/5= Active motion against full resistance. Normal
29
Assessing ROM in the Fingers
Ask the client to (A) spread the fingers apart (abduction), (B) make a fist (adduction), (C) bend the fingers down (flexion) and then up (hyperextension), (D) move the thumb away from other fingers, and then (E) touch the thumb to the base of the small finger.
30
Assessing ROM in the Wrists
- Ask the client to bend the wrist down and back (flexion and extension; ).
- Next have the client hold the wrist straight and move the hand outward and inward (deviation).
31
Assessing ROM in the Elbows
- Ask the client to perform the following movements to test ROM, flexion, extension, pronation, and supination.
- Flex the elbow and bring the hand to the forehead.
- Straighten the elbow.
- Then hold arm out, turn the palm down, then turn the palm up.
32
Assessing ROM in the Shoulders
- Explain to the client that you will be assessing ROM (consisting of flexion, extension, adduction, abduction, and motion against resistance). Ask client to stand with both arms straight down at the sides. Next, ask the client to move the arms forward (flexion), then backward with elbows straight
- Then have the client bring both hands together overhead, elbows straight, followed by moving both hands in front of the body past the midline with elbows straight (this tests adduction and abduction)
- In a continuous motion, have the client bring the hands together behind the head with elbows flexed (this tests external rotation) and behind the back (internal rotation)..
33
Assessing ROM in the Spine
- Test ROM of the cervical spine by asking the client to touch the chin to the chest (flexion) and to look up at the ceiling (hyperextension).
- Test ROM of the lumbar spine. Ask the client to bend forward and touch the toes. Observe for symmetry of the shoulders, scapula, and hips.
- Test lateral bending. Ask the client to touch each ear to the shoulder on that side
- Evaluate rotation. Ask the client to turn the head to the right and left
34
Assessing ROM in the Hips
o With the client supine, ask the client to:
o Raise extended leg.
o Flex knee up to chest while keeping other leg extended.
o Move extended leg away from midline of body as far as possible and then toward midline of body as far as possible (abduction and adduction).
o Bend knee and turn leg inward (rotation) and then outward (rotation).
o Ask the client to lie prone and lift extended leg off table. Alternatively, ask the client to stand and swing extended leg backward.
35
Assessing ROM in the Knees
o Ask the client to:
o Bend each knee up (flexion) toward buttocks or back.
o Straighten the knee (extension/hyperextension).
o Walk normally.
36
Assessing ROM in the Ankles
o Ask the client to:
o Point toes upward (dorsiflexion) and then downward (plantarflexion).
o Turn soles outward (eversion) and then inward (inversion).
o Rotate foot outward (abduction) and then inward (adduction).
o Turn toes under foot (flexion) and then upward (extension).
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Crepitus
A crackling sound/tactile sensation due to air under the skin; may also be heard in joints
38
I: Olfactory Nerve
-Assessment:
For all assessments of the cranial nerves, have client sit in a comfortable position at your eye level. Ask the client to clear the nose to remove any mucus, then to close eyes, occlude one nostril, and identify a scented object that you are holding such as soap, coffee, or vanilla.
39
II: Optic Nerve
-Assessment:
Use a Snellen chart to assess vision in each eye, Ask the client to read a newspaper or magazine paragraph to assess near vision, Assess visual fields of each eye by confrontation, Use an ophthalmoscope to view the retina and optic disc of each eye.
40
III: Oculomotor Nerve
-Assessment:
Inspect margins of the eyelids of each eye, Assess extra-ocular movements, Assess pupillary response to light (direct and indirect) and accommodation in both eyes.
41
IV: Trochlear Nerve
-Assessment:
Inspect margins of the eyelids of each eye, Assess extraocular movements, Assess pupillary response to light (direct and indirect) and accommodation in both eyes.
42
V: Trigeminal Nerve
-Assessment:
Test motor function. Ask the client to clench the teeth while you palpate the temporal and masseter muscles for contraction. Tell the client: “I am going to touch your forehead, cheeks, and chin with the sharp or dull side of this paper clip. Please close your eyes and tell me if you feel a sharp or dull sensation. Ask the client to look away and up while you lightly touch the cornea with a fine wisp of
43
VI: Abducens Nerve
-Assessment:
Inspect margins of the eyelids of each eye, Assess extraocular movements, Assess pupillary response to light (direct and indirect) and accommodation in both eyes.
44
VII: Facial Nerve
```
-Assessment:
Test motor function. Ask the client to:
• Smile
• Frown and wrinkle forehead
• Show teeth
• Puff out cheeks
• Purse lips
• Raise eyebrows
• Close eyes tightly against resistance
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45
VIII: Acoustic, Vestibulocochlear Nerve
-Assessment:
| Test the client’s hearing ability in each ear
46
IX: Glossopharyngeal Nerve
-Assessment:
Ask the client to open mouth wide and say “ah” while you use a tongue depressor on the client’s tongue, Test the gag reflex by touching the posterior pharynx with the tongue depressor, check ability to swallow.
47
X: Vagus Nerve
-Assessment:
Ask the client to open mouth wide and say “ah” while you use a tongue depressor on the client’s tongue, Test the gag reflex by touching the posterior pharynx with the tongue depressor, test ability to swallow.
48
XI: Spinal Accessory Nerve
-Assessment:
Ask the client to shrug the shoulders against resistance to assess the trapezius muscles, Ask the client to turn the head against resistance
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XII: Hypoglossal Nerve
-Assessment:
To assess strength and mobility of the tongue, ask the client to protrude tongue, move it to each side against the resistance of a tongue depressor, and then put it back in the mouth.
50
Assess Bicep reflexes
-Ask the client to partially bend the arm at the elbow with palm up. Place your thumb over the biceps tendon and strike your thumb with the pointed side of the reflex hammer. Elbow flexes and contraction of the biceps muscle is seen or felt. Ranges from 1+ to 3+. Forearm flexes and supinates. Ranges from 1+ to 3+.
51
Assess Brachioradialis reflexes
-Ask the client to flex elbow with palm down and hand resting on the abdomen or lap. Use the flat side of the reflex hammer to tap the tendon at the radius about 2 in above the wrist. Flexion and supination of forearm.
52
Assess Tricep reflexes
-Ask the client to hang the arm freely (“limp, like it is hanging from a clothesline to dry”) while you support it with your nondominant hand. With the elbow flexed, use the flat side of the reflex hammer to tap the tendon above the olecranon process. Elbow extends, triceps contracts. Ranges from 1+ to 3+.
53
Assess Patellar reflexes
-Ask the client to let both legs hang freely off the side of the examination table. Using the flat side of the reflex hammer, tap the patellar tendon, which is located just below the patella. Knee extends, quadriceps muscle contracts. Ranges from 1+ to 3+.
54
Assess Achilles reflexes
- With the client’s leg still hanging freely, dorsiflex the foot. Tap the Achilles tendon with the flat side of the reflex hammer. Normal response is plantarflexion of the foot. Ranges from 1+ to 3+.
- Babinski- The toes will fan out for abnormal response (positive Babinski response).
55
Name the 3 functions that are assessed with the Glasgow Coma Scale:
Eye opening
Verbal response
Motor response
-Score of 7 or lower is considered to be in a coma. Higher the score the better.
56
Deep tendon reflex grading scale:
- 0: No Response
- 1+: Decreased, less active than normal
- 2+: Normal, usual response
- 3+: More brisk or active than normal, but not indicative of a disorder
- 4+: Hyperactive, very brisk, rhythmic oscillations; abnormal and indicative of disorder
57
Describe how an examiner would test balance:
An examiner may assess balance by watching a client walk naturally across a room. Then they may ask the client to walk in heel-to-toe fashion. (Tandem walking). You would also test balance by performing the Romberg Test. Then ask the client to stand on one foot and to bend the knee of the leg the client is standing on.
58
Describe how an examiner would test coordination:
Demonstrate the finger-to-nose test to assess accuracy of movements, then ask the client to extend and hold arms out to the side with eyes open. Next, say, “Touch the tip of your nose first with your right index finger, then with your left index finger. Repeat this three times. Next, ask the client to repeat these movements with eyes closed.
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Central Nervous System
- CNS: Brain and Spinal Cord
- Cerebrum- 2 hemispheres: 1 on right and 1 on left (results show on opposite side)
- Diencephalon- composed on thalamus (points and direct impulses to the cerebral cortex) and hypothalamus (responsible for regulating body functions: water balance, appetite, VS, sleep cycle, perception of pain, emotional status)
- Brain stem- midbrain: relay center for ear and eye reflexes, medulla oblongata, pons (sends messages between the brain and rest of body, control breathing rate, BP, and consciousness)
- Cerebellum- coordinates smooth voluntary movements
- Neural pathways (reflexes)
- Meninges- dura, adenoid, pia mater (protect brain) 3 layers
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Peripheral Nervous System
- PNS: Carry information to and from the CNS
- Somatic fibers carry CNS impulses to voluntary skeletal muscles; autonomic fibers carry CNS impulses to smooth, involuntary muscles (in the heart and glands). The somatic nervous system mediates conscious, or voluntary, activities; the autonomic nervous system mediates unconscious, or involuntary, activities.
- 12 pairs of cranial nerves
- 31 pairs of spinal nerves
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Lobes of the Brain
- Frontal: voluntary skeletal actions on opposite sides, (left side of lobe controls right side of body and right side of lobe controls left side of body) (communication, aggressive emotions, intellect and responding, judgement and behavior.)
- Parietal: tactile sensations; touch, pain, temp, shapes.
- Occipital: reading and understanding, primary receptor for vision
- Temporal: hearing
62
Stroke (CVA)
- Ischemic: Blood vessel carrying blood to the brain is blocked by a clot. These clots can be embolic (move through the vessel) or thrombotic (develop within the vessel). 85% of all strokes
- TIA: transient ischemic accident: clot is struggling to pass through- less than 24 hours of symptoms, warning sign for stroke
-Hemorrhagic: When brain aneurysm bursts or a weakened blood vessel in the brain leaks. (rupture, malformation, aneurism that ruptures) bleeding from artery
Less common, but account for 40% of all stroke deaths.
63
Stroke Symptoms
- Sudden numbness or weakness on one side of body
- Sudden confusion,
- trouble speaking, or understanding speech
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden severe headache with no known cause
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Act FAST: Warning signs of a stroke
- FACE: Ask the person to smile. Does one side of the face droop?
- ARMS: Ask the person to raise both arms. Does one arm drift downward?
- SPEECH: Ask the person to repeat a simple phrase. Is speech slurred or strange?
- TIME: If you observe any of these signs, call 9-1-1 immediately.
- A stroke is time sensitive
- Do not wait for symptoms to get better, seek help!
- Do not go to ER, they have to call 911 (they have to get there fast)
65
Risk Factors for Stroke
- Hypertension
- Diabetes mellitus
- Heart disease
- Smoking and exposure to second-hand smoke
- Age and gender
- Race and ethnicity
- Personal or family history
- Brain aneurysms or arteriovenous malformations (AVMs)
- Younger men are at a higher risk
- women more likely to die from a stroke
- African American, native American, and Alaska native are at a higher risk than white or Hispanic pt
- Sickle cell anemia
- musculitis
- bleeding disorders
- Atriofibrilation- electrical defect on heart that put pt at higher risk for developing clots (which can travel to brain)- will be on an anticoagulant or anti-platelet
- AVM- hemorrhagic
66
Risk Factors For Stroke that can be controlled
- Alcohol and illegal drug use
- Certain medical conditions
- Lack of physical inactivity
- Overweight and obesity
- Stress and depression
- Unhealthy cholesterol levels: Cholesterol- low total: less than 200, LDL: less than 130
- Unhealthy diet
- Use (especially prolonged use of ) NSAID medications
67
Teaching Topics for Stroke
- Smoking cessation
- Maintain cholesterol levels low
- Control high blood pressure.
- Control diabetes
- Exercise
- Healthy diet
- Avoid sodium (salt)
- Limit alcohol intake
- Avoid illegal drugs.
- Birth control pills- Higher Risk
- Talk to doctor about aspirin
68
Collecting Subjective Data: Neurologic System
- History of present health concern: Do you experience headaches, seizures, dizziness, numbness, tingling/prickling?
- Past Health History: Any type of head injury? Meningitis, encephalitis, injury to spinal cord, or a stroke?
- Family History: Any history of high blood pressure, stroke, Alzheimer’s, dementia, epilepsy, brain cancer?
- Lifestyle and health practices: Medications, smoking, diet, exposure to chemicals, lift heavy objects?
69
Stroke Scale
NIHSS, the higher the score the worse the score is.
70
Collecting Objective Data: Neurologic System
Neurologic Examination:
-Mental status examinations provide information about cerebral cortex function. Cerebral abnormalities disturb the client’s intellectual ability, communication ability, or emotional behaviors.
- The cranial nerve evaluation provides information regarding the transmission of motor and sensory messages, primarily to the head and neck. Many of the cranial nerves are evaluated during the head, neck, eye, and ear examinations.
- The motor and cerebellar systems are assessed to determine functioning of the pyramidal and extrapyramidal tracts. The cerebellar system is assessed to determine the client’s level of balance and coordination. The motor system examination is usually performed during the musculoskeletal examination.
- Examining the sensory system provides information regarding the integrity of the spinothalamic tract, posterior columns of the spinal cord, and parietal lobes of the brain, whereas testing reflexes provides clues to the integrity of deep and superficial reflexes.
```
-A neuro check includes the following assessment points:
Level of consciousness
Pupillary checks
Movement and strength of extremities
Sensation in extremities
Vital signs
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71
Orientation: Neurologic System
-Orientation X 4
Normal = Oriented to person, place, time and situation
Disoriented
72
Equipment for Neurologic Assessment
-Motor and Cerebellar Examination
-Sensory Examination
Cotton ball
Objects to feel such as a quarter or key
Paper clip
Test tubes containing hot and cold water
Tuning fork (low pitched)
-Reflex Examination
Cotton-tipped applicator
Reflex (percussion) hammer
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Motor and Cerebellar Systems
- Assess condition and movement of muscles.
- Evaluate balance.
- Perform Romberg test.
- Assess coordination.
74
Sensory System
- Assess light touch, pain, and temperature sensations.
- Test vibratory sensation
- Test sensitivity to position.
- Assess tactile discrimination: Remember that the client should have eyes closed. To test stereognosis, place a familiar object such as a quarter, paper clip, or key in the client’s hand and ask the client to identify it
75
Sensory Function
- Vibratory Sense: Vibrating tuning fork on distal joint
- Position Sense: Up & down movement with eyes closed
- Stereognosis: Identifies familiar object with eyes closed
- Graphesthesia: Identifies number written on palm
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Reflexes
```
-Test deep tendon reflexes:
Biceps, brachioradialis
Triceps, patellar, Achilles reflex
-Test superficial reflexes:
Plantar, abdominal, cremasteric
```
77
Meninges
- Assess the client’s neck mobility.
- Test for Brudzinski sign (flexing neck forward): As you flex the neck, watch the hips and knees in reaction to your maneuver. : If they have pain when flexing neck then they have to flex knees up also- reflex
- Test for Kernig sign (flexing leg at knee/hip): Flex the client’s leg at both the hip and the knee, then straighten the knee. have them lay down, it will pull up neck
78
Abnormal Muscle Movements
- Fasciculations and atrophy of the tongue may be seen with peripheral nerve disease or amyotrophic lateral sclerosis.
- Eye tic. Tics are brief, repetitive, stereotyped, coordinated movements occurring at irregular intervals. Examples include repetitive winking, grimacing, and shoulder shrugging. Causes include Tourette syndrome and drugs such as phenothiazines and amphetamines.
- Chorea choreiform movements of the hand. Chorea choreiform movements are brief, rapid, jerky, irregular, and unpredictable. They occur at rest or interrupt normal coordinated movements. Unlike tics, they seldom repeat themselves. The face, head, lower arms, and hands are often involved. Causes include Sydenham chorea (with rheumatic fever) and Huntington disease.
- Resting (static) tremors. These tremors are most prominent at rest, and may decrease or disappear with voluntary movement. Illustrated is the common, relatively slow, fine, pill-rolling tremor of parkinsonism, about 5 per second.
- Postural tremor. These tremors appear when the affected part is actively maintaining a posture. Examples include the fine, rapid tremor of hyperthyroidism, the tremors of anxiety and fatigue, and benign essential (and sometimes familial) tremor. Tremor may worsen somewhat with intention.
- Intention tremor of a pointed finger. Intention tremors, absent at rest, appear with activity and often get worse as the target is neared. Causes include disorders of cerebellar pathways, as in multiple sclerosis.
- Athetosis. Athetoid movements are slower and more twisting and writhing than choreiform movements, and have a larger amplitude. They most commonly involve the face and the distal extremities. Athetosis is often associated with spasticity. Causes include cerebral palsy.
79
Abnormal Gait
-CEREBELLAR ATAXIA
Wide-based, staggering, unsteady gait.
Romberg test results are positive (client cannot stand with feet together).
Seen with cerebellar diseases or alcohol or drug intoxication.
-PARKINSONIAN GAIT
Shuffling gait, turns accomplished in very stiff manner.
Stooped-over posture with flexed hips and knees.
Typically seen in Parkinson disease and drug-induced parkinsonian because of effects on the basal ganglia.
-SCISSORS GAIT
Stiff, short gait; thighs overlap each other with each step.
Seen with partial paralysis of the legs.
-SPASTIC HEMIPARESIS
Flexed arm held close to body while client drags toe of leg or circles it stiffly outward and forward.
Seen with lesions of the upper motor neurons in the cortical spinal tract, such as occurs in stroke.
-FOOTDROP
Client lifts foot and knee high with each step, then slaps the foot down hard on the ground.
Client cannot walk on heels.
Characteristic of diseases of the lower motor neurons
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Older Clients: Neurologic System
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-Decreased:
Taste
Smelling
Hearing
Sight
Touching (toes position)
Muscle mass
Reaction time (reflexes) Achilles reflex may be absent
flexibility
-Hands/head tremors (dyskinesia: repetitive movements of the lips, jaw, or tongue)
-slow and uncertain gait.
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81
Asymmetrical findings are usually
Abnormal
82
The best way to prevent infection is
Handwashing
83
Pain is always
Subjective
84
Scoliosis
A lateral curvature of the spine with an increase in convexity on the side that is curved. Unequal leg lengths.
85
Barrel Chest
Ribs appearing horizontal at an angle greater than 45 degrees with the spinal column are frequently the result of an increased (1 to 1) ratio between the anteroposterior and transverse diameter (barrel chest).
86
Kyphosis
A rounded thoracic convexity.
87
Osteoarthritis
Osteoarthritis (degenerative joint disease) nodules on the dorsolateral aspects of the distal interphalangeal joints (Heberden nodes) are due to the bony overgrowth of osteoarthritis. Usually hard and painless, they may affect middle-aged or older adults and often, although not always, are associated with arthritic changes in other joints. Flexion and deviation deformities may develop.
Osteoarthritis pain usually begins in one set of joints and on one side of the body, with a feeling of pain deep in the joint, improving with rest but worsening with rainy weather, perhaps a sensation of bones grating together, with stiffness early in the morning improving with movement.
88
Osteoporosis signs and symptoms
-Uncontrollable risk factors:
Age, gender, family history, previous fracture, ethnicity, menopause/hysterectomy, long-term glucocorticoid therapy, rheumatoid arthritis, primary/secondary hypogonadism in men
-Modifiable risk factors:
Alcohol, smoking, low body mass index, poor nutrition, vitamin D deficiency, eating disorders, low dietary calcium intake, insufficient exercise (sedentary lifestyle), frequent falls
-The bone loss occurs silently and progressively, and often no symptoms are noted until the first fracture occurs.
89
Recent Memory
Ask the client “What did you have to eat today?” or “What is the weather like today?”
90
Remote Memory
Remote Memory: Ask client: When did you get your first job? “When is your birthday?” Information on past health history also gives clues as to the client’s ability to recall remote events.
91
Describe the ways in which the ear changes in older adults:
- Presbycusis: A gradual sensorineural hearing loss due to degeneration of the cochlea or vestibulocochlear nerve common after 50 years of age.
- Negative self-image with hearing aid
- Elongated earlobes with linear wrinkles
- Harder cerumen builds as cilia in ear canal become more rigid, causing conductive hearing impairment.
- Coarse, thick wire-like hair may grow at ear canal entrance
- Eardrum appears cloudy
92
Describe the way a normal tympanic membrane should look upon assessment:
The tympanic membrane should be pearly gray, shiny, and translucent, with no bulging or retraction. It is slightly concave, smooth, and intact. A cone-shaped reflection of the otoscope light is normally seen at 5 o’clock in the right ear and 7 o’clock in the left ear. The short process and handle of the malleus and the umbo are clearly visible
93
Describe the ways in which the skin changes in older adults:
Skin becomes pale, skin lesions, dryer, loses turgor because of a decrease in elasticity and collagen fibers. Sagging or wrinkled skin.
94
List the 6 categories that are included on the Braden Scale:
1. Sensory Perception: Ability to respond meaningfully to pressure-related discomfort.
2. Moisture: Degree to which skin is exposed to moisture
3. Activity: Degree of physical activity.
4. Mobility: Ability to change and control body position.
5. Nutrition: Usual food intake pattern.
6. Friction and Shear
Also, have a good idea of how the scale works (the lower the number, the higher the risk for developing pressure ulcers)
95
Describe the signs/symptoms of depression:
Sadness, apathy, irritability, anxiety, fatigue, poor appetite, insomnia, hypersomnolence, reduced eye contact, slumped posture, slow speech,
96
Name the 4 basic assessment techniques in order:
a. Inspect
b. Palpate
c. Percussion
d. Auscultate
97
Abdominal assessment Order
Inspect, Auscultate, percussion, and palpate.
98
What clinical findings would you expect when hearing hyperactive bowel sounds?
Loud, prolonged, gurgles, one’s stomach growling. May be heard with bowel obstruction, gastroenteritis, diarrhea, or use of laxatives.
99
What clinical findings would you expect when hearing hypoactive bowel sounds?
Diminished bowel motility because of paralytic ileus, inflammation of the peritoneum, late bowel obstruction, constipation.
100
What are the normal ranges (in adults) for the following vital signs?
- Pulse: 60-100
- Temperature (Fahrenheit): 96.0°F and 99.9°F orally
- Respirations: 12-20
- B/P: 120/80
- SpO2: 95%
101
Describe the ways in which vital signs change when a client is in pain:
- Increased heart rate with pain, a normal heart rate may be seen with chronic pain. -Respiratory rate may increase, and breathing may be irregular and shallow.
- Increased blood pressure, normal blood pressure may be seen in chronic pain.
102
What type of questions are best to use when beginning an interview? This is also the type of question that will elicit the most information from your client.
Open-ended Questions
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Subjective Data
-Subjective data: Sensations or symptoms (pain,hunger) feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.
-The major areas of subjective data include:
Biographical information (name, age, religion, occupation)
History of present health concern: physical symptoms related to each body part or system (e.g., eyes and ears, abdomen)
Personal health history
Family history
Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment)
Review of systems
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Objective Data
-Objective Data: Directly observed by the examiner. May be found through observation, health care professionals, also family or significant other.
-These data include:
Physical characteristics (e.g., skin color, posture)
Body functions (e.g., heart rate, respiratory rate)
Appearance (e.g., dress and hygiene)
Behavior (e.g., mood, affect)
Measurements (e.g., blood pressure, temperature, height, weight)
Results of laboratory testing (e.g., platelet count, x-ray findings.
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Bronchial lung sounds are heard here:
Trachea and Thorax
106
Bronchovesicular lung sounds are heard here:
Over the major bronchi—posterior: between the scapulae; anterior: around the upper sternum in the first and second intercostal spaces
107
Vesicular lung sounds are heard here
Peripheral lung fields
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Wheezing
Air passes through constricted passages (caused by swelling, secretions, or tumor).
109
Crackles
Inhaled air suddenly opens the small, deflated air passages that are coated and sticky with exudate.
110
Crackles (Coarse)
inhaled air comes into contact with secretions in the large bronchi and trachea.
111
Friction Rub
Sound is the result of rubbing of two inflamed pleural surfaces.
112
What assessment tool is used to assess for color blindness?
Ishihara Test
113
What assessment tool is used to assess for distance vision?
Snellen Chart: Normal acuity is 20/20 with or without corrective lenses
114
What assessment tool is used to assess for near vision?
* Jaeger Test: Handheld vision chart
* Jaeger test or Rosenbaum chart (pocket screener)
* Normal acuity is 14/14 with or without corrective lenses
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What are the signs/symptoms of cataracts?
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-Open-angle Glaucoma:
Patchy blind spots in your side (peripheral) or central vision, frequently in both eyes
Tunnel vision in the advanced stages
-Acute Angle-closure Glaucoma
Severe headache
Eye pain
Nausea and vomiting
Blurred vision
Halos around lights
Eye redness
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Macule
Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red). Macules are less than 1 cm with a circumscribed border, whereas patches are greater than 1 cm, and may have an irregular border. Examples include freckles, flat moles, petechiae, rubella (pictured below), vitiligo, port wine stains, and ecchymosis.
117
What assessment technique is used to elicit kidney pain?
Blunt Percussion
118
What does jugular venous distention indicate? (hint: think of what’s going wrong with the heart)
Right sided heart failure
119
Murmur intensity grading scale:
1: Very faint, no thrill
2: Soft, heard in all positions, no thrill
3: Moderately loud, no thrill
4: Loud and associated with a palpable thrill
5: Very loud, with thrill
6: Loudest, with thrill
120
S1 is heart the loudest at the
Apex
121
S2 is heard the loudest at the
Base
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What does a heart murmur sound like upon auscultation? What causes this sound?
a. Turbulent blood flow with a swooshing or blowing sound.
b. The valves could be too narrow or regurgitation issues. Valve isn’t shutting all the way and blood is backflowing.
c. Conditions that contribute to heart murmurs
d. Increased blood velocity
e. Structural valve defects
f. Valve malfunction
g. Abnormal chamber openings (septal difect)
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Where would you auscultate S3 and S4 heart sounds?
Listen at the apex (Bottom of the heart).
124
What is the best position to put your client in to hear the S3 and S4 sounds?
Lateral position: Lay them back, turn them on their left side.
125
Which part of your stethoscope should you use for S3 and S4 sounds?
Bell
126
Which pain scale is used in pediatric patients who are 3 and older?
FACES
127
What are the signs/symptoms of gastroesophageal reflux disease (GERD)?
Symptoms of GERD include hoarseness, laryngitis, chronic dry cough, asthma or worsening of asthma symptoms, feeling as if there is a lump in the throat, sudden increase in saliva, bad breath (halitosis), earaches, and/or chest pain or discomfort
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Apical Pulse
Found in the mitral area. Remain on client’s right side and client supine. Use on or two fingers to palpate.
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Carotid Pulse
Palpate the carotid arteries individually. Palpate medial to the sternocleidomastoid muscle on the neck.
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Radial Pulse
Can be found in the radial artery against the radial bone. Gently press against the radial artery.
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Brachial Pulse
Found in the groove between the biceps and triceps. Place three fingers on the client to palpate.
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Popliteal Pulse
Can be found in the bend of the back of the knee. Ask the client to raise the knee partially, place thumbs on the knee while positioning fingers deep in the bend of the knee. Apply pressure to locate the pulse.
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Dorsalis Pedis
Found lateral to and along the side of the extensor tendon of the big toe. Dorsiflex the client’s foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe. The pulses of both feet can be assessed at the same time.
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Growth and Development
- 4 weeks: Turn their head when lying in a prone position.
- 12 weeks: Push up from a prone position.
- 21 weeks: Sit up, but tilts forward for balance
- 30 weeks: Crawling around.
- 43 weeks: Baby is standing and getting ready to walk. Holding onto something and standing on their own.
135
Gross Motor skills in infants and newborns
- Newborns can turn their heads side to side when prone unless they are lying on a soft surface
- By 3-4 months, infants may push up to prone position
- Infants roll from front to back at 5 months
- Infants sit unsupported by 6-7 months
- By 9 months, infants can usually pull to stand up
- Infants can usually cruise by 10 months
- Can walk with hand held by 12 months
- "Back to sleep"
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Fine Motor skills in infants and newborns
- Grasp reflex is present at birth and strengthens at 1 month
- By 3 months, the reflex fades and the infant can actively grasp items
- By 5 months, infants can grasp voluntarily
- 7 month old infants can hand-to-hand transfer
- The pincer grasp develops by 9 months
- 12 month old infants will attempt to build a two-block tower
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Sensory Perception in infants and newborns
- Newborn vision is unfocused
- Ability to distinguish colors is not developed until 8 months
- Newborns can distinguish sounds and turn toward voices/noises
- Smell is fully developed at birth
- Touch is fully developed at birth
138
Collecting Objective Data in newborns and infants
-Preparing the client: Explain the procedure to the caregiver, baby cannot understand.
-Equipment
Measuring tape, scale, stethoscope, thermometer
- Undress the baby.
- Do not leave the baby unattended.
- Use a blanket to prevent them from getting to cold.
- New baby's can lose body heat pretty quick.
- You will assess a new baby immediately after birth.
- If the assessment is on an older infant you can obtain information from a caregiver.
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Initial Newborn Assessment
-Apgar score: Done right when baby is born 1,5, 10 minutes after birth. Rating the heart rate, respiratory rate, reflex irritability muscle tone, and color of the newborn. The total number is out of 10, the closer to 10 is better. (Do not need to be able to score, just know what this is and what we are looking for.)
- Vital signs
- Measurements: weight, length, head circumference, chest circumference
- Head to toe exam
- Chest circumference isn't always done.
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Physical Assessment in Newborns and Infants
- Done after babies first head to toe assessment.
- Head-to-toe examination with developmental screening
- General appearance and behavior
- Developmental assessment
- Vital signs: You will do an axillary temp most of the time, the very first vitals done on a newborn you would do a rectal temperature, this is one way we know they have a anal opening. You would count apical pulse, the normal range for babies is 120-160, the rate decreases with age so 6-12 months the rate would drop to 110, respirations is 30-60, look for retractions, nasal flaring, grunting, or apnea. BP is routinely checked, they may check this in the NICU.
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Skin, hair, and nails in newborns and infants
Skin, hair, and nails: Look for any lesions, discolorations, odors. Their hands and feet stay blue and pale for awhile. Body temperature drops and hands/feet appear blue(Acrocyanosis). They can also have mottled look to their skin, a lacy look. Look for any bruising from trauma with birth, birth marks, milia (baby acne), vernix caseaosa (white cheesy substance), jaundice, pallor, edema, Mongolian spots, mocomian staining is if the baby poops in the uterus. The poop can stain their skin and have a odor to them.
Reassure parents that blue and pale is normal.
-Skin: smooth and thin, ineffective temperature regulation. Skin may be mottled.
-Hair: Lanugo: Fine hairs all over the body. May have hair loss (Alopecia)
-Nails: Pink, convex, and smooth.
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Head and Neck in newborns and infants
-Inspect and palpate this. Traumatic birth we would want to palpate the head and neck. Look to see if everything is symmetrical, if there is edema, discoloration, wanna note this to see if it improves. Fontanels are the soft spots on a babies head and they should be nice and flat. Should not be bulging or sunken.
Bulging: Increased pressure in the brain.
Sunken: Dehydration
Molding: Sutures of the skull give them the cone headed look when they are born.
Ensure that the baby can turn head back and forth.
Face should be symmetrical.
-Cranial bones are soft and separated by sutures, and they have and anterior and posterior fontanelle. Newborns skull is typically asymmetric because of molding. Visible pulsations. Brain growth is reflected by head circumference.
-Posterior Fontanelle: Triangular shape, closes by 2 months.
-Anterior Fontanelle: Towards the front, diamond shape, should be able to feel that. Closes by 12-18 months
-Look at the overall size of the head.
-Small head: Might be microcephaly or baby was exposed to congenital infections in the womb.
-Bigger than normal head: Hydrocephalus, swelling in the brain.
-Capit: Fluid collection over the skull bone under the skin. Can be anywhere on the head. Can cross the suture line and cover the whole head.
-Hematoma: Collection of blood can be more serious. Can increase pressure. Does not cross the suture line, on one side or the other.
143
Eyes in infants and newborns
Eyelid edema is normal for babies who are brand new. Inspect the eyes, shade the eyes so they will open their eyes.
144
Ears in infants and newborns
- Ears: Hearing tested in nursery before baby is discharged.
- Basic test with the startle or moro reflex by making a loud noise.
- Inspect the external ear, oracle, discharge, edema, discoloration, low set or malformed ears can indicate a problem like down syndrome. Eyes in line with top of ear is what we want to see.
145
Weighing and measuring a newborn
- Baby should be naked when you weigh them. Zero the scale out with the blanket so you get the weight of just the baby.
- Length: Have the baby fully extended with the leg straight.
146
Mouth, throat, nose, and sinuses in newborns and infants
- Mouth and Throat: Look for tooth eruptions, some babies are born with teeth. Look at gums, lips, palates. Want to palpate the hard and soft palate. Look at tonsils, tongue, and buccal mucosa.
- Look at nose and sinuses for discharge, tenderness. Make sure that both nares are patent and that they can breathe.
147
Thorax, breasts, heart, and abdomen in newborns and infants
-Thorax: Smooth, rounded, and symmetric. Irregular respirations are normal in newborns.
Abnormal for a baby to retract when breathing.
- Breasts: May be enlarged from moms hormones.
- Heart: Placement of the stethoscope. Apical: 4th intercostal space until they hit 7 years old. Then it drops to the 5th space. It is in the midclavicular line until age 4.
- Abdomen: Soft, no masses. Umbilica: 3 vessels, 2 arteries and 1 vein.
148
Male and Female Genitalia in newborns
- Male: Ensure the urethra is in the center of the penis. Lesions, edema. Edema is pretty normal. Inspect and palpate the scrotum and testes. Are both present, distended. Sometimes one or both may not be distended yet. Discoloration and edema. This is time sensitive. Inspect the anal opening.
- Female: Labia, urinary meatus, vaginal opening, swollen is normal. Inspect the anal opening.
149
Hands, feet, arms, and legs in newborns
-Symmetry, movement, shape, and positioning of the feet and the legs. Extremities should be warm and mobile with adequate capillary refills. Pulses should be strong and equal bilaterally.
- Inward pointing of feet can be normal.
- Assess for congenital hip dysplasia.
- Ortolani and Barlow maneuvers should be negative, that is how you will look for hip dysplasia.
- Ortolani: Infant on the back, flex the knees holding your thumbs on mid thigh and fingers on greater trochanter. Abduct the legs moving the knees outward and knees down to the table.
- Barlow: Adduct the legs. Feeling the head of the femur slipping out of the hip socket.
150
Spines, joints, and muscles in newborns
- Spine and posture. Spine is pretty flexible. In infants under 3 months the spine is rounded. The babies should be able to bring their extremities to their core.
- Joints: ROM, swelling, redness, and tenderness.
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Diagnostic Reasoning
-Nursing diagnosis:
Actual
Risk
Wellness
-Collaborative problems
-Validate the assessment data you have collected to verify that the data are reliable and accurate by:
asking additional questions
verifying data with another health care professional
comparing objective with subjective findings
-Document the assessment data following the health care facility or agency policy
152
The sense of smell develops fully by the sixth month in infants.
False, develops fully at birth.
153
The apical pulse is at the 5th intercostal space in infants.
False, it is at the 4th until 7 years.
154
Interviewing Children and Adolescents
- Assessing children you involve them in the discussion, but you will get a lot of information from the parent.
- Introductory Stage: Introduce yourself, trusting relationship, open, friendly, nonjudgmental. Encouraging talk.
- Want the child to be comfortable. You can use play, talk at eye level, use play and verbalization to gather information about their illness. Make them feel comfortable, respect their emotions, be open minded. Offer choices when available. Be clear and honest with procedures.
- Sometimes you may need to speak with adolescent’s privately. This is for sexual activity, drug use, they may want that to be private. If you make them comfortable and trust you, they may tell you more.
155
Objective Data for children and adolescents
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Preparing the client
Equipment
Denver Developmental Kit: Used to measure development in kids.
Scale
Snellen eye chart
Stethoscope
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156
Physical Assessment for Children and Adolescents
- General appearance and behavior
- Developmental assessment
- Vital signs
- Measurements
- Body systems
157
Physical Exam Techniques for Children and Adolescents
- Least to most invasive
- Explain clearly
- Allow client to see/touch equipment before it is used
- Use age-appropriate diversions (toys, books, etc.)
- Use security item if available
- Use parent/caregiver as a safe space, involve them if needed
- Consider altering the sequence of your head to toe assessment if needed
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Female Breast Development
Stage 1: Prepubertal, elevation of nipple only.
Stage 2: Breast bud stage, elevation of breast and nipple as small mound, enlargement of areolar diameter.
Stage 3: Enlargement of the breasts and aerola, with no separation of contours.
Stage 4: Projection of areola and nipple to form secondary mound above level of breat.
Stage 5: Adult configuration; projection of nipple only, areola receded into contour of breast.
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Male Genitalia Development
Stage 1: Genitalia: Prepubertal: pubic hair, Prepubertal: No pubic hair, fine vellus hair.
Stage 2: Genitalia: Initial enlargement of scrotum and testes with rugation and reddening of the scrotum. Pubic hair: sparse, long, straight, downy hair.
Stage 3: Genitalia: Elongation of the penis, testes and scrotum further enlarge. Pubic Hair: Darker, coarser, curly; sparse over entire pubis.
Stage 4: Genitalia: Increase in size and width of penis and the development of the glans; scrotum darkens. Pubic hair: Dark, curly, and abundant in pubic area; no growth on thighs or up toward umbilicus.
Stage 5: Genitalia: Adult configuration. Pubic hair: Adult pattern; growth continues until mid-20's
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Female Pubic Hair
Stage 1: Prepubertal: No pubic hair; fine vallus hair
Stage 2: Sparse, long, straight, downy hair
Stage 3: Darker, coarser, curly; sparse over mons pubis
Stage 4: Dark Curly, and abundant on mons pubis; no growth on medial thighs
Stage 5: Adult pattern of inverse triangle growth on medial thighs.
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Unexpected Findings in children and adolescents
- Congenital abnormalities: They are born with it.
- Cleft lip: The lip has a divide in it, babies with a cleft lip have a cleft palate. Feeding may be harder.
- Club feet: Can get surgical repair or wear braces.
- Bow legged and knocked kneed: Abnormalities in the way the legs form.
162
Port-Wine Stain
Birthmark consisting of capillaries is dark red or bluish and darkens with exertion or temperature exposure. It appears as a large, irregular, macular patch on the scalp or face. unlike a hemangioma, this birthmark does not fade with time.
163
Hemangioma
The skin variation is caused by an increased amount of blood vessels in the dermis.
164
Cafe-Au-Lait Spot
Birthmark is light brown, round, or oval patch. Normal
165
Body piercing and tattoos
Adolescents express their identity in different ways. Body piercing and tattoos make a strong statement.
166
Skeletal growth continues throughout Tanner’s stage 5 for both males and females
True
167
An enlargement of breast tissue in males is a normal finding during puberty.
True
168
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Older Adults:
Skin, hair, and nails
Eyes and vision
Ears and hearing
Head and neck
```
-Normal Skin Changes: Skin tags, seborrheic keratosis: Flat lesions found on people with fair skin, cherry angiomas: Small red spots, liver spots: Hyperpigmented areas from sun exposure
-Decreased vascularity and diminished neurologic responses this means older adults are at risk for hyperthermia and hypothermia they don’t hold body temperature as easily.
Wrinkles dry skin, and tinting from loss of collagen are common. Pinching skin is not a great tests of skin turgor, especially the back of the hand.
-Decreases in body hair and subcutaneous tissue which is fat tissue. They become a little more bony.
Loss of hair on the scalp should be symmetrical, patchy or asymmetrical is not normal. Symmetrical thinning of the hair on the scalp is normal.
- Toenails thicken and become yellow or bluish.
- Fingernails become thinner.
- Women may develop hair growth on the upper lip because of decreased estrogen levels after menopause or a hysterectomy,
- Reduced ROM in the head and neck. Face and neck muscles may atrophy, the neck may shorten and a hump at the top of the cervical vertebrae.
- The limbs in the eyes loses elasticity which results in decreased near visual acuity, poor night vision, and decreased tolerance to glare.
- Skin tissue, eye tissue, its all losing elasticity.
- Wrinkled and stretched skin around the eyelids.
- The earlobes may elongate, and hair becomes thicker in the external ear canal. This can cause a buildup of earwax or cerumen in the ear. Can cause dryness and increased chance of infection. Hair cells of the inner ear can degenerate resulting in the inability to hear high frequency sounds. They will tell you to speak up. They can hear you if you speak low and slow.
169
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Older Adults:
Mouth and throat
Nutrition; swallowing and dysphagia
Nose and sinuses
Thorax and lungs
Respiratory infections
```
- Saliva production decreases, tooth surfaces become warm from use, mild decrease in swallowing ability and a sluggish gag reflex.
- Older adults can have difficulty swallowing non-thickened liquids.
- Dysphagia: Difficulty Swallowing. We worry about issues with nutrition and aspiration.
- Aspiration: When they cough and inhale some of the fluid into the lungs- Pneumonia.
- Sense of smell and ability to detect odors decreases.
- The loss of skeletal muscle strength in the thorax can cause a slight barrel chest, because of the muscle loss.
- Pneumonia: Most common cause of infection related deaths. Doesn’t always present like it does with younger people.
- Confusion or mental status change can be your first and only clue that there is an infection going on.
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Older Adults:
Heart and blood vessels: valvular changes, dysrhythmias, blood pressure
Breasts
Abdomen: gastrointestinal changes
Genitalia
```
- BP increases as elasticity decreases in the arteries. We lose the ability to stretch and give and bounce back, so the arteries and blood vessels do the same thing.
- Tissues harden and become less elastic causing increase in BP.
- Barrel Receptor Response to positional changes is less efficient and can cause orthostatic hypotension.
- Orthostatic Hypotension: When someone stands up to quickly and BP drops because the barrel receptors aren’t responding correctly. They get light headed.
- Distal lower extremities pulses may be more difficult to palpate. Pedel pulses less easy to palpate.
- Varicose and spider veins common in lower extremeties.
- Aortic and mitral valves may become calcified causing a soft systolic murmur. This does not mean there is any other heart disease.
- May have some dysrhythmias even in the absence of heart disease. Due to changes in pacemaker cells, could be that their valves are becoming calcified and hardened or the SA valves of the heart are effected
- Women lose breast tissue so what is left becomes more fibrous or lumpy.
- Intestinal motility is reduced or loss of muscle tone so older adults have more trouble with bowel movements and regularity. Loss of subcutaneous fat in the abdomen, makes the organs more easily palpable.
- Genitalia: Loss of pubic hair, everything hangs lower, wrinkly.
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Older Adults: Musculoskeletal and Neurologic System
- Musculoskeletal system: bone loss, muscle weakness, joint disease, pain
- Neurologic system: mobility and motor function; mental and emotional status
- Wresting tremors increase, not considered pathologic unless accompanied by a disease process. (Parkinons)
- Touch and vibratory senses may diminish, minimal swaying without loss of balance is normal.
- Degenerative Joint Disease: Happens with overuse of the joints over time.
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SPICES
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Skin impairment
Poor nutrition
Incontinence
Cognitive impairment
Evidence of falls or functional decline
Sleep disturbances
”Spices” Major areas that if something changes with these then we may need to follow up with them. Could develop into something bigger. None of these are considered normal for aging.
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173
Older Adults Subjective Data
-Adapting interview techniques
-Determining functional status (ability to carry out ADLs)
-Family and caregiver assessment (support they need vs support they have)
-Recognizing geriatric syndromes
-Older adults hesitant to admit to having health problems because they are afraid of being admitted to a hospital or nursing home. They don’t want to lose their independence. We may have to point out the things they are doing that are keeping them healthy or things they are still able to do on their own. Allow them to participate in their own care.
-Five conditions considered geriatric syndromes:
Pressure Ulcers
Incontinence
Falls
Functional Decline
Delirium
-Assessment of urinary incontinence
-Types of urinary incontinence; intervention
-Fall assessment
-Pain assessment
-Pain is assessed the same as in younger adults, unless the older adult has advanced dementia.
-With severe dementia or nonverbal clients pain can be indicated by grimacing, moaning, aggression, or even striking. Pain can lead to social isolization and depression so it is very important to assess. You can even use the faces scale.
174
Katz ADL's
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Bathing
Dressing
Toileting
Transferring
Continence
Feeding
1 or 0 points, 6 points is high
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175
Older Adults: Objective Data
- Preparing the client
- Equipment
- Physical assessment (head to toe)
176
Older Adults: Exam Techniques
- It may be more acceptable to be more formal than informal. Only address the client by their first name if they give you permission to do so.
- Speak clearly and at a moderate pace. Face clients when speaking to them.
- Do not assume clients can’t answer questions if they have a cognitive impairment. Ask simple questions and give simple, one-step directions.
- If you need to question caregivers to validate or clarify information, avoid consulting them in the presence of the client.
- Remember that the assessment of the older adult is considered a specialty assessment. A true comprehensive assessment requires expertise and experience.
177
In elderly clients, there is a gradual replacement of elastic collagen with more fibrous tissue in the skin.
True, we lose elasticity and collagen and replaced with fibrous or hard tissue.
178
In the acronym SPICES, the letter P stands for “poor appetite” in elderly clients.
False. P stands for poor nutrition.
179
Increased thirst sensation is common with aging.
False
180
A urinary tract infection in elderly clients may present without fever or elevation in white blood cell counts, dysuria, or urinary frequency.
True, the only symptom they may have is confusion.
181
Older adults present their illnesses in a unique manner not typically seen in younger adults.
True
182
12 cranial nerves
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I – Olfactory nerve
II – Optic nerve
III – Oculomotor nerve
IV – Trochlear nerve
V – Trigeminal nerve/dentist nerve
VI – Abducens nerve
VII – Facial nerve
VIII – Vestibulocochlear nerve/Auditory nerve
IX – Glossopharyngeal nerve
X – Vagus nerve
XI – Accessory nerve/Spinal accessory nerve
XII – Hypoglossal nerve
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183
functions of cranial nerves
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Cranial I: Sensory
Cranial II: Sensory
Cranial III: Motor
Cranial IV: Motor
Cranial V: Both (sensory & motor)
Cranial VI: Motor
Cranial VII: Both (sensory & motor)
Cranial VIII: Sensory
Cranial IX: Both (sensory & motor)
Cranial X: Both (sensory & motor)
Cranial XI: Motor
Cranial XII: Motor
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