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NURS 335 > Quiz 2 > Flashcards

Quiz 2 Flashcards

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1
Q

3 Major Frameworks For Health Assessment

A

Functional:
-Questioning during health history + functional physical assessments

Head to toe:
- Efficient conduction of a physical exam

Body Systems:
- Organize findings to document and communicate
- Guides learning
- Requires critical thinking

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2
Q

Neurologic Health History

A

-Vertigo
-Headache
-Sleep
-Syncope
-Seizures
-Paralysis
-Pain
-Loss of consciousness
-Memory loss
-Paresthesia
-Falls
-Tremor
-Speech and cognitive Disorders
- Hearing loss
Bowel and Bladder
- Left or Right handed

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3
Q

General Pattern of Progression

A
  • Rapid vs Slow
  • Same vs Dynamic
  • Progressively worse OR getting better
  • Remitting or relapsing (Eg MS, always getting worse or better)
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4
Q

Neurologic Physical Exam

A

LOC
Vitals/BMI
Gait
Pronator Drift (hands out, eyes closed)
Tremor
Cognitive function
Communication
CN function & Reflexes
Motor function
Sensory function

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5
Q

AVPU

A

A - Pt is awake
V - Pt responds to verbal stimulation
P - Pt responds to painful stim
U - Pt is completely unresponsive

Alert - Confused - Delirious - Drowsy (lethargic & Obtunded) - Stupor (responds to pain, groans and mumbles) - coma

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6
Q

Romberg Test

A

Standing with arms by side and feet together (eyes open and also eyes closed) for 20sec
- maintain posture
CN VIII
- Not a cerebeller test***
- Vision
- Vestibular sense

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7
Q

Pronator Drift Test

A

Palms up and hold position
-Observe eyes open and then closed

Forearm Pronates (with or without downward movement):
- Contralateral pyramidal tract = muscle weakness

Slow pronation with Upward Movement:
- Rebound test or “searching movement”

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8
Q

CN I

A

Olfactory

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9
Q

CN II

A

Optic
- Visual Acuity
- Field of Vision
- Visualization of the Fundus
- Pupillary Light Response
PERRLA

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10
Q

CN III

A

Oculomotor
- Move eyes
- Constricts pupils and accommodates
- Opens eyes
PERRLA

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11
Q

CN IV

A

Trochlear
- Moves eyes
RIR/LSO & RSO/LIR

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12
Q

CN V

A

Trigeminal
- Chews
- Feels Face
- Front of the head

Motor Pathways Tests
- Ask to open mouth and observe for jaw deviation
- Palpate masseter & temporalis muscles and ask patient to clench jaw
- Move jaw side to side and examiner attempts to push midline in each direction

Sensory Pathways Tests:
- Compare sides, close to midline
- Pain and temperature (cool end of tuning fork)
- Light touch
- Remember pain/temp/touch to eyes and tongue

Corneal Reflex
Conjunctival Reflex

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13
Q

CN VI

A

Abducens
- Moves
RLR/LMR & LLR/RMR

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14
Q

CN VII

A

Facial
- Moves face
- Tastes
- Salivates
- Cries
- Feels some ear parts (external ear sensation - rarely detected)

Tests:
- Raise eyebrows
- Closes eyes tight
- Close lips/puff cheeks
- Show teeth
Corneal Reflex & conjunctival reflex

Sensation Taste Anterior 2/3 (CN IX posterior 1/3)

Test with Tympanometry:
-Damage proximal to stapedius muscle = Hyperacusis
- Sensorineural hearing loss = diminished reflex

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15
Q

CN VIII

A

Vestibulocochlear
- Hears
- Regulates balance
- Observes eyes for nystagmus

Rinne Test
Webber Test
Romberg Test:
- Requires proprioception, vision, and vestibular function

Acoustic Reflex

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16
Q

CN IX

A

Glossopharyngeal
- Tastes
- Salivates
- Swallows
- Monitors carotid body and sinus
Posterior 1/3 of tongue - gag reflex posterior of tongue

Test IX & X together:
- “KKKK” - oropharyngeal muscles
“mmm” (+ CN VII)
“la la la” (+ CN XII)
- Swallowing

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17
Q

CN X

A

Vagus
- Tastes
- Swallows
- Lifts palate
- Talks
- Communication to and from thoraco-abdominal viscera

Test Palatal Arches:
- Damaged side can’t counteract
- Look for lowered and flattened palatal arch

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18
Q

CN XI

A

Accessory
- Turns head
- Lifts shoulders

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19
Q

CN XII

A

Hypoglossal
- Moves tongue

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20
Q

Cardinal Movements

A
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21
Q

NOT DONE Tone

A

Hypotonic - low tone (floppy)
Hypertonic/Spasticity - Lots of tone
Atony - No tone

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22
Q

ABCDE’s Screening for Moles

A
  • Asymmetry
  • Border irregularity (ragged or notched)
  • Colour (variety of shades or different colours)
  • Diameter (>6mm)
  • Evolution (Evolved or changed over time)
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23
Q

Topics for Skin Health Promotion

Study These Flashcards
A
  • Risk Factors for skin cancer
  • Skin self-examination
  • Sun safety
  • Tanning Booths
  • Vitamin D deficiency
24
Q

Common Integumentary Symptoms and Signs

Study These Flashcards
A

Itchiness
Rash
Moles
Lesions
Hair loss
Dry skin or winter skin

25
Inspection and Palpation of skin lesions/rashes
- Size - Shape - Colour - Texture - Exudate - Tenderness - Configuration - Location and distribution - Vascular = check for pulsations and blanching
26
Visual Acuity
Test of Macular Function - Macula gives rise to the majority of optic nerve fibres Snellen's Test: Distance Visual Acuity - Distance from the chart (always 20ft) - Legal blindness is best corrected vision 20/200 Jaegar Test: Near Vision - 14" from eye - Read smallest letter (eg. 14/14)
27
Testing Extraocular Muscles and Movements
Cardinal Directions Corneal Reflection Cover Test
28
Esotropia
Eyes turned in
29
Exotropia
Eyes turned out
30
Perimetry
Precise measures by eye care professionals
31
Important Screening Tool for Children
Red Reflex - Retinoblastoma
32
Ear Health History
- Earaches (otalgia) - Infections/discharge (otorrhea) - Hearing Loss - Environmental noise - Tinnitus - Medications - Vertigo - Self-care behaviours
33
2 Types of Cerumen
1) dry, light, flaky 2) wet, brown/yellowish, smellier
34
Otoscope Examination Adult vs Child
Adult - Pull pinna up, back and out Child - Pull pinna straight down
35
Rinne Test
Tuning fork on back ear bone until they can't hear it anymore, then place it by ear and count until they can't hear anymore. - By the ear should be twice as long as on ear bone
36
Weber Test
Place tuning fork on top of the head to see if there's equalization in both ears or if one hears it more than the other
37
Conductive Deafness Weber vs Rinne
Weber: Deaf ear > good Rinne: Bone conduction > air
38
Partial Sensorineural Deafness
Weber: Good ear > deaf ear Rinne: Air conduction > bone
39
Cranial Nerves for Eyes
II III IV V VI VII
40
Cranial Nerves for Ears
VII VIII (IX, X - tiny but of sensation of outer ear)
41
Red Flags for Eyes and Ears
- Trauma to E or E - Sudden changes in vision or hearing - Raccoon eyes/battle sign - Fluid leaking from the ears following head trauma
42
Dermatones
Region served by a single spinal sensory nerve root C1-C3 = innervate movement in and above the neck (including larynx) C4-C6 = innervate the neck and shoulder and diaphragm (C3-C5 = breathing independently) C7-T1 = innervate the arms and fingers and hand grasp to perform self-care and transfers with arms T1-T6 = provide trunk stability for balance when sitting and innervate intercostal muscles for respirations T6-T12 = innervate intercostal and ab muscles for respirations and transfer strength T12-L4 = innervate muscles of the abs and upper leg (quads and hip adductors) L4-S4 = innervate hip abductors and extensors (hamstrings) and muscles of the knee, ankles, and feet and the perineum for leg strength and bowel/bladder control
43
Upper Motor Neuron Lesions (UMN)
- Spastic paresis or paralysis strength - Increased muscle tone (spasticity) - Increased muscle stretch reflexes. Babinski sign present - NO muscle atrophy - NO muscle fasiculations - Hyperreflexia
44
Lower Motor Neuron Lesions (LMN)
- Flaccid paresis or paralysis strength - Decreased or absent muscle tone (flaccidity) - Decreased or absent muscle stretch reflexes - YES Muscle atrophy - YES muscle fasiculations
45
Assessing Gait/posture/balance
Tandem Walk aka "Sober Police Walk" - Evaluating gait and posture - Walk on heels and toes too
46
Coordination Tests (Cerebeller function)
Inspection: - Point to Point - Rapid Alternating Movements
47
Tests intended to Test Discriminative Sensations
Extinction Stereognosis Graphesthesia
48
Sensory Function
Sensory Function: - Light touch - Superficial Pain ("sharp end touch") - Temp Sensation (warm/cold tuning fork) - Motion/Position sense (demonstrate up/down, then eyes closed etc) - Point Localization (eyes closed, where did I touch you?) - Vibration Sensation (Strike tuning fork, then place on bony prominences beginning most distal - toes to sternum) - Sternognosis (eyes closed, Cortical Sensory; Identify familiar object) - Graphesthesia (eyes closed, draw number on pt's palm) - Two-Point Discrimination (slowly move two cotton swabs together until pt says they feel like one) - Extinction (Eyes closed, touch pt on both corresponding body sides and ask where it's felt)
49
Reflex Testing
Percussion: Graded on a 4 point scale (4+ = very brisk & hyperactive w/ clonus, 3+ brisker than average, 2+ average, 1+ diminished & sluggish, 0 = no response) - 2+ average - DTRs tested (biceps, triceps, brachioradialis, patellar, & achilles)
50
Extraocular Muscle Functions
Superior Rectus - Elevates eye upward and adducts (toward nose) and rotates eye medially (inward) Inferior Rectus - Rotates eye downward and adducts and rotates eye medially Lateral Rectus - moves eye laterally (toward the temple) Medial Rectus - Moves eye medially Superior Oblique - Turns eye downward and abducts (toward temple) and rotates eye laterally Inferior Oblique - Turns eye upward and abducts and turns eye laterally
51
To Inspect the Thyroid Gland Instruct the Client to...?
Tilt head back slightly and swallow a sip of water
52
Lymph Nodes Anatomical Location
Preauricular: - In front of ear Posterior Auricular: - Superficial to the mastoid process (right behind ear) Occipital: - Base of skull posteriorly Tonsillar: - At the angle of the mandible (near ear scar) Submandibular: - Midway between the angle of the mandible and the tip of the mandible Submental: - Midline, a few cm behind tip of mandible (where Erin felt her lymph) Anterior (Deep) Cervical: - Deep to the Sternomastoid muscle (upside down V muscle, side of neck. One in front) Posterior Cervical: - Along anterior edge of trapezius (Upside down V muscle, one in back) Superficial Cervical: - Superficial to sternomastoid (just below posterior auricular, between that and the deep cervical) Supraclavicular: -In the angle formed by the clavicle and the sternomastoid (just above collarbone)
53
Neck Anatomy
Hyoid Bone Thyroid Notch Laryngeal prominence Cricothyroid ligament Arch of cricoid Thyroid cartilage = Adam's apple Isthmus = just below thyroid is cricoid (circular), isthmus is below tracheal ring 2 or 3
54
Sinuses
Can't palpate ethmoid sinuses
55

NURS 335 (4 decks)

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