1J02 Nursing Test 1 Flashcards
Active ROM
Is movement initiated and completed by the athlete without assistance.
Ankyloses
stiff or fixed joint
Anosmia
loss of sense of smell
Anoxia
lack of oxygen
Apgar Scores
a scale of 1-10 to evaluate a newborn infant’s physical status at 1 and 5 minutes after birth
Appearance, pulse, grimace, activity, respiration (Absent, n, below normal, normal)
Aphasia
inability to speak or understand speech
Arthritis
inflammation of a joint
Articulation
where two bones meet (joint)
Ataxia
the loss of full control of bodily movements
Atelectasis
collapse of alveoli
Auscultation
Listening with a stethoscope to parts of the body
Apathy
lack of initiation and persistence
Bouchard’s Nodes
hard, bony outgrowths on proximal interphalangeal joints (associated with osteoarthritis)
Braden Scale
Pressure ulcers:
- lower the number, higher the risk -scale is from: 4-23
- less than 17 = risk for pressure ulcers
Canes
-held on the stronger foot side (opposite the weak leg for oppositional arm swings)
1. Place cane 15-25cm forward
2. step weaker leg to cane
3. step stronger leg slightly in front of the cane -always keeps two points of contact on the ground
UPSTAIRS:
-good leg first, then use good leg and handrail to support weak leg and cane
DOWNSTAIRS:
-bad leg and cane go first and then good leg Up with the good and down with the bad
Canes
Canes have less support than walkers, although quad cane is used for partial or complete leg paralysis
Cerebellar Test
Romberg test
Gait- observe how patient walks 3-6 meters and then turns around
Characteristics of percussion notes
resonant (over normal lung tissue) hyperresonant (abnormal finding in adult lungs)
tympany (over air filled viscera ex. stomach) dull (dense organ ex. liver)
flat (no air is present ex. thigh muscle)
contracture
shortening of a muscle leading to limited ROM of joint
cranial nerves
- Olfactory
- Optic
- Oculomotor
- Trochlear
- Trigeminal
- Abducens
- Facial
- Vestibulocochlear
- Glossopharyngeal
- Vagus
- Spinal Accessory
- Hypoglossal
crepitation
- audible and palpable crunching or grating that accompanies movement
- can be normal since most joints crack of pop occasionally, more concerning if it does this all the time and is combined with swelling, pain, tenderness or other symptoms
crutch palsy
paralysis of the brachial plexus due to pressure from prolonged use of a crutch
Dysarthria
difficulty in articulating words
dyskinesia
difficult movement
dysphagia
difficulty swallowing
embolus
A clot that breaks lose and travels through the bloodstream.
facial nerve test
-smile, frown, close eyes tight (try and open their eye lids), try and puff up cheeks (try and push air out of cheeks)
foot drop
a weakness of muscles in the feet and ankles that causes problems with the ability to flex the ankles and walk normally (foot is permanently in plantar flexion)
gait
rhythm, cadence & speed
General Survey
age, gender, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, patient abuse, substance abuse
Genu valgum (knock knees)
This is a condition in which the knees touch but the ankles do not. Can be normal in children up to age 3.
-how they walk
Genu varum (bowlegs)
legs are much wider than normal and bones are straight (makes stance look a little bigger than shoulder-width apart at all times)
-normal in children up to age 3
Glasgow Coma Scale
eye opening, verbal, motor
Max- 15 pts, below 7= coma
-can’t get lower than 3 if your alive -calling name
-light touch on patient’s arm -vigorous shake of patient’s shoulder -pain applied (look for flinch or drawback)
Glossopharyngeal (9) and vagus (10)
-tongue depressor and say ahh (uvula should vibrate and walls should move in)
Graphesthesia
ability to “read” a number by having it traced on the skin
Health History
Biographical data Reason for seeking care Current health or history of current illness Past health (developmental history and nutritional history) Family history Review of systems Functional assessment or ADLs
Health history (neuro)
- headache
- head injury
- dizziness or vertigo
- seizures
- tremors
- weakness
- incoordination
- numbness or tingling sensation -difficulty swallowing
- difficulty speaking
- significant past history -environmental and occupational hazards
Heberden’s nodes
bony swellings of the interphalangeal joints (associated with osteoarthritis)
hemi-paresis
paralysis of one side of the body
hemiplegia
paralysis of one side of the body
hypoglossal (12) test
stick out tongue, move up and down, side to side
-say light, tight, dynamite
hypostatic pneumonia
inflammation of the lung from stasis or pooling of secretions
Immobility issues
- pooling of lung secretions
- decreased metabolic rate
- decreased peristalsis in GI tract
- muscle atrophy
- joint contractures
- urinary stasis (increasing risk of UTIs and renal calculi)
- pressure ulcers and ischemia
infant reflexes
Laudau (swan dive), palmar grasp, rooting, sucking, plantar grasp, babinski, tonic neck, moro, placing and stepping
Inspect gait
- posture
- ball to toe feet -oppositional arm swings -smoothness/ effortless
inspection
concentrated watching
- compare left and right sides of the body to ensure symmetry
- look for size, shape, colour, symmetry, position, drainage and abnormalities
joint contracture
an abnormal and possibly permanent condition characterized by fixation of the joint
kyphosis
hunchback
levels of consciousness
Alert (awake and easily roused)
Lethargic (inattentive, drowsy, decreased spontaneous movement)
Obtunded (difficulty to rouse, confused when roused, wakes only with loud shouting) Stupor/Semi-Coma (unconscious, responds only to vigorous shaking may moan)
Coma
Ligament
Connects bone to bone
lordosis
inward curve of the spine (looks like an exaggerated C)
Mental Health Assessment
- Appearance (posture, body movements, dress, grooming and hygiene)
- Behaviour (LOC, facial expression, speech, mood and affect)
- Cognitive Functions (orientation, attention span, immediate memory, recent memory, remote memory, new learning with four unrelated word test)
- Thought processes (thought content and perceptions)
myalgia
muscle pain (usually cramping or aching)
Neurological
Assessment (mental health)
- LOC
- Orientation (assess time, where they are, who they are)
- Posture, movements, dress, grooming, hygiene, facial expression, speech, mood, attention span, immediate/recent and remote memory, new learning test
Neurological Recheck
LOC, motor function, pupillary response, vital signs
Nystagmus
involuntary, jerking movements of the eyes, generally in the lateral position
Objective vertigo
room is spinning
Obstetrical History -GTPAL
G Gravida or number of pregnancies T Number of Term pregnancies P Number of Preterm infants A Number of spontaneous (miscarriages) or induced Abortions L Number of Living children
Oculomotor (3), Trochlear (4), Abducens (6) test
check pupil for PERLA (pupils are equal, reactive to light and accomodation) -accommodation is when you move pen close to their nose, their pupils should contract and when they look at the far wall they should dilate
- otherwise do consensual check (check for reactiveness/equality and then do again with hand on their nose)
- do cardinal gaze test (an H)
Olfaction
sense of smell as an examination technique
Olfactory test
have them smell something familar; lemon, coffee
Optic test
do the snellen chart
-leave the prescription glasses/contacts on -read smallest line they can and then ask to try and read one lower
-O.D. means right eye
-O.S. means left eye
do confrontation test (test peripheral vision by comparing to your own vision)
orthostatic hypotension
temporary low BP and dizziness when suddenly rising from a sitting or reclining position
systolic decreas >20, diastolic decreas >10 within 3mins of standing
Ortolani test
To detect hip dislocation or subluxation; Slowly abduct the thigh while maintaining axial pressure; With fingertips on the greater trochanter, exert a lever movement in the opposite direction so that your fingertips press the head of the femur back toward the acetabulum center. If the head of the femur slips back into the acetabulum with a palpable clunk when pressure is exerted, suspect hip subluxation or dislocation. -congenital dislocations
Osteoarthritis
cartilage cushioning on the ends of bones wears down
-less severe than rheumatoid arthritis -generally affects >40yrs old
Pain Assessment
PQRSTUV
- provocative/palliative
- quantity/quality
- region (location, radiating or referred?) severity (1-10)
- timing
- underlying factors (other associated symptoms)
- values (affects on ADLs)
Palpation
an examination technique in which the examiner’s hands are used to feel for lumps, bumps, heat, swelling, tenderness/pain, distension, moisture
palpation types
- fingertips for fine tactile discrimination
- grasping action between fingers and thumb to detect mass
- backs of hands for temp.
- base of fingers for vibration
paraesthesia
tingling or prickling (pins and needles) or burning
paraplegia
paralysis from the waist down
paresis
muscle weakness caused by nerve damage
Passive ROM
Movements that are performed by the examiner with the athlete relaxed.
Percussion
tapping on a surface to determine the difference in the density of the underlying structure (penetrates about 5cm deep) -direct percussion (one hand on skin) -indirect percussion (both hands)
Phalen test
wrists are bent down with backs of each hand touching / carpal tunnel sufferers feel tingling or pain within 60 seconds
ptosis
eye droop
quadriplegia
paralysis of all four limbs
rheumatoid arthritis
A chronic systemic disease characterized by inflammation of the joints, stiffness, pain, and swelling that results in crippling deformities
-immune system is attacking the body -more severe than osteoarthritis
Romberg test
- ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed
- expected finding: client should be able to stand with minimal swaying for at least 5 seconds
- shows that client still has cerebellar function (if no sway)
scoliosis
sideways curvature of spine (off-center spine)
seizure
a sudden surge of electrical activity in the brain that affects how a person feels or acts for a short time
shear
force directed parallel to a surface
-force exerted against the skin while the skin remains stationary and the bony structures move
Sign
Something you can see
spinal/accessory
test
- rotate head against jaw (apply resistance)
- shrug shoulders against resistance
Spinal levels
cervical (8), thoracic (12), lumbar (5), sacral (5), coccygeal (1)
Spine levels
cervical-concave, thoracic-convex, lumbar-concave, sacral-concave, coccygeal-convex
Stereognosis
ability to recognize objects by feeling their form, size, and weight while the eyes are closed
Stethoscope
diaphragm is better for high-pitched sounds
bell is used for soft, low-pitched sounds
strabismus
abnormal deviation of the eye (cross-eyed or squint)
-deviated gaze and limited eye movement
straight leg test
Patient supine, passively raise patient’s leg to point of pain or 90 degrees
+ pain from 0-35: piriformis syndrome, SI joint lesion
+ pain from 35-70: herniated disc (nucleus pulposa)
+ pain from 70-90: lumbar joint problem
stroke prevention
FAST
Face droop
Arm can’t be raised on one side Speech slurred
Time to call 911
Subjective vertigo
Person feels like he or she is spinning
subluxation
partial dislocation of a joint
Substance abuse
CAGE questions
- felt need to Cut down?
- people felt Annoyed by your habit? -felt Guilty about habit?
- used as an Eye-opener in the morning?
swing through gait
crutches forward, lift both feet and swing forward
symptom
subjective evidence of a disease, such as pain or a headache (they tell you they feel but you can’t see)
syncope
fainting
-temporary loss of consciousness by fall of BP
Tangential lighting
a source of illumination directed from an angle to the side of what is being examined; used to make a raised lesion cast a shadow, for example
Tendon
connects muscle to bone
three point gait
Both crutches and involved leg advance together
Uninvolved leg follows
Tinel’s sign
“pins and needles” sensation felt when an injured nerve site is tapped (tap median nerve at wrist to see if you have carpal tunnel syndrome)
Trendelenburg test
The patient stands and rises one foot and then the other while the doctor observes the buttocks.
Positive sign is when the buttock drops on the side that the foot is elevated indicating hip abductor weakness on the stance leg side.
-weakness in gluteus medius (on opposite side of weakened leg)
Trigeminal test
- palpate jaw muscles as they clench their jar (try against resistance)
- brush cotton ball on forehead, cheek and chin on both sides and ask them to tell you when they feel the cotton ball
tripod position
5cm to side of feet
15cm in front of feet
is where you place crutches
-one foot (strong) on ground as well as the two crutches creates a tripod position
Two-point gait
One crutch and opposite extremity move together followed by opposite crutch and extremity
types of gaits
propulsive, scissors (both knees are touching and you slide legs forward, when toes are facing each other), spastic, steppage (can’t lift toe off ground), waddling
Variation of percussion notes
- amplitude (intenseness, loudness of the sound)
- pitch (frequency, or number of vibrations per second)
- quality (timbre, difference in sounds over organs)
- duration (length of time note lingers)
vertigo
Condition of dizziness, “room spinning” (or are you spinning?)
vestibulocochlear (8) test
- whisper voice test (get them to close one ear and whisper in the other a word and get them to repeat it)
- do weber or rinne test
- weber test is use a tuning fork and place on top of head, plug an ear and should hear it better in the plugged ear (bone conduction is faster than air conduction)
- rinne test is use tuning fork and place next to ear, count how long until it stops ringing and then place on mastoid air cells and try again (should be longer when holding in air)
Virchow Triad (what affects thrombus formation)
Venous stasis (can’t get blood back to heart), hypercoagulability (increased platelet activity), and injuries to the endothelial cells that line the vessels (loss of integrity to BV wall)
Wheelchairs
- always position on the patient’s strong side (so strong side is closest to where they are headed) -brakes on and foot plates should be raised
- should back wheelchair into and out of the elevator
- ramps or inclines should always have patient pushing on you (backwards down and regular up)
