301 Test 2 muscle skeletal Flashcards
At times, you will assess the musculoskeletal system and the ____ system together
neurological
Musculoskeletal Assessment: Ask clients if they have had previous problems with falls, fractures, trauma, or ___ deficit.
neurological
excessive inward curvature of the spine
lordosis
humpback
kyphosis
5 NDX of musculoskeletal assessment
Impaired mobility impaired ADLs risk for fall activity intolerance self-health management
main point of body mechanics
To move your body without causing injury
Avoid bending and __
twisting
when lifting ___ abdominal muscles and tuck ___
tighten
pelvis
how many minutes a week of moderate and vigorous-intensity exercise are recommended
150–300
a complete or partial collapse of a lung
Atelectasis
Atelectasis/pneumonia can be caused by
Immobility
Increased coagulability can be caused by
Immobility
Glucose intolerance can be caused by
Immobility
Orthostatic hypotension can be caused by
Immobility
Renal calculi can be caused by
Immobility
Paralytic ileus can be caused by
Immobility
Urinary tract infection can be caused by
Immobility
Obstruction of the intestine due to paralysis of the intestinal muscles
Paralytic ileus
NDX with the external related factors: chemical substance, extremes in age, hyperthermia, hypothermia, moisture, medications, radiation
impaired skin integrity
NDX with the internal related factors: change in fluid status, change in pigment, change in turgor, immunological deficit, impaired metabolic state
impaired skin integrity
NDX defining characteristic: invasion of body structures
impaired skin integrity
If the patient has no neural complaints, it acceptable to
only check if they’re alter and oriented
If patient has neural issues, the first question you ask is
do they have a headache
A headache could signify
increased cranial pressure which could lead to stroke
numbness and tingling could mean the pt is having a
stroke
if patient has numbness and tingling next step is to assess
motor ability
difficulty or discomfort in swallowing
dysphagia
cranial nerve, most EOM movement
oculomotor
cranial nerve, opening eyelids
oculomotor
cranial nerve, pupil constriction/lens shape
oculomotor
cranial nerve, down and outward eye movement
trochlear
cranial nerve, lateral eye movement
abducens
cranial nerve, chewing
trigeminal
cranial nerve, sensation in face, scalp, cornea
trigeminal
cranial nerve, sensation in mucous membrane and mouth and nose
trigeminal
cranial nerve, close eye
facial
cranial nerve, labial speech, close mouth
facial
cranial nerve, taste in front of tongue
facial
cranial nerve, saliva and tear secretion
facial
cranial nerve, swallowing
glossopharyngeal, vagus
cranial nerve, gag reflex/taste in back of tongue
glossopharyngeal
cranial nerve, movement of tongue
hypoglossal
optic disc swelling that is caused by increased intracranial pressure
papilledema
PERRLA tests which cranial nerve
Oculomotor
PERRLA
Pupils are equal, round, reactive to light, accommodate
which cranial nerve is tested by asking the patient to clench teeth and then you try to open them
trigeminal (which does chewing)
which cranial nerve is test when you do light touch on the person’s face
trigeminal (sensation in the face)
which cranial nerve is tested when you ask the person to smile, frown, etc
facial (face muscles)
which cranial nerves are tested when you depress with tongue blade and ask the person to say Ahh
glossopharyngeal and vagus
When a person says Ahh the soft palate and uvula should rise in the midline and the tonsil pillars should move
medially
which nerve is tested when you ask the patient to forcefully turn their head
spinal
which nerve is tested when you ask the person to stick out their tongue or say “light tight dynamite”
hypoglossal (does tongue movement)
being unable to see might be a precursor to
MS
when you shine the light on one eye, the other should constrict too, this is called
consensual constriction
when looking at an object that’s far away, your eyes
dilate
characterized by severe pain in the cheek. Cause can be unknown or can be from facial radiation
Trigeminal neuralgia
acoustic nerve problems often have to do with a
tumor
if someone has a hearing nerve problem, it involves the nerve on the same side as the ear (aka it’s ___)
ipsilateral
for peripheral neuropathy and diabetes, test with light, random touch. Do not use
strokes
“as part of a neuro exam I’m going to ask you to identify some objects with your eyes closed”
stereogenesis
If someone can identify an object they are stereogenesis ___
positive
In scales, what number usually indicates normal
2
reflex that’s normal from 2 1/2 months to 2 1/2 years
babinski
in the babinski reflex the toes
extend
3 areas tested in the glascow coma scale
eye
motor
verbal
glascow eye is a scale of what to what
1 to 4
glascow motor is a scale of what to what
1 to 6
glascow verbal is a scale of what to what
1 to 5
glascow opens eye spontaneous
4
glascow opens eye to speech
3
glascow opens eye to pain
2
glascow no response is always (not 0)
1
glascow moves in response to speech
6
glascow localizes pain
5
glascow flexion withdraw
4
glascow flexion abnormal
3
glascow extension abnormal
2
glascow oriented x3
5
glascow conversation confused (thinks it’s 1962, but said it normally)
4
glascow speech inappropriate (says normal words but they dont make sense it this context)
3
glascow speech incomprehensible
2
patient holding 1 arm and liming could indicate
stroke
spinal cord injury increases risk for (3)
cant pee, constipated, impaction
to check for urinary retention, palpate
superpubic region
fecal impaction can lead to death because it effects which nerve
vagus
arms at the core, feet flexed and turned in. Means serious brain issues
decorticate rigidity
For pain stimulation, we do not use
sternal rubbing
which is more serious between decerebrate rigidity and decorticate rigidity
decerebrate
arms adducted to the persons sides
decerebrate rigidity
acute confusion is aka
delirium
Everyone in an ICU gets screened for
delirium
best test to confirm dementia is
beside cognitive exam
PET scan is used for
cancer patients
cardiac ischemia leads to
angina
difficult or labored breathing
dyspnea
the most important vital to check if someone has activity intolerance
SAO2
normal range for albumin
3.5 to 5.0
low sodium is aka
hyponutrenia
tensing legs and then relaxing is what kind of exercise
isometric exercise
walking is what kind of exercise
weight bearing
cycling and swimming dont do bone growth but they’re good for
joint mobility
joint becomes fused in place
contracture
how often should you do range of motion
every 2 hours
atelectasis is caused by
ineffective breathing. Can esp be a problem for someone who is laying down and therefore can’t take a deep breath. This means the lower alveoli don’t get used, which can lead to bacterial infection
best way to prevent pneumonia is
oral care QID
temp of a DVT leg will be
increased
3 cranial nerves usually assessed together
oculomotor, trochlear, abducens
cranial nerve for superior oblique
trochlear
weakness of which nerve causes ptosis
oculomotor
testing how well someone can move his jaw
trigeminal
asking someone to open his eyes
facial
can you clench your eyes shut
facial
can you smile, puff cheeks, etc
facial
tuning fork is used for which 2 tests
weber and rinne
weber and rinne test which nerve
acoustic
Weber involves placing the tuning fork where?
forehead
can you cough?
vagus and glossopharyngeal
can you stick out your tongue?
hypoglossal
what kind of vitamin deficiency causes loss of smell
zinc
An intact corneal reflex is a normal finding for which nerve
trigeminal
being able to feel light touch in the face is a normal finding of which nerve
trigeminal
being able to taste at the front of the tongue
facial
a negative romberg test is a normal finding for which nerve
acoustic
ability to talk
vagus and glossopharyngeal
able to swallow
vagus and glossopharyngeal
gag reflex
vagus and glossopharyngeal
uvula and soft palate rise symmetrically
vagus and glossopharyngeal
poor voice quality is an abnormal finding for which nerve
vagus
test if client can say “d, l, n, t”
hypoglossal
optic nerve deficits may be due to __ or __
tumor or CVA
EOMs and pupillary reaction can result from change in
ICP
asymmetrical movement of the face (facial nerve) can result from CVA or
Bells Palsy
Ptosis is caused by damage to which nerve
oculomotor
horner syndrome is
decreased pupil size/ptosis
back and forth oscillation of the eyes
nystagmus
uncoordinated/unsteady gate
ataxia
positive romberg can indicate which disease
MS
loss of vibration sense occurs in diabetes and
alcoholism
__ and __ are unreliable indicators of CNS deficit
pulse and BP
muscle twitching
fasiculation
sudden jerk at fairly regular intervals (ie hiccup, arm jerk)
myoclonus
most common tremor in older adults
essential tremor
the 3 main medications included in risk for falls
diuretics, opiates, antihypertensives
Standing: crutches on __ side
bad
client should not to lean on ___ to support body weight
crutches
walk w cane on __ side
good
Preventing complications of immobility: Provide high-protein, high-caloric diet with vitamin _ and _ supplements
B and C
Preventing complications of immobility: Cough and deep breathe every
1 to 2 hours
Vitamin _ is needed for skin integrity and wound healing
B
SCDs
sequential compression device
CPM
continuous passive motion
Clients need between ___ to 3000 ml of fluids per day to help prevent renal calculi and UTIs
2000
head tilts to one side
Torticollis
Grading Muscle Strength, full ROM against gravity, full resistance
5
Grading Muscle Strength, full ROM against gravity, some resistance
4
Grading Muscle Strength, full ROM with gravity
3
Grading Muscle Strength, full ROM with gravity eliminated (passive motion)
2
Grading Muscle Strength, slight contraction
1
Grading Muscle Strength, no contraction
0
Order of the muscle examination
Inspection, palpation, ROM, muscle strength test
Inflammatory conditions of joints include RA and
Ankylosing spondylitis
Degenerative conditions of joints include
Osteoarthritis
Osteoporosis
Serotonin __ pain
inhibits
Prostaglandins ___ pain
promote
bind to peripheral nerve receptors and promote pain; bind to cells to produce prostaglandins
Bradykinin
Body’s natural supply of morphine like substances
Neuromodulators
Increased blood glucose is sympathetic or para?
sympthathetic
Pallor, Muscle tension, Rapid irregular breathing is sympathetic or para?
para
pain that arises in the skin or the subcutaneous tissue.
Superficial
pain that originates in the ligaments, tendons, nerves, blood vessels, and bones.
Somatic
fracture or sprain, arthritis, and bone cancer can cause deep __ pain
somatic
pain that occurs in an area that is distant from the original site. For example, the pain from a heart attack may be experienced down the left arm
Referred
pain that is believed to arise from the mind
Psychogenic
complex and often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of painful stimuli
Neuropathic
pain that is both chronic and highly resistant to relief
Intractable
older adult feel drugs more ___ than younger
strongly
Fatigue increases the perception of
pain
VS not valid indication of __
pain
TENS
Transcutaneous electrical nerve stimulation (TENS)
PENS
Percutaneous electrical nerve stimulation (PENS)
drugs used to treat other conditions but they also have analgesic qualities (tricyclic antidepressants and anticonvulsants).
Adjuvants and coanalgesics
