307 Final Flashcards
Know the difference between “growth” and “development.
Growth: Increase in physical size
Development: Sequential process by which infants and children various skills and functions
Cephalocaudal
Proximodistal
2 month milestone
Looks at face, reacts to loud sounds, Smiles when talked to, Holds head up on tummy
6 month milestone
Knows familiar people, takes turns making sounds with you, Reaches to grab a wanted toy, Rolls from tummy to back
1 year milestone
Play games like patty cake, says mama and dada, Pulls up to stand, places things in containers
18 month milestone
Copies you doing chores, tries to use spoon, Points to show interest, 3 or more words at a time
2 year milestone
Tries to use switches, knobs or buttons on toy, kicks a ball, looks at your face to learn how to react to new situation, two or more words together
30 month milestone
About 50 words, Uses things to pretend, Shows you what they can do, jumps off ground with both feet
3 year milestone
Talk in conversation, Draws a circle, Notices other children and joins to play, Use fork
4 year mile stone
Answer simple questions, Name a few colors of items, unbutton some buttons, likes to be a helper
What are the normal vital sign ranges for pediatric patients?
Normal Respiratory Rate
Newborn 30-55 breaths/min
1 year 25-40
3 years 20-30
6 years 16-22
12 years 12-20
Normal Heart Rate
Newborn 100-170 beats/min
Infant to age 2 years 80-130
2-6 years 70-120
7-10 years 70-110
10-16 years 60-100
What is meant by “primitive reflexes”?
automatic, involuntary movements that babies are born with to help them survive outside the womb
What are the primitive reflexes?
Eye blinking
Rooting (Stroke cheek near corner of mouth)
Sucking (Place finger in infant mouth)
Swimming (Place infant face down in water)
Moro (Hold infant on back and let head drop slightly)
Palmar grasp (Place fingers in palm of infant hand)
Tonic Neck (Turn infants head to one side while they are awake)
Stepping ( Hold infant under arms and allow bare feet to touch flat surface)
Babinski (Stroke sole of foot from toe to heel)
Assessing Infants
HR and RR while asleep
Warm environment/equipment
Head to toe
Intrusive assessments until the end
Engage infant if awake
Assessign toddler
Allow parents to hold child
Expose only what is being examined
Tell toddler what you are going to do (don’t ask permission)
Incorporate play
Use lots of praise!!
Assessing preschoolers
Explain in simple terms
Allow them to help
Offer reassurance
Give choices
Assessing school age
Give simple, honest explanations
Provide privacy; respect feelings
Educate
Assessing adolescents
Provide privacy; confidentiality
Discuss findings, “matter of factly”
Encourage questions
Define Sudden Infant Death syndrome. What are the major risk factors?
Sudden, unexplained death of a child less than one year of age
- sleeping incorrectly or with stuffed animals in crib
What is meant by “failure to thrive”?
When the weight or rate of weight gain is significantly below that of other children of the same age and sex
What is the expected rate of growth for a newborn through one year?
Weight doubles by 6 months, triples by first year
Height increases by 12 in
Head circumference increases by 4 in
First tooth at 6 months
Reflexive behavior -> purposeful movement
Expected Respiratory Changes
Respiratory: Gradual decrease in respiratory performance
Decrease in O2, Increased level of CO2, Decrease in ability to perform strenuous exercise, harder to breath, more susceptible to pneumonia
Expected cardiovascular changes
Cardiovascular: Loss of elasticity in blood vessels and arteries (atherosclerosis), valves thicken and stiffen, more likely to have a heart murmur, Orthostatic hypotension, RBC production slows, Neutrophils decrease
Expected abdomen changes
Abdomen: Increased abdominal size, decreased lean mass, increased adipose tissue, altered ability to move food through gi tract, increased constipation, GERD
Expected musculoskeletal changes
Musculoskeletal: Decreased muscle mass, ROM and balance, Decreased stamina and performance in activities, decreased bone density, osteoarthritis
Expected breast and lymphatic changes
Breast and Lymphatic: Decrease in breast size, atrophy of breast tissue, less adipose, more pendulous breasts. Males: Gynecomastia (Enlarged breast tissue)
Expected anal and genitourinary changes
Anal and genitourinary: Decreased estrogen, thinning pubic hair, atrophy of mucous membranes, altered ph, itching and infection, pendulous scrotum, enlarged prostate
Recognize expected cognitive changes in aging adults.
Slowed memory retrieval and information processing
Recognize expected physical changes in aging adults.
Looser skin, Increased skin tags, Age spots
Dry, thinning hair, grey or white hair, loss of hair
Dry eyes, presbyopia, Age related macular degeneration, cataracts
Increased cerumen, increased hair growth in outer ear canal, presbycusis, tinnitus
Altered Smell
Receding gums, decreased sense of taste, dry mouth, stained teeth
Slowed memory retrieval process
Understand older adult abuse issues.
Neglect, Financial, Emotional/Psychological, Physical, Sexual
Be familiar with Functional Assessment tools used in the aging population.
SPICES
Sleep disorder, problems with eating, incontinence, confusion, evidence of falls, skin breakdown
Assess home safety
ADLs
Fall risk
Recognize fall risk factors.
Cognition
Previous falls
Medications
Lab values (Potassium)
Vital signs (Orthostatic hypotension)
Recognize common communication barriers seen in aging adults and know how to adjust your care when they are present.
Be aware of altered cognition, build rapport and trust, look at client when speaking, dont yell
What are the 4 types of assessments and when is each one indicated?
Comprehensive/Initial Assessment: Performed within a specified time upon administration to a healthcare facility (Going to establish a baseline
Focused Assessment: Ongoing care to determine status of pre-identified problem
Full Bedside Assessment: Head to toe assessment with subjective and objective assessment (Performed as part of the nurses shift assessment.)
Expedited Bedside Assessment: Done in an emergent situation to assess physiologic or psychological status
When would you do a comprehensive assessment? When would you select a different assessment type? Why?
A comprehensive assessment is performed within a specified time frame upon admission to a healthcare facility. It contains a full health and physical exam.
What are the 2 main components to a comprehensive health history?
Full health history (Symptoms)
Physical Exam (Signs)
Define subjective data.
Anything that is not directly observed, an example would be how the patient describes what they are feeling.
Define objective data.
Anything you observed, such as diaphoresis, lab values, grimacing
What is meant by a General Survey?
First impression prior to exploring any systems in detail, Collecting objective data, helps to guide subjective questioning
Looking at physical appearance, body structure, mobility, behaviors, vital signs, etc
What measurements and observations are included in the General Survey?
Vital signs may be a measurement included, also included may be the physical appearance (Maybe examining how diaphoretic someone is), looking at body structure and mobility (Do they need assistance, is the circumstance safe), as well as behaviors (are they agitated- which could be a sign a pain)
What are the 4 primary techniques used in physical assessment?
Inspection: Using visual cues to perform an examination
Palpation: Using your sense of touch to make observations (Fingertips- fine tactile discrimination, grasping- feel shapes or consistency, Dorsal- Temperature, Base of fingers- Vibrations)
Percussion: Tapping the skin to assess underlying structures based on the vibration and sound produced. Gives information of location, size and density.
Auscultation: Using your ears and stethoscope to listen
What is meant by “Oriented x 4”?
Someone is oriented to Person, Place, Time, Event
What are the components of the adult health history?
A health history is a structured conversation to gather important details, and about background and current medical status
Components include, Demographics, Chief Concern (OLDCARTS), Past health history, Family History, Psychosocial history, health prevention behaviors, Review of symptoms
What does SBARR stand for? What is the purpose of SBARR?
Identify: State name and title
Situation: What is happening that is requiring the communication
Background: Background data about the client and situation
Assessment: Recent Assessment findings, vital signs, labs, or anything else important to the situation
Recommendations: Suggestions you have
Read Back Orders: Clarify any unclear orders
Understand which information would fall into which component of SBARR. Example – Current temperature would fall into the “A” (assessment) component.
I: Your name, Title
S: Client name, age, gender, Problem or symptoms, stable or unstable
B: Relevant details to clinical history, admitting diagnosis, medications/allergies
A: Current conditions, explain examination and test results
R: What should happen next, When does it need to happen
R: Clarify any unclear information
Know the purposes of documentation.
Clear and accurate documentation is the best way to provide a precise and factual account of the status of the client.
Understand the different types of therapeutic communication.
Open ended questions: Allowing the client to expand and elaborate on current questions
Close ended questions: Yes or No type of questions
Active listening, Clarifying questions, Back channeling, Probing, Summarizing
What is the definition of a Closed-Ended and an Open-Ended question? When might you use each of these?
Open ended questions- Provide the opportunity for more than a one word answer. Allows the client to expand upon the current question asked. (How are you feeling today, are you interested in the cessation of smoking?) May use it in times of attempting to build rapport, or when assessing a problem on a deeper level
Close ended question: Typically are simple questions that result with a yes or no answer. (Does it hurt when I do this? Do you smoke?) May use it when clarifying responses to open ended questions.
What does normal skin look and feel like?
Uniform in color based on ethnicity, It is warm, dry, intact, with elastic turgor. No lesions, scaring, erythema (Redness), or edema
Define pressure injury.
Occur in areas that are under pressure, usually over a bony prominence or related to medical devices
Who is at greatest risk of developing A pressure injury?
Elderly individuals with thin skin, people who are bedridden, any individual who may experience incontinence (Too much moisture can assist in the breakdown of the skin). Also individuals with impaired sensory perception because they may not feel any pain with the injury.
Know the stages of the Pressure Injury Staging system.
Stage 1: Skin is still intact, the skin does not blanch (Turn white) when pushed on.
Stage 2: Partial thickness loss of skin with exposed dermis. Wound bed is viable, its pink or red and moist.
Stage 3: Full thickness loss of skin in which adipose (Fat Tissue) is visible in the ulcer and possible granulation tissue and epibole are present.
Stage 4: Full thickness skin and tissue loss with palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
What is the Braden Scale?
The braden scale is a scale used to assess a clients risk of developing a pressure injury. It measures moisture, mobility, activity, nutrition, sensory perception and someone at risk for friction or shearing.
What is a commonly used mnemonic for skin cancer screening? What does each letter stand for?
A: Asymmetry
B: Borders (Irregular)
C: Color (Change in color)
D: Diameter (Anything larger than 6mm)
E: Evolving (Changing in size, symptoms)
Define skin lesions, primary and secondary.
A skin lesion is a part of the skin that has an abnormal growth or appearance compared to the skin around it.
Primary Lesion: Abnormal skin conditions that are present at birth or acquired over a person’s lifetime. Arise from healthy skin tissue (Mole)
Secondary Lesion: Result of alteration of a primary skin lesion (Melanoma)
What are the characteristics used when describing skin lesions?
Location, Size, Shape, Color, Texture (Smooth, rough, scaly), Surface relationship, Exudate, Comfort
What is turgor?
Turgor is the elasticity of the skin
What does poor turgor suggest?
Dehydration
When is the integumentary system assessment typically done?
One of the first tests performed upon admission in order to determine that the skin has remained in contact while during the stay at the healthcare facility.
What is meant by blanching?
Applying pressure to the skin, removing the blood from the local capillaries. The skin (In fair skin individuals) will go from a pink-ish to a white and refill back to its original pink-ish state
What is cyanosis?
Cyanosis is a result of the lack of oxygen reaching the body tissues resulting in a bluish color of the skin in areas such as finger tips, lips, and oral mucosa.
Why would a lesion or pressure injury not blanch?
An injury such as a pressure ulcer may have affected the integrity of the nearby capillaries and in severe cases blood vessels affecting the skin’s ability to be blanched.
What is jaundice?
Jaundice is a result of excess bilirubin in the blood causing the skin to become yellow. Areas that will be affected could range from the entire body but mainly palms of hands, soles of feet, sclera.
What is erythema?
Erythema is when the skin is reddened. Although not expected in someone who is physically exerting themselves. In individuals with darker skin it may be hard to see, check for warmth associated with reddened skin.
Understand the structure of the thorax and the lungs.
Thoracic cage consists of the sternum (Top part is called the manubrium), Ribs, Thoracic vertebrae connect the ribs in the back, and the diaphragm which is a large skeletal muscle which aids in chest expansion for breathing
- Lungs- Right lung consists of three lobes, Upper, Middle, and Lower Lung (Right middle lung can only be heard on the anterior portion of the body). The Left lung is composed of two lobes, Upper and lower.
*Breathing- Air enters the lungs through the mouth or nose, travels through the pharynx down the trachea and to the two primary bronchi (Left and Right, Right bronchi being larger and straighter which typically causes problems when it comes to aspiration). Oxygen goes through the primary bronchi, to secondary bronchus and then to tertiary bronchus and into the alveoli where gas exchange can occur
What are anatomical landmarks to assist with assessment of the thorax and lungs?
Angle of Louis is a small bump on/below the manubrium (Upper sternum) is indicative of the second intercostal space.
Midclavicular line
Mid axillary line
What are the 4 normal breath sounds and where are they best auscultated?
Tracheal (Over the Trachea and neck)
Vesicular (Over the larger portion of the lungs, more lateral)
Bronchial vesicular (More medial than vesicular closer to the sternum)
Bronchial (Heard over the upper sternum and neck)
What is tactile fremitus?
Palpation (Feeling) the chest for vibrations when the client is talking. If there is vibration its indicative of lung consolidation
How is gas exchange evaluated (non-invasive and invasive)?
Non-invasive: SpO2 monitors (95% or greater is considered normal), Inspection for cyanosis
Invasive: ABG (Arterial Blood Gas), Hemoglobin and Hematocrit
What are 3 types of vocal fremitus?
- Bronchophony: Increasing in intensity and clarity of spoken sounds when auscultating with the stethoscope (Have the client say “ninety-nine”
- Egophony: Have the client say E-E-E-E, if it sounds like A-A-A-A, lung consolidation is present
- Whispered pectoriloquy: Unusually clear transmission of whispered words indicating lung consolidation (Have the client say ninety-Nine)
What are normal findings when inspecting the thorax?
Chest AP diameter is less than the Transverse chest diameter (The chest is longer side to side than it is front to back), Skin is warm, dry, and intact. Equal expansion of the lungs, equal sounds bilaterally, no use of accessory muscles, no nasal flaring.
What is the normal adult respiratory rate and SaO2?
The normal respiratory rate is between 12-20, and the SaO2 is 95% and above
What are adventitious breath sounds?
Adventitious breath sounds are unexpected or abnormal sounds heard while auscultating the lungs.
The names of the adventitious sounds are,
- Crackling (Course: Breathing through large mucous filled airways, Fine: Alveoli popping open),
- Wheezing: (High pitched, continuous sounds produced by narrowing of the airways),
- Friction Rub (Usually continuous, dry rubbing sounds, like leather, heard on inspiration and expiration)
- Stridor: Continuous high pitched sounds due to the narrowing of airways in the upper respiratory tract
- Rhonchi: Low-Pitched, continuous sounds resembling snoring. Airway is very narrow almost closed
What is meant by the AP diameter?
AP diameter represents Anteroposterior diameter which is represented by the diameter of the chest from front to back.
What are signs suggestive of breast cancer?
Masses or lumps that are hard, irregular in shape, fixed to tissue and/or tender
Dimpling of skin
Change in breast shape
Edema
Nipple discharge
List risk factors for breast cancer.
Nonmodifiable risk factors: Age and Gender, Family History, Race, Breast density, previous breast cancer, early menarche, late menopause, genetics
Modifiable risk factors: Postmenopausal obesity, hormone replacement, alcohol use, physical inactivity, no children.
What is the function of the lymphatic system?
Designed to fight off pathogenic microorganisms, also removes excess fluids in between cells and returns it to the bloodstream. Lymph is also responsible for the absorption of fats.
Define lymphedema.
An accumulation of fluid that is normally drained through the lymphatic system but isn’t either due to a blockage or removal of lymph nodes.
Examination Sequence For GI System
- Inspect
- Auscultate
- Percussion
- Palpate
Usual Examination Sequence
- Inspect
- Palpate
- Percuss
- Auscultate
Describe “hyperactive” bowl sounds. What could they indicate?
-More sounds than normal
-Could indicate illness
Describe “hypoactive” bowl sounds. What could they indicate?
-Decreased bowl sounds
-Constipation, blockage/obstruction
What are the characteristics assessed for in the “Inspection” portion of the abdominal assessment?
-Contour, symmetry, size
-Skin: color lesions, veins, hernias, hair
-Movements: Pulsations, peristalsis
-Umbilicus: size and position
If chyme moves more slowly through the intestines would the stool be harder or softer, and why?
Chyme will be harder because it has more time for water to be reabsorbed into the body mostly through the large intestine
List “normal” findings for inspection of abdominal assessment
-Flat or rounded
-Positive bowel sounds in all four quadrants
-Soft, nontender
-Bilaterally symmetrical
-Skin smooth, intact with no pulsations or visible peristalsis
-No masses or profusions
-Umbilicus midline
What could you see on the abdomen that would alert you that palpation is contraindicated? What would you do?
-Abdominal Aortic Aneurysm
-Call the provider
Define appendicitis, how it typically presents, and assessments to aid in diagnosis.
-Inflammation of appendix
-Pain in lower right quadrant
-Nausea and or fever
-McBurney’s Point: 2/3 the distance from navel to right hip
-Rebound Tenderness: Pain with release of palpation
Define peritonitis. List 3 signs typically associated with it and the definition of them.
-Inflammation of peritoneum
-Rigidity, rebound tenderness
-Localized or pain spread out
Know the 2 Types of Bowel Obstruction
- Mechanical
- Functional (Ileus)
Mechanical Bowl Obstruction Characteristics
-Partial: Liquid stool and gas can pass
-Complete: Nothing can pass
Functional (Ileus) Bowl Obstruction Characterisitics
-Will disrupt peristalsis
-Due to neurological dysfunction
What are potential normal abdominal/gastrointestinal findings related to pregnancy?
-Striae on skin as it stretches
-Diastasis Recti (separation of rectus abdominus muscles)
-Acid Reflux
-Constipation
List ways that the abdominal/gastrointestinal system changes as we age
-Altered gastric motility
-Decreased secretion of digestive enzymes and protective mucus
-Can impair digestive ability and lead to food intolerances
-Decreased taste and smell
Gravida Definition
Number of pregnancies
Para Definition
-Number of births after 20 weeks
Five Digit System (GTPAL)
-G: total number of pregnancies
-T: full term (37-40wks)
-P: Preterm (20-36wks)
-A: Abortions and miscarriages (before 20wks)
-L: Living Children
What is Benign Prostatic Hypertrophy (BPH)?
-Enlargement of the prostate that is non-cancerous
Symptoms of BPH
-Increased frequency of urination
-Peeing more often at night
-Trouble starting stream
-Weak stream
-Dribbling
-Not fully emptying bladder
Signs of pyelonephritis
-fever
-chills
-pain in low back
-confusion in elderly
-pain with urination
-bloody or cloudy pee
-urgency to pee
Where is palpation done to aid in diagnosis of pyelonephritis
-One hand flat against back, thump with fist
-Patient will yelp
Signs of bladder infection
-Fever
-Increased WBC count
-Confusion in elderly
-Pain/difficulty with urination
What could a black tarry stool indicate?
-Called: Melena
-Indicates blood in stool
-More likely blood is coming from small intestine due to darker color
What creates S1 heart sound?
Sound of mitral and tricuspid (atrioventricular) valves closing
What creates S2 heart sound?
Pulmonic and aortic (semi-lunar) valves closing
What causes S3 heart sound?
Sound of large amount of blood hitting a compliant left ventricle
(can be normal)
What causes S4 heart sound?
Caused by atria contracting forcefully to overcome an abnormally stiff or hypertrophic ventricle
(not normal)
What does an elevated jugular venous pressure indicate?
-Inadequate blood draining from the head
-Blockage or weakness of right side of heart causing backup of blood
What is meant by Mean Arterial Pressure (MAP)?
-MAP is average blood pressure throughout one cardiac cycle
What is normal MAP range?
- 70-100mmHg
(less than 60, not enough blood flow to perfuse through critical organs)
What are cardiac auscultation landmarks?
-A: Aortic Area
-P: Pulmonic Area
-E: Erb’s Point (use bell)
-T: Tricuspid Area
-M: Mitral Area or Apex
What heart sounds should be loudest at each landmark?
-A: Aortic valve
-P: Pulmonary valves
-E: S2 sound
-T: Tricuspid valves
-M: Mitral valve
What is Hypovolemia
-Body fluid loss
-Decrease in BP and MAP
-low blood volume
How is the cardio/peripheral system impacted with aging?
-Arteries stiffen with age
-Myocardium decreases in elasticity and becomes more rigid
-Decreases response to stress
-Increase in 02 demand
What is Peripheral Arterial Disease (PAD)
-Narrowing of the arteries usually in legs or pelvis
-Symptoms: Cramping, pain, tired legs, tired muscles, pain worsens with walking/activity and decreases with rest
-Hyperlipidemia causes atherosclerosis
Venous Insufficiency
-Vein walls are weakened and valves are damaged
-Veins stay filled with blood, especially when standing
- Swelling, Bounding Pulse,
What is Deep Vein Thrombosis (DVT)
-Blood clot that forms in deep veins (usually legs but sometimes arms)
-Can be caused by decreased blood flow, high cholesterol
-Major risk is clot can move to lungs cutting off blood flow (pulmonary embolism)
Why is circulation different in the fetus?
-Circulating blood bypasses the lungs and liver by flowing in different pathways and openings called shunts
-When umbilical cord is clamped, first breath causes lungs to expand and the shunts close, allowing normal circulatory function
Cranial Nerve I
-Olfactory Nerve
- Sensory
-Function: Smell
-Test: Have patient identify a scent with eyes closed in each nostril separately
Cranial Nerve II
-Optic Nerve
- Sensory
-Function: Visual acuity and field
-Test: Have patient perform visual field test and visual acuity test with Snellen and Rosenbaum charts. Size, shape of pupil and reaction to light (direct and consensual)
Cranial Nerve III
-Oculomotor Nerve
- Motor
-Function: Opening and moving your eyes and adjusting pupil width
-Test: Test extraocular movements and convergence
Cranial Nerve IV
-Trochlear Nerve
- Motor
-Function: Looking down and moving your eyes toward your nose or away from it
-Test: Follow penlight down and sidways
Cranial Nerve V
-Trigeminal Nerve
- Both
-Function: Providing sensations in your eyes, most of your face, and inside of mouth. Allows you to chew food
-Test: Place fingers over masseter muscles and ask patient to clench teeth. Light touch sensation on forehead, cheeks and jaw
Cranial Nerve VI
-Abducens Nerve
- Motor
-Function: Moving your eyes from left to right
-Test: Move penlight side to side and diagonal
Cranial Nerve IX
-Glossopharyngeal Nerve
- Both
-Function: Provide taste sensation, control muscles for swallowing
-Test: Asses swallowing and gag reflex
Cranial Nerve VII
-Facial Nerve
- Both
-Function: Controlling facial muscles to make facial expressions and provide the sense of taste in part of your tongue
-Test: have patient raise eyebrows, close eyes tightly, smile, and puff cheeks
Cranial Nerve VIII
-Vestibulocochlear Nerve
- sensory
-Function: Provide sense of hearing and balance
-Test: Assess hearing (use finger rub or whisper test)
Cranial Nerve X
-Vagus Nerve
- Both
-Function: Regulate digestion, blood pressure, heart rate, breathing, mood, saliva production
-Test: Asses gag reflex and swallowing
Cranial Nerve XI
-Accessory Nerve
- Motor
-Function: Control shoulder and neck movement
-Test: Shrug shoulders, turn head (with and without resistance)
Cranial Nerve XII
-Hypoglossal Nerve
- Motor
-Function: Controlling tongue movement (for speech, eating, and swallowing)
-Test: Assess tongue fasciculations, symmetry, deviation, movement, and strength (listen to speech, have patient stick out tongue and move side to side)
Central Nervous System (CNS) Components
-Brain
-Spinal Cord
-Neurons
Function: Integrate sensory info and respond accordingly
Afferent and Efferent Neuron Function
-Afferent: Carry info from sensory receptors (skin and organs) to CNS
-Efferent: Carry motor info from CNS to muscles, organs, and glands of the body
Peripheral Nervous System (PNS) Comoponets and Function
-Nerves and ganglia outside the spinal cord
-31 pairs of spinal nerves
Autonomic Nervous System
-Unconscious movements
-Includes: Sympathetic and parasympathetic nervous systems
Somatic Nervous System
Guides voluntary movements
PERRLA
Pupils equal, round, reactive to light and Accommodation
Consensus of the Eye
Both pupils react equally when light is shone in only one eye
Snellen test
-Vision test conducted with chart at 20ft
-EX: 20/30 means you see at 20ft what perfect vision sees at 30ft
Confrontation Eye Test
-Tests visual filed including peripheral vision
-Have patient cover one eye and test all 4 quadrants of visual field by holding up fingers
-Do with both eyes one at a time
Extraocular Muscle (EOM) Function
-Have client follow fingers as you through all 6 fields of gaze (H pattern)
Palpation of Frontal Sinus
-Place thumbs above eyes under boney ridge of upper orbits
-Apply gentle pressure
-Ask if tenderness
Palpation of Maxillary Sinus
-Place thumbs on each side of nose just below cheek bone with fingertips on forehead
-Apply gentle pressure
-Ask if tenderness or pain
Nasal Patency Test
-Occlude one nostril and breath
-Repeat with other
Palatal Reflex Test (CN IX & X)
-While visualizing with pen light and tongue depressor have client say “ah”
-Soft palate and uvula should rise symmetrically and remain midline
Ischemic Stroke
-Blood to brain blocked or reduced
-87% of strokes
Hemorrhagic Stroke
-Vessels in brain leak or burst causing bleeding and increased pressure on brain
-17% of strokes
Autonomic Nervous System (ANS) Components
-Sympathetic Nervous System (fight or flight)
-Parasympathetic Nervous System (rest and digest)
Non-synovial Joints
-Cartilaginous (slightly moveable ex: vertebrae)
-Fibrous (immovable sutures ex: skull)
Synovial Joints
-Freely movable
-Bones are separated from one another in joint filled with synovial fluid
-Bursa: Sac of viscous synovial fluid
Skeletal Muscle
Voluntary movements
Smooth Muscle
-Involuntary movements
-Peristalsis, uterine contractions
Cardiac Muscle
Involuntary, striated muscle
Synovial Joint Types
-Ball and Socket (shoulder and hip)
-Hinge (elbow and knee)
-Condyloid (Wrist and finger)
Function of Skeletal System
-Support
-Movement
-Protect vital organs
-Produce WBC, RBC, platelets
-Reservoir of essential minerals (calcium and phosphorus)
Normal For Joints and Muscles
-No crepitation (hearing or feeling cracking/popping in joint)
-Normal ROM
-Symmetry of muscles
-No tenderness or bogginess
-Not squishy
Active Range of Motion (AROM)
-Ability to move joint with own strength
-Full or Limited ROM
Passive Range of Motion (PROM)
-Someone moves your joints through movements
-Full or Limited ROM
CMS
-Circulation (color, pulse, temp, capillary refill)
-Motion (passive and active ROM)
-Sensation (assess with light touch, soft and sharp, joint position)
Sterognosis
Identify object by feeling in hand
Graphesthesia
Identify number drawn in palm
DTR 4-point scale
0: no response
1+: slight response but present
2+: brisk response, normal
3+: very brisk response, can be normal/abnormal
4+: Tap elicits repeating reflex (clonus), abnormal
Level of Consciousness (LOC)
-Alert: Normal
-Lethargy: Appear drowsy, respond then fall asleep
-Obtunded: Open, look at you, respond slow and confused
-Stupor: Wake with painful stimuli, verbal response slow or absent (return unresponsive when stimuli stops)
-Coma: Fully unconscious
Fracture Risk Factors
-Age and gender
-Postmenopausal
-Osteoporosis
-Falls
-Low body weight
-Smoking
-Alcohol abuse
-Steroids
-Theumatoid Arthritis
-Family history
-Previous fracture
Rheumatoid Arthritis
-Swollen, inflamed synovial membrane
-Erosion of bone
-Symmetrical
-Stiffness longer than 30min in the morning
Osteoarthritis
-Loss of cartilage
-Bones rub together
-Asymmetrical
Special Considerations for Infant Bone Growth
-Bones increase in girth all around
-Bones increase in length at growth plate (epiphyses)
-Ligaments are strong than bones until adolescents
Special Considerations for Pregnancy and Musculoskeletal
-Increase hormone levels cause elasticity of ligaments and softer cartilage in pelvis (12-20wks gestation)
-Lordosis to shift center of gravity
-Lower back pain due to physical stress
-Increased incidence of carpal tunnel syndrome
Special Considerations for Aging Adult and Musculoskeletal
-Decrease in muscle mass, tone, strength
-Decrease in reaction time, speed, agility, endurance
-Post menopause, decreased estrogen leads to increase bone resorption and decreases calcium deposition (by 80yrs, women can lost 30% of bone mass)
Spacicity
Increased rigidity of muscles due to brain or spinal cord injury
Contracture
-Tightening of muscles, tendons, skin, and tissues
-Causes joints to shorten and become stiff
Know how the blood flows through the heart.
Inferior/Superior Vena Cava -> Right Atrium -> Tricuspid Valve -> Right Ventricle -> Pulmonary valve -> Pulmonary artery -> Lungs -> Pulmonary Vein -> Left Atrium -> Mitral Valve -> Left Ventricle -> Aortic Valve -> Aorta -> Rest of Body
What creates the following heart sounds.
S1: Closing of the Mitral and Tricuspid Valves ( AV Valves) Dull, low pitch
S2: Closing of Pulmonic and Aortic Valves (Semi-Lunar) Slightly higher pitch
S3: Sound of a large amount of blood hitting a compliant left ventricle (Can be normal)
S4: Caused by atria contracting (Vibration) forcefully to overcome an abnormally stiff or hypertrophic ventricle (Not normal)
What does an elevated jugular venous pressure indicate?
Blood is having trouble returning to the right side of the heart from the head.
Possible blockage
What are concerning signs and/or symptoms that suggest a cardiac issue?
Jugular Vein Distension
What is mean arterial pressure (MAP)?
What is a normal range?
the average blood pressure in an artery during a cardiac cycle
70-100 mmHG
Where are the cardiac auscultation landmarks?
APETM
Aortic: Second intercostal space, right sternal border
Pulmonic: Second intercostal space, left sternal border
Erbs Point: Third intercostal space, left sternal border
Tricuspid: Fourth intercostal space, left sternal border
Mitral: Fifth intercostal space, midclavicular line
Which heart sounds should be the loudest at each landmark?
Aortic: Second intercostal space, right sternal border
Tricuspid: Fifth intercostal space, left sternal border
Mitral: Fifth intercostal space, Midclavicular line
Pulmonary: Second intercostal space, left sternal border
Which lifestyle habits would be good to encourage when teaching about cardiac health?
Healthy diet (Lower sodium, Omega 3)
Exercise
No smoking or drinking
How is the cardio/peripheral system impacted with aging?
Arteries Stiffen
Myocardium becomes less elastic, more rigid
Less efficient response to stress
Increases O2 demand
What is meant by hypovolemia?
Low Blood volume
How would a hypovolemic state impact blood pressure and MAP?
Low Blood pressure
Low MAP
What is peripheral arterial disease (PAD)?
Narrowing of the arteries, commonly the pelvis and legs
Hyperlipidemia (Cause of atherosclerosis)
What is the main cause of PAD?
atherosclerosis.
Clinical Symptoms: Cramping, pain, tired legs or hip muscles that worses during walking/activity and subsides with rest
Define venous insufficiency.
Inadequate return of venous blood from the legs to the heart
Clinical symptoms: Tired/Heavy, achy cramping in the legs, pain worsens when standing and improves with leg elevation and with activity
What is a potential life-threatening emergency that could arise from a deep vein thrombosis?
Pulmonary embolism, the next smallest location that the clot could affect is in the lungs.
Embolism: Blockage or obstruction
What is a deep vein thrombosis?
Insufficient return of blood from the legs that creates a clot most commonly in the legs or arms
Why is circulation different in the fetus?
Fetal circulation compensates for non-functional fetal lungs. The fetus is oxygenated with maternal blood flow through the placenta
Circulating blood bypasses the lungs and liver by flowing in different pathways and through special openings called shunts
At birth, the umbilical cord is clamped (Baby no longer receives nutrients from the placenta). With the first breath of air the lungs start to expand and the ductus arteriosus and the foramen ovale both close
What is the purpose of the shunts in the fetal heart?
Shunts are special openings that allow the circulating blood to bypass the lungs and the liver, because it gets oxygen from mother through the placenta.
Right Upper Quadrant:
Liver, Right Kidney, Gall Bladder, Colon, Pancreas
Right Lower Quadrant:
Appendix, Colon, Small intestine, Ureter, Major vein, and artery to right leg
Left Upper Quadrant:
Stomach, Left Kidney, Spleen, Colon, Pancreas
Left Lower Quadrant:
Colon, small intestine, Ureter, Major vein, and artery to the left leg
Midline:
Aorta, Pancreas, Small intestine, Bladder, Spine
What is the usual examination sequence for all systems except the gastrointestinal? What is the examination sequence of the gastrointestinal system and why does it differ from the others?
Gastrointestinal Examination Sequence:
Inspection: (Symmetry, Size, Condition of skin, Pulsations… Etc)
Auscultation: (All 4 quadrants, if NG tube present turn off) Normal is 5-34 per minute. If no sounds, listen for 5 minutes before deciding they are absent
Percussion
Palpation: Overall impression of the skin surface, looking for tenderness. DO NOT PALPATE aortic aneurism
Done in this order so palpation does not create false bowel sounds
Describe “hyperactive” bowel sounds and what they indicate.
(increased) bowel sounds are louder and more intense than expected because of increased motility or peristalsis of the bowels as with diarrhea. You might hear rushing sounds or tinkling at a frequency of about every few seconds, and greater than 34 per minute.
Describe “hypoactive” bowel sounds and what the indicate.
(decreased) bowel sounds are diminished, soft sounds that occur less than 5 per minute and could be related to impaired motility. This can be related to side effects from medication or anesthesia, constipation, or bowel obstruction.
If chyme moves more slowly through the intestines would the stool be harder or softer, and why?
The speed at which chyme moves through the intestines dictates how much water is reabsorbed in the Large intestine. If the chyme moves too quickly, less water will be absorbed therefore resulting in softer stool. If chyme moves too slowly, lots of water is reabsorbed, drying it out making it harder
What are the characteristics assessed for in the “Inspection” portion of the abdominal assessment? List “normal” findings.
*Flat or Rounded Contour
*Positive bowel sounds all 4 quadrants
*Soft, nontender
*Bilaterally Symmetrical
*Skin smooth and intact without pulsations
or visible peristalsis
*No masses or protrusions note
*Umbilicus midline
What could you see on the abdomen that would alert you that palpation is contraindicated? What would you do?
Pulsation that would indicate an aortic aneurysm. Call provider
What do hyperactive bowel sounds indicate? Hypoactive?
Hyperactive: increased motility or peristalsis of the bowels as with diarrhea.
Hypoactive: This can be related to side effects from medication or anesthesia, constipation, or bowel obstruction.
Define appendicitis, how it typically presents, and assessments to aid in diagnosis.
Appendicitis – Inflammation of the appendix
Pain in lower right quadrant
Mcberneys point
rebound tenderness
Define peritonitis. List 3 signs typically associated with it and the definition of them.
Peritonitis – Inflammation of the peritoneum
Rebound tenderness, Ridgidity, Extreme pain, localized or general
Know the 2 types of bowel obstruction. List possible findings with assessment. Who is at greatest risk?
Functional: occurs when the muscles in the bowel don’t contract properly, preventing the movement of feces through the digestive tract
Mechanical: occurs when the flow of contents in the bowel is blocked, preventing the normal movement of digested food
What are potential normal abdominal/gastrointestinal findings related to pregnancy?
Pregnancy
*Striae on the skin as it stretches
*Diastasis Recti (separation of the rectus abdominus muscles)
*Acid Reflux
*Constipation
List ways that the abdominal/gastrointestinal system changes as we age
Aging Adult
* Altered gastric motility
* Decreased secretion of digestive enzymes and protective mucus
Can impair digestive ability and lead to food intolerances
* Decreased taste and smell
Be able to define and calculate gravida, para, abortus and living (GTPAL).
Gravida: Total number of pregnancies
Para: Number of pregnancies after 20 weeks
G- Total number of pregnancies
T- Full term pregnancies (37-40 weeks)
P-Preterm deliveries (20-36 weeks)
A- Abortions and miscarriages (Before 20 weeks)
L- Living Children
What is Benign Prostatic Hypertrophy(BPH)? What are the symptoms?
a non-cancerous condition that occurs when the prostate gland in men becomes enlarge
Difficulty urinating
List abnormalities that might be seen on inspection of the external genitalia.
Urethra meatus not midline, Masses/Lumps, Cysts
What are signs of pyelonephritis? Where is palpation done to aid in diagnosis?
High fever, severe tenderness to tapping over the CVA
Palpation is done over the CVA
List signs of a bladder infection. How does this change in the aging adult?
Pain or burning when urinating
Frequent urination, even after emptying your bladder
Cloudy, bloody, red, or bright pink urine
Urine that has a strong odor
In older adults, signs of confusion are also associated with a UTI
What could a black tarry stool indicate?
Blood in stool (melena). Likely related to gastrointestinal bleeding
What symptoms might you see that would lead you to suspect traumatic brain injury?
Clear drainage from nose or ears after hit to the head
Define the function of the thyroid. What would be abnormal findings? What signs and symptoms you might assess in someone who is hypothyroid? Hyperthyroid?
produces hormones that regulate the body’s metabolic rate, growth and development.
Hyperthyroidism: Nervousness, weight loss, excessive sweating, palpitations, frequent bowel movements
Hypothyroidism: Fatigue, lethargy, weight gain, dry skin, constipation
Abnormal: increase in size or nodules
Know what assessments are made in the neck region. What would be normal findings?
Inspection –
Inspect the position of the trachea
Assess for abnormal nodules and swelling
Evaluate range of motion (ROM) of the neck
Assess ability to swallow
Check for jugular vein distension
- Palpation –
Carotid pulse (one side at a time). Do this only after auscultation. - Trachea to determine if midline -Trachea place thumbs along each side of trachea and determine if equal distance between the out edge and sternocleidomastoid muscle.
- Lymph Nodes – Using pads of fingers feel for size, symmetry, shape, mobility, consistency and ask about tenderness.
- Thyroid – While gently palpating lower trachea have client swallow. Isthmus should rise. Palpate each lobe for enlargement, nodules or tenderness.
- Auscultation –
Listen to carotids with bell of stethoscope. The presence of bruits is an abnormal finding.
Auscultate thyroid with bell only if you observe or palpate enlargement. Bruit could indicate a hypermetabolic state.
What is meant by consensus in an eye exam?
Shine light into one eye briefly while examining the pupillary reaction in the other eye. Both eyes should constrict with light.
What is a goiter?
a swelling in the neck that occurs when the thyroid gland enlarges
What does PERRLA stand for?
Pupils equal, round, reactive to light and accommodation
What does the Snellen eye assessment test for? What do the numeric results indicate?
Snellen – Tests visual acuity (CN II). Have client stand 20 feet from chart.
Cover one eye and read the lowest line. Repeat with second eye and then with
both eyes uncovered. (Option the “E” chart)
How is the Whisper Test done?
Occlude non-tested ear and whisper 3 words in other ear asking client to repeat the whispered words
What is the Weber test? How is it done? What is it testing for?
Place vibrating tuning fork on client’s temporal bone.. Ask if they
can hear it better in the left ear, right ear or both ears equally.
Normal finding – hear equally in both ears (negative Weber)
What is the Rinne test used for?
Place vibrating tuning fork against mastoid bone. Have client tell you when they can no longer hear it. Note length of time it was heard. (Bone conduction – BC))
Move tuning fork in front of the ear canal and have client indicate when they can no longer hear it. Document length of time it was heard. (Air conduction – AC) AC should be longer than BC – ratio of 2:1
What is a “normal” finding when inspecting the tonsils? What is “tonsil grading”?
Tonsils – Same color as surrounding mucosa, vary in size and visibility
Tonsils are graded on a scale of 0 to 4, with each grade indicating the size of the tonsils relative to the oropharynx
Grade 0: Tonsils are within the tonsillar fossa, or the tonsils have been removed
Grade 1: Tonsils are just outside the tonsillar fossa and take up 25% or less of the oropharynx
Grade 2: Tonsils take up 26–50% of the oropharynx
Grade 3: Tonsils take up 51–75% of the oropharynx
Grade 4: Tonsils take up more than 75% of the oropharynx
Where is the uvula and what is its function?
Uvula – Pink, midline moves with vocalization
secretes saliva, Prevents food from entering nasal passagw while swallowing, helps with speech, gag reflex to prevent choking
What is meant by fasciculation? Is it always an abnormal finding?
a condition where a muscle involuntarily twitches, or contracts, in a small, localized area
Not always abnormal
What is a normal finding of the uvula with phonation?
the uvula and soft palate are directed upward, thereby walling off the nasal cavity from the pharynx.
How is patency of the nares tested for? What would it indicate if one side was not patent?
Have client occlude one nostril and breath in and out through the other. Repeat on the other nostril.
What are the parts of the CNS (central nervous system)?
Brain and spinal cord and neurons
List the XII cranial nerves.
Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glosopharyngeal
Vagus
Accessory
Hypoglossal
What assessments are utilized to determine if each of the XII cranial nerves is functioning appropriately?
Olfactory - Identify smell with eyes closed
Optic - Visual field/ visual acuity test
Oculomotor- PERRLA
Trochlear- Follow movement of penlight down and sideways
Trigeminal - Identify sharp or soft touch on face
Abducens- Follow penlight movement side to side and diagonally
Facial- Frown, Smile, Raise eyebrows, puff out cheeks, close eyes tightly
Vestibulocochlear - Whisper test
Glosopharyngeal- Have patient say ah and to swallow
Vagus- Gag reflex, swallowing
Accessory - Shrug shoulders, have patient turn head
Hypoglossal - Stick out tongue, move side to side
What activities are associated with each of the nerves (sensory, motor or both)?
Olfactory - Sensory
Optic - Sensory
Oculomotor- Motor
Trochlear- Motor
Trigeminal -Both
Abducens- Motor
Facial -Both
Vestibulocochlear - Sensory
Glosopharyngeal - Both
Vagus- Both
Accessory - Motor
Hypoglossal - Motor
What is a dermatome?
a specific area of skin that is supplied by a single spinal nerve
Define afferent and efferent neurons.
Afferent- carry info from sensory receptors (skin and other organs) to the CNS
Efferent- carry motor info from the CNS to muscles and glands of the body
What makes up the PNS (peripheral nervous system)?
All of the nerves extending to the periphery of the body
What do the autonomic and somatic nervous systems control?
Somatic nervous system: Guides voluntary movements.
Autonomic nervous system: Responsible for control of the bodily functions not consciously directed, such as breathing, the heartbeat and digestive processes
Sympathetic: Fight or flight
Parasympathetic: Rest and digest
Define pronator drift. When might you see this?
occurs when one arm and palm turn inward and downward. This is an indication of muscle weakness and an abnormal function of the corticospinal tract, the upper motor neurons in the brain and spinal cord that control voluntary muscle movement
When would nurses use the NIHSS (National Institute of Health Scale)?
a tool that healthcare professionals use to assess the severity of a stroke
Ischemic – blood supply to part of the brain blocked or reduced (87%)
Hemorrhagic - Blood vessels in the brain leaks or bursts causing bleeding in the brain and increased pressure on brain cells (17%)
Define sympathetic and parasympathetic regarding the nervous systems?
Sympathetic: Fight or flight
Parasympathetic: Rest and digest
What does the Romberg test assess?
a physical exam that assesses balance and neurological function
A positive test is an inability to maintain an erect posture over 60 seconds with eyes closed.
What is the Glascow Coma Scale? What does it assess?
a neurological tool used to measure a patient’s level of consciousness and the severity of a brain injury
The GCS assesses a patient’s responsiveness to stimuli in three areas: eye opening, motor response, and verbal response
Scored 3-15, high score is better neurological functioning
What are some normal reflexes for infants that disappear as the child ages?
Stepping- When held upright they try to walk
Moro- Cause body to stiffen and shoot arms out and open hands
Grasp- Close hand when palm is touched
Tonic neck- One side of the body will straighten when head is turned
Babinski- Fanning out of toes
List signs of a cerebral vascular accident.
Loss of balance, headache or dizziness, blurred vision, drooping of one side of the face, arm or leg weakness, speech problems
Explain the difference between a synovial and non-synovial joint.
Synovial – Freely moveable, bones are separated from one another and enclosed in a joint cavity filled with lubricant or synovial fluid (knee, shoulder)
Non-synovial – bones are united by fibrous tissue or cartilage
Fibrous: Immovable joints
Cartilagenous: slightly movable
What is a ligament?
Ligaments - flexible fibrous bands running from one bone to another strengthening the joint and helping to prevent movement in undesirable directions.
What is the difference between a ligament and a tendon?
Tendon connects muscle to bone where Ligament is Bone to Bone
What is a tendon?
Tendon - band of dense fibrous connective tissue that connects muscle to bone.
What is a bursa and what is its purpose?
Bursa – Enclosed sac filled with viscous synovial fluid.
to reduce friction between moving parts of the body, such as bones, joints, tendons, and skin
List the 3 muscle types.
Skeletal
Smooth- Internal organs
Cardiac- Heart muscle
What is the difference between “full” ROM and “limited” ROM?
Full ROM is moving as far as anatomically possible during an exercise.
Limited ROM is when a joint can’t move through its normal range
What is the difference between “active” ROM and “passive” ROM?
*Active Range of Motion (AROM) - the range of flexibility in a joint reached by voluntary movement.
*Passive Range of Motion (PROM) - the range that can be achieved by external means such as another person or a device.
What is osteoporosis and the role estrogen plays in it for post-menopausal women?
a disease that weakens bones, making them more likely to break
Low estrogen levels can cause osteoporosis by increasing bone resorption and decreasing bone formation
What are the 3 main types of spinal deformities?
Scoliosis: lateral curvature of the spine
Kyphosis: Outward curvature of the cervical spine
Lordosis: Common in pregnancy, Inward curvature of lumbar spine
Explain the difference between cartilage and bone.
Bones: Hard, Ridgid, Rich blood supply, Protect vital organs
Cartilage: Soft flexible, lacks blood vessles, Protect bones from rubbing together
What does CMS stand for? How do you assess it?
Circulation: assess color, pulse, temperature and capillary refill ( a measure of peripheral circulation)
Motion: ◦Assess motion using passive and active ROM movements.
Sensation: assess sensation using light touch of soft or sharp object and joint position.
When would you assess for CMS?
Post Operation?
Suspicion of neurological damage?
What are symptoms that there are problems with the patients CMS?
Cool skin, Poor cap refill, Lack of range of motion, lack of sensation
What are the 4 signs of inflammation?
Heat, Swelling, Redness, Pain
Define the skeletal muscle movements (flexion, extension etc).
- Plantar Flexion – Standing on the toes
- Dorsiflexion – Foot lifted towards the shin
- Flexion – Decreases joint angle
- Extension – Increases joint angle
- Hyperextension – Extension of body part beyond normal range of movement
- Adduction – Movement of limb towards midline
- Abduction – Movement of limb away from midline
- Inversion – Turning sole of foot inward
- Eversion – Turning sole of foot outward
- Rotation – Turning on a singe axis
- Pronation – Rotation of the hand or foot so palm or sole faces backward or downward
- Supination – Rotation of the hand or foot so palm or sole faces upward or outward.
- Internal Rotation- Rotation of hip or shoulder towards midline
- External Rotation – Rotation of hip or shoulder away from midline
- Circumduction – The movement of a limb in a circle.
