Exam 2 Flashcards
1
Q
General survey: Focus on 4 areas which are?
A
- physical appearance
- body structure
- mobility
- behavior
2
Q
Physical appearance includes
A
- Age
- Sex
- LOC
- Skin color
- Facial features
3
Q
Body structure includes
A
- Stature (natural height)
- Nutrition
- Symmetry
- Posture
- Body build (arm span/body length)
- obvious physical deformities
4
Q
Wen looking at gate what is the norm?
A
Normally, base is as wide as shoulder width
5
Q
foot placement for gait findings
A
Smooth, even, well balanced
6
Q
Range of motion for Gait findings
A
- full mobility of each joint
- no involuntary movement
7
Q
Behavior includes
A
- Facial expression
- Mood and affect
- Speech
- Dress
- Personal hygiene
8
Q
Mnemonic: SOME TEAMS
A
- symmetry: face and body symmetrical
- old: does he look his age
- mental acuity: alert, confused, agitated, or inattentive
- expression: does he appear ill, in pain, or anxious
- trunk: Lean, stocky, obese, barrel-chested
- extremities: joint abnormalities
- appearance: clean, appropriately dressed
- movement: posture, gait, coordination
- speech: understandable, clear
9
Q
BMI def
A
- body mass index is a practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition
10
Q
Normal newborn general appearance
A
- Awake, vigorous cry, well-flexed, full range of motion, spontaneous movement
- posture limp
- Asymmetry of movement
- Persistent tremor, twitching
11
Q
development considerations for infant and children
A
weight
- upright scale is 2-3
Length
- measure supine until age 2
11
Q
lifestyle modifications
A
- weight
- alcohol/smoke use
-diet
11
Q
CNS: cerebral cortex:
What is it the center for?
how many hemispheres; how many lobes?
A
center for higher functions
- 2 Hemispheres
- 4 lobes
11
Q
the 6 components of the CNS
A
TBH-CBS
- Thalamus
- Basal Ganglia
- Hypothalamus
- Cerebellum
- Brain Stem
- Spinal Cord
11
Q
CNS Pathways: Sensory - what are the 2 tracts?
A
Spinothalamic tract
Posterior Tract
11
Q
CNS Pathways: MOTOR, what are the 2 tracts
A
- Pyramidal (Corticospinal) tract
- Extrapyramidal Tract
11
Q
what are the 2 motor neurons?
A
upper and lower motor neurons
11
Q
the PNS consists of nerves, what are the 2 nerves and how many pairs for each
A
Cranial nerve = 12 pairs
Spinal nerves = 31 pairs (dermatomes)
11
Q
Which CN are sensory: contain only Afferent fibers
A
CN I olfactory
CN II Optic
CN VIII Vestibulocochlear
11
Q
Which CN are motor: contain only Efferent fibers
A
CN III (Oculomotor)
CN IV (Trochlear)
CN VI (Abducens)
CN XI (Accessory)
CN XII (Hypoglossal)
11
Q
What involuntary muscles are innervated by the PNS autonomic nervous system
also, what is the function of this?
A
- Cardiac muscle
- Smooth muscle
- Glands
Function: to maintain the body’s homeostasis
11
Q
The riflex arc is part of the function of which nervous system?
A
the Peripheral NS
11
Q
Subjective data for neuro assessment
A
- headache
- Head injury
- Dizziness/vertigo/ syncope
- seizures
- tremors
- weakness
- difficulty with coordination
- numbing or tingling
- difficulty swallowing
- history
- environmental hazards
11
Q
Health promotion for Older adults
A
- fall prevention
- understanding cautions wth taking medications
11
Health promotion for patients at risk for impaired intracranial regulation
- wearing a medical alert bracelet
- discussing care plans at school or workplace
- helmets for young children in case of seizure
12
health promotion for patients wth history of stroke, seizure disorder, or brain injury
- understand the side effects of prescription and OTC meds
- avoid alcohol and nicotine
13
3 types of exams for neuro assessment
- Screening neurological exam - for well persons with no sig. subjective findings
- Complete neurological exam - for persons with neurologic concerns or findings
- neurologic recheck- person requiring periodic reassessment
14
for the neurologic screening exam, it is screening for a mental status concerning which CN?
What motor function?
What sensory function?
What reflexes?
Mental Status
* CN: II, III, IV, V, VI, VII
* Motor Function: Gait/balance
* Sensory Function: Pain, light touch, vibration
* Reflexes: Biceps, triceps, patellar, achilles
15
for the Complete exam, it is concerning which CN?
What motor function?
What sensory function?
What reflexes?
Mental Status
* CN II-XII
* Motor Function: size, strength, tone, gait, balance, RAM
* Sensory: pain, light touch, vibration, position sense, stereognosis, graphesthesia
* Reflexes: DTR’s, superficial, plantar
16
For the recheck neuro assessment, it is looking for what generally?
- LOC
- Motor function
- pupillary response
- Vital signs
17
A complete Neuro Exam consists of what 5 things?
- Mental Status
- Cranial Nerves
- Sensory System
- Motor System
- Reflexes
18
For the mental status, at the patient we are looking at what 4 things?
- Appearance
- Behavior
- Cognition: attention span, learning, memory
- Thought process
19
CN I olfactory
sense of smell
20
CN II
What’s the name and action for it?
Optic
Visual acuity and confrontation
21
CN III oculomotor, IV trochlear, VI abducens
EOM's by six cardinal positions, pupil constriction
22
CN V trigeminal (includes motor and sensory)
Motor: strength of temporal and masseter muscles
Sensory: Sensation forehead, cheek, jaw
23
CN VII (Contains motor and sensory)
Facial
motor: mobility and facial symmetry
Sensory: taste
24
VIII Acoustic
normal conversation, whispered words, weber and rinne
25
CN IX Glossopharyngeal and CN X Vagus
uvula and soft palate rise "ahhh",gag reflex, smooth voice sounds
26
CN XI spinal accessory
strength of sternomastoid and trapezius muscle
27
CN XII Hypoglossal
tongue midline
"light, tight, dynamite"
28
the sensory assessment consists of a few things to assess the senses. What would these be?
- Pain
- Touch
- Vibration
- Position
- Discrimination
29
For the motor system: Muscles, what are we looking at (visually) for them?
their size
- strength
- tone
- involuntary movement
30
For the balance tests, what are we looking at?
- Gait
- Tandem walk/heel to toe -- sensitive to UMN lesion
- Romberg balance - cerebral ataxia
31
for coordination in the motor system, what are we looking for?
- Rapid alternating movements
- Finger to finger
- finger to nose
- Heel to shin
32
The bicep reflexes are connected to which cervical vertebrae
C5-C6
33
The triceps reflexes are connected to which cervical vertebrae
C7-C8
34
The Brachioradialis is connected to which cervical vertebrae
C5-C6, same as biceps reflex
35
The Quadriceps are connected to which Lumbar vertebrae
L2-L4
knee jerk (patellar)
36
The Achilles are connected to which vertebrae
Ankle jerk
L5-S2
37
Reflexes are involuntary or voluntary?
Involuntary
38
what are the three superficial reflexes?
- Abdominal reflex
- Cremasteric Reflex
- Plantar (Babinski) Reflex
39
What are the three types of brainstem reflexes?
- Pupillary
- Corneal
- Gag reflex
40
What are the 3 primitive reflexes?
- Suck reflex
- Grasp reflex
- Babinski
41
What does the test for the Brudzinski sign show?
a test for meningitis
Stiff neck causes hips and knees to flex
42
What does the test for the Brudzinski sign show?
Meningitis
cannot straighten leg when hip is flexed to 90 degrees (raise leg up, can't bend straight)
43
a GCS of 13-15 is considered what type of head injury?
a mild head injury
44
a GCS of 9-12 is considered what type of head injury?
a moderate head injury
45
a GCS of 3-8 is considered what type of head injury?
Severe head injury
46
Developmental considerations for a newborn from a neuro assessment perspective
Assess the newborn’s and infant’s cry, responsiveness, and adaptation
❖ Moro (Startle) reflex disappears in 3 months
❖ Babinski response Rooting reflex disappears in 3–4 months
❖ Tonic neck reflex disappears by 4–6 months
47
Developmental considerations for pediatrics from a neuro assessment perspective
pretty much similar to adults
- development takes place in an orderly progression but each develops at their own pace
- at 2 months, the posterior fontanel is closed, at 12-18 months, the anterior fontanel is closed
48
Developmental considerations for Autism from a neuro assessment perspective
- Developmental Screening
49
Developmental considerations for Older adults from a neuro assessment perspective
Decreased taste and scent sensation.
❖ Presbycusis (hearing loss)
❖ visual loss
❖ Tremors
❖ May have reduced muscle mass
- have slow/uncertain gait
- Decreased sensory
50
Presbycusis
- sensorineural hearing loss caused by
the natural aging of the auditory system affects the ability to hear higher-pitched (higher frequency) sounds.
51
Presbyopia
impaired near vision
52
how often does someone hav or die from a stroke
every 40 seconds have a stroke
every 4 minutes dies from. stroke
53
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)
❖ Alcohol and illegal drug use
❖ Certain medical conditions
❖ Lack of physical inactivity
❖ Overweight and obesity
❖ Stress and depression
❖ Unhealthy cholesterol levels
❖ Unhealthy diet
❖ Prolonged use of NSAID medications
54
FAST stands for
Face, Arms, Speech, Time to call 9-1-1
55
The musculoskeletal system consists of what 3 systems?
- bones
- joints
- muscles
56
What are the 5 functions of the Musculoskeletal system
- supports
- Allows for movement
- Encase and protect organs
- Produce RBC's
- Acts as a reservoir for minerals (Ca, Ph)
57
How many vertebrae does the body have?
and separate them out into sections?
33 Vertebral bodies
- 7 Cervical
- 12 Thoracic
- 5 Lumbar
- 5 Sacral (fused)
- 4 coccygeal (fused)
58
Joints, what are they?
What are the 2 types?
Joints (or articulations) are places of union of 2 or more bones
two types: non-synovial, synovial
59
What is in the Joint cavity?
- the opposing bones are covered by cartilage
- the joint is surrounded by ligaments - add strength
- Bursa (fluid-filled sacs)
60
Bursa
Enclosed sac located in areas of potential friction - help muscles and tendons glide smoothly over bones
61
What are the joints in the head?
- Temporamandibular (mandible, Temporal bone)
62
What are the joints in the upper extremities (3)
- Shoulder (glenohumeral joint)
- Elbow (Radius, Ulna, Humerus)
- Wrist (Radiocarpal joint)
63
What are the joints in the lower extremities? (3 things)
- Hip (Acetabulum, Femur)
- Knee (Femur, tibia, patella)
- Ankle (Tibia, Fibula, Talus)
64
What are the 8 major muscle groups
- Deltoid
- Biceps
- Triceps
- Pectoralis Major
- Abdominal
- Quadriceps
- Hamstrings
- Gastrocnemius
65
What are the 7 musculoskeletal movements of the body?
Flexion
Extension
Abduction
Adduction
Pronation
Supination
Inversion
Eversion
Protraction
Retraction
Elevation
Depression
Circumduction
Rotation
66
What is the Subjective (symptoms) Data questions for the musculoskeletal system
- Bone Problems?
- Joint Problems?
- Muscle Problems?
- Occupational Hazards?
- Falls?
- Self-care Behaviors (assistive devices)
67
What are the primary risk factors for impaired mobility (non-modifiable)
Aging
- Joint problems decrease mobility
- Risk of fractures (associated with osteoporosis)
- Genetic factors: Mutations that affect musculoskeletal, and nervous systems
68
What kinds of joint problems/diseases decrease mobility (5 things)
KILOG
- Osteoarthritis
- Gout
- Kyphosis
- Lower back pain
- Inflammatory Disorders
69
What are the primary risk factors for impaired mobility (modifiable)
- Nutrition
- Obesity: weight strains joints, destructs cartilage and other tissues; hinders movements
- Maternal nutrition before birth: folic acid
70
What health promotions can we do to protect the musculoskeletal system
- helmets, pads
- assistive devices
- Exercise: stretching, weight-bearing. low-impact
71
What are the 2 abuses of the musculoskeletal system?
- Repetitive movements
- Over-training
72
Objective Data: What is the purpose of the musculoskeletal examination?
- To assess function for ADLs and to screen for abnormalities
73
what 3 things are included in the objective data musculoskeletal assessment? What action are you doing when assessing?
- inspection
- palpation
- Range of motion: Grade muscle strength
74
Muscle test grading 0-5 Rating
0 - no muscular contraction: Paralysis
1 - Slight flicker of contraction
Strength Classification: Severe weakness
2 - Passive ROM (gravity removed and assisted by the examiner)
Strength Classification: Poor ROM
3 - Active motion against gravity
Strength Classification: Average weakness
4 - Active motion against some resistance Strength Classification: Slight weakness
5 - Active motion against full resistance Strength Classification: Normal
75
The musculoskeletal assessment for the Head?
includes TMJ
- hinge action
- Gliding action
76
The musculoskeletal assessment for the Spine?
How many bones?
Name for bone
What is the lateral view?
What does the motion consist of?
consists of 33 connecting bones
- intervertebral discs
- lateral view: double S shape
- Motions: flexion, extension, abduction, rotation
77
the musculoskeletal assessment for the shoulder consists of what 2 things?
What joint is here? and what bones connect the joints?
What motion does it have?
- Glenohumeral joint: Articulation of humerus with the glenoid fossa of the scapula, ball and socket
- Motions: flexion, hypertension, internal rotation, external rotation, abduction, adduction
78
what are the 3 bony landmarks on the shoulder?
- Acromion process: first bump off shoulder
- Greater tubercle: second down a few centimeters and laterally
- Coracoid process: medially
79
What are the three categories for the musculoskeletal assessment of the elbow?
Articulation?
Bony landmarks?
Motion?
- Articulation of humerus, radius, and ulna
- Bony landmarks: medial and lateral epicondyles
- Motion: flexion, extension, pronation, supination
80
What are the 3 categories for the musculoskeletal assessment of the wrist?
Articulation?
What joint is here?
What motion does it possess?
- Wrist and carpals: Articulation of the radius and a row of carpals
- radiocarpal joint
- Motion: Flexion, extension, side to side, pronation, supination
81
What are the 3 categories for the musculoskeletal assessment of the Hands, Wrist, and Fingers?
1. Inspect what?
2. You know...
3. Test what?
- Inspect for size, shape, deformities, redness, or swelling
- Palpate
- test active ROM with and without resistance
82
What are the 4 categories for the musculoskeletal assessment of the Hand?
- Metacarpophalangeal (MCP)
- Articulation between metacarpals and phalanges
- Proximal interphalangeal - PIP
- Distal interphalangeal - DIP
- Motion: extension, flexion, hyperextension, radial/ulnar deviation, Adduction
83
What are the 4 categories for the musculoskeletal assessment of the Hip?
Articulation?
What type of joint?
Bony landmarks?
Motion?
- Articulation between acetabulum and head of the femur
- Ball and socket joint
- Bony landmarks: Anterior superior iliac spine, ischial tuberosity, greater trochanter
- Motion: flexion, extension, internal rotation, external rotation, abduction, adduction
84
What are the 5 categories for the musculoskeletal assessment of the Knee?
- Articulation?
- How would you describe the size of the knee?
- What type of joint is it?
- What are its bony landmarks?
- What is its motion?
- Articulation of femur, tibia, and patella
Largest joint, complex
Hinge-type
Bony landmarks: tibial tuberosity
Motion: flexion, extension
85
What are the 4 categories for the musculoskeletal assessment of the Ankle and Foot?
What type of joint?
Articulation of what?
Bony landmarks?
Motion?
- Articulation of tibia, fibula and talus
Hinge joint
Bony Landmarks: medial malleolus (useful for posterior tibial pulse), lateral malleolus
Motions: inversion, eversion, dorsiflexion, plantar
flexion
86
Musculoskeletal assessment: when inspecting the patient's body from a distance, what are 6 Normal findings for adults?
- includes patients' movement
- 2 has to do with inflammation
Erect posture and spine
Fullness to muscles
Symmetrical range of motion (ROM)
No deformities
No swelling
No warmth or redness to joints
87
Lifespan considerations for the musculoskeletal assessment
For infants?
Children?
Older adults?
Pregnant individuals?
(all have to do with negative things)
- Alterations more prevalent in certain age groups
Infants, and children may have genetic disorders or congenital malformations
Children, adolescents, and young adults prone to trauma from sports, abuse or accidents
Older adults present inflammatory and “wear-and-tear” problems
Pregnant individuals may have a decreased range of motion (ROM) and increased back pain
88
Lifespan considerations for the Newborn musculoskeletal system?
What to look for specifically (6 things)
Musculoskeletal so bones. muscle
- Clavicle
- Palmar simian crease
- Congenital Hip Dysplasia
- Spina Bifida
- Polydactyly syndactyly
- Fontanelles
89
Lifespan consideration for an infant
- Why is this age crucial?
- What is the difference in spinal curvature
- what is important about the skull?
- Posterior and anterior fontanelle close at what months of age
Greatest growth rate
C-shaped spinal curve at birth in comparison to the double S curvature that is present in late adolescence
Skull is not rigid during infancy, and the sutures of the cranium do not fuse completely until approximately 12 to 18 months of age
Posterior fontanelle closes at 2-3 months
Anterior fontanelle closes between 1-3 years of age
90
Pediatric/adolescent Considerations for musculoskeletal System
What are we looking at for the musculoskeletal system?
- What spine disorders should we consider for both age groups?
- Gait
Spine
- Lordosis in Toddlers
- Scoliosis in School-age children/adolescent patients
91
Older adult Lifespan considerations for the musculoskeletal system
What are we worrying about for older adults for musculoskeletal?
- Osteomalacia
- Osteoporosis
- Joint and disk cartilage dehydrates, loss of flexibility contributes to degenerative joint disease (osteoarthritis); joints stiffen, lose range of motion
92
Older clients typically have
What kind of movement?
What kind of flexibility?
muscle strength?
Anything with the spine?
Change in senses?
Slower movement, reduced flexibility, and decreased muscle strength
- Kyphosis
- Impaired sense of position in space, can cause falling
93
What is arthritis?
Inflammatory condition of the joints, characterized by pain, swelling, heat, redness, and limitation of movement
94
Osteoarthritis
- What is it?
- how does it start?
- What bones in the body does it typically involve?
- Cartilage starts to break down, becomes rough, wears away: Allows bone to rub on bone
- Particles break off joint, irritate synovial tissue: Pain and stiffness, inflammation and swelling
- Slow-developing changes to synovium, subchondral bone, cartilage
Typically involves
- Weight-bearing joint of hips, knees
- Digits of hand, big toe
- Cervical and lumbar spine
95
Clinical Manifestation of Osteoarthritis
- How does it begin?
- How do symptoms vary?
What happens when you do activities?
What happens when you don't move for a while?
When you touch it is it tender or soft?
what is the noise called ith osteoarthritis?
- How is the range of motion (ROM)
- It begins with mild symptoms, and progressively worsens
Symptoms vary depending on the affected joint,individual factors
Joint pain
Worsened by activity, relieved by rest
Pain, and stiffness associated with prolonged inactivity such as sleeping or taking a long car ride
Tenderness to touch
Swelling related to excess fluid in joint
Crepitus of joint
Bone spurs
Decreased range of motion (ROM)
96
Clinical Manifestation of Osteoarthritis
- What are the complications as conditions worse?
Joints?
What happens with taking medications?
- Financial health for the patient?
- Mental development of...?
- May lead to difficulty in what social aspect?
Joint pain, degeneration, stiffness
Unsteady gait
Increased risk of falling as side effect of some medications
Decreased ability to perform activities of daily living (ADLs),
work responsibilities
Financial difficulties resulting from cost of treatment, lost
wages
Development of depression, anxiety, feelings of helplessness
May lead to difficulty participating in social, family activities
97
What are the 5 Risk factors of osteoarthritis
What is the greatest risk factor?
woman and OA?
Mcdonalds
- What are the medical conditions
- Family history?
- Older age: greatest risk factor
Approximately 40% are over age 65, just over 85% are over age 45
- 60% of people with OA are women
Men: OA in hips, knees, spine
Women: OA in hips, knees, hands
- Obesity
- Certain medical conditions
Malformed joints or defective cartilage
Diabetes, hypothyroid, gout, Paget disease
Joint injuries from sports, accidents, repetitive use
- Individuals with family member who has OA have higher risk of developing OA
98
5 Osteoporosis Health Promotion Opportunities
Maintain ideal body weight
Participate regularly in moderate exercise program
Use good posture, proper body mechanics
Avoid repetitive stress on joints
Seek treatment immediately if joint is injured
99
Osteoporosis
What are the risks for men and women that they will receive a fractured bone
- What percent of osteoporosis is accounted for by Europeans and Americans
- Which ethnicity has the lowest risk and which has the highest risk?
1 out of 3 women and 1out of 5
men will have a fractured bone.
Europeans and Americans
accounted for 51% of
osteoporosis-related fractures
Osteoporosis is lowest in black
males and highest in white
females.
100
What are Osteoproris uncontrollable risk factors?
Age, gender, family history, previous fracture, ethnicity,
menopause/hysterectomy, long-term glucocorticoid therapy,
rheumatoid arthritis, primary/secondary hypogonadism in
men
101
What are Osteoporosis 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
102
What are the 5 risk reductions for osteoporosis?
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.
103
Spinal Cord Injuries (SCI)
- what is the leading cause of SCI for uounger individuals
- What is a leading cause for SCI for people over 65?
Motor vehicle accidents
- Falls
104
Layers of the skin
what are the 3?
What are there descriptions?
Epidermis: outer layer
- thin except for palms and soles
- protective barrier
- avascular
- Contains melanocytes
dermis: Inner, supportive layer
- consists of connective tissue or collagen
- Elastic tissue
- Blood vessels, nerves, hair follicles, sweat and sebaceous glands
subcutaneous:
- lies below dermis
- adipose tissue
- Stores fat for energy
-Provides insulation for temperature control
105
Hair
- what is it made up of?
- where are cells produced?
What are the two types of hair and what are their description?
- Made from keratin, shaft, and root
- Cells produced in bulb matrix at the root
- Growth cyclical
Vellus hair: fine, faint
- Covers most of the body
Terminal hair: dark, thick
- Grows on the scalp, eyebrows, axillae, pubic area, face
106
Nails
- consists of hard plates of what material?
The nail plate is what?
What is a lunula?
What is the nail matrix?
Hard plates of keratin
Nail plate is clear
Vascular epithelial cell under nail bed – pink color
Lunula – white, opaque semilunar area at the proximal end of nail
Matrix is site of nail growth
107
Sebaceous glands
- What do they produce?
- What is their function?
- Where are they found?
- Produce sebum, a productive lipid substance
- Oils and lubricates skin and hair
- Found on scalp, face, forehead, chin
108
Sweat Glands
what are these glands called
- what do they do?
Eccrine glands
- Open directly on skin surface
- Produce sweat
- Regulates body temperature
109
Apocrine glands
Where do they open into
- what do they secrete
- where is it located?
- when is it active
- open into hair follicles
- secrete thick, milky substance
- located mainly axillae and genital areas
- Active during puberty
110
integumentary Subjective data: What 6 symptoms are we looking at for the history of skin illness?
- skin problems (rash, dryness, swelling, bruising)
- changes in lesion appearance
- sensation changes
- body odor problems
- Hair loss or changes
- Nail changes
111
Subjective data: What 5 categories are we finding for the integumentary history of the patient?
- Personal health history
- Family history
- medications
- Self-care
Lifestyle and health practices
112
Integumentary (skin) system: health promotion for skin cancer
Reduce: reduce skin exposure
Use: Always use sunscreen when sun exposure is anticipated
Wear: Wear long-sleeve shirts and wide-brimmed hats
Avoid: Avoid sunburn
Wear: Wear sunglasses that wrap around
Understand: understand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on developing cancers
Have: Have annual skin cancer screenings
113
How to examine the skin for early detection?
ABCDE
Asymmetry
Border
Color
Diameter
Evolution (changes over time)
114
HEALTH PROMOTION OPPORTUNITY:
Ways to reduce risk of pressure ulcers
- Inspect the skin daily and more often (Braden scale or PUSH tool)
- Bathe with mild soap or other agent ; limit friction; use warm, not hot, water; set bath schedule that is individualized
- Moisturize skin and maintain hydration levels
115
ASSESS FOR PRESSURE ULCER
RISK FACTORS: Braden scale assess for what 6 things?
- perception
- mobility
- moisture
- nutrition
- friction or shear aginst surfaces
- Tissue tolerance decreased
116
the braden scale: Sensory 1-4
1- completely limited: unresponsive to pain
2- very limited: responds only to painful stimuli, cannot verbalize
3- slightly limited: responds to verbal commands but cannot always communicate discomfort
4- no impairment: responds and can voice pain
117
Objective Data (skin): You do a skin assessment with what 2 techniques
inspection and palpation
118
objective data (skin): What 4 things does the inspection involve
Inspection
- General pigmentation
- Lesions
- Benign
- Malignant
119
The Fitzpatrick classification scale for skin types: Type I
Type I
Features: pale white skin/ red or blonde hair/ blue eyes/ freckles
Characteristics: Always burns never tans
120
The Fitzpatrick classification scale for skin types: Type II
features: white or fair skin/ red or blond hair/ blue, hazel, or green eyes
Characteristics: usually burns, tans with difficulty
121
The Fitzpatrick classification scale for skin types: Type III
Features: Cream white or fair skin/ any eye or hair color
Characteristics: Gradually tans, sometimes has a mild burn
122
The Fitzpatrick classification scale for skin types: Type IV
Features: light brown skin
characteristics: Tans with ease, rarely burns
123
The Fitzpatrick classification scale for skin types: Type V
Features: Dark brown skin
Characteristics: Tans very easily, very rarely burns
124
The Fitzpatrick classification scale for skin types: Type VI
Features: Deeply pigmented dark brown
Characteristics: Tans very easily, never burns
125
Skin assessment: What 4 things are we looking for when there is a widespread color change?
pallor
erythema
cyanosis
jaundice
126
When looking at lesions, and whether they are benign or malignant, what 5 things are we looking for in a lesion (mole)
Color (Brown, red, blue? Consistent throughout?
Elevation (Flat, raised, pedunculated?)
Pattern/Shape (Linear, circular, grouped?)
Size (cm)
Location/Distribution (Generalized or localized?)
Exudate? (color, amount, consistency, odor?)
127
What do benign lesions consist of and what is their further description?
vascular
- Angiomas
Pigmented
- Ephelides
- Nevus
extra benign lesion
- vesicle
- Bulla
- crust
- papule
- cyst
- Keloid
128
For malignant lesions, what do we memorize for findings of concern?
ABCDE
Asymmetry
Border irregularity
Color variation
Diameter - >6mm
Elevation
129
When doing (objective data) palpation of the skin, what are we feeling for?
- temperature
- moisture
- texture
- turgor
- edema
130
When doing objective data inspection of the Hair, what are we looking at/for? (4 things)
-color
-distribution
-lesions
-infestations
131
When doing objective data inspection of the Nails, what are we looking at/for? (3 things)
- Color
- Shape/contour
- Texture/ Consistency
132
what does nail clubbing show?
Pulmonary and Cardiovascular Disease
133
When palpating the nails, what 2 things are we looking for?
- Texture/consistency
- Capillary refill
134
What are the 8 risk factors for skin cancer (need to know all for the exam!)
Nonsolar sources of ultraviolet radiation
Medical therapies
Family history and genetic susceptibility
Moles
Pigmentation irregularities
Fair skin that burns and freckles easily; light hair
Age
Actinic keratosis
Male gender
Chemical exposure
Human papillomavirus
Long-term skin inflammation or injury
Alcohol intake; smoking
Inadequate niacin in diet
Depressed immune system
135
What is the most common of all cancers?
Skin cancer
136
what are the 3 types of skin cancer?
- Basal cell (small, fleshy bumps)
- Squamous cell skin cancer (red, or pink scaly patches)
- Melanoma
137
Melanoma
What color can they be?
where do they grow?
Usually brown or black, but they can be blue, red, or a combination of colors.
They can also have no color.
Melanomas can grow anywhere on the skin but are more likely to start in certain locations.
Trunk (men), Legs (women), Neck, Face
138
What is the PUSH tool
it is a tool used to evaluate a pressure ulcer that is already in existence
139
What are the characteristics of the skin of a newborn?
What is the color?
At 24-36 hrs what is the skin description?
- what is the turgor
What is the white cheesy substance on the skin called?
May physiologically show what?
Skin reddish in color, smooth and puffy at birth
At 24 - 36 hours of age, skin flaky, dry and pink in color
Turgor good with quick recoil
Vernix caseosa
Jaundice
140
What is vernix caseosa? know for exam!!!
white, cheesy substance covering the newborn's body. Often present only in the skin folds.
141
What are the 3 common newborn skin variations
- Mongolian spots
- Milia
- Mottling
142
Mongolian spots, what are they?
Patch of dark pigmented skin distributed over coccygeal and sacral regions of infants of AA or Asian descent. Not malignant
143
Milia, what is it?
where is it located?
Tiny white papules (plugged sebaceous glands) located over nose, cheek and chin
144
Mottling, what is it?
Whats the color?
Generalized red and white discoloration of skin of chilled infants with fair complexion
145
What is lanugo?
at what point does it disappear?
Fine, downy body hair distributed over the shoulder, sacral area, and back of newborns
- usually disappears before birth or shortly after birth
146
newborn hair description
- Hair silky and soft with individual strands vellus
Through childhood there is a gradual transition from vellus to intermediate and then terminal hairs longer coarser and pigmented.
147
Adolescents skin see an increase in...
Hair growth
- sebaceous gland activity (Acne)
148
Pregnant individuals skin
Is there an increase in pigmentation?
where is this inc. pigmentation
What 3 other things are affect the pregnant individuals skin?
Increased pigmentation
- Areolae, nipples
- vulva
- abdomen
- face
- Vascular spiders
- Palmar erythema
- Striae Gravidarum
149
Older adults skin
What 4 things change in older adults skin characteristics?
What 2 other things are affected?
Skin
Elasticity
Collagen
Apocrine and Sebaceous Glands
Lesions
Hair - decreased melanocytes
- nail growth slows
150
learn the face anatomy, neck anatomy, and
take online quizzes
151
how many vertebrae in the cervical vertebrae
What do the cervical vertebrae do?
how many pairs of nerves?
7
C1-C7
- Support and promote the movement of the head and neck
8 pairs of cervical nerves
152
What are the 10 lymph nodes on the head ad neck
preoricular
- postoricular
- submandibular
- submental
- occipital
- superficial (anterior) cervical
- posterior cervical
- Supraclavicular
- Deep cervical chain
153
Subjective Data for the Head/face/neck assessment
- headache
-head injury
- dizziness
- neck pain
- problems with ROM
- facial pain
- lumps or swelling
- injury/ trauma/ surgery
- medications
- lifestyle: ETOH or tobacco
154
Sinus headache description
-Character: deep, constant, throbbing pain; pressure-like pain in one specific area of the face or head
- Onset/precipitating factor: occurs with or without cold, acute sinusitis or acute febrile illness with purulent discharge from the nose
Location: on one area of the face or along the eyebrow
Severity: mod. severe
155
cluster headache desc.
character: Stabbing pain; may be accompanied by tearing, eyelid drooping, reddened eye, or runny nose
- Onset/ precipitating factors: sudden onset; drinking alcohol starts it
- Location: localized in eye and orbit and radiating to the facial/temporal regions
severity: intense
156
Tension headache description
character: Dull, tight, diffuse
- Onset/precipitating factors: no prodromal stage; may occur with stress, anxiety, or depression
- location: Usually located in the frontal, temporal, or occipital region
- Severity: aching
157
Migraine headache description
Character: Accompanied by nausea, vomiting, and sensitivity to noise or light
- onset/precipitating factors: vertigo. numbness or tingling, anxiety, alcohol, and other client sensitivity
- Location: around eyes, temples. cheeks forehead, may affect only one side of the face
- Severity: Throbbing, severe
158
tumor-related headache description
Character: aching, steady; nausea, vomiting may develop
onset/precipitating factors: no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head
Location: depends on the location of the tumor
Severity: varies; occurs in the morning
159
head/face/neck risk factors for infants and toddlers
What are the environmental risks focused on? what injury?
- environmental risk (for falls)
- Lack of parental knowledge of shaken baby syndrome
- Caregivers risk of shake baby syndrome
160
head/face/neck risk factors for children and teens
safe practices while driving
161
head/face/neck risk factors for adults and older adults (what things can affect the head/face/neck?)
- safe driving
- domestic violence
- impairment of physical or mental stability
162
TBI
what does it stand for?
what does it mean?
What causes TBI's?
Def: disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury
-Driving acidents
- Violence to the head
- Falling
- Alcohol ingestion
163
Risk reduction/ health promotion opportunity: what can we do to keep us safe from injuries to head/face/neck?
- Using a seat belt
- Making sure the living area is safe for children
- Wear a helmet when necessary
- don't Drink and Drive
- Exercise
164
what are we looking for when inspecting head/skull?
- size and shape
165
what are we looking for when inspecting face?
- symmetry
- Movement
- Expression
- Cranial nerve function
166
what are we looking for when inspecting Neck?
- Symmetry
167
what are we looking for when palpating head?
contour
texture
tenderness
168
what are we looking for when palpating Face?
contour
texture
pulses
sinuses
169
what 3 things are we palpating in the neck?
Trachea
Thyroid gland
Lymph nodes
170
what are we looking for when testing the ROM of the neck?
What actions are we performing to test this?
motor function
- rotate head against resistance
- shrug shoulders against resistance
(shoulder shrug and head movement intact and equal bilaterally)
171
For infants and children, what are we asking (the PARENTS) when asking subjective data? (things we cannot assess but can ask)
- any use of drugs or alcohol
- how did baby grow in womb/afterwards
172
For infants and children, what are we assessing when checking objective data?
Fontanels
- Anterior
- Posterior
Head circumference: Chest circumference
Lymphoid tissue (can palpate before 6yrs)
173
how do we measure infants head circumference
we measure the largest circumference of the had with measuring tape
174
what are the 5 Abnormal findings in the Head/face/neck assessment
- hydrocephalus: inc. ICP bc of obstruction in drainage of CSF
- Paget disease: a bone disease that softens the bone
- Acromegaly: excessive secretion of growth hormone from pituitary gland/ large skull, bones get thicker
- Torticollis: (aka wryneck) hematoma in one sternomastoid muscle; Result of how the fetus was in the womb
- Pilar cyst: Cyst on the scalp at the base of the hair follicle (benign)
175
Braden scale: Moisture 1-4
1- constantly moist
2- moist: often but not always
3- occasionally moist: occasionally moist
4- rarely moist: skin usually dry
176
Braden scale: Activity 1-4
1. Bedfast: confined to bed
2. chair fast: limited ability to walk
3. walks occasionally: can do very short distances
4. Walks frequently: walks out the room twice a day
177
Braden scale: Mobility 1-4
1. completely immobile
2. very limited
3. slightly limited
4. no limitations
178
Braden Scale: Nutrition 1-4
1. very poor: never eats a complete meal
2. Probably inadequate: rarely eats all food
3. adequate: over half of meals
4. Excellent
179
Braden Scale: Friction and Shear 1-3
1. Problem: moves in bed: requires help
2. Potential problem: requires minimum assistance
3. No apparent problem
180
cerebellum
motor condition, equilibrium, balance
181
Cerebral cortex:
left lateral view
182
Temporal lobe:
Hearing, taste, smell
183
Broca’s area:
motor speech
184
Frontal lobe:
Personality, behavior, emotion, intellectual functions
185
Precentral gyrus:
Primary motor area
186
Central sulcus:
Trunk, hand, fingers, face, lips, tongue
187
Postcentral gyrus:
primary sensory area
188
Parietal lobe:
sensation
189
-Wernickes area:
Speech comprehension
190
Occipital lobe:
Visual reception
