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Health Assessment > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Nociceptive pain (NP)

A

o specialized nerve endings located in the cutaneous and deep musculoskeletal tissue that detect painful stimuli from the periphery and communicate this information to the CNS

o Nociceptors carry pain signal to the CNS by two primary sensory (afferent) fibers: Aδ and C fibers

o NP starts outside of the nervous system from actual or potential tissue damage. It has 4 phases.

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2
Q

Know the 4 phases of Nociception

A

o Transduction

o Transmission

o Perception

o Modulation

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3
Q

Transduction

A

noxious stimulus takes place in periphery

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4
Q

Transmission

A

pain impulse moves from spinal cord to brain

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5
Q

Perception

A

conscious awareness of painful sensation

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6
Q

Modulation

A

inhibition of pain message

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7
Q

neuropathic pain (NEP)

A

o results from an abnormal processing of the pain message from an injury to nerve fibers

o Pain is described as: Constant dull ache, Burning, Stabbing, Electric shock, Tingling

o Much more difficult to assess and treat

o Nociceptive pain can develop into Neuropathic pain if poorly controlled

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8
Q

what can cause neuropathic pain

A

diabetes mellitus, shingles (herpes zoster), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, chemotherapy, stroke, multiple sclerosis, tumor

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9
Q

visceral pain

A

originates from larger internal organs (stomach, intestine, gallbladder, pancreas); described as dull, deep, squeezing, or cramping

pain impulses transmitted along the autonomic nervous system (ANS)

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10
Q

deep somatic pain

A

comes from blood vessels, joints, tendons, muscles, bone; may result from pressure, trauma, or ischemia

  • pain feels aching or throbbing
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11
Q

cutaneous pain

A

derived from skin surface and subQ tissues

pain feels sharp, superficial, burning

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12
Q

referred pain

A

pain felt in a site different from pain origin (pain is referred to where the organ was located in fetal development)

(Ex. Appendix felt in umbilical region)

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13
Q

Acute pain

A

Short-term self limiting; often follows a predictable trajectory and dissipates after an injury heals

-Serves as a protective measure

-Ceases after an injury heals

ex. surgery, trauma, kidney stones

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14
Q

Chronic (persistent) pain

A

Greater than 6 months

  • malignant or non-malignant
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15
Q

Recognize nonverbal behaviors associated with pain

A

guarding, grimacing, moaning, agitation, restlessness, stillness, diaphoresis, change in vital signs

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16
Q

developmental variations in pain for the aging adult

A

pain is a common experience among 65yo and older, but is not normal

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17
Q

Understand the physiologic effect of pain on vital signs

A

cardiac (tachycardia, increased BP)

pulmonary (hypoventilation, hypoxia, atelectasis)

gastrointestinal (nausea, vomiting)

renal (oliguria, urinary retention)

musculoskeletal (spasms, joint stiffness)

central nervous system (fear, anxiety, fatigue)

immune (impaired wound healing)

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18
Q

developmental variations in pain for the infant

A

changes in facial activity and body movements may help in deciphering pain in infants; CRIES score is a tool for postoperative pain in neonates; FLACC is another tool used

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19
Q

how to test cerebellum

A

-Rhomberg’s: swaying side to side while standing and eyes closed

-Finger-to-nose (“point to point”) testing

-Heel-knee-shin

-Rapid Alternating Movements in UE & LE

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20
Q

pain rating scales for children

A

faces pain scale or oucher scale, CRIES scale, FLACC scale

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21
Q

Reinforcement for patellar reflex

A

Crossing arms

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22
Q

pain rating scales for adults

A

PQRST

initial pain assessment

brief pain inventory

short-form McGill Pain questionnaire

pain-rating scales

numeric rating scales

verbal descriptor scale

visual analogue scale

descriptor scale

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23
Q

the normal changes in mental status and neurological findings frequently seen with aging

A
  • Expect slower response
  • Observe for tremors
  • Peripheral sensation may be slightly diminished
  • DTRs less brisk
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24
Q

CRIES scale

A

crying, requires O2, increased vital signs, expression, sleeplessness

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25
Q

what subjective data do adults have for the neuro system

A

headache, head injuries, weakness, seizures, dizziness/vertigo, tremors, weakness, incoordination, numbness/tingling, trouble swallowing

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26
Q

FLACC scale

A

face, legs, activity, cry, consolability

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27
Q

what subjective data do children have for the neuro system

A

prenatal history, family history, balance, reflexes, if baby is pre-term, developmental issues/learning disabilities, environmental exposure (lead), if they play sports (concussion)

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28
Q

PAINAD scale

A

pain assessment in advanced dementia

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29
Q

how to perform objective examination

A

metal status, cranial nerves, motor system (tandom walk), sensory systems, reflexes, glasgow coma scale

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30
Q

initial pain assessment

A

asks the pt to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors

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31
Q

types of neurological screening

A

screening neurologic exam, complete neurologic exam, neurologic check

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32
Q

numeric rating scale

A

asks a pt to choose a number that rates the level of pain for each painful site; 0 is no pain 10 is excruciating pain

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33
Q

who do we use a screening neurologic exam for

A

healthy people with no significant history

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34
Q

what is the PQRST method of pain assessment?

A

provocation/palliation, quality/quantity, region/radiation, severity scale, timing

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35
Q

who do we use a complete neurologic exam for

A

people who have neurologic concerns (headache, weakness, loss of coordination)

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36
Q

who do we use a neurologic check on

A

hospital pt with head trauma or neurological defect (stroke, seizure, brain surgery); done frequently (abt every 15 min)

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37
Q

How do we test for mental status

A

Using ABCT (appearance, behavior, cognitive abilities, and thought processes and perceptions

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38
Q

What do we look for in appearance test

A

posture, dress, grooming, and hygiene

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39
Q

What do we look for in behavior test

A

LOC, facial expression, speech, and mood/affect

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40
Q

What do we look for in cognitive abilities test

A

Orientation (person place and time (not clock time)). Recent memory (what did you eat this morning), and remote memory (who was our previous president).

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41
Q

What do we look for in a thoughts processes and perceptions test

A

Reasoning (what does looking for a needle in a haystack mean), and judgement (ask about job plans, family obligations and plans for future)

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42
Q

Cranial Nerve 1

A

Olfactory nerve

Sensory

š-(not tested routinely)

š -Check patency of nares!!

š -With person’s eyes closed, occlude one nostril and present familiar aromatic substance, e.g., coffee, orange, vanilla, soap, or peppermint

šš -Normally, person can identify an odor on each side of nose; normally decreased with aging; any asymmetry in sense of smell is important

šš -Abnormal: anosmia – upper respiratory infection, tobacco or cocaine use, frontal lobe lesion

43
Q

Cranial Nerve 2

A

Optic Nerve

Motor

šTest visual acuity:

š -Describe use of Snellen Chart, 20/200

š -Demonstrate use of Hand Held Vision Screener and interpret

43
Q

Cranial Nerve 3

A

Oculomotor

Motor

š -PERRLAC: Check pupils for equal size/round, reactive (direct and consensual), accommodation, and convergence

š -Abnormal with tumor/lesion, increased intracranial pressure (unilateral dilation, nonreactive pupil), neuromuscular disease

43
Q

Cranial Nerve 5

A

Trigeminal Nerve (Facial)

Motor and Sensory

*Motor function: palpating temporal and masseter muscles as person clenches teeth, try to separate jaws by pushing down on chin

*Sensory function: with person’s eyes closed, test light touch sensation by touching a cotton wisp to forehead, cheeks, and chin

44
Q

Cranial Nerve 7

A

Facial Nerve

Motor and Sensory

šMotor function:

šš -Note mobility and facial symmetry as person responds to requests to smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth, puff cheeks

šš -Abnormal in stroke or Bell Palsy

šSensory function: (not tested routinely)

š -Test only when you suspect facial nerve injury

šš -Describe, test sense of taste by applying cotton applicator covered with solution of sugar, salt, or lemon juice to tongue and ask person to identify taste

šš -Anterior 2/3 of tongue

44
Q

Cranial Nerve 8

A

Acoustic Nerve (Vestibulocochlear)

Sensory

šTest hearing acuity by ability to hear spoken word whisper test

45
Q

Cranial Nerve 11

A

Spinal Accessory Nerve

Motor

ššš -Symmetry of muscles of neck/shoulders

ššš -Check equal strength by asking person to rotate head against resistance applied to side of chin

ššš -Ask person to shrug shoulders against resistance

ššš -These movements should feel equally strong on both sides

ššš -Abnormal – stroke (opposite side of lesion)

46
Q

Cranial Nerve 12

A

Hypoglossal Nerve

Motor

šššš -Note forward thrust in midline as person protrudes tongue

šššš -Ask person to say “light, tight, dynamite,” and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct

šššš -Abnormal – tongue deviates to side of lesion/stroke

47
Q

how to test motor system

A

šBalance Tests

š - Gait (normal and tandem)

š - Romberg Test – 20 seconds. State results

48
Q

how to test sensory system

A

Peripheral Pain:

  • Sharp/dull extremities
  • Abnormal: peripheral neuropathy (diabetes, peripheral arterial disease)
49
Q

what are reflexes and what are the four types of them

A

šReflexes: basic defense mechanisms of nervous system

š-Involuntary

below level of conscious control permitting quick reaction to potentially painful or damaging situations

šFour types of reflexes:

š - Deep tendon reflexes (myotatic), e.g., knee jerk

š. - Superficial, e.g., corneal reflex, abdominal reflex

š - Visceral, e.g., pupillary response to light

š - Pathologic (abnormal), e.g., Babinski’s reflex or extensor plantar reflex

50
Q

Recognize the normal primitive reflexes seen in the infant

A

šHave primitive reflexes resolved at normal time?Rooting – brush cheek (birth to 3 – 4 months)

šSucking – birth to 10 – 12 months

šPalmar grasp - birth to 3 – 4 months

šBabinski reflex – toes fan (positive Babinski) birth to about 2 years

šTonic neck

šMoro Reflex

šPlacing and Stepping Reflex

51
Q

Know how to assess LOC and the importance of doing such

A

Level of consciousness (change is earliest and most sensitive index of change in neurologic status), Orientation, Motor function - strength extremities (follow commands), facial movement, arm drift; Pupillary Response (PERRLAC); Vital Signs, including Glasgow Coma Scale

52
Q

Spasticity

A

types of increased resistance that occur with central weakness

53
Q

Paralysis

A

loss of ability to move and sometimes feel

54
Q

Flaccidity

A

decreased muscle tone; muscle feels limp/soft/flabby

55
Q

Rest tremor

A

when a person’s hands/legs shake when they are at rest; often only affects hands

56
Q

Intention tremor

A

increases as an extremity approaches the endpoint of deliberate and visually guided movement (like when someone cannot feed themselves because their hand shakes so much upon completion of moving a spoon to their mouth)

57
Q

Opisthotonos

A

when someone holds their body in an awkward position

58
Q

Decorticate rigidity or posturing

A

flexion of arm, wrist, fingers; arm tight against thorax; lower extremity internal rotation

59
Q

Decerebrate rigidity or posturing

A

upper extremities stiffly extended; palms pronated; teeth clenched; hyperextended back

60
Q

What does the Central Nervous System consist of?

A

brain and spinal cord

61
Q

Kinesthesia test

A

tests a person’s ability to perceive passive movements of the extremities; move fingers/toes up and down and ask pt to tell you which way it moved

62
Q

Stereognosis test

A

tests pt ability to recognize objects by feeling their forms, sizes and weights; close pt eyes, place a familiar object into hand, ask them to identify

63
Q

Graphesthesia test

A

tests pt ability to read a number or letter by having it traced in the skin; close pt eyes and using a blunt instrument trace a single digit into palm, ask them to identify

64
Q

Perception test

A

test pt ability to distinguish two separate points on the skin; apply 2 points of percussion hammer (sharp/dull) on skin and have pt note different points

65
Q

Romberg test (include what a negative and positive Romberg test means/indicates)

A

tests pt balance and posture; have pt stand with feet and arms together with eyes closed for 20 seconds and maintain balance/posture

66
Q

6 reflexes tested in the Neurological System

A

biceps

triceps

brachioradialis

patella

achilles

plantar/babinski

67
Q

Paraplegia

A

symmetric paralysis (two extremities)

68
Q

Quadriplegia

A

paralysis of all four extremities

69
Q

What is the primary purpose of the Glascow Coma Scale?

A

Used to asses a pt’s level of consciousness and assess functional state of the brain as a whole

*Monitor LOC over time (improving or deteriorating)

70
Q

What is the highest and lowest score you can receive on the Glascow Coma Scale?

A

*Total Numeric value: highest 15, lowest 3, less than 7 coma

71
Q

How do we get the Glascow Coma Scale score?

A
  • Eye Opening: 1 - 4
  • Motor Response: 1 - 6
  • Verbal Response: 1 - 5
72
Q

What does the finger to nose test allow assessment of?

A

assesses coordinated, smooth, skilled movement and fine motor function

73
Q

an abbreviated mental status examination is generally conducted when

A

The interview process, frequently upon admission to the hospital. It is a 10 point test for rapidly assessing elderly patients for possibility of dementia

74
Q

Deep tendon reflexes

A

š- Reveals intactness of reflex arc at specific spinal levels

š- Limb should be relaxed and muscle partially stretched

š- Stimulate reflex by directing short, snappy blow of reflex hammer onto muscle’s insertion tendon

š- Compare right and left sides: responses should be equal

šReflex response graded on 4-point scale

š4 = very brisk, hyperactive with clonus, indicative of disease

š3 = brisker than average, may indicate disease

š2 = Average, normal

š1 = diminished, low normal, or occurs with reinforcement

š0 = no response

75
Q

bicep reflexes

A

contraction of biceps muscle and flexion of forearm

76
Q

tricep reflexes

A

extension of forearm

77
Q

Brachioradialis reflexes

A

flexion and supination of forearm

78
Q

Patellar or Quadriceps reflex

A

extension of lower leg

79
Q

Achilles reflex

A

foot plantar against hand

80
Q

Superficial (Cutaneous) Reflex

A

Plantar/Babinski Reflex

  • plantar flexion of toes and inversion/flexion of forefoot (toes should curl for adults but fan for infants)

Interpret response

“positive or negative Babinski”

81
Q

Cranial Nerves 3, 4, 6

A

Oculomotor

Trochlear

Abducens

Motor

  • Assess extraocular movements (EOMs) by cardinal positions of gaze

*Results: Expect parallel tracking with no nystagmus.

*Nystagmus – disease of vestibular system, cerebellum, or brainstem

82
Q

Cranial nerves IX and X:

A

Glossopharyngeal and Vagus Nerves

Motor and Sensory

šMotor function

š -Clarity of speech, ability to swallow, and note pharyngeal movement as person says “ahhh”; uvula and soft palate should rise in midline

šš -(NOT DOING) Verbalize - touch posterior pharyngeal wall with tongue blade, and note gag reflex

Sensory Function

šš -(NOT DOING) Verbalize - sense of taste posterior third of tongue

šš -Abnormal: Stroke, risk for aspiration

83
Q

what are the 12 cranial nerves (number and name)

A

I. olfactory

II. optic

III. occulomotor

IV. trochlear

V. trigeminal

VI. abducens

VII. facial

VIII. acoustic

IX. glossopharyngeal

X. vagus

XI. spinal accessory

XII. hypoglossal

84
Q

Negative Romberg test

A

pt has normal balance and posture

85
Q

Positive Romberg test

A

pt had loss of balance/posture

86
Q

what is the expected response seen with the triceps reflex

A

extension of forearm

87
Q

infants/children and mental status

A

emotional and cognitive functions develop over time

88
Q

aging adults and mental status

A

no decrease in general knowledge/vocab; response time may be slower; recent memory decreased by remote memory not; some sensory loss

89
Q

what is the Four Unrelated Words test and why is it used?

A

tests a pt’s ability to lay down new memories; highly sensitive and valid memory test; used for alzheimer dementia pts, anxiety pts, and depression

90
Q

risk factors for suicide and how to determine if a pt is serious

A

previous risk; giving away valuables; risk of hurting themselves; feelings of hopelessness, despair, etc.

91
Q

why would a mini-status exam be used?

A

screens for cognitive function only and detects organic disease; useful for initial and serial measurement of cognition over time

92
Q

what are organic diseases

A

mental diseases that develop over time instead of a psychiatric illness; delirium, dementia, Alzheimer’s, intoxication, withdrawl

93
Q

psychiatric illness

A

anxiety, Schizophrenia, manic depression, OCD

  • With increasing age, there is no decrease in general knowledge but people have a slower response time, recent memory is decreased, remote memory is usually not affected. There may also be some vision and hearing impairments that can affect socialization and memory.
94
Q

The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:, the patient drew a clock with the numbers out of order nd with an incorrect time. This result indicates which finding?

a. Cognitive Impairment

b. Amnesia

c. Delirium

d. Attention-deficit disorder

A

a. Cognitive Impairment

95
Q

what are the normal milestones for children

A

hold head up, roll over, sat alone, walked alone, first tooth, first words, first sentence, potty trained, ties shoes, dressed without help

96
Q

when testing various parts of the nervous system, would a negative response be considered normal or abnormal?

A

normal

97
Q

what does decorticate rigidity/posturing indicate

A

hemispheric lesion of cerebral cortex

98
Q

what does decerebrate rigidity or posturing indicate

A

lesions in brainstem or upper pons

99
Q

which is more life threatening, decorticate rigidity or decerebrate rigidity?

A

decerebrate rigidity

100
Q

what is different about the vagus nerve

A

it goes down your spine instead of just staying in the head and neck area

Health Assessment (5 decks)

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