Final Flashcards
Structure of the Bones
- 206 bones
- Axial (head and trunk) and appendicular (extremities, shoulders, and hips) skeleton
- Compact bone: Hard and dense and makes up the shaft and outer layers.
- Spongy bone: Numerous spaces and makes up the ends and centers of the bones.
- Osteoblasts and osteoclasts are the cells that make up the bones.
Skeletal Muscles
Three types: Skeletal voluntary (650), smooth, cardiac
Movements of Skeletal Muscles
- Abduction: Moving away from midline of the body
- Adduction: Moving toward midline of the body
- Circumduction: Circular motion
- Inversion: Moving inward
- Eversion: Moving outward
- Extension: Straightening the extremity at the joint and increasing the angle of the joint
- Hyperextension: Joint bends greater than 180 degrees
- Flexion: Bending the extremity at the joint and decreasing the angle of the joint
- Dorsiflexion: Toes draw upward to ankle
- Plantar flexion: Toes point away from ankle
- Pronation: Turning or facing downward
- Supination: Turning or facing upward
- Protraction: Moving forward
- Retraction: Moving backward
- Rotation: Turning of a bone on its own long axis
- Internal rotation: Turning of a bone toward the center of the body
- External rotation: Turning of a bone away from the center of the body
Structure of the Joints
- Fibrous joints are joined by fibrous connective tissue and are immovable. Sutures between the skull bones.
- Cartilaginous joints: Joined by cartilage (joints between vertebrae)
- Synovial: Shoulders, wrists, hips, knees, ankles, contains a space between bones filled with synovial fluid: acts as a lubricant. Bones in these joints are joined by ligaments. Some contain bursae: small sacs filled with synovial fluid that cushion the joints, a knee joint.
-Ligaments: Strong dense bands of fibrous connective tissue.
Osteoporosis
- One in three women and one in five men will have a fractured bone, with hip, forearm, and vertebral fractures predominating.
- Europeans and Americans accounted for 51% of osteoporosis-related fractures in the year 2000, followed by people from the Western Pacific and Southeast Asia.
- Osteoporosis is lowest in black males and highest in white females.
Osteoporosis Risk Factors
-Uncontrollable risk factors:
Age, gender, family history, previous fracture, ethnicity, menopause/hysterectomy, long-term glucocorticoid therapy, rheumatoid arthritis, primary/secondary hypogonadism in men
-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
Risk Reduction: 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.
Collection of Subjective Data: Musculoskeletal System
- History of present health concern: Have you had any recent weight gain? Describe any difficulty chewing. Describe any joint, muscle, or bone pain you have. Do a pain assessment.
- Past health history: Describe any problems or injuries you have had to your joints, muscles, or bones. Diagnoses of diabetes, sickle cell anemia, systemic lupus, osteoporosis.
- Family History: Any history of rheumatoid arthritis, gout, or osteoporosis.
- Lifestyle and Health Practices: What activities do you engage in to promote the health of your muscles and bones. What medications do you take? Do you smoke?
Collection of Objective Data : Musculoskeletal System
-Preparing the client
-Equipment required:
Tape measure
Skin marking pencil
Musculoskeletal System: Gait
- Gait: Note the base of support, weight bearing stability, foot position, arm swing, and posture.
- Normal gait: Feet pointing forward, parallel to each other, bear weight evenly. Arm swing should be in opposition from the feet. Posture should be erect: stand up straight.
- Overall risk for falling: walker, Cain, assistive device. Are they steady on their feet.
Musculoskeletal System: Temporomandibular Joint
- Temporomandibular Joint: Inspect and palpate TMJ, put index and middle fingers anterior to the external ear opening and have client open their mouth. Have them move their jaw from side to side. Finally protrude and retract the jaw.
- ROM of the TMJ: Ask the client to open the mouth and move the jaw laterally against resistance. Next, as the client clenches the teeth, feel for the contraction of the temporal and masseter muscles to test the integrity of cranial nerve V (trigeminal nerve).
Musculoskeletal System: Sternoclavicular Joint
Sternoclavicular joint: Observe it for midline location, color, swelling, and masses. Where the clavicle meets the sternum. Palpate to look for swelling, masses, crepitus, make sure where it joins on each side is symmetrical.
Musculoskeletal System: Cervical, thoracic, and lumbar spine
- Observe the cervical, thoracic, and lumbar curvesfrom the side, then from behind. Have the client standing erect with the gown positioned to allow an adequate view of the spine. Observe for symmetry, noting differences in height of the shoulders, iliac crests, and buttock creases.
- Palpate the spinous processes and the paravertebral muscleson both sides of the spine for tenderness or pain.
- Test ROM of the cervical, thoracic, lumbar spine.
- Test for back and leg pain.
- Measure leg length.
Musculoskeletal System: Shoulders, arms, and elbows.
-Shoulders, arms, and elbows; inspection, palpation, ROM
-Elbows:
Inspect for size, shape, deformities, redness, or swelling.
Test ROM.
Musculoskeletal System: Wrists, Hands and Fingers, Hips
- Wrists: inspection, palpation, test ROM
- Hands and fingers: inspection, palpation, test ROM
- Hips: inspection, palpation, test ROM
Musculoskeletal System: Knees
- Knees: inspection, palpation
- Assess for swelling.
- Test for ROM.
- Assess for pain and injury.
Musculoskeletal System: Ankles and Feet
-Ankles and feet:
Inspect position, alignment, shape, and skin.
Palpate ankles and feet for tenderness, heat, swelling, or nodules.
Test ROM.
Abnormal Spinal Curvatures
- Kyphosis: A rounded thoracic convexity (kyphosis). older adults as the spine breaks down, kyphotic curve in the thoracic spine.
- Scoliosis: A lateral curvature of the spine with an increase in convexity on the side that is curved is seen in scoliosis.
- Normal: Mild S curve.
Wrist Abnormalities
-Acute rheumatoid arthritis: Tender, painful, swollen, stiff joints are seen in acute rheumatoid arthritis.
-CHRONIC RHEUMATOID ARTHRITIS:
Chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints, limited range of motion, and finger deviation toward the ulnar side are seen in chronic rheumatoid arthritis.
-BOUTONNIÈRE AND SWAN-NECK DEFORMITIES:
Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint (boutonnière deformity) and hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint (swan-neck deformity) are also common in chronic rheumatoid arthritis.
-GANGLION:
Nontender, round, enlarged, swollen, fluid-filled cyst (ganglion) is commonly seen at the dorsum of the wrist.
-OSTEOARTHRITIS:
Osteoarthritis (degenerative joint disease) nodules on the dorsolateral aspects of the distal interphalangeal joints (Heberden nodes) are due to the bony overgrowth of osteoarthritis. Usually hard and painless, they may affect middle-aged or older adults and often, although not always, are associated with arthritic changes in other joints. Flexion and deviation deformities may develop.
-TENOSYNOVITIS:
Painful extension of a finger may be seen in acute tenosynovitis (infection of the flexor tendon sheaths).
-THENAR ATROPHY:
Atrophy of the thenar prominence due to pressure on the median nerve is seen in carpal tunnel syndrome.
Feet and Toes Abnormalities
-ACUTE GOUTY ARTHRITIS:
In gouty arthritis, the metatarsophalangeal joint of the great toe is tender, painful, reddened, hot, and swollen.
-FLAT FEET:
A flat foot (pes planus) has no arch and may cause pain and swelling of the foot surface.
-CALLUS:
Calluses are nonpainful, thickened skin that occurs at pressure points.
-HALLUX VALGUS:
Hallux valgus is an abnormality in which the great toe is deviated laterally and may overlap the second toe. An enlarged, painful, inflamed bursa (bunion) may form on the medial side.
-CORN:
Corns are painful thickenings of the skin that occur over bony prominences and at pressure points. The circular, central, translucent core resembles a kernel of corn.
-HAMMER TOE:
Hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint (hammer toe) commonly occurs with the second toe.
-PLANTAR WART:
Plantar warts are painful warts (verruca vulgaris) that often occur under a callus, appearing as tiny dark spots.
Older Clients: Musculoskeletal System
- Older clients usually have slower movements, reduced flexibility, and decreased muscle strength because of age-related muscle fiber and joint degeneration, reduced elasticity of the tendons, and joint capsule calcification.
- An exaggerated thoracic curve (kyphosis) is common with aging.
Older Client Frequent Findings: Musculoskeletal System
- Bones lose their density with age, putting the older client at risk for bone fractures, especially of the wrists, hips, and vertebrae. Older clients who have osteomalacia or osteoporosis are at an even greater risk for fractures.
- Joint-stiffening conditions may be misdiagnosed as arthritis, especially in the older adult.
- Osteoporosis is more common as a person ages because bone resorption increases, calcium absorption decreases, and production of osteoblasts decreases as well.
- Some older clients have an impaired sense of position in space, which may contribute to the risks of falling.
Analysis of Data: Musculoskeletal System
Analyze the data from the interview and physical assessment of the musculoskeletal system to formulate valid nursing diagnoses, collaborative problems, and/or referrals.
General Routine Screening vs Focused Assessment of the Musculoskeletal System
- The nurse routinely observes the client’s posture, gait, and movements, along with activities of daily living.
- If the client describes the inability or limited ability to move a joint or extremity or describes pain in a joint or muscle, a more complete assessment is required. This would include inspection of symmetry, color, range of motion, and strength. In addition, the nurse would palpate the joint, bone, or muscles for tenderness, heat, swelling, or nodules.
- More advanced or specialty tests include testing for carpal tunnel, the bulge test, and the ballottement test.
- A total head-to-toe musculoskeletal examination would more likely be performed by a physical therapist or a primary care provider.
Which skeletal muscle movement means “to move forward”?
Protraction
Is the following statement true or false?
Decreased estrogen levels after menopause increase the risk of osteoporosis.
True
Is the following statement true or false?
Calluses are painful thickenings of the skin that occur over bony prominences and at pressure points.
False, they are nonpainful
Muscle strength grading scale:
- 0/5= No muscular contraction. Paralysis
- 1/5= Slight flicker of contraction. Severe weakness
- 2/5= Passive ROM (gravity removed and assisted by examiner) Poor ROM
- 3/5= Active motion against gravity. Average weakness
- 4/5= Active motion against some resistance. Slight weakness
- 5/5= Active motion against full resistance. Normal
Assessing ROM in the Fingers
Ask the client to (A) spread the fingers apart (abduction), (B) make a fist (adduction), (C) bend the fingers down (flexion) and then up (hyperextension), (D) move the thumb away from other fingers, and then (E) touch the thumb to the base of the small finger.
Assessing ROM in the Wrists
- Ask the client to bend the wrist down and back (flexion and extension; ).
- Next have the client hold the wrist straight and move the hand outward and inward (deviation).
Assessing ROM in the Elbows
- Ask the client to perform the following movements to test ROM, flexion, extension, pronation, and supination.
- Flex the elbow and bring the hand to the forehead.
- Straighten the elbow.
- Then hold arm out, turn the palm down, then turn the palm up.
Assessing ROM in the Shoulders
- Explain to the client that you will be assessing ROM (consisting of flexion, extension, adduction, abduction, and motion against resistance). Ask client to stand with both arms straight down at the sides. Next, ask the client to move the arms forward (flexion), then backward with elbows straight
- Then have the client bring both hands together overhead, elbows straight, followed by moving both hands in front of the body past the midline with elbows straight (this tests adduction and abduction)
- In a continuous motion, have the client bring the hands together behind the head with elbows flexed (this tests external rotation) and behind the back (internal rotation)..
Assessing ROM in the Spine
- Test ROM of the cervical spine by asking the client to touch the chin to the chest (flexion) and to look up at the ceiling (hyperextension).
- Test ROM of the lumbar spine. Ask the client to bend forward and touch the toes. Observe for symmetry of the shoulders, scapula, and hips.
- Test lateral bending. Ask the client to touch each ear to the shoulder on that side
- Evaluate rotation. Ask the client to turn the head to the right and left
Assessing ROM in the Hips
o With the client supine, ask the client to:
o Raise extended leg.
o Flex knee up to chest while keeping other leg extended.
o Move extended leg away from midline of body as far as possible and then toward midline of body as far as possible (abduction and adduction).
o Bend knee and turn leg inward (rotation) and then outward (rotation).
o Ask the client to lie prone and lift extended leg off table. Alternatively, ask the client to stand and swing extended leg backward.
Assessing ROM in the Knees
o Ask the client to:
o Bend each knee up (flexion) toward buttocks or back.
o Straighten the knee (extension/hyperextension).
o Walk normally.
Assessing ROM in the Ankles
o Ask the client to:
o Point toes upward (dorsiflexion) and then downward (plantarflexion).
o Turn soles outward (eversion) and then inward (inversion).
o Rotate foot outward (abduction) and then inward (adduction).
o Turn toes under foot (flexion) and then upward (extension).
Crepitus
A crackling sound/tactile sensation due to air under the skin; may also be heard in joints
I: Olfactory Nerve
-Assessment:
For all assessments of the cranial nerves, have client sit in a comfortable position at your eye level. Ask the client to clear the nose to remove any mucus, then to close eyes, occlude one nostril, and identify a scented object that you are holding such as soap, coffee, or vanilla.
II: Optic Nerve
-Assessment:
Use a Snellen chart to assess vision in each eye, Ask the client to read a newspaper or magazine paragraph to assess near vision, Assess visual fields of each eye by confrontation, Use an ophthalmoscope to view the retina and optic disc of each eye.
III: Oculomotor Nerve
-Assessment:
Inspect margins of the eyelids of each eye, Assess extra-ocular movements, Assess pupillary response to light (direct and indirect) and accommodation in both eyes.
IV: Trochlear Nerve
-Assessment:
Inspect margins of the eyelids of each eye, Assess extraocular movements, Assess pupillary response to light (direct and indirect) and accommodation in both eyes.
V: Trigeminal Nerve
-Assessment:
Test motor function. Ask the client to clench the teeth while you palpate the temporal and masseter muscles for contraction. Tell the client: “I am going to touch your forehead, cheeks, and chin with the sharp or dull side of this paper clip. Please close your eyes and tell me if you feel a sharp or dull sensation. Ask the client to look away and up while you lightly touch the cornea with a fine wisp of
VI: Abducens Nerve
-Assessment:
Inspect margins of the eyelids of each eye, Assess extraocular movements, Assess pupillary response to light (direct and indirect) and accommodation in both eyes.
VII: Facial Nerve
-Assessment: Test motor function. Ask the client to: • Smile • Frown and wrinkle forehead • Show teeth • Puff out cheeks • Purse lips • Raise eyebrows • Close eyes tightly against resistance
VIII: Acoustic, Vestibulocochlear Nerve
-Assessment:
Test the client’s hearing ability in each ear
IX: Glossopharyngeal Nerve
-Assessment:
Ask the client to open mouth wide and say “ah” while you use a tongue depressor on the client’s tongue, Test the gag reflex by touching the posterior pharynx with the tongue depressor, check ability to swallow.
X: Vagus Nerve
-Assessment:
Ask the client to open mouth wide and say “ah” while you use a tongue depressor on the client’s tongue, Test the gag reflex by touching the posterior pharynx with the tongue depressor, test ability to swallow.
XI: Spinal Accessory Nerve
-Assessment:
Ask the client to shrug the shoulders against resistance to assess the trapezius muscles, Ask the client to turn the head against resistance
XII: Hypoglossal Nerve
-Assessment:
To assess strength and mobility of the tongue, ask the client to protrude tongue, move it to each side against the resistance of a tongue depressor, and then put it back in the mouth.
Assess Bicep reflexes
-Ask the client to partially bend the arm at the elbow with palm up. Place your thumb over the biceps tendon and strike your thumb with the pointed side of the reflex hammer. Elbow flexes and contraction of the biceps muscle is seen or felt. Ranges from 1+ to 3+. Forearm flexes and supinates. Ranges from 1+ to 3+.
Assess Brachioradialis reflexes
-Ask the client to flex elbow with palm down and hand resting on the abdomen or lap. Use the flat side of the reflex hammer to tap the tendon at the radius about 2 in above the wrist. Flexion and supination of forearm.
Assess Tricep reflexes
-Ask the client to hang the arm freely (“limp, like it is hanging from a clothesline to dry”) while you support it with your nondominant hand. With the elbow flexed, use the flat side of the reflex hammer to tap the tendon above the olecranon process. Elbow extends, triceps contracts. Ranges from 1+ to 3+.
Assess Patellar reflexes
-Ask the client to let both legs hang freely off the side of the examination table. Using the flat side of the reflex hammer, tap the patellar tendon, which is located just below the patella. Knee extends, quadriceps muscle contracts. Ranges from 1+ to 3+.
Assess Achilles reflexes
- With the client’s leg still hanging freely, dorsiflex the foot. Tap the Achilles tendon with the flat side of the reflex hammer. Normal response is plantarflexion of the foot. Ranges from 1+ to 3+.
- Babinski- The toes will fan out for abnormal response (positive Babinski response).
Name the 3 functions that are assessed with the Glasgow Coma Scale:
Eye opening
Verbal response
Motor response
-Score of 7 or lower is considered to be in a coma. Higher the score the better.
Deep tendon reflex grading scale:
- 0: No Response
- 1+: Decreased, less active than normal
- 2+: Normal, usual response
- 3+: More brisk or active than normal, but not indicative of a disorder
- 4+: Hyperactive, very brisk, rhythmic oscillations; abnormal and indicative of disorder
Describe how an examiner would test balance:
An examiner may assess balance by watching a client walk naturally across a room. Then they may ask the client to walk in heel-to-toe fashion. (Tandem walking). You would also test balance by performing the Romberg Test. Then ask the client to stand on one foot and to bend the knee of the leg the client is standing on.
Describe how an examiner would test coordination:
Demonstrate the finger-to-nose test to assess accuracy of movements, then ask the client to extend and hold arms out to the side with eyes open. Next, say, “Touch the tip of your nose first with your right index finger, then with your left index finger. Repeat this three times. Next, ask the client to repeat these movements with eyes closed.
Central Nervous System
- CNS: Brain and Spinal Cord
- Cerebrum- 2 hemispheres: 1 on right and 1 on left (results show on opposite side)
- Diencephalon- composed on thalamus (points and direct impulses to the cerebral cortex) and hypothalamus (responsible for regulating body functions: water balance, appetite, VS, sleep cycle, perception of pain, emotional status)
- Brain stem- midbrain: relay center for ear and eye reflexes, medulla oblongata, pons (sends messages between the brain and rest of body, control breathing rate, BP, and consciousness)
- Cerebellum- coordinates smooth voluntary movements
- Neural pathways (reflexes)
- Meninges- dura, adenoid, pia mater (protect brain) 3 layers
Peripheral Nervous System
- PNS: Carry information to and from the CNS
- Somatic fibers carry CNS impulses to voluntary skeletal muscles; autonomic fibers carry CNS impulses to smooth, involuntary muscles (in the heart and glands). The somatic nervous system mediates conscious, or voluntary, activities; the autonomic nervous system mediates unconscious, or involuntary, activities.
- 12 pairs of cranial nerves
- 31 pairs of spinal nerves
Lobes of the Brain
- Frontal: voluntary skeletal actions on opposite sides, (left side of lobe controls right side of body and right side of lobe controls left side of body) (communication, aggressive emotions, intellect and responding, judgement and behavior.)
- Parietal: tactile sensations; touch, pain, temp, shapes.
- Occipital: reading and understanding, primary receptor for vision
- Temporal: hearing
Stroke (CVA)
- Ischemic: Blood vessel carrying blood to the brain is blocked by a clot. These clots can be embolic (move through the vessel) or thrombotic (develop within the vessel).85% of all strokes
- TIA: transient ischemic accident: clot is struggling to pass through- less than 24 hours of symptoms, warning sign for stroke
-Hemorrhagic: When brain aneurysm bursts or a weakened blood vessel in the brain leaks. (rupture, malformation, aneurism that ruptures) bleeding from artery
Less common, but account for 40% of all stroke deaths.
Stroke Symptoms
- Sudden numbness or weakness on one side of body
- Sudden confusion,
- trouble speaking, or understanding speech
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden severe headache with no known cause
Act FAST: Warning signs of a stroke
- FACE: Ask the person to smile. Does one side of the face droop?
- ARMS: Ask the person to raise both arms. Does one arm drift downward?
- SPEECH: Ask the person to repeat a simple phrase. Is speech slurred or strange?
- TIME: If you observe any of these signs, call 9-1-1 immediately.
- A stroke is time sensitive
- Do not wait for symptoms to get better, seek help!
- Do not go to ER, they have to call 911 (they have to get there fast)
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)
- Younger men are at a higher risk
- women more likely to die from a stroke
- African American, native American, and Alaska native are at a higher risk than white or Hispanic pt
- Sickle cell anemia
- musculitis
- bleeding disorders
- Atriofibrilation- electrical defect on heart that put pt at higher risk for developing clots (which can travel to brain)- will be on an anticoagulant or anti-platelet
- AVM- hemorrhagic
Risk Factors For Stroke that can be controlled
- Alcohol and illegal drug use
- Certain medical conditions
- Lack of physical inactivity
- Overweight and obesity
- Stress and depression
- Unhealthy cholesterol levels: Cholesterol- low total: less than 200, LDL: less than 130
- Unhealthy diet
- Use (especially prolonged use of ) NSAID medications
Teaching Topics for Stroke
- Smoking cessation
- Maintain cholesterol levels low
- Control high blood pressure.
- Control diabetes
- Exercise
- Healthy diet
- Avoid sodium (salt)
- Limit alcohol intake
- Avoid illegal drugs.
- Birth control pills- Higher Risk
- Talk to doctor about aspirin
Collecting Subjective Data: Neurologic System
- History of present health concern: Do you experience headaches, seizures, dizziness, numbness, tingling/prickling?
- Past Health History: Any type of head injury? Meningitis, encephalitis, injury to spinal cord, or a stroke?
- Family History: Any history of high blood pressure, stroke, Alzheimer’s, dementia, epilepsy, brain cancer?
- Lifestyle and health practices: Medications, smoking, diet, exposure to chemicals, lift heavy objects?
Stroke Scale
NIHSS, the higher the score the worse the score is.
Collecting Objective Data: Neurologic System
Neurologic Examination:
-Mental status examinationsprovide information about cerebral cortex function. Cerebral abnormalities disturb the client’s intellectual ability, communication ability, or emotional behaviors.
- Thecranial nerve evaluationprovides information regarding the transmission of motor and sensory messages, primarily to the head and neck. Many of the cranial nerves are evaluated during the head, neck, eye, and ear examinations.
- Themotor and cerebellar systemsare assessed to determine functioning of the pyramidal and extrapyramidal tracts. The cerebellar system is assessed to determine the client’s level of balance and coordination. The motor system examination is usually performed during the musculoskeletal examination.
- Examining thesensory systemprovides information regarding the integrity of the spinothalamic tract, posterior columns of the spinal cord, and parietal lobes of the brain, whereas testingreflexesprovides clues to the integrity of deep and superficial reflexes.
-A neuro check includes the following assessment points: Level of consciousness Pupillary checks Movement and strength of extremities Sensation in extremities Vital signs
Orientation: Neurologic System
-Orientation X 4
Normal = Oriented to person, place, time and situation
Disoriented
Equipment for Neurologic Assessment
-Motor and Cerebellar Examination
-Sensory Examination
Cotton ball
Objects to feel such as a quarter or key
Paper clip
Test tubes containing hot and cold water
Tuning fork (low pitched)
-Reflex Examination
Cotton-tipped applicator
Reflex (percussion) hammer
Motor and Cerebellar Systems
- Assess condition and movement of muscles.
- Evaluate balance.
- Perform Romberg test.
- Assess coordination.
