knowledge assessment II Flashcards
(405 cards)
1
Q
thoracic cage is composed of
A
sternum, clavicle, scapulae, 12 vertebrae, and 12 pairs of ribs
2
Q
three main compartments of thoracic cage
A
airways
blood vessels
interstitinum
3
Q
mediastinum
A
heart, great vessels, lymph nodes, nerves, fat
4
Q
additional structures within the thorax
A
thymus, distal part of trachea, and most of the esophagous
5
Q
thoracic muscles
A
- intercostals
- transverse thoracic
- subcostal
6
Q
blood supply within thorax
A
arterial: thoracic aorta, subclavian, brachial, axillary
venous: various veins
pulmonary arteries, pulmonary veins
7
Q
pulmonary arteries
A
carry deoxygenated blood from the right side of the heart to each lung
8
Q
pulmonary veins
A
return oxygenated blood from lungs to the left side of the heart
9
Q
anterior thoracic landmarks
A
begin at suprasternal (jugular notch)
10
Q
costal angle
A
angle between ribs at the costal margins located at bottom of sternum at the xiphoid process
typically 90 degrees or less
11
Q
why wouldn’t you palpate ribs posteriorly?
A
harder to do as a result of overlying musculature so easiest to assess at vertebrae
12
Q
midsternal line
A
anterior in center of sternum
13
Q
midclavicular line
A
in middle of clavicle or collar bone
14
Q
anterior axiallary line
A
aligns where arms closed
15
Q
vertebral line
A
middle of vertebrae posteriorly
16
Q
scapular line
A
starts closest to vertebral line right where scapula starts
17
Q
midscapular line
A
starts in middle of scapula
18
Q
posterior axillary line
A
runs vertically along posterior edge from top of axilla between anterior and posterior axiallary lines
19
Q
the right lung has how many lobes?
A
3
20
Q
the left lung has how many lobes?
A
2
21
Q
RML is ausculatated using an
A
anterior approach, although a small portion can be ausculatated laterally
- may be difficult with women due to breast tissue
22
Q
horixontal fissue
A
divides RUL and RML of lung
23
Q
RML extends from
A
4th rib at sternal border to the 5th rib at midaxillary line
24
Q
the lower border of right lung is
A
higher than the left because the liver displaces the lung tissue upward
25
the left lung is
narrower than right because the heart and pericardium bulge to the left displacing the lung tissue
26
the base of the lungs refers to
very bottom of lung fieldsd
27
apex of lungs refers to
very top of lungs
28
components of respiratory tracts
nasal cavity
eipglottis
nasopharynx
oropharynx
laryngeal pharynx
larynx and vocal cords
esophagous
trachea
right and left lung
right and left bronchus
terminal bronchiole
diaphargm
29
the trachea bifurcates at the
caring into right and left mainstem bronchi which turn into smaller bronchi and continue to separate until becoming terminal bronchioles which give rise to alveolar sacs lined by alveoli
30
the right mainstem broncus is
shorter, wider, and more vertical than left
31
the upper respiratory tract is responsible for
moisturizing inhaled air and filtering noxious particles
32
what triggers respiration
automatic process initiated by pons and medulla
33
main trigger in respiration
increased CO2 levels in blood
34
other triggers of respiration
decreased oxygen levels, increased acidity, certain medication (drug overdoses, opiates, sedatives) causing hypoventilation or apnea, brain injury (hyperventilation)
35
inspiration
- diaphragm contract and flattens pulling lungs downward
- thorax and lungs elongate increasing in length
- external intercostal muscles open ribs and lift sternum
- increase in anteroposterior diamter fo thorax causing 500-800 mL of air to enter lungs of adults
36
with increased thoracic size
pressure within the thorax is less than pressure in the atmosphere causing influx of atmospheric air to enter the lungs
37
expiration
- diaphragm, internal intercostal muscles, abdominal muscles relax
- pressure in lungs is greater than atmosphere
- air is pushed out and chest and abdomen return to relaxed position
38
effective breathing depends on sufficient
nerve innervation, muscle excursion, strength
39
pts with conditions effecting the spinal cord (especially c3-5) may need
ventilator support
40
extreme obesity can limit
chest wall expansion therefore compromising breathing
41
progressive loss of muscle function can
limit ability to ventilate and cough
(muscular dystrophy)
42
respiratory issues in older adults
- decline in respiratory strength
- lungs lose elasticity
- decreased flexibility in rib cartilage
- bone density decreases
- decreased AP ratio (barrel chest)
- diminished respiratory volume
43
immobility in older adults creates risk for
- atelectasis (airway collapse)
- reduced air exchange
- hypoxia
- hypercapnia
- acidosis
44
older people having a reduced cough and gag reflex puts them at higher risk for
aspiration of secretions
aspiration pneumonia
45
risk of postoperative respiratory complications in older adults due to
impaired cough reflex, weaker muscles, and decreased respiratory capacity
46
stress increases what in older adults
respiratory complications
47
genetic patterns of inheritance increase risk for respiratory disorders such as
cystic fibrosis
alpha-1 antitrypsin deficiency (associated w/ early onset emphysema)
asthma
48
cultural and ethnic variability of respiratory illnesses
TB
smoking
49
risk factors of TB
HIV +
immigrants
homeless
drug and alc abuse
50
ABC
airway breathing circulation
51
acute shortness of breath priorty assessment
assess airway, RR, PR, BP, and O2 sat
auscultate lungs for possible abnormalities
administer O2 as orderd
administer bronchodilators as ordered
elevate head of bed
52
important factors for those with acute SOB
keep patient calm as anxiety increases respiratory decline
53
as O2 level in blood and tissues decrease,
pts become more dyspneic and cyanotic causing insufficient blood supply to brain resulting in confusion and decreasing level of consciousness
54
priority urgent assessment #3 for acute SOB
- may be unable to cooperate fully
- ausculatate when turning client
- prioritize subjective data
- ask only pertinent Qs related to situation
- cluster interventions
- assess when client is more relaxed
55
assessment of risk factors for respiratory conditions
past medical history
lifestyle and personal habits
occupational history
environmental exposures
medications
family hx
56
teaching and health promotion for respiratory conditions
smoking cessation
prevention of occupation exposure
prevention of asthma
immunizations
57
all smokers should be
asked at every appointment about readiness to stop as smoking has been linked to lung cancer, emphysema, chronic bronchitis, CV disease, and oropharyngeal cancer
58
asthma triggers
tobacco smoke
dust
molds
furred and feathered animals
cockroaches
pests
59
have you ever been diagnosed with a respiratory disease or condition such as asthma, bronchitis, emphysema, pneumonia or lung cancer?
you want to ask this as certain diseases like COPD have long term effects that result in slow progressive decline in function, asthma symptoms may occur at any age and improve or worsen over time, pneumonia usually has acute onset and resolves itself after meds
60
common chest symptoms
- chest pain
- dyspnea
- orthopnea
- paroxysmal nocturnal dyspnea
- cough
- sputum
- wheezing
- functional abilities
- older adults
- cultural factors
61
general appearance of respiratory examination
observe pt posture and positioning
posture is upright and ANOx3/4, facial expression relaxed
abnormal: pts in tripod position (common in COPD or those w respiratory distress)
62
inspection of posterior chest
moving around to inspect posterior chest, inspect and compare AP to assess overall shape of thoracic cage, observe spontaneous chest expansion
63
palpation of posterior chest
palpate chest for tender areas
use fingertips starting above scapula over the lung apex and progress from sid eto side compare findings bilaterally, palpate for crepitus
abnormal: lesions, lumps, massess, crepitus (air filled massess underneath skin)
64
tactile fremitus posterior chest
evaluates density of lung tissue
- place palmar base or ulnar surface of hand on patients chest above scapula and ask patient to say 99, vibrations of air in bronchial tree are transmitted allowing assessment of intensity and symmetry of fremitus from L + R lungs
65
percussion in posterior chest
can help discover if tissue is air filled, fluid filled, or solid, usually interpreted in combination with otehr examination techniques
percuss anteriorly, posteriorly, and laterally
66
ausculatation posterior chest
ask pt to breathe deeply through mouth
ID breath sounds by listening for intensity, quality, pitch, and duration of inspriation compared with expiration
67
vesicular breath sounds
soft, low pitched and found over fine airways near site of air exchange (lung periphery)
68
bronchovesicular sounds
found more centrally, over major bronchi that have fever alveoli
69
bronchial breath sounds are
loud high pitched and found over trachea and larynx
common to hear crackles on inspiration with first deep breath (if heard ask patient to cough)
70
inspection of anterior chest
use same techniques
inspect chest wall for deformities or asymmetry between right and left sides, assess size of costal angle, observe for use of accessory muscles to breathe, no barrel chest, inspect ICSs for retractions or bulging
71
palpation of anterior chest
Palpate the anterior chest for tenderness, masses, or lesions. Begin at the lung apices and move from side to side, ending below the costal angle and moving laterally to the midaxillary line-No tenderness, masses, or lesions should be observed
72
percussion anterior chest
precuss anterior and lateral chest in the ICSs
avoid percussion over bone and/or breast tissue
73
percussion in anterior chest should sound
resonant in lungs
74
auscultation of anterior chest
auscultate the trachea and anaterior and lateral lung fields
listen to lung apices
listen down to the 6th ICS bilaterally or when breath sounds become absent signalling end of lung fields
75
bronchial breath sounds are audible over
the trachea
76
bronchovesicular sounds are heard over the
2nd-3rd ICSs to the right and left of sternum over the bronchi
77
vesicular sounds are heard in
other areas of lung fields
78
making clinical decisions regarding respiratory conditions
- analyze lab and diagnostic testing
- prioritize hypotheses and take action
- analyzing changing findings
- interprofessional collaboration w respiratory therapy
- plan the care
- evaluate outcomes
79
RR: elevated WBC count may indicate
infection like pneumonia
80
analysis of sputum sample may help ID
causative microorganism
81
arterial blood gas is a direct measure of
blood O2 , CO2, and acid balance
82
radiographic studies can provide
objective evidence of disease process within thorax and lungs
83
PET scans
measure the metabolic rate of various body tissues, providing info about presence and stage of a malignancy
if PET scans revealed adrenal metasisis the potentially lethal surgery would not benefit pt
84
Acute shortness of breath is a medical emergency. Immediate assessments are necessary. What is the priority assessment the nurse would make with a client who has acute shortness of breath?
A. Administer inhalers
B. Administer oxygen
C. Raise the head of the bed
D. Auscultate lungs
D. auscultate
acute SOB; immediate auscultation then o2 is administered and inhalers may be given then head of bed elevated
85
nurses measure nutritional status by
- taking height and weight measurements
- monitoring I&Os
- measuring lab values
86
body function is affected by intake of
primary nutrients
87
nutrients
- carbohydrates
- proteins and amino acids
- lipids and fatty acids
- vitamins and minerals
- supplements
- fluid and electrolytes
88
carbohydrates
main source of bodily energy
simple and complex
should comprise 45-65% of caloric intake
89
proteins and amino acids
proteins function in cell structure and tissue maintenance
amino acids are building blocks of protein
total amount needed per day increases when ill
90
lipids and fatty acids
- triglycerides, sterols, and phospholipids
- maintain total body function (promote absorption of fat soluble vitamins A, D, E, K
- saturated, unsaturated, and monosaturated
- HDLs and LDLs
91
clinical significance of lipids and fatty acids
excess leads to atherosclerosis, stroke, and MI
increase in obesity
92
USDA and AHA recommend how much fat intake
20-35% of caloric intake
93
vitamins and minerals
- foundation of cellular structures
- key role in nutrient metabolism
- vitamin B and D are commonly lacking
- minerals of importance: iron, zinc, calcium
94
water
body loses 1500-2800mL/day
requires minimum intake of 1500 mL/day to maintain excretion of metabolic waste
95
sodium and potassium
essential
limited to 2300 mg/day
96
medications commonly prescribed for individuals w/ chronic illness can lead to
alteration in K+ levels
abnormal K+ levels can lead to lethal cardiac dysrhythmias
97
utilize MyPlate guidelines mad eby USDA and HHS
- consider food choices that meet personal, cultural, and budget preferences
- recognize that eating is part of lifestyle, social system, and way of living
98
goals for nutritional guidelines
encourage individuals to meet nutritional needs
choose variety of options
pay attention to portions
99
pregnancy and lactation
additional 300-500 calories per day
emphasis on protein
vitamin and mineral supplement may be required
100
vitamin b
neccessary for those trying to get preganant at least 1 month before conception and 2-3 months after
101
infants, children, and adolescents
protein is ciritcal
milk:
- under 2: whole milk
- 2-5: low fat milk
102
older adults have decreased
taste and third drive
poor dentition
BMR decline
high risk of malnutrition and dehydration
103
factors influencing nutrition
culture
religion
geographic location
food and fluid preferences
eating patterns, digestions, allergies
shopping resources and skills
kitchen facilities and ability to prepare food
meaning behind food and feeding
social patterns at means
GI structures and dentititon
104
subjective cues in nutritional assessment
- deficits develop over time
- during stress or trauma caloric need increases
- ask pt nutritional preferences
- if pt in unable to make decisions, consider consult
105
nurses role in nutritional assessment
- look at developmental, social, economic, and cultural facotrs
- complete nutrition screening (risk factor assessment, comp. nutritional history, physical exam, calculated measurements, serial lab values)
- pt teaching
106
main causes of malnutrition
poverty, alcoholism, hospitalization, aging, and eating disorders
107
alcohol recommeded intake
1 drink/day - females
2 drink/day - males
108
if pt is at risk for altered nutrition this should be done
- food records
- food frequency questionnaires
- direct observation
109
comprehensive physcial assessment for nutrition
body time - small, average, large
general appearance
swallowing
BMI (18.5-24.9)
110
CBC
can exclude anemias from nutritional deficiencies like iron, folate, and b12
111
serum albumin
longer half life protein than prealbumin
inflammation will decrease serum albumin making it an unreliable serum marker for malnutrition
112
prealbumin
half life is much shorter (2 days) and its total body pool is smaller and is a more reliable indicator of pt nutritional status
113
prealbumin is degraded by
kidneys so any renal dysfunction causes increase in its serum levels
114
transferrin
iron deficiency states (chronic blood loss anemia) levels of transferrin are elevated because of increase amount of iron absorption
levels increase w renal failure
oral contraceptives or estrogen formulas also alter levels
115
rentinol binding protein
vitamin a and zinc are vital in proper functioning of RBP and hence any abnormalities in levels of these micronutrients affect levels of RBP in serum
116
creatinine and blood urea nitrogen
- nitrogen balance means more loss than intake
nitrogen balance is measured w concentration of urea in urine
117
diagnosis or hypothesis: UNDERWEIGHT
description
nutrient intake that fails to meet energy and metabolic needs
assessment
body weight 20% of more below ideal, BMI <18.5, lack of interest in food, nausea, vomiting, diarrhea
interventions
weight pt daily, monitor intake, nutritional supplements, offer food frequently
118
OVERWEIGHT
description
adult BMI over >30kg/m2
assessment
body weight more than 20% above ideal, BMI > 24.9 eating in response to cues other than hunger, triceps skin fold >25 mm in females or 15 mm in males
interventions
have pt keep food diary and record every intake
teach reading of food labels, weight 2x/week, iteach increased intake of fruits and vegetables
119
fluid imablance
description
increased fluid usually due to impaired heart and circulation or low excretion by kidneys
assessment
altered electrolytes, elevated creatinine, decreased hematocrit, and hemoglobin, weight gain
interventions
monitior I&Os, wieght daily at same time of day, evaluate serum sodium ,creatinine, and hematocrit
120
dehydration
description
decreased intravascular, interstitial, or intracellular fluid; dehydration
assessment
decreased BP, increased HR, orthostatic BP changes, thirst, dry skin, sunken eyes
interventions
monitor intake and output, weigh daily, provide fluids every 2 hrs, treat causes of nausea, vomitting, or diarrhea
121
reference locations of abdomen
R hypochondriac region
epigastric region
L hypocondriac region
R lumbar region
umbilical region
L lumbar region
R iliac region
hypogastric region
L illiac region
122
what organs are within right hypochondriac region
liver and gallbladder, right kidney, small intestine
123
organs within epigastrium region
stomach, liver, pancreas, duodenum, adrenal glands, spleen
124
organs within left hypochondriac region
spleen, colon, left kidney, pancreas
125
organs within right lumbar
gallbladder, liver, right colon
126
organs within umbilical region
umbilicus, parts of small intestine, duodenum
127
organs within left lumbar
descending colon, left kidney
128
organs within right iliac
appendix, colon
129
organs within hypogastric
urinary bladder, sigmoid colon, female reproductive organs
130
organs within left iliac
descending colon, sigmoid colon
131
GI organs
stomach
small intestine
colon
132
GI accessory organs
liver
pancreas
gallbladder
133
GU organs
urinary system: KUB
genital system: spermatic cord for males and ovaries and uterus for females
134
blood vessels, peritoneum, and muscles abdominal organs
abdominal aorta
muscles
spleen
135
funciton of GI tract
ingestion and digestion
absorption of nutrients
elimination
136
steps of kidney filtration
1. glomerulus
filters small solutes from blood
2. proximal convoluted tubules
reabsorbs ions, water, and nutrients; removes toxins and adjusts filtrate pH
3. descending loop of henle
aquaporins allow water to pass from filtrate into interstitial fluid
4. ascending loop of henle
reabsorb na+ and cl- from filtrate into the interstitial fluid
5. distal tubule
selectively secretes and absorbs different ions to maintain blood pH and electrolyte imbalance
6. collecting duct
reabsorbs solutes and water from filtrate
137
GI considerations for older adults
- decreased saliva and stomach acid produciton
- difficulty swallowing, absobing, and digesting
- motility and peristalsis decrease
- dentition changes
- financial constraints
- less likely to feel abdominal pain
- fat accumulates in lower abdomen making assessment more difficult
- liver decreases in size and function
- renal function declines
- diminished thirst sensation
138
GI issues among AA
sickle cell anemia
glucose-6-phosphate dehydrogenase deficiency
lactose intolerance
139
GI issues among Americans of Greek and Italian Decesent
lactose intolerance
thalassemia
anemia
140
AA have highest incidence of
hep B
141
AA and hispancis have higher mortality rates from
hep B and C
142
AA hispanics native hawaiians/islanders, native americans have higher
diabetes, obesity, and related complications
143
risk factors for focused abdominal assessment
- past medical/surgical hx
- general GI questions
- lifestyle and personal habits (weight gain, GU issues, female vs male, neurologic complaints, metabolism, skin, lymph, alc/substance abuse)
- occupation
- foreign travel
- high-risk behaviors
- meds
- family hx
144
abdominal complications
colorectal cancer
foodborne illness and allergy
hepatitis
145
symptoms of abdominal complications
- indigestion
- anorexia
- n/v, hematemesis
- dysphagia, odynophagia
- change in bowel habits/function (constipation, diarrhea)
- jaundice/icterus
- urinary/renal symptoms (incontinence, kidney pain, ureteral colic)
146
oder of operations for abdominal assessment
inspection
auscultation
percussion
palpation
147
contour of GI
flat, rounded, distended, scaphoid, or protuberant
148
symmetry of GI
shine a light across the abdomen to view for symmetry
149
umbillicus
midline and inverted with no discoloration
150
skin of GI
smooth, even, all one color, good place to assess skin pigmentation because it is typically protected from sunlight
151
pulsation or movement of GI
no pulses or abnormal movements
152
output of GI
emesis or stool
153
focus on urine output
make note of urine characteristics
- pale/straw, yellow, clear, little to no odor
154
clear urine indicates
over hydration
155
dark yellow urine indicates
mild dehydration
156
amber urine indicates
moderate dehydration
157
orange urine indicates
severe dehydration, excess bilirubin or some meds
158
red (hematuria) urine indicates
blood in urine
pyelonephritis, cystitis, bladder or prostate CA
159
tea colored urine
liver disease
160
auscultate vascular sounds on GI
listen with the bell of the stethescope
listen for bruits, venous hums, friction rubs
161
percussion of GI
determine organ size and tenderness
detects fluid air or masses in abdominal cavity
percuss all 4 quadrants
blunt percussion over kidney at CVA
162
what sounds should be heard in abdomen
tympany
163
palpation of GI
check for areas of pain
check blumberg sign
164
never palpate abdomen of patients who have had
organ transplants or of a child with a suspected Wilms tumor
165
lab tests for GI
CBC and BMP can evaluate some functions
gastroccult tests for blood in emesis
hemoccult tests for blood in stool
166
diagnostic tests for GI
esophagogastroduodenoscopy (EGD)
barium enema
colonoscopy
endoscopic retrograde cholangiopancreatography (ERCP)
computed tomography (CT) scan
magnetic resonance imaging (MRI)
167
deficient food intake
- dietary intake that is inadequate in quantity, quality, or both for metabolic needs
- body weight decreased, BMI less than normal
- rovide nutritional supplements (e.g., milk shakes) administer antiemetics as ordered
168
diarrhea
- at least 3 liquid stools per day
- passage of loose unformed stools
- obtain stool specimen to determine infection (e.g., C. diff)
169
constipation
- decrease in normal frequency of defecation with hard dry stool
- abdominal distention, pain, tenderness, firm abdomen, no stool for days
- obtain order for stool softener if pt is on opioids, increase intake of fiber, assist with ambulation, ensure adequate intake of fluids
170
impaired urinartion
- differentiate functional overflow, reflex, stress, and urge continence, impaired elimination, and urinary retention
- voiding more than every 2 hrs while awake, awakening at night to urinate, voiding more than 8x in 24 hrs
- review meds that may contribute to incontinence, perform bladder scan to evaluate if residual is present, teach principles of bladder training
171
urinary retention
- inability to empty bladder completely
- absence of urine output, bladder distension, dribbling, frequent voiding
- void every 2 hrs double void, teach kegel exercises, avoid fluids before bed
172
4 heart valves
tricuspid
mitral
pulmonic
aortic
173
carotid arteries carry blood from
heart to head
174
jugular veins
internal and external
175
steps of conduction system
1. SA node
2. AV node
3. Bundle of His
4. R/L bundle branches
5. purkinje fibers
176
flow of blood
1. SVC receives blood from limbs neck and head while IVC receives blood from trunk viscera and lower limbs. both IVC and SVC bring this deoxygenated blood into the right atria
2. the right atrium contracts and the tricuspid valve opens causing blood flow into the ventricles
3. the ventricles then contract causing the pulmonary artery / semilunar valve to open and send deoxygenated blood to the lungs to become oxygenated
4. gas exchange occurs in lungs and oxygenated blood then enters back into heart through left atria
5. left atria contracts causing bicuspid valve to open and have blood enter left ventricle
6. left ventricle contracts causing aortic semilunar valve to open to spread blood throughout the entire body
177
right atrium
deoxygenated blood via vena cavae
178
left atrium
oxygenated blood via pulmonary veins
179
right ventricle
deoxygenated blood via pulmonary arteries
180
left ventricle
oxygenated blood via aorta
181
systole
refers to phase of heartbeat where the heart contracts and pumps blood from chambers into artery
182
diastole
phase of heartbeat where heart relaxes and allows blood to fill within heart chambers
183
S1 heart sounds
s1 is consistent with the closing of mitral and tricuspid valves
184
s2 heart sounds
consistent with closure of aortic and pulmonic valves
185
stroke volume
the volume of blood pumped by the ventricles with each heartbeat
186
cardiac output
amount of blood pumped by the heart in a minute
187
preload
volume in the right atrium at the end of diastole
188
preload is an indicator of
how much blood will be forwarded to and ejected from the ventricles
189
formula of cardiac output
HR x stroke volume
190
cardiac cycle
1. atria fill passively
2. atria contract
- all valves close, isovolumentric phase of contraction
3. pressure builds in ventricular chambers
4. semilunar valves open, ventricles eject blood
5. ventricles relax; all valves close
191
p wave
arises from contraction of atria
192
qrs complex
ventricular contraction
193
t wave
repolarization of heart
194
older adults (heart)
- increased risk of hypertension and heart disease
- changees in heart and BP due to age related siffening of vasculature and decreased responsiveness to stress hormones
- changes in BMI, late diastolic filling, cardiac reserves, left ventricualr wall, left atrial size, mitral valve, responses to stress hormones lead to poor responses
195
in the older population you would assess for (heart)
heart failure, atrial fibrillation, chest pain, fatigue, dyspnea associated with symptoms
196
leading cause of death worldwide
heart disease
197
coronary heart disease is most present amongst
65+, men, and native americans/alaska natives
198
leading cause of death in hispanic americans
heart disease and stroke
199
african americans are at increased risk for what heart problem
CV disease and stroke
200
in asian americans and pacific islanders heart disease causes
1/3 of deaths
201
diabetics are at increased risk for
a-fib and heart disease
202
priority urgent assessment and interventions for cardiac issues
- cardiac emergencies: rapid assessemnt + intervention
- focused physical exam; cardiac, respiratory
- additional priority assessments: arrythmias, fluid volume overload; decompensated heart failure
- data clustering
203
symptoms of heart issues
- chest pain
- sob
- abnormal BP
- inadequate tissue perfusion
- orthopnea / paroxysmal nocturnal dyspnea (PND)
- dyspnea
- cough; diaphoressis
- fatigue
- edema
- noctuira
- palpitations
204
assessment of risk factor for cardiac complications
- biographical information
- past medical history
- lifestyle and personal habits
- medications
- family history
- teaching and health promotion
- smoking cessation
- control of BP and cholesterol level
205
older adults tend to have what issues regarding cardiac problems
decreased activity tolerance
syncope
arrythmias; heart failure
206
techniques for assessing heart
- inspect jugular veins
- palpate carotid arteries
- ausculate carotid
- inspect precordium
- palpate PMI, precordium
- ausculatate the pulse, extra heart sounds (s3 and 4), systolic and diastolic murmors
207
variations in heart sounds
- split heart sounds
- systolic ejection click
- snap
- pericardial friction rib
208
diagnostic testing and labs for cardiac
- lipid profile; cardiac enzymes and proteins
- ECG, chest xray, echocardiogram, hemodynamic monitoring, stress test, cardiac catheterization and coronary angiography, cardiac electrophysiology
209
s1 sounds are louder at
apex of heart (bottom)
210
s2 sounds are louder at
base of heart (top)
211
s1 sound is
result from closure of mitral and tricuspid valves
212
s2 sound is
result from closure of aortic and pulmonic valves
213
risk factors for cvd
- old age
- family hx
- male
- high BP
- high cholesterol
- smoking
- diabetes mellitus
- obesity
- decreased acitvity
- high fat diet
- excessive alcohol intake
- elevated C-reactive proteion
- elevated BNP
214
capillaries
connection between arteries and veins that exchange nutrients, agses, and metabolites between blood vessel and tissues
215
arterioles
delivers oxygen and nutrients
216
venules
collect metabolites
217
lymphatic system is composed of
lymph nodes
lymphatic vessels
spleen
tonsils
thymus
tonsils/adenoids
appendix
bone marrow
small intestine
218
thymus
maintains fluid and protein balance
works w immune system
carries lymphatic fluid in tissues to blood stream
219
lymphedema
lymph in tissues is greater than capacity
220
primary lymphedema
congenital
221
secondary lymphedema
injury
222
older adults with vessel and lymph issues
- systolic hypertension
- arterial disease (atherrosclerosis; PAD; chronic venous insufficiency (CVI)
- deep vein thrombosis (DVT)
- venous thromboembolism (VTE)
- venous insufficiency and chronic lymphedema
- primary varicose veins
223
peripheral arterial disease mainly impacts
african americans (male and female)
mexican american females
224
CV disease is most prominent in
african americans and hispanics
225
hypertension is most common in
african americans
226
genetics impact what vascular issues
atherosclerosis
hypertension
diabetes
hyperlipidemia
227
PAD continues to increase in
low, middle, and high income countries
228
CVI (chronic venous insufficiency)
more prevalent in females in industrialized countries
229
pad is greater in what gender in US
females
230
priority urgent assessment for vascular issues
- prioritize based on acute rather than chronic
- complete arterial occlusion: limb threatening situations
- deep vein thrombosis (DVT): immediate anticoagulant therpay necessary
- pulmonary embolism: life threatening
231
symptoms of complete arterial occlusion
pain
numbness
coolness
extremity color change
232
deep vein thrombosis symptoms
pain
edema
extremity warmth
233
pulmonary embolism symptoms
acute dyspnea
chest pain
tachycardia
diaphoresis
anxiety
234
seven Ps for vascular issues
1. pain
2. pallor: pale skin color
3. poikilothermia: inability to regulate core body temo
4. paresthesias: numbness, tingling
5. pulselessness: lack of pulse via palpation, auscultation
6. paralysis: complete loss of muscle function
7. perfusion: capillary refill
235
assessment of risk factors for vascular complications
past medical hx
lifestyle and personal habits
medications
family hx
236
teaching for patients with PAD
risk factor mod:
smoking
high fat diet
limited activity
hypertension and diabetes
daily assessment of feet
other risk factorsL hypertension, diabetes, chronic kidney disease, hereditary
237
teaching and health promotion: venous disease
education: methods of decreasing venous pressure
avoid standing and sitting long periods of time, elevate legs periodically
compression stockings
educate on signs of DVT and PE
238
risk reduction and health promotion for lymphatic disorders: extremity edema
avoid sitting, standing long periods of time
address chronic lymphedema early
239
common symptoms of lymphatic disorders
pain
numbness and tingling
cramping
skin changes
edema
decreased functional ability
older adults
240
basic techniques of vascular/lymphatic assessment
- inspect arms and legs
- palpate arms and legs
- palpate peripheral pulses
- auscultate BP; doppler
- assess for edema
- perform allen test: ABI assessment
- assess for color change
241
skin changes in arterial issues
cool to touch
thin, dry, scaly skin
hairless
thick toe nails
"DR. EP" - dangle legs = rubor, elevate legs = pale
242
skin changes in venous issues
warm to tocuh
thick tough skin
brownish color
243
assessment of arms in vascular assessment
inspection of size, symmetry, color, edema, lesions
palpation- temperature, texture, and turgor, capfill
auscultation of BP
244
assessment of legs in vascular assessment
Inspection- size, symmetry, atrophy, color, cap refill, edema
Palpation- temperature, texture & turgor, pulses
Auscultation- doppler
245
lab and diagnostic testing for vascular issues
wells score system; arterial versus venous; seven Ps; cholesterol and triglyceride levels; glucose levels, HbAIC; serum D-dimer; ultrasound; doppler; lymphoscintigraphy
246
normal capillary refill
less than 2 seconds
247
pain
one of the most common reasons for seeking health care
248
pain affects
quality of life
social interactions
sense of well being, self-esteem
financial resources
249
peripheral nervous systems (PNS)
contains two main types of nerve fibers
- A-delta (sharp stabbing pain)
- C fibers (achy, ongoing)
A and C fibers are commonly referred to as nociceptors
250
nociceptors carry
pain to central nervous system
251
central nervous system is composed of
brain and spinal cord
252
neuroanatomy of pain
1. nerve endings in finger sense pain
2. signals of pain get sent to dorsal horn
3. signals then travel to thalamus
4. then to cerebral cortex
5. then the spinal cord sends it back to dorsal horn
6. endorphins in spinal cord release blocking pain
253
gate control theory
states body responds to pain by:
- opening a neural gate to allow pain to be prodced
- creating a blocking effect at the synaptic junction to stop the pain
254
steps for pain transmission
- gate opens due to continued painful stimulus
- pain passes from pns to cns
- pain passes from spine to limbic system, cerebral cortex
- stimulus identified as pain; passes through efferent pathways; reaction created
255
nociception
most common clinical interpretation of pain
256
steps in nociception
- transduction
- transmission
- perception
- modulation
257
transduction
trauma to peripheral nociceptors
258
transmission
sending of signal from peripheral nociceptors to dorsal root ganglion
259
modulation
alteration of pain signal towards the brain
260
perception
brain percieves pain and decreases modulation
261
neuronal plasticity
nervous system modification in pain transmission
*may causes increase in pain severity*
262
types of pain
- acute
- chronic
- visceral
- somatic
- cutaneous
- referred
- phantom
263
acute pain
recent tissue damage
if untreated may lead to chronic pain
264
chronic pain
approximately 10% of us adults experience daily
stima sometimes associated
HICP - high impact chronic pain that limits at least one major life activity
265
neuropathic pain
more constant stimulus resulting in neuronal plasticity
peripheral sensitization (results of inflammatory process, nonpainful touch/pressure becomes painful)
266
nociplastic pain
pain w/ no identifable cause
ex. fibromyalgia, chronic low back pain, irritable bowel syndrome, headaches, restless leg syndrome, TMJ
- neuronal windup
physiological responses to painful stimuli
- windup
- peripheral sensitization
- central sensitization
267
pain in older adults
- chronic pain present in 25-40% of 65+
- more common along women, adults over 85, lower BMI, more than one pain location, higher severity and longer duration
- chronic diseases may affect assessment of pain
- no evidence available to suggest pain sensation diminished
- cognitive impairment, dementia, and delirium more common in older patients, presesnting challenges for assessing pain
- use of behavioral observations may be helpful
268
cultural variations and health disparities of pain
- disparity in assessment and treatment of pain in racial and ethnic minorities
- no evidence of biological or psychosocial factors between races
- may be unconscious bias
- more likely to rate pain scores lower, receive less pain meds
- cultural differences in communicating about pain
- sex differences between females and males
- need to be aware of sociocultural varibale that influence pain behavior and expression
269
some pain must be assessed and treated to prevent
chest pain = mycardial infarction
worst headache ever = stroke/ cerebral hemmorhage
270
acute pain produces
- high BP
- tachycardia
- diaphoresis
- shallow respirations
- restlessness
- facial grimacing
- guarding behavior
- pallor
-pupil dilation
271
assessment or risk factors for pain
- undertreated or untreated acute pain especially after surgery or crush type injury
- complex regional pain syndrome (CRPS)
- develop neuropathic pain
272
teaching and health promotion of pain
- report pain and take pain meds
- continue to refuse pain meds, ask patient why
- pain is what patient says it is
273
common symptoms of pain
pain intensity
pain quality
274
impact of pain on quality of life
location
duration
intensity
275
OLDCARTS
onset
location
duration
character
aggravating
relieving factors
timing
severity
276
physiological effects of pain
neurologic, cardiac, pulmonary, GI, GU, musculoskeletal, skin, metabolic
277
behavioral responses to pain
emotional, social, vocalization, verbalization, facial expression, body action
278
patients unable to verbalize pain
moaning, facial grimacing, bracing, rubbing painful areas, restlessness, vocal complaints
279
pain assessment tools
- visual analog scale
- numeric pain intensity scale
- brief pain inventory (BPI) - pain intensity scale, body diaphragm, functional assessment efficacy of pain meds
- mggill pain questionairre (MPQ)- set of verbal descriptiors used to capture sensory aspect o fpain, VAS, present pain intensity
- pain enjoyment and general acitivty tool (PEG)
- clinically aligned pain assessment tool
280
lifespan considerations of pain
newborns, infants, children
- painful for adult = painful for child
- FLACC (2mo-7yo)
- FACES (> 3yo)
281
older adults in pain
prevalent (may be seen as natural part of aging)
chronic illness
may be stoic and conceal pain
may fear result of having pain so wont communicate
assess effects of pain on lifestyle
ask about comorbities
review meds, vitamins, and herbs
282
patients unableto report pain
attempt self report, try to ID cause
observe behaviors, ask family
attempt analgesic trial
opioid crisis
misuse and abuse of opoids
CDC guidelines for pain managment
283
what organization set standards on pain mangament
the joint commision
284
barriers to pain assessment
predjudices/bias
- educational values
- family values
- cultural values
- inaccurate or ineffective assessment can result in incorrect dose and/or treatment
285
function of skeletal system
support
movement
protection
produce RBCs (bone marrow)
storage of minerals (i.e., calcium)
286
muscle
skeletal voluntary control connected by tendon to bone
287
cartilage
specialized forms of connective tissue allows bone to slide, reduces
288
fibrous, cartilaginous and synovial joints
places of union of two or more bones
289
ligaments
fibrous bands from one bone to another that strengthen the joint, prevent unwanted movement
290
bursae
enclosed fluid filled sac, serves as a cushion, reduces friction
291
meniscus
cartilage disk between bones to cushion joints and absorb shcok
292
fascia
flat sheets that line and protect muscle fibers, attach muscle to bone and provide structure for nerves, blood vessels, and lymphatics
293
flexion
decreases angle of bones
294
dorsiflexion
bending the ankle so that the toes move toward head
295
plantar flexion
move foot so that the toes move away from the head
296
extension
increases the angle to a straight line or zero degrees
297
hyperextension
extension beyond the neutral position
298
abduction
movement away from center of body
299
adduction
movement toward center of body
300
rotation
turing of joint around longitudinal axis
301
internal rotation
rotating an extermity medially along its axis
302
external rotation
rotating an extremity laterally along its axis
303
pronation
turning forearm so palm is down
304
supination
turning forearm so palm is up
305
circumduction
circular motion that combines flexion, extension, abduction, and adduction
306
inversion
turning sole of foot inaward
307
eversion
turning sole of foot outward
308
protraction
moving body part forward and parallel to ground
309
retraction
moving body part backward and parallel to groun
310
elevation
moving body part upward
311
depression
moving body aprt downward
312
opposition
moving thumb to touch little finger
313
temporomandibular joint (TMJ)
three motions:
- hinge (open and close jaws)
- gliding (protrusion and retraction)
- gliding (side to side movement of lower jaw)
314
shoulder girdle belt of 3 large bones
humerus
scapula
clavicle
joints and muscles
315
glenohumeral joint
ball and socket action allows mobility of arm on many axes
316
rotator cuff
group of muscles and tendons
support and stabilize shoulder
317
subacromial bursa
assists with abduction of arm
318
shoulder is what kind of joint
ball and socket
319
elbow joint has 3 articulation
humerus
radius
ulna
320
palpable landmarks
medial and lateral epicondyles of humerus and large olecranon process of ulna
321
radius and ulna articulate with each other at two joints
elbow and wrist
322
wrist and hands
radiocarpal joint
articulation of radius on thumb side and row of carpal bones
323
condyloid action permits wrist to
flex and extend, deviation (side to side)
324
midcarpal joint
flexion, extension, and some rotation
325
hips
articulation of acetabulum and head of femur
326
hip joints
ball and socket
stability for weight bearing function
muscles - stability, bursae - movement
327
palpation of bony landmarks
iliac crest
ischial tuberosity
greater trochanter of the femur
328
knee joint
three bones - femur, tibia, and patella
329
knees are the
largest joint in the body
hinge joint
flexion and extension of lower leg
330
cartilage of knee
medial and lateral menisci
cushion tibia and femur
331
stabilization of knee
two sets of ligaments
cruciate and collateral
332
ankle (tibotalar) joint
fibula tibia and talus
hinge joint
flexion (dorsiflexion) and extension (plantar flexion)
333
landmarks are two bony prominences
medial malleolus and lateral malleoulus
help stability of ankle
334
joints distal to ankle give additional mobility to foot
subtalar joint - inversion and eversion of foot
foot has longitudional arch with weight bearing distributed between parts that touch ground, the heads of metatarsals and calcaneous heel
335
vertebrae
33 connecting bones stacked in vertical columm
336
motions of vertebral column
flexion
extension
abduction
rotation
337
lateral view of spine
4 curves, double s shape
cervical and lumbar curves concave (inward or anterior)
thoracic and sacrococcygeal curves are convex
338
curves in spine together with intervertebral disks allow spine to
absorb shock
339
aging adults in development
- after 40, resportion occurs more rapidly than deposition causing risk for osteoporosis
- postural and height changes occur (kyphosis with slight flexion of hips and knees to compensate)
- loss of fat leaves bony prominence more marked
- loss in muscle mass (decrease in size and atrophy producing weakness, sedentary lifestyle)
- cartilage degeneration
- joint stiffness
340
infant/child developmental competence
bone grows rapidly during infancy and steadily in childhood, adolescent growth spurt
weight increase - muscles and fat; vary in size and strength due to genetics, nutrition, and exercise
341
epiphyses
growth plates at end of long bones
342
longitudonal growth of bones in infants and children continues until
closure of epiphyses; last closure about 20
343
pregnancy developmental competence
inreased mobility in sacroiliac, sacrococcygeal, and symphysis pubis joints in pelvis contributes to change in posture
lordosis leading to back strain
anterior flexion of neck and slumping of shoulder
344
cultural variation to musculoskeletal system
- bone mineral density
- curvature of long bones
- conversion of active metabolites by sunlights
- biologic sex: exposure to testosterone, estrogen, menopause
- working conditions, physical activity, frequent repetitive movements, poor ergonomic design, lack of movement
345
common musculoskeletal symptoms
pain
discomfort
weakness
limited movement
deformity
lack of balance/coordination
346
skeletal system exam
inspect - size and countour of joiny, skin color, and characteristics, symmetry
palpation - of joint area, skin, muscles, bony articulations, and joint capsules
ROM
active or passive
347
subjective assessment of skeletal system
joints: pain, stiffness, swelling, heat, redness, limitation of movement
knee joint (if injured)
muscles: pain (cramps) or weakness
bones: pain, deformity, trauma (fractures, sprains, or dislocation)
functional assessment (ADLs)
patient centered care
348
questions for joint pain
Pain: any pain or problems w/ joints?
Location: unilateral or bilateral
Characteristics: quality and/or severity
Onset duration and frequency
Aggravating or precipitating factors
Associated clinical presentations
Limitation of motion, stiffness, swelling or erythmea
Impact on ADLs
349
Questions for muscles
location of pain or cramping
pain while walking or at rest
associated clinical presentations
muscle characteristics: weakness and size
onset and duration
350
questions for bones
pain at rest and/or affect by movement
presence of deformity from injury or trauma and effect on ROM
hx of accidents or trauma with impact on boens
medical and.or surgical treatment - any residual deficits
presence of back pain - provide descriptors
presence of neurological or physical deficits
351
functional assessment of ADLs in skeletal system
do joint (muscle, bone) problems create limits in usualy ADLs
screen for safety of independent living, need for home services and QOL
aks specifics about - bathing, toileting, dressing, grooming, eating, mobility, communicating
352
morse fall scale
1. history of falling: immediate or within 3 months( yes = 25 )
2. secondary diagnoses (yes=15)
3. ambulatory aid (crutches = 15, furniture = 30) (wheelchair, nurse, none, bed rest = 0)
4. IV/heparin lock (yes=20)
5. gait/transferring (weak = 10, impaired- 20)
6. mental status (forgetful = 15)
353
morse fall scale risk levels
no risk (0-24) - no action
low risk (25-50) - fall prevention interventions
high risk (>51) - high risk fall prevention
354
infants and children questions for skeletal system
labor and delivery information
achievement of developmental milestones
hx of broken bones/trauma with treatment and/or residual deficits
presence of bone/spinal deformity
355
questions for adolescents regarding skeletal system
hx of sports activities
pattern of warm up and exercise
interventions if injury occurs
356
risk factors for musculoskeletal issues
- occupational hazards
- execise program pattern
- dietary review: gain or loss in weight
- medications rx and over counter related to muscle and bone health
- supplements and vitamins like vit D and calcium
- smoking history
- impact on ADLs : acute vs chronic
357
goniometer
for measuring angle at which joint can flex or extend
358
parkinsons gait
taking small steps with back and neck bent forawrd
359
hemiplegic gait
occurs in ppl with history of stroke, which leads to weakness of arm and legs, arms don't swing and legs are dragged while walking
360
ataxic gait
inability to walk in straight line, certain drugs, positional vertigo and cerebral problems can lead to ataxic gait
361
scissor gait
caused by spasticity of muscles
both knees and thighs cross each other like a scissor, seen among those with cerbral palsy and congenital issues
362
muscle testing
test strength of prime mover muscle groups for each joint; repeat motions for active ROM
ask person to flex and hold as you apply force
muscle strength should be equal bilaterally and should fully resist opposing force
363
rating scale for muscle strength
5/5 (100%) - normal: complete ROM against gravity and full resistance
4/5 (75%) - good: complete ROM against gravity and moderate resistance
3/5 (50%)- fair: complete ROM against gravity
2/5 (25%)- poor: complete ROM with joint supported, cannot perform ROM against gravity
1/5 (10%)- trace: muscle contraction detectable but no movement of joint
0/5 (0%)- zero: no visible muscle contraction
364
atony
lack of normal muscle tone or strength
365
hypotonicity
diminished tone of skeletal muscles
366
spasticity
hypertonic so muscles are stiff and movements are awkward
367
spasm
sudden violent involuntary contraction of a muscle
368
fasciculation
involuntary twitching of muscle fibers
369
tremores
involuntary contraction of muscles
370
physcial exam for TMJ
inspect and palpate
vertical
lateral (side to side)
protrustion (forward and back)
clench of teeth
371
cervical spin physical exam
inspect (should be straight and erect
palpate spinous processes and sternomastoid, trapezius, and paravertebral muscles - nontender
372
ROM of cervical spin
chin to chest - flexion
look to ceiling - hyperextension
ear to shoulder - lateral flexion
look to right center left - rotation
repeat w resistance
373
thoracic spine physical exam
standing draped gown open at back
inspect (from side, note normal convex thoracic curve and concave lumbar curve, kyphosis, lordosis)
palpate spinous processes - not tender
palpate vertebral muscles - firm no tenderness or spasms
chekc ROM - toe touches: look for flexion of 75-90 degress, smoothness and symmetry of movement
374
check ROM of spine
bend sideways, backward, twist shoulders to one side then the other; rotation
walk on toes for a ew steps then return walking on heels
375
straight leg (lasegues) test
raise affected leg just short of point where it produces pain, then dorsiflex foot
positive if reproduces sciatic pain (confirms presence of herniated disc)
376
testing for carpal tunnel syndrome
phalen test - acute flexion of wrist if produces number and burning if +
tinel sign test = percussion of median nerve produces burning and tingling if +
377
amyotrophic lateral sclerosis
median age= 55-66 yo
more common in males
most common in whites
378
ankylosing spondylitis
females 17-35
males 20-30
3x more common in males
native american at higher risk
379
bursitis
older than 40
no sex-related differences, related to chronic stress or acute injury
occurs in all ethnicities
380
carpal tunnel syndrome
25-50 yo
3x more likely in people who are pregnant and in menopause; and those with diabetes and thyroid imbalance
more common in whites
381
duputyren contracture
older than 40
more common in males
most common in whites
382
gout
older than 50
3x more common in males
slightly more common in african americans
383
low back pain
30-50yo
males
affects all ethnicities
384
multiple scleorsis
18-35 but can occur at any age
2x more common in females
most common in whites but more aggressive form is prevalent in african americans
385
multiple myeloma
older than 50
males
2-4x more common in african americans
386
myasthenia gravis
women 18-25, males 60+
2x more common in females
all ethnicities
387
osteoarthritis
50+ in females, 40-50 in males
more common in females, however hip osteoarthritis is similar
more common in whites
388
osteoporosis types I and II
postmenopausal individuals 50-70yo in males
type I more common in females
type I more common in white individuals
389
osteosarcoma
younger than 20 , 50-60+
slightly more common in males
slightly more common in african americans
390
paget disease of bone
40+
males
whites
391
polymyalgia rheymatics
50+
females
white
392
rheumatoid arthritis
20-40yo
2-3x more likely in females
native americans
393
scleroderma
30-50yo
2-8x more common in females
Choctaw indians, followed by african, hispanic, white, and japanese americans
394
scoliosis
10-15yo
8x more common in females assigned at birth
all ethnicities
395
systemic lupus erythematosus
20-30yo
10x more common in females
non-white individuals
396
shortleg gait
discrepancy in length of one leg, flexion contracture of hip or knee, birth hip dislocation
ex. pt limps while walking unless wearing adaptive shoes
397
footdrop or steppage gait
peroneal or anterior tibial nerve injury, paralysis of dorsiflexor muscles, lower motor neuron damage, damage to spinal nerve roots L5 and S1
ex. pt lifts advancing leg high so that toes may clear ground, pt places sole of foot on floor and one time instead of placing heel first (unilateral or bilateral)
398
apraxic gait
frontal lobe tumors, alxheimers disease
ex. pt has difficulty initiating walking, after starting gait is slow and shuffling, motor and sensory systems are intact
399
trendelenburg (compensated gluteus medius gait)
developmental hip dysplasia, muscular dystrophy
ex. trunk lists toward the affect side when weight bearing is on that side, waddling gait may develop if both hips affected
400
rheymatoid arthritis
risk: physical and emotional stress
pain: upper extremities
onset: young adulthood
stiffness: signficant in mornings and after inactivity
generalized complaints: weakness, fatigue, low fever
physical exam: tender, swollen, may be warm
diagnostic tests: serum proteins and synovial fluid - rheumatoid factor
401
osteoarthritis
risk: obesity, aging
pain: lower extremities
onset: 50-60s
stiffness: worse later in day and after inactivity
generalized complaints: none
physical exam: may be tender
diagnostics: xray, ct, mri
402
gouty arthritis
risk factors: family hx, diet high in urine-rich foods, alcohol, stress
pain: base of big toe, may effect feet, ankles, knees, and elbows
onset: middle aged males
stiffness: none in acute cases, develops w chronic disease
generalized complaints: painful, monoarticular, nocturnal joints, later more joints, great toe most often
physical exam: swollen, warm, tender, shiny, red
diagnostic test: synovial fluid aspiration
403
fibromyalgia
risk: family hx, emotional stress
pain: any joints especially neck, back, shoulders, knees, and hands
onset: adult females, 22-55 years of age
stiffness: some stiffness especially in morning
complaints: sleep disturbance, morning fatigue
physical exam: no swellin, tender to touch
diangostic tests: not definitive rule out other diagnosis
404
health promotion and teaching for skeletal isssues
diet to protect and maintain healthy bones
smoking cessation
alcohol intake pattern
exercise programs
osteoporosis screening
fall prevention risk
405
