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knowledge assessment III Flashcards

1
Q

skeletal structure

A

cranium is composed of 22 bones supporting the soft tissue structures of the head

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2
Q

anatomy of head

A

contains:
- muscles
- blood supply
- nerve supply
- salivary glands

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3
Q

blood supply to the head

A
  • carotid arteries
  • temporal artery
  • internal and external jugular veins
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4
Q

nerve supply to face

A

cranial nerve V - facial nerve

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5
Q

salivary glands

A

parotid
submandibular
sublingual

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6
Q

CN VIII can interfere with

A

vestibulocochlear nerve can interfere with balance

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7
Q

facial nerve innervates ear which can

A

interfere with balance

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8
Q

facial muscles are responsible for

A

all movement of the face
CN V responsible for movement

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9
Q

any injury to ear

A

effects coordination and hearing

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10
Q

brainstem injury

A

very disoriented and confused

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11
Q

anatomy of the nose

A
  • allows air to enter the respiratory tract
  • primary organ for smell
  • nerve and blood supply consits of CN 5, 7, 9, and 10, internal and external carotid arteries, and kiesselbach plexus
  • lymphatic drainage
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12
Q

kiesselbach plexus

A

blood supply to the nose, most common for nose bleeds

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13
Q

ethmoid bone

A

only bone separating brain from nose

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14
Q

if ethmoid bone breaks

A

risk for infection, leakage of cerebrospinal fluid

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15
Q

sigmoid bone

A

helps protect against infection

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16
Q

sinuses all come together to form

A

osteomeatal complex

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17
Q

sinus anatomy

A

frontal sinus
maxillary sinus
ethmoid sinus

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18
Q

most common site of anterior nose bleeds

A

kiesselbach
common in cases of trauma, should stop with pressure

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19
Q

mouth

A
  • eat, taste, chewing, speech
  • very vascular tongue
  • salivary glands
  • teeth and gums
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20
Q

vascularity of tongue allows for

A

sublingual meds
quick acting meds

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21
Q

tongue

A
  • muscle (most vascular muscle)
  • front 2/3 should be covered in tastebuds
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22
Q

salivary glands

A
  • produce 2-4 L/day of saliva
  • affected by aging and certain meds, xerostomia, chemo
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23
Q

issues with salivary gland causes

A

harder to swallow food, and protection

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24
Q

xerostomia

A

dry mouth

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25
Q

teeth and gums

A
  • 32 full grown adult teeth
  • dentures
  • state insurance and medicate may not include dental care
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26
Q

C1-C7

A

helps support neck

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27
Q

C3, C4, C5 …

A

keep lungs alive
will not be able to breathe on own if injured

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28
Q

neck is composed of

A
  • vertebrae
  • muscles
  • trachea
  • thyroid and parathyroid glands
  • lymphatics
  • throat
  • tonsils and adenoids
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29
Q

neck muscles

A

sternocleidomastoid and trapezius contribute to use of accessory muscles for breathin

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30
Q

tracheal deviation

A
  • should be midline
  • should not be painful, or deviated
  • if deviated s/o lung collapse
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31
Q

thyroid

A

should not be felt
should be sticking out

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32
Q

hypothyroidism

A

fatigue, high BP, increase in BW

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33
Q

hyperthyroidism

A

decrease wiehgt, increase BP, increase HR, increase metabolism

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34
Q

posterior auricular lymph nodes

A

behind ear

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35
Q

occipital lymph nodes

A

base of head posteriorly

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36
Q

superficial cervical lymph nodes

A

lower ear and parotid

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37
Q

deep cervical lymph nodes

A

other nodes of head and neck, occiptal scalp, ear, back of neck, tongue, trachea, nasopharynx, nasal cavities, palate, esophagous

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38
Q

posterior cervical lymph nodes

A

in between sternocliedomastoid and traps

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39
Q

supraclavicular lymph nodes

A

thorax and abdomen

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40
Q

preauricular lymph nodes

A

in front of ear

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41
Q

parotid lymph nodes

A

below ear, on parotid gland

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42
Q

tonsillar lymph nodes (jugulodiagastric)

A

at jawline

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43
Q

submental lymph nodes

A

lower lip, floor of mouth, apex of tongue

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44
Q

submandibular lymph nodes

A

cheek, side of nose, lower lip, gums, anterior tongue

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45
Q

if lymph nodes are palpable..

A

could be signs of infection or cancer

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46
Q

if lymph nodes arent draining

A

gets larger

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47
Q

tonsils

A

pain, breathing, swelling, infection

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48
Q

older adult considerations for H&N

A
  • facial skin becomes less elastic
  • bony structures are more pronounced causing alteration in facial appearance
  • hair begins to thin (may be related to thyroid)
  • spinal structure may become concave and reduced ROM in neck can appear
  • hypothyroid is common in pts 60+, all older adults should be evaluated
  • gustatory rhinitis (clear rhinorrhea stimulated by smell and taste of food)
  • decreased olfactory sensory fibers
  • thinning of soft tissues of oral cavity - increased risk of ulcer, infection, and oral CA
  • decreased enamel on the teeth - gums beging to recede and teeth appear larger (increased bone resorption and teeth may loosen, brittle teeth, may break, may need implants or dentures, may need altered diet due to dentition change)
  • smooth glossy tongue may result from deficiencies in different B vitamins
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49
Q

vitamin B impacts

A

brain function

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50
Q

cultural variations and health disparities for H&N

A
  • shape and size of facial features, head and neck
  • females have higher risk of both hypo and hyper thyroidism
  • oropharyngeal cancer occurs more frequently in economically developed countries
  • oral disease higher amongst those of low socioeconomic status
  • congenital defects in children
  • head and neck cancer (high risk with HPV infection)
  • sleep disorderd breahthing (2x-4x more MI or stroke)
  • cavities increase among decrease socioeconomic status
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51
Q

priority urgent assessment H&N

A
  • acute head and neck injury (C-spine stabilization is priority, assess for neurologic changes)
  • obtain H&P
  • neck pain
  • lymph node assessment
  • thyroid assessment
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52
Q

c-spine stabilization

A

neck not stable, turning can sever spinal cord causing death

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53
Q

educate patients on

A

wearing helmet

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54
Q

full hx only when pt is

A

stable

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55
Q

lymph nodes concerns

A

> 1 cm
hard
rubbery
immobile

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56
Q

thyroid - BMR

A

increase in BMR is life threatening
called thyroid storm

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57
Q

priority urgent assessment mouth and nose

A
  • epistaxis
  • post-op bleeding after tonsillectomy
  • ludwig angina
  • aspiration risk
  • ansomnia
  • anaphylaxis and airway obstruction
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58
Q

epistaxis

A
  • nosebleed
  • posterior nose bleed, no pressure works, likely to swallow blood and experience n/v
  • 3-5 days of tubing
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59
Q

tonsillectomy

A

increased risk of bleeding
hypotensive
tachycardic

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60
Q

ludwig angina

A

swelling of tongue

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61
Q

aspiration

A

food/fluid in lungs
increased risk after stroke (sit up, assess ANOx4)
silent aspiration is more dangerous

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62
Q

anosmia

A

loss of smell
signs of neuro issue (early sign of parkinson)
viral

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63
Q

anaphalyaxis

A

airway
!emergent!

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64
Q

subjective data collection for head and neck

A
  • assess risk factors (health promotion and educational opportunity)
  • past medical hx
  • lifestyle and personal habits
  • dental health
  • substance use hx
  • environmental exposure
  • meds or allergies
  • family hx
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65
Q

teaching and health promotion

A
  • tobacco use (always assess interest in quitting)
  • sleep disorders (insufficient sleep = poor brain development)
  • cancer (risks)
  • oral health
  • hereditary hemorrhagic telangiectasia
  • headache or facial pain
  • limited ROM of neck
  • lumps of masses
  • hypo/hyperthyroidism
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66
Q

hereditary hemorrhagic telangiectasia

A

malformations of vessels in body causing increased risk of bleeding
nose bleeds is common sign (use humidifiers and saline)

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67
Q

objective data collection

A
  • inspect head, neck, mouth, hair, and throat
  • evaluate swallowing
  • assess aspiration risk
  • vision test
  • hearing test
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68
Q

sinus cultures indicate

A

sinusitis

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69
Q

biopsies are done in

A

cases where lymph nodes can be palpated

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70
Q

lab values - cbc for wbc, thyroid levels

A

infection, TH levels

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71
Q

radioallergosorbent testing (rast) for allergies

A

skin testing

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72
Q

xray

A

observe bones

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73
Q

CT scan and MRI

A

observe soft tissue

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74
Q

xray ct scan and mri

A

observe structural abnormalities

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75
Q

sleep studies

A

sleep apnea

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76
Q

prioritize hypotheses and take action

A
  • cluster data and ID patterns
  • nose, sinus, mouth, throat (impaired airway clearance, impaired swallowing, sleep deprivation
  • head and neck (activity intolerance, fatigue, chronic pain)
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77
Q

anatomy of neurological system

A

composed of central and peripheral nervous system

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78
Q

central nervous system

A
  • composed of brain and spinal cord
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79
Q

peripheral nervous system

A

composed of cranial and spinal nerves

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80
Q

the cerebrum

A
  • right and left hemisphere which control motion of opposite side of body
  • composed of four lobes; frontal, parietal, occipital, temporal
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81
Q

frontal lobe

A

personality, behavior, emotions, intellectual function (broca’s area- mediates speech)

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82
Q

parietal lobe

A

sensation

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83
Q

occipital lobe

A

visual reception

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84
Q

temporal lobe

A

auditory reception (hearing), taste, smell
wernicke’s area - language comprehension

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85
Q

hypothalamus

A
  • respiratory center, temperature regulation, appetite, sex drive, heart rate, BP regulation
  • regulates anterior/posterior pituitary (hormone regulation)
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86
Q

traumatic injury to frontal lobe can lead to

A

impulsive changes in personality and sometimes memories

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87
Q

impaired hypothalamus causes

A

vital signs to be abnormal

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88
Q

cerebellum

A

motor coordination of voluntary movements, equilibrium muscle tone, walking, balance, ADLs

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89
Q

brainstem regulates

A

primitive reflexes (coughing, gagging, HR, BP)

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90
Q

neuro change =

A

cardiac change

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91
Q

ascending spinal cord

A

carries sensory information

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92
Q

descending spinal cord

A

sends motor information

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93
Q

neurons

A
  • basic functional unit of nervous system
  • receives/transmits electrochemical nerve impulses
  • afferent and efferent neurons
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94
Q

afferent neurons

A

sensory neurons
carry impulses from the body to the CNS

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95
Q

efferent neurons

A

motor neurons
carry impulses from the CNS to the body
responds to afferent neuron stimulation

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96
Q

peripheral nervous system

A
  • all the nerves outside the brain and spinal cord
  • relays messages from brain to the rest of the body
  • cranial nerves
  • spinal nerves
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97
Q

cranial nerves

A
  • 12 pairs that exit from the brain
  • sensory, motor, or both
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98
Q

spinal nerves

A
  • arise from spinal cord and innervate the rest of the body
  • 31 pairs
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99
Q

c1-c6 contain

A

most of spinal nerves

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100
Q

if spinal cord injury to c1-6

A

pt may have difficult time breathing

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101
Q

cranial nerves responsible for eye movement

A
  • CN II: optic (2)
  • CN III: oculomotor (3)
  • CN IV: trochlear (4)
  • CN VI: abducens (6)
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102
Q

CN I

A

olfactory nerve
smell
sensory

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103
Q

what cranial nerve is responsible for sensory of face

A

CN V: trigeminal

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104
Q

what cranial nerve allows for movement of face and certain aspects of taste

A

CN VII: facial nerve

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105
Q

what cranial nerve is responsible for neck and shoulder movement

A

CN XI: accessory

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106
Q

CN II

A

optic nerve
sight
sensory

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107
Q

CN III

A

oculomotor

eyeball movement and movement of upper eyelid
motor
parasympathetic: pupillary light reflex

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108
Q

CN IV

A

trochlear
eyeball movement: superior oblique
motor

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109
Q

CN V

A

trigeminal

V1: opthalmic
facial sensation (S)
pupillary dilation (SM)

V2: maxillary
facial sensation (S)

V3: mandibular
chewing (M)
facial sensation (S)

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110
Q

CN VI

A

abducens
eyeball movement - lateral rectus (M)

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111
Q

CN VII

A

facial nerve

taste: anterior 2/3 of tongue (S)

facial expression, eyelid closing, stapedius muscle: dampens sounds (M)

lacrimation salvation - submandibular + sublingual glands (P)

112
Q

CN VIII

A

vestibulocochlear nerve
hearing: cochlea (S)
balance: vestiublar apparatus (S)

113
Q

CN IX

A

glossopharyngeal nerve

sensation from posterior 1/3 of tongue, tonsils, middle ear, pharynx, taste from posterior 1/3 of tongue (S)

stylopharyngess muscle elevates pharynx and larynx (M)

salivation - parotid gland (P)

114
Q

CN X

A

vagus nerve

swallowing, elevation of palate, talking, coughing, gag reflex (M)

heart rate, GI peristalsis, sweating, vasovagal syncope (P)

peripheral chemoreceptors - hypoxemia (SM)

115
Q

CN XI

A

accessory nerve

head turning: SCM (M)
shrugging: trapezius (M)

116
Q

CN XII

A

hypoglossal nerve

most muscles of tongue (except palatoglossus) - tongue movement (M)

117
Q

reflex arc

A
  • basic defense mechanism (involuntary)
  • stretch (deep tendon) - knee jerk response
  • superficial - plantar reflex
  • visceral (organ) - pupillary response
118
Q

neurological system on aging adult

A
  • loss of muscle bulk/tone (atrophy)
  • delayed reaction time
  • decreased ability to multitask or respond to multiple stimuli
  • decreased cerebeal blood flow
  • peripheral nervous system decline
119
Q

loss of muscle/tone (atrophy) in older adults

A
  • disuse
  • loss of neural structures in brain and spinal cord
120
Q

delayed reaction time in older adults

A
  • velocity of nerve impulses is slowed
  • motor system (movement) slows
121
Q

decreased cerebral blood flow in older adults

A
  • decreased gas exchange ability
  • impaired BF (cardiac, vascular)
122
Q

peripheral nervous system decline in older adults

A
  • decreased balance
  • postural hypotension
123
Q

impact of culture and genetics on strokes

A
  • 5th most common cause of death
  • 1.3% Asian/Pacific Islanders
  • 2.3% Hispanics
  • 2.5% whites
  • 4% African Americans
  • 4.6% Amercian Indians
  • decreased incidence with HTN/HLD screening and cholesterol and BP meds
  • “stroke belt”
  • functional status
124
Q

health promotion for neuro assessment

A
  • stroke prevention
  • injury prevention (wear helmet, diet, drinking, sports, drugs, falls)
  • chronic neurological conditions (alz. parkinsons)
125
Q

basic neurological assessment

A
  • chief complaint
  • admitting diagnosis
  • PMH
  • if pt has concerns - focused assessment
126
Q

focused assessment

A
  • neurologic concenrs
  • significant neurologic PMH
  • basic neurological assessment reveals an abnormality
127
Q

indicators of significant changes in neuro status

A
  • acute change in mental status
  • changes in consciousness not explained by known causes
  • seizures
  • onset of flexor or extensor posturing
  • change in size and decreased reactivity to light in one or both pupils
  • onset of conjugate or dysconjugate eye deviation
  • progressing weakness (paresis) or paralysis of extremity or one side of body
  • facial weakness
  • significant changes in VS
  • changes in BP, HR or heart rythm may threaten tissue oxygenation or result in direct injury from hemmorhage
  • progressively rising BP leading to widening pulse pressure, decreasing pulse, and decreasing respirations, the classic signs of increased intracranial pressure (Cushing response); these are late signs of lower brainstem compression
  • irregular breathing patterns may indicate progressing brainstem compression
128
Q

sequence of neurological assessment

A
  • mental status (cognition)
  • subjective questions
  • brain function (motor, sensory, reflexes)
129
Q

headache

130
Q

head injury

A

event hx, type and description
loc and recall of event

131
Q

dizziness/vertigo

A
  • OLDCARTS
  • position changes, activity, meds
132
Q

memory

A

OLDCARTS
decrease in mental function or confusion

133
Q

time =

134
Q

seizures

A
  • OLDCARTS
  • associated clinical presentations
  • postictal phase
  • precipitating factors
  • med therapy and coping strategies
135
Q

tremors

A
  • OLDCARTS
  • precipitating and alleviating factors
136
Q

weakness

A
  • localized or generalized
  • distal or proximal
  • impact on mobility or ADLs
137
Q

vision changes: sudden

A
  • onset duration frequency
  • loc and safety
138
Q

incoordination

A
  • problem with balance while standing or ambulating
  • lateral drifting, stumbling, or falling
  • legs giving way and/or clumsy movements
139
Q

numbness or tingling

A
  • OLDCARTS
  • whether it occurs with activity
140
Q

difficulty swallowing

A

with solids or liquids
drooling

141
Q

difficulty speaking

A
  • OLDCARTS
  • clarity
  • forming words or saying what you want to say
142
Q

patient centered care

A
  • information regarding past pertinent medical hx
  • alcohol history
  • substance abuse/drug history
143
Q

mental status

A
  • level of consciousness
  • level of arousal
  • orientation status
144
Q

assessing brain function

A
  • symmetry at rest
  • speech
  • pupillary response (PEERLA) (cardinal positions of gaze)
  • strength
  • sensation
145
Q

level of consciousness

A

is the patient…
- alert
- confusion
- drowsiness, lethargic, obtunded
- stuporous
- comatose

146
Q

level or arousal (eye opening)

A
  • spontaneous: no stimuli needed
  • normal verbal stimuli: name calling
  • loud verbal stimuli: loud voice if no response to normal voice
  • tactile: light touch, place hand on pt’s arms or legs, gently rub/shake
  • noxious stimuli: vigorous touch, shaking, sternal rub, nail bed pressure
147
Q

orientation status

A
  • person (name DOB)
  • place (where are they)
  • time (what day is it)
  • situation (what is happening)
148
Q

glasgow coma scale (GCS)

A
  1. eye opening response
    spontaneous - 4
    to voice - 3
    to pain -2
    none - 1
  2. best verbal response
    oriented -5
    confused -4
    inappropriate words - 3
    incomprehensible sounds - 2
    none - 1
  3. best motor response
    - obeys command - 6
    - localized pain - 5
    - withdraws - 4
    - flexion - 3
    - extension - 2
    - none - 1
    total: 3-15
149
Q

facial structures to observe for symmetry

A
  • eyebrows
  • eyese
  • nose
  • ears
  • mouth
150
Q

observe pt for (facial)

A
  • size comparison if applicable
  • placement (plane)
  • drooping
151
Q

judge the quality of persons speech

A
  • pace - rate of speech (normal, abnormal - slowed, rapid)
  • word choice - appropriateness
  • clarity - understandibility of speech
152
Q

aphasia

A

difficulty with language comprehension and production of speech

153
Q

expressive aphasia

A
  • understands spoken and written language
  • cannot express oneself verbally or transcribed
154
Q

receptive aphasia

A
  • cannot understand written or spoken language (hears sounds/reads words but cannot relate these to any previous experience)
  • can speak fluently and effortlessly with clear speech but they substitute wrong or made up words when speaking
155
Q

global aphasia

A

experiences components of both expressive and receptive aphasia

156
Q

PERRLA

A

pupillary assessment
equal - on both sides
round
reactive to
light
accommodation

157
Q

strength

A
  • where to test? (upper and lower extermities)
  • how to rate (strong, moderate (average), weak, or absent)
158
Q

sensation

A
  • palpate arms, legs, and feet bilaterally
  • determine if sensation is equal on both sides
159
Q

ask pt to

A

smile
frown
close eyes
lift eyebrows
puff cheeks
stick out tongue

160
Q

sternomastoid assessment

A
  • rotation of head against resistance
  • place hand on side of chin and apply resistance
  • ask pt to rotate head forcibly against resistance
161
Q

big pupils

A

non reactive
brain herniation

162
Q

trapezius assessment

A
  • also known as shoulder shrugs
  • apply resistance against top of shoulders
163
Q

DTRs

A
  • evaluates reflex arc
  • equipment: reflex hammer, used to strike tendon at muscle insertion site, two sides, pointed end - small target area (upper extremities), flat end - wider targets (lower extremities)
164
Q

4 point reflex response grading

A

4+ = brisk/hyperactive
3+ = brisker than average
2+ = average (normal)
1+= diminished
0 = no response

165
Q

optimize results

A

extremity should be relaxed
muscle partially stretched
swing hammer by moving wrist
excess force is not needed

166
Q

clonus

A

rapid rhythmic contraction of muscle
seizures, rapid contraction and tremor happens

167
Q

hyperreflexia

A

exaggerated reflex

168
Q

hyporeflexia

A

diminished or absent reflex

169
Q

knee pats

A

pat both knees with hands, flip hands, pat, flip hands, pat

170
Q

finger thumb test

A

touch thumb with each finger starting with index finger
repeat in opposite direction

171
Q

finger- nose finger

A

touch examiners index finger then their own nose, then back to examiners index finger

172
Q

assess cerebrallar function through

A

rapid alternating movements
balance (heel-to-toe walking)
stationary balance (romberg’s test)

173
Q

superficial reflexes

A

elicited by stimulation of the skin
plantar resopnse

174
Q

meningeal assessment

A

nucal rigidity
brudzinski sign
kernig sign

175
Q

nuchal rugidity

A

associated with meningitis and intracranial hemorrhage
neck stiffness (flex head forward passively, would cause severe pain)

176
Q

toes pointing up is not normal

A

+ babinski
babies do this and cannot walk until it goes away

177
Q

brudziniski sign

A

body curls up

178
Q

kernig sign

A

lay on back, life leg up and straight, pain in lower back

179
Q

assessing unconscious patient

A
  • urgent evaluation
  • risk for life threatening condition
  • client cannot participate
  • perform GCS
  • PERRLA
  • brainstem assessment
  • motor function
  • patterns of progressive decline or brain herniation
180
Q

lumbar puncture

A

used to observe meningitis (assess CSF), brain pressure

181
Q

CT scan for neuro

A

staple, quickest easiet

182
Q

MRI

A

spinal cord injuries
if patient is confused must be minfull

183
Q

angiograph

A

look at vessels

184
Q

EEG

A

sees brain activity

185
Q

assessments include

A
  1. admision, comprehensive assessment
  2. shift or ongoing assessment
  3. focused assessment (specific)
  4. urgent assessment (emergency)
186
Q

comprehensive assessment

A
  • any pain?
  • mind body soul past hx
  • past surgeries, past illness, family hx
  • can you tell me why you’re here?
  • allergies?
  • do you drink, smoke, do drugs?
  • meds?
187
Q

assessment begins at

A

admission, continues until client is transitioned to next phase of care

188
Q

nurses cannot delegate

A

main functions of assessment, planning, evaluation, and nursing judgement

189
Q

RNs can delegate

A
  • ADLs
  • assistive devices
  • nutrition and oral hydration
  • mobility/immobility
  • rest and sleep
  • non pharmacological comfort interventions
190
Q

RN responsible for delegation

A
  • right task
  • right circumstances
  • right person
  • right direction and communication
  • right supervision
  • right evaluation
191
Q

older adults

A
  • have special needs related to physiological changes of aging and diminished physiological reserve
  • increased risks of falls w/ fractures, delirium, HAI, medication interactions
  • may develop acute med problems within 30 days of last hospitalization causing rehabilitation
  • 2x the risk of developing various complication: abscess, wound infection, emphysema, URI, pneumonia, thrombosis, pneumothorax, compartment syndrome
192
Q

racial and ethnic minorities experience

A

lower quality of care, less likely to receive routine medical care, face higher rates of morbidity and mortality

193
Q

urgent assessment

A
  • occurs during any physiologic or psychological change in client
  • nurses need to ID S/S of deteroiration based on knowledge of physiological compensatory mechanisms and correlation of pathophysiology of illness
  • nurses ability to recognize and resopnd to signs and worsening client in timely manner plays a pivotal role in client outcomes
194
Q

examples of urgent assessment

A
  • vital signs outside normal parameters
  • acute change in O2 sat, pupillary response, urine output
  • threatened airway
  • new onset chest pain
  • acutely cold, cyanotic, or pulseless extremity
  • confusion, agitation, or delirium, unexplained, lethargy, acute altered mental status
  • signs of stroke, difficulty speaking
195
Q

communicating the assessment

A
  • use effective and appropraite communication of the changed or abnormal parameters
  • clear, concise, timely reporting to provider is required
  • SBAR format
  • follow facility protocols
  • RRT
196
Q

comprehensive admitting assessment

A
  • V.S.
  • general survey
  • neurological assessment
  • head, face, eyes, ears, nose, mouth, throat, assessment
  • anterior thorax assessment
  • upper extremities assesment
  • abdominal assessment
  • posterior thorax assessment
  • lower extremities assessment
  • intake and elmination
  • psychosocial assessment
197
Q

general shift assessment

A
  • head to toe
  • client immediate conern
  • immediate treatment/teaching/discharge planning
  • care priorities
198
Q

focused shift assessment

A
  • integration into shift assesment
  • clinical judgement: determine client priorities
199
Q

specialized assessment for hospitalized patients

A
  • injuries from falls
  • immobility
  • pressure injury
  • DVT
  • adverse drug events
  • catheter-associated UTIs
  • central line associated bloodstream infections
  • surgical site infections
  • ventricular associated penumonia
  • sepsis
200
Q

making clinical decisions

A
  • analyze labs and diagnostic testing
  • prioritize hypotheses and take action
  • analyzing changing findings: progress notes
  • interprofessional collaboration w/ discharge planning team
  • plan the care
  • evaluate outcomes
201
Q

newborns and infants

A

circumcision
57% of males in US are circumcised

202
Q

children and adolescents

A

tanner’s stages of maturation

203
Q

between 13-15…

A

the pubic hair and testicles and penis are still growing

204
Q

around 14-17…

A

fll size and pubic hair grow triangular

205
Q

older adults

A
  • stool retention, incontinence
  • declining testosterone levels
  • testes drop lower in scrotum
  • benign prostatic hyperplasia (BPH)
  • erectile dysfunction
206
Q

cultural considerations for male genitalia

A
  • cultural beliefs, gender identity, sexual orientation
  • piercings and tattoos
  • transgender female
207
Q

many meds can cause issues with ED and libido

A
  • can cause isssues with ED and libido
  • statins
  • diuretics
  • antidepressants
  • beta-blockers (heart med assess hx of CV illness)
  • anticonvulsants
208
Q

older adults are more likely to experience

A

constipation with decrease in sensation isn’t firing to brain

209
Q

priority urgent assessment of male genitalia

A
  • testicular torsion versus epididymitis
  • fournier’s gangrene
  • cathether-acquierd urinary tract infection
  • anorectal difficulties
  • colorectal cancer
210
Q

testicular torsion versus epididymitis

A
  • penile pain
  • scrotal pain
  • twisting of spermatic cord cutting BF from area surrounding it
  • surgical emergency
  • epididymis inflammation
211
Q

fournier’s gangrene

A
  • happens mostly to diabetics
  • necrotizing bacteria of the perineum or around area causing gangrene
  • can be from peripheral neuropathy due to diabetes
  • presents as swelling pain, worsening
  • surgical intervention
212
Q

CAUTI

A
  • high incidence of UTIs without proper cleaning and maintenance of catheter
  • 75% of hospital admissions
213
Q

colorectal cancers

A
  • encourage people to have rectal exams as it is one of the most curable to without having proper precautions of self assessment, there will be a society with increase prevalence` of colorectal cancer
214
Q

assessment of risk factors for male genitalia

A
  • past med hx
  • med and surgical hx
  • life style and personal habits: 5Ps (partners, practices, protection, past hx of STIs; prevention or pregnancy)
  • meds
  • family history
215
Q

health goals

A

testicular/prostate cancer; family planning, STIs

216
Q

common symptoms of male genitalia issues

A
  • pain
  • difficulties with urination
  • ED
  • penile lesions, discharge, rash
  • scrotal enlargement
  • older adults
  • cultural considerations
217
Q

comprehensive male genitalia assessment

A
  • utilize inspection and palpation as appropriate
  • groin
  • penis
  • scrotum
  • sacrococcygeal areas
  • perineal area
  • inguinal region and femoral aras
218
Q

anterior pituitary gland

A

secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

219
Q

hypothalamus

A

releases FSH and LH via gonadotropin-releasing hormones (GnRH) and luteinizing-releasing hormones (LnRH); inhibits prolactin release

220
Q

ovaries

A

estrogen and progesterone

221
Q

ectopic pregnancy

A

fertilized egg that has implanted other than uterus
usually fallopian tubes but can be anywhere
burst fallopian tube can cause death

222
Q

significant vaginal bleeding is equivalent to

A

soiling a pad every 30 minutes

223
Q

high HR due to low BP from significant bleeding from uterus causes

A

anemia
low iron
pale
dizziness

224
Q

placenta previa

A

placenta blocking way of vaginal birth

225
Q

placental abruptio

A

bursting of placenta

226
Q

gestational hypertension

A

preclampsia - 140/90
check kidney function, urine output, BUN/creatinine - objective data for hypotension

227
Q

preterm labor

A

contractions more than 6/hr before 37 weeks

228
Q

ambiguous genitalia at birth

A

common for drainage and swelling but if it doesn’t go down there may be a concern for hermaphrodites, congenital abnormality

229
Q

puberty: tanner stages

A

when taking care of adolescents

230
Q

menopause

A

12 consecutive months without menses

231
Q

menopause causes

A
  • changes related to lack of estrogen and progesterone production
  • vaginal infections, UTIs, dyspareunia, diminished libido
  • increased risk for endometrial, vaginal, and vulvar cancers; unexpected signs and symptoms
  • intmacy difficulties and physiological changes
232
Q

age of onset of puberty

A

5 mo prior in african americans compared to whites

233
Q

cultural variations and health disparities female genitalia

A
  • some with greater sexual fluency and candidiness about sexuality
  • personal choice, unrelated to culture and responsibility
  • latina females have highest rates of cervical cancer and are more likely to die as a result
  • african americans 2x more likely to die from cervical cancers compared to whites
  • female circumcision
234
Q

priority urgent assessment for female genitalia

A
  • severe pain
  • excessive vaginal bleeding
235
Q

severe pain of female genitalia

A
  • acute infection (PID, UTI)
  • appendicits
  • pancreatitis
  • cholescystitis
  • strangulated hernia
  • muskuloskeletal trauma (ruptured bladder, spleen, liver)
  • ectopic pregnancy
  • ovarian cyst
236
Q

excessive vaginal bleeding

A

change from normal menstruation cycle occurring outside normal menses, during pregnancy, trauma

237
Q

subjective data of female genitalia assessment

A
  • past medical hx
  • menstrual hx
  • obstetrical hx: gravida; para; term; preterm; abortion; living
  • menopause
  • gynecological hx
  • immunizations
  • sexual history
  • lifestyle (sexual activity, birth control)
  • STIs
  • obesity
  • osteoporosis
  • contraceptives
    -meds
  • family hx
238
Q

teaching and health promotion of female gentialia

A
  • prevention of STIs
  • menopause changes
  • prevention of HPV and cancer
  • genital self-exam
  • elimination of female genital circumcision
  • appropriate screenings
  • immunizations: HPV vaccine
239
Q

common symptoms of female genitalia pain

A
  • pelvic pain
  • vaginal burning, discharge, itching
  • menstrual disorders
  • structural difficulties
  • sexual dysfunction
  • hemorrhoids
240
Q

pap smear if for

A

cervical cancers not STDs

241
Q

role of the nurse in mental health scenarios

A
  • assessment is subtle and indirect
  • sensitive issues
  • allow sufficient time to provide therapuetic interventions
  • need time, follow-up, and allow for closure
  • requires advanced education
242
Q

violence

A

many forms, each with unique risk factors and characteristics

243
Q

family violence

A
  • biologically or legally related to offender
  • domestic violence, intimate partner violence, male violence against women, child abuse, sibling violence, elder abuse, abuse during pregnancy
  • threatened or actual physical or sexual violence, physiological/emotional abuse, and/or abuse during pregnancy
  • acceptable by some cultures
244
Q

intimate partner violence/domestic violence

A
  • poorer the household, higher rate DV
  • 6x more likely if female in lower socioeconomic status
245
Q

female immigrants have higher rates of

246
Q

sexual violence

A
  • forced sex in dating and marital relationships, gang rape, sexual harassment, inappropriate touching, molestation, sex w. patient, forced prostitiution, forced exposure to sexually explicit behavior
  • child sexual abuse: adult rape
  • cultural differences
247
Q

human trafficking

A
  • form of slavery
  • sexual exploitation, forced marriage, cheap labor for domestic or commericial purposes
248
Q

child abuse and maltreatment

A
  • “red flags”: anxiety, depression, aggression, anger
  • sibling violence
  • punking and bullying
249
Q

most common form of child abuse

A

sibling abuse

250
Q

elder abuse

A
  • neglect, financial exploitation, abdonment
  • intentional actions by caregiver or other person
  • elder assessment instrument
251
Q

vulnerable adults

A
  • more likely to have disabilities
  • abuse and neglect
  • physical, sexual, physiological, financial abuse, and neglect
252
Q

hate crimes

A
  • “acts of physical harm and specific criminal threats motivated by animus based on race, color, national origin, religion, gender, sexual orientation, gender identity, or disability”
  • victims develop depression and physiological trauma
  • affect other = families, communities, entire nation
253
Q

misuse of drugs

A

not taking drugs as prescribed
“instead of taking 2 i take 3”

254
Q

addiction

A

have craving/obession with drug
chronic relapsing brain disease that craves that high despite any consequence

255
Q

dependence

A

tolerance to med
if it is stopped, withdrawals

256
Q

common substances

A
  • alcohol
  • caffeine
  • canabis
  • hallucinogens
  • inhalants
  • opioid
  • sedatives, hypnotics or anxiolytics
  • stimulants
257
Q

substance abuse is most notable among

A

women, racial/ethnic minorities, older age adults, and lower education level and socioeconomic class

258
Q

stats for substance abuse

A

stress, caregiver role strain, depression, anxiety, binge drinking, heavy alcohol use

259
Q

alcohol use disorder

A
  • needs to meet certain criteria
  • mild, moderate, severe
  • clinical institue withdrawal assessment for alcohol (CIWA)
260
Q

CIWA

A

done with 2 nurses
treatment during withdrawls, visual hallucinations, auditory hallucinations, headache, feeling sick

261
Q

opioid crisis

A
  • includes prescription opioids, heroin, synthetic opioids (fentanyl), animal sedatives (carfentanil)
  • commonly results in overdose death
  • requires immediate emergency interaction with multiple doses of naloxone
  • nonfatal cases leave emotional ,physiological physical impacts on pt and family
262
Q

priority urgent assessment of mental health

A
  • includes questions about violence and harm to self or others: risk for injury w/ psychotic states, depression, dementia delirium, suspected violence, risk for harm requires urgent attention, homicidal or suicidal thoughts require urgent attention
  • question safety first, presenting situation last
  • prevents forgetting to ask critical questions about safety
  • allows more time to focus on pressnting situation
263
Q

subjective data collection for mental health

A
  • includes what pt says directly to you, what you overhear pt say, and what family and friends report
  • open-ended questions
  • validate patient given information through family or friends
  • must listen not only for what is said but what is unsaid
  • nurse must be comfortable and deal with own feelings and beliefs to help pt
  • pt may use diversionary tactics, avoid answering questions, be fearful
264
Q

interviewing pt about violence

A
  • key aspect: asking about personal experiences of violence
  • universal rule: conduct patient interview in private, with no one else: pay attention to individual who comes with pt and does not want or refuses to leave pt with you
  • assess violent experiences as normal and natural
  • following listening principles
265
Q

alcohol and drug use disorder interview

A
  • occurs together in about half the population
  • may be labeled “dual diagnosis”
  • may be linked to personality disorders, PTSD, OCD, panic disorder, social phobias, seecific phobias, major depression, manic depression, schizophrenia
  • often needs psych referral
  • denial part of substance use disorder
  • assess curent and past use of tobacco, alcohol, prescription, and OTC products
  • CAGE assessment
266
Q

risk factors for mental health conditions

A
  • past med hx
  • violence
  • alcohol and drug use
  • meds
  • family hx
267
Q

delirium, dementia, and depression assessment

A

onset:
- delirium: acute over few hours; lasting hours to weeks. occurs in context of medical illness, substance misuse, or withdrawal
- dementia: slow, lasting months to years
- depression: slow

description:
- delirium: impaired recent remote memory; fluctuating attention; thoughts disorganized; change in cognition; clouding of consciousness; perceptual disturbances; without mood components
- dementia: impaired remote memory; attention preserved; thoughts impoverished; global impairment of intellect; alert
- depression: impaired memory; aware; attention intact; impaired concentration; if psychosis present, usually systematized normal emotional responses; perceptual disturbances; sad effect or mood

268
Q

DDD Assessment

A
  • can be acute
  • delirium can place patient at risk for injury
  • risk of suicide increases with depression
  • risk of suicide increases with depression
  • effective treatment relies upon accurate assessment and diagnosis
269
Q

teaching and health promotion: mental health

A
  • current stressors and coping
  • pervasive worry or anxiety
  • altered mood or affect
  • memory, concentration, and problem soliving abilities
270
Q

general health goals for mental health

A
  • decrease suicide risk
  • increase # of individuals with co-occurring substance use and mental health disorders who receive treatment
  • increase # of adults w/ serious mental illness to receive treatment
  • reduce ED visits for harms from nonmedical use of prescription opioids
271
Q

signs and symptoms of mental health issues

A
  • suicidal ideation (SAD PERSONAS)
  • homicidal ideation and aggressive behavior
  • altered mood and affect (mood disorders)
  • auditory or visual hallucinations
  • olfactory and tactile hallucinations
272
Q

older adults and mental health

A

geriatric depression scale
delrium, dementia and depression table

273
Q

ABCT

A
  • A: appearance (overall appearance, posture, movement, hygeine, grooming, dress)
  • B: behavior (LOC, eye contact and facial expressions, speech)
  • C: cognitive function (orientation, attention span, memory MMSE, minicog, judgement)
  • T: thought processes and perceptions
274
Q

drug and alcohol use test

A

CAGE
CAGE-AID

275
Q

alcohol withdrawal test

276
Q

mini-cog

A

used to assess cognitive function in individuals presenting with signs of dementia

nur306 (4 decks)

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