- Accidents, trauma - Cirrhosis - Cardiomyopathy, arrhythmias, HTN - Cancers of mouth, liver, esophagus

Severe withdrawal alcohol - AKA - S/S

Severe withdrawal = withdrawal delirium - Marked autonomic hyperactivity - Anxiety, nausea, - Increased tremors - Vivid hallucinations - Life threatening - Fever

3 or more of: - Can't stop or attain limits - Spent lots of time drinking - Spent less time on things that needed to be done - Showing tolerance (need more to have effect) - Showing signs of withdrawal (tremors, anxiety, sweating) - Keep drinking despite problems

One or more of: - Risk for bodily harm - Relationship problems - Run ins with the law - Role failure

Last minute freak out Flashcards by Nicole Hayashi

Pulse grading

0-3

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Normal assessment order

Inspect - palpate - percuss - auscultate

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Drug Abuse assessment/help

Assist - give medical advice
Asses - readiness for change?
Assist - offer help
Arrange - refer to specialists

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% of people over the age of 12 who drink

52%

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% of the 52% who drink who binge drink?

23%

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% of those who heavily drink

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Risks from drinking

Accidents, trauma
Cirrhosis
Cardiomyopathy, arrhythmias, HTN
Cancers of mouth, liver, esophagus

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Severe withdrawal alcohol

Severe withdrawal = withdrawal delirium

Marked autonomic hyperactivity
Anxiety, nausea,
Increased tremors
Vivid hallucinations
Life threatening
Fever

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CIWA scale - Severe withdrawal

More than 20

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COWS - severe withdrawal

More than 36

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Alcohol Dependence

3 or more of:

Can’t stop or attain limits
Spent lots of time drinking
Spent less time on things that needed to be done
Showing tolerance (need more to have effect)
Showing signs of withdrawal (tremors, anxiety, sweating)
Keep drinking despite problems

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At Risk Drinking

Binge drinkers who are neither alcohol use disorder or alcohol dependent

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Uncomplicated withdrawal

-Anxiety
-Tremors
-Hallucinations
-Autonomic hyperactivity (sweat, tachycardic, elevated BP)
Peaks on 2nd day, resolves by 4th or 5th day

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Alcohol abuse

One or more of:

Risk for bodily harm
Relationship problems
Run ins with the law
Role failure

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Palpation for heart

Apical pulse 
Carotid Arteries (0-3, 2+ normal)

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Binge #s

Men: 5 drinks/2hrs
Women: 4 drinks/2 hrs

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Risk for drinking when pregnant

Fetal alcohol syndrome

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Steps for Alcohol Screening/Intervention

Ask
Assess
Assist
Follow-Up

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ROM Scale

0-5

3 - ROM with gravity (can lift but no resistance)

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Assess muscles for…

Size, tone, strength, sensory, ROM

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Normal abdominal/GI sounds with percussion

Stomach and intestines: tympany

Liver and spleen: dull

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Abnormal GI percussion sounds

Dull over fluid, mass, tumor

ascites, feces, tumor

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Bowel sound order

RLQ - RUQ - LLQ - RLQ

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Abdominal bruits indicate

Aortic aneurysm
Femoral artery occlusion
Renal artery stenosis

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CVA tenderness indicates

Kidney inflammation (pyelonephritis)

Order of abdominal assessment

Inspection - auscultation - percussion - palpation

Distension

Obese - uniformly round with everted umbilicus Ascites - round with everted umbilicus Feces or tumor- localized distension

Painful ROM in every direction

Inflammation (ex: arthritis)

Painful ROM in one direction

ligament, tendon problem

Pronator drift

Patient holds arms out with eyes closed Hold for 10 seconds - negative If one arm pronates and drifts down - positive for UE weakness

Straight Leg Test

aka Lasegue Test | Positive: herniated lumbar disc or nerve irritation

Phalen's Sign

Inverted prayer that tests for carpal tunnel

Tinel's Sign

Tap medial nerve to check for nerve irritation

Confrontation tests CN

II - optic

Jaw movement tests CN

V - trigeminal

PERRLA tests CN

III, IV, VI | Oculomoter, trochlear, abducens

Heaves, lifts, and pulsations may indicate

Ventricular hypertrophy Right side: near sternal border Left: apex

Graphesthesia

Draw number on palm and have pt identify number

Reflex grading

0-4 | +2 is normal

Clonus

Repeated muscular movements (jerking)

Plantar Reflex

J motion from heel to lateral | Positive: babinski and big toe reflex

In babies, babinski is...

Normal

Hyperreflexia

Upper motor neuron injury

PMI

Point of maximal impulse - 5th intercostal space

Top of the heart is called

base

Bottom of heart is called

apex

Facial movement tests CN

VII - facial

Sensory tests on face test CN

V - trigeminal

Whisper tests tests CN

VIII - vestibulochlear

Gag reflex tests CNs

IX and X - glossopharyngeal, vagus

Should shrug tests CN

XI - accessory

Bruit

Low swooshing sound heart with turbulent blood flow, indicating partial occlusion in the artery -Could indicate atherosclerosis

Light tight dynamite tests CN

XII - hypoglossal

Hyperparesthesia

Increased touch sensation

Hypoparesthesia

Decreased touch sensation

Anesthesia

No touch sensation

Position sense

kinesthesia

Tests for kinesthesia

Move patient's distal joints and have them identify the direction of movement

Stereognosis

Place a familiar object in the patient's hand and have them identify it

Which is higher pitched, murmur or bruit?

Bruit

What do you use to listen to the bruit?

Bell

JVD distension is

abnormal

JVD indicates

Excess fluid volume | Heart failure

Technique to assess JVD

Inspect at 45 degrees (head turned slightly)

Ventricular gallop Kentucky Heard after S2

S3 indicates

Heart failure, fluid overload

S3 is normal in

children

S3 and S4 are what type of sounds?

Diastolic

Atrial gallop Tennessee Heard before S1 after S3

S4 indicates

Ventricular deficiency | Seen with coronary artery disease

S4 is normal in

older adults

"Lub" Beginning of systolic Closure of AV valves (mitral and tricuspid) Heard better at base

"Dub" End of systolic Closure of Semilunar valves (pulmonic and aortic) Heard better at apex

Abnormal palpation finding at precordium

Thrill

Palpable vibration that signifies turbulent blood flow

What should you use to feel thrill?

Palm surface of hand

what should you use to palpate for temperature on a patient?

Dorsal

One pulse is

Lub Dub | S1, S2

Hyporeflexia

Lower motor neuron damage

Glasgow coma components

Verbal response Best motor response Eye opening

Glasgow - totally unresponsive

3 or less

Flaccidity

Hypotonia | Limp, soft tissue

Spascity

Hypertonia | Resistant to lengthening

Rigidity

Constant resistance during passive ROM

Hypotonia

Flaccidity

Hypertonia

Spascity

FAST

Face (droop) Arms (does one fall?) Speech (slurred, slow) Time

6 P's of PAD

- pallor - pulselessness - paresthesia - poikilothermia (cool) - paralysis - pain

Murmurs

``` Gentle, blowing, swooshing sound that indicates congenital or valve defects 0-6 on loudness Quality Location Duration ```

What can cause murmurs?

Exercise, increased blood viscosity, defects

When does the heart reach adult size?

7 yrs old

Is it normal for child to experience SOB when feeding?

Is labored breathing normal in child?

Noo

One UE edema

lymph problem

One LE edema

DVT

Bilateral LE edemas

CHF | or Kidney failure/problem

Edema grading

1 - 4 1: 2 mm, less than 10 seconds 2: 4 mm, 10-15 seconds 3: 6 mm, 1 min or greater 4: 8 mm, 2-5 min

Slow cap refill could indicate

Low CO, hypothermia, vasoconstriction

Thin shiny skin and hair loss in LE

malnutrition and arterial insufficiency