Physical Assessment Flashcards
Rombergs?
Pt stands with arms at sides and feet together and to close eyes. If swaying, means positive sign of vestibular neurological loss
- cerebellar ataxia
- loss of proprioception
Babinski’s?
Dorsiflexion of ankle and big toe and fanning of other toes. Older than 2 means CNS disease
Cheyne stokes respirations?
Rhythmic with periods of apnea. Metabolic dysfunction in cerebral hemisphere or basal ganglia.
Neurogenic hyperventilation?
Reg, rapid and deep sustained respiration that = dysfunction in low midbrain and middle pons
Cushings?
High cortisol
Syndrome caused by external eg admin of steroids
Disease caused internally eg pituitary gland secreting too much ACTH
Cushings S&S?
“STRESSEDD”
Skin fragile
Truncal obesity
Round face (moon face) & reproductive issues
Ecchymosis, elevated BP
Striae on extremities & abdo (purple)
Sugar extremely high (more glucose metabolism) hyperglycaemia
Excessive body hair esp women) hirsutism
Dorso-cervical fat pad (buffalo hump)
Depression
Addisons?
Low secretion of cortisol AND aldosterone (that loves sodium therefore BP low, K+ high).
Caused by usually autoimmune (body attacks adrenal cortex) eg cancer, TB, trauma
Addisons S&S?
Remember “STEROID”
Sodium and sugar low (decreased cortisol = minimal glucose metabolism, and salt cravings (because there is low sodium)
Tired and weak muscles
Electrolyte imbalance hyponatremia and hyper. Also ^ calcium eg hypokalemia and hypercalcemia
Reproductive changes (amenorrhea and erectile dysfunction
lOw blood pressure (at risk of vascular collapse, going into shock
Increased pigmentation of skin
Diarrhoea (nausea) and depression
Nursing interventions for Cushings
Prep for surgery to remove tumours on pituitary or adrenals
If on adrenal will need HRT as body won’t produce cortisol.
Watch ^ glucs
Low K+
S&S infection (excess cortisol)
Skin breakdown
Emotional supprt
Nsg interventions for Addisons?
Monitor low blood sugars
Monitor high K+
HRT cortisol (prednisone or hydrocortisone)
Advise pt that if the get sick/gonna have surgery/extra stress in life need to ^ dose. Don’t stop suddenly!
HRT aldosterone (fludrocortisone/florinef) ensure consuming enough salt because sodium is already low.
Medic alert bracelet
Diet high in protein, carb and sodium
Avoid stress, strenuous exercise and illness
What is Addisonian crisis?
Adrenal crisis
- pt hasn’t taken meds and there is no cortisol in the body
- Life threatening
S&S addisonian crisis
5 s’s
- sudden stomach, back & leg pain
Syncope
Shock
Super low BP (vascular collapse)
Severe vomiting, diarrhoea, headache
Treatment for addisonian crisis?
Cortisol (iv) solu-cortef push
IV Fluids as they have vascular collapse, no BP, shock, low sugar (d5ns) to increase sugar, sodium, BP
at risk for infection
How to care for an arteriovenous (AV) fistula?
Assess for thrill (palpate vibration) and bruit (auscultate with stethoscope) for patency every 4 hours
Myasthenia gravis?
Chronic, autoimmune, neuromuscular disease of skeletal muscles that is worse after activity and affects breathing, swallowing.
