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-different perspective
-planned
-needs of patient
-focus on problem solving
-encourage a patient to express feelings and concern
-nurse terminates
-genuineness: there for the patient, not about you
-respect: address patient by name and tone of voice
-empathy: recognize what patient is going through.. make connection, more willing to share info
Social communication
-spontaneous
-needs of both
-mutual sharing
-both parties express naturally
-reciprocal approval
-terminates spontaneously
Patient interview
-based on trust
-cant promise info patient shares is strictly confidential; only share w. people that need to know
-privacy
-confidentiality
-nonjudgemental
-do not react, use eye contact
-documentation
-writing; need to be aware how much time spent
-electronic health records
Stages of an interview
Stage 1- introduction
-purpose of interview
State 2- working
-collect data
Verbal techniques
-best way = open ended to allow patient to tell story in their own words
Closed questionFacilitation
Silence- facilitate conversation
Reflection- pick up on emotion they are expressing and reflect back on patient
Summary-theurapeutic approach
EmpathyClarification
ConfrontationInterpretationExplanationSummaryNon verbal techniques
Professional appearance
Posture- keep self open
Gestures and facial expressionEye contact-
Health History
*basis to use when you plan care
*need to judge how reliable the information given is
-Subjective information
-Database of persons health status including social, emotional, physical, cultural, and spiritual wellbeing
-Serves as a basis for planning care
-Reliability of informant
Types of Health History
Complete- only when general check up, not for a specific problem
-essential: co morbidity, medications, allergies, past health history
EpisodicInterval or follow upEmergencyComponents of a health history
-Biographical Information
-Informant
-Patient or significant other
-Reliability of informant
-Reason for seeking health care- Chief Complaint
Characteristics of chief complaint
-Location
-Radiation: does it spread?
-Quality: what does it feel like .. open ended
-Quantity (severity): scale 1-10
-Associated symptoms
-aggravating factors: what makes it worse?
-alleviating factors: what makes it best?
-setting
-timing (when, duration)
-meaning/impact
COLDSPAM
C- Character: how does it look, feel, sound, smell
O Onset
L Location: where, ? Radiation
D Duration
S Severity
P Pattern: what makes it worse/better
A Associated manifestations
M What Meaning does this have for you
PQRSTU
-Provokes/Palliative
-Quality/Quantity
-Region & Radiation
-Severity
-Timing
-Understanding Patients Perception
Vital Signs
T-temperature
-Celcius
-equivalent to 5/9 x Temp in Farenheight 32 degrees
-Routes:
-Oral
-Average: 37 C or 98.6 F
-Range: 36-38 C or 96.8-100.4 F
-Advantages: MOST COMMON
-convenient and accessible
-Disadvantages:
-safety, physical abilities, accuracy
-Rectal
-Average: 0.7 C or 0.4 F higher than oral
-Range: 36.7-38.5 C or 98.0 101.6 F
-Advantages: MOST ACCURATE
-rounded bulb doesnt injur rectal mucosa
-Disadvantages: INVASE
-uncomfortable
-if immunesuppressed, not enough platelet and can rectally bleed co agulation
-axillary
-average: .6 C or 1 F lower than oral
-range: 35.4-37.4 C or 95.8 -99.4 F
-advantages: safe, noninvasive
-under armpit child doesnt fight
-disadvantages: accuracy? Length of time to obtain measurement 6-8 min
-tympanic
-average: calibrated to oral or rectal scales
-range: same as oral/rectal
-advantages: convenient, fast, safe
-calibrate to oral or rectal scale
-Disadvantages
-Accuracy? Technique affects reading
-in adult; take pinna of ear and pull it up and back to straighten ear canal, place snuggly in ear
and hear beep
-in child; take pinna of ear and pull it up and back; need for infrared to hit tympanic
membrane to get an accurate temperature
**if hypothermic, may just be temp of ear canal; not tympanic membrane
-thermal artery thermometer
-As accurate as rectal and pulmonary artery temps
-More accurate than tympanic
-Press and run across forehead and temporal artery
-Systole Contraction
-Diastole Relaxation
-Pulse pressure
-difference between systolic and diastolic pressurev
-Equipment
-Mercury sphyg: eye needs to be eye level w. mercury because visual perception will change
-Aneroid manometer: measure in ml/mercury pressure
-Sphygmomanometer:
-Sites:
-Brachial
-thigh **difficult to auscultate due to lots of movement and adipose tissue
-avoid AV shunts or fistulas, affect arm of postmastectomy patient
-Documentation
-position of patient
-location where taken
-Normal findings
-<120/80
-prehypertension = 120-140/80-90
-hypertension= >140/90
Pulse pressure- systolic diastolic
-average = 40
-average < 40 indicate not profusing blood throughout body
-average > 40 indicate neurological damage in the brain
Common error in blood pressure measurements
-incorrect cuff size
-if too largefalsely low
-if too small falsely high
-unrecognized ausculatory gap
-not testing by palpation before auscultating
-common in people w. hypertension
-incorrect cuff placement
Factors influencing B/P
-age: male > female
-race: African American high BP.. prone to cardio vascular
-weight: increase BMI, more force heart has to use to contract to spread blood throughout whole
body
-diurnal rhythm: BP decrease during sleep
-exercise
-emotion/stress
-white coat syndrome: when practioner come in, BP elevated because nervous
-Hypervolemia: increase blood volume
-Hypovolemia: decrease in blood volume
Age variations in B/P
-newborn; 80/46
-infant: 90:61
6 yr: 100/56
14 yr: 118/61
Adult: 120/80
Elderly: 130/80
P-pulse oximetry
-measurement of oxygen saturation of hemoglobin molecule
-normal: > 95%
-dark nail polish, ambient lighting will interfere w. reading, hypothermic or low BP
-interpert reading w. blood count and hemoglobin level
-indicate percent of oxygen breathing at a time: normal is 20.8%.. The other percentage is nitrogen
P-pain assessment
-subjective feeling and an individual response
-need to asses, treat and evaluate pain
Pain Characteristics
-location
-radiation
-quality
-quantity/severity
-associated manifestation
-aggrevating factors
-alleviating factors
-timing/duration
-meaning and impact
Pain Scales
- Wong baker scale: 4-5 yr range understand scale of faces to communicate level of pain; severity scale --- FLACC: used in infants and adults in ICU; look at behavioral cues indicating pain (face, legs, activity, cry and
consolability)
-PAINAD Scale: pain assessment in Advanced Dementia
Mrs. Samuels is admitted to the hospital with a diagnosis of Right Middle Lobe pneumonia. Her vital signs are
Temp 101.7 F, Apical pulse 112, radial pulse 104 BPM +2, Resp 28 and shallow; B/P 132/84; pulse ox on AA = 88%.
-Respiration: Tachypnea
-Apical pulse rate: tachycardia
-Pulse pressure: 48 (systolic/diastolic)
-Pulse defecit: 8 (apical/radial).. Indicates extra beats ..not enough contraction to push blood through
body
-Pulse oximetry reading: need 95% or abovehypoxnea: low blood oxygen level
-AA: indicates use of ambiant air; source of aid
A 28 year old male is brought to the ED by a friend who found him outside on the sidewalk. He is unresponsive,
Temp 94F rectally; apical pulse 48 BPM & irregular; Resp 5 and shallow; B/P 82/42; pulse ox 74% on AA.
Vital signs:
-hypothermic, bradycardic, bradypnea, hypotensive, hypoxemic b/c < 95% on AA
Concerns:
-breathing!!!!!
Pallor- paleness to skin due to anemia, blood loss, not sufficient amount of RBC produced from bone
marrow
Erythema- redness of skin; reflect dermatitis or some inflammatory disorder
Ecchymosis- type of bruising of skin due to bleeding into subcutaneous layer
-body reabsorb bleeding skin changes yellow
Vitigo- complete absence of melanin
-patchy areas
-occurs in all races
-auto immune test: attacks own melanocytes
-hypopituitary: lack of melanocytic stimulating hormone
-body image disturbance
Albinism- total body depigmentation; white cast to the skin
-congenital
-easily sunburned
-increase risk for skin cancer
Hyperpigmentation of skin
-sun exposure; tan lines
-over production of melanocytic stimulating from:
-pituitary tumor
-adrenal insufficiency
-renal disease
-birthmarkpink/purple markings
Lesions
Discrete- distinct; isolated
Confluent- run together
Annular- circular
Generalized- trunk or extremity where is located
Grouped- clustered together
Linear- scabies, creases of fingers
Target- bullseye rash
Zosterform- follow nervepath, very painful .. Herpes zoster
-can develop shingles
-Macules and patches
-flat lesion w. a change in pigmentation
Eg. freckle or nevus
-Papules and Plaque
-solid, elevated lesion
-papules < .5 cm
-plaques > .5cm
-Blisters vesicles and bullae
-sharply delineated elevation filled w. clear fluid
-< 1 cm = vesicle
-> 1 cm= bullae
Eg. chicken pox or small pox
-Pustules and Abscess
-vesicles or bullae filled with pus
Eg. acne or abcess in deeper layers
-Nodules and Tumor
-elevated lesion under the skincan be moved over the lesion
-0.5-2cm = nodule
-> 2cm = tumor
-Wheal
B Border irregularcancer?
C Color variedcancer?
D Diameter larger than 6 mm
E - Elevation
Basal cell carincoma-waxy translucent appearance; sharply defined border
Squamous cell carcinoma- rough, elevated, irregular
-doesnt metastasize and spread cancer beyond lesion
Malignant melanoma- uneven surface, irregular outline, varying pigmentation
-will metastasize can result in death
Palpation of the Skin
-Moisture dry, diaphoretic
-Influenced by environment, muscular activity, body temp., stress
-Temperature warm bilaterally
-Hands & Feet can be cooler but =
-Palpate using back of hands/fingers
-No Tenderness
-Texture smooth, even, firm
-skin tugor; skin doesnt go back; not well hydrated or loss of adipose tissue
Edema
-Fluid build-up in intercellular spaces
- 0 no pitting
-+1 0 - 1/4 (mild)
-+2 - (moderate)
-+3 - 1 (severe)
-+4 - > 1 (severe)
Alopecia; Hair loss
-male pattern baldness
-drug/radiation
-trichotillomania
--loss 15 -40 hairs a day
-male pattern baldness assoc with genetics and testosterone
-known as alopecia.. Can develop to medical therapies as well
-hair will come back, with diff texture or color
-Trichotillomania- psych disorder manually pull hair out to scope w. stress
-Female baldness- hormonal imbalance often during pregnancy
-can reflect vitamin/defic or interraction w. medication
-inability for women to break down testerone into DHT
-develop hair follicle atrophy
-can be due to hot comb or traction (corn row)
Excess hair; Hirsutism
-drug induced
-over production of adrenal glands
-hormonal imbalance
Nails
-Nails should be pink, adherant to nail bed
-Surface of nail bed- smooth and flat
-Nail bed perfusion can reflect cardiovascular perfusion
-blanch out nail bed and determine how long reperfussion takes (should be less
than 3 sec)
-160 degree angle .. If greater indicate systemic illness
-pigmented
-90% of black individuals
Nail Growth
-Infant/Children:
-Rapid every 6-8 weeks
-Softer
-Adult:
-12-16 weeks
-Elderly:
-26-32 weeks
-Thicker
Beau Lines- transverse growth arrest lines
-generalized serious illness
Clubbing
-Distal finger becomes rounded drumstick
-Nail angle > 180
-Birds beak
-reflect pulmonary and cardiovascular
-diamond shape should form when nails together
Onychomycosis
-fungal infection of nail bed
-common in toenails
-dark, warm, most envioment
-common in people with diabetes
--difficult to treat; nails are keratinized so difficult to get medication down to where the infection is
-oral antifungal medications interact w. liver
-takes 6-8 months for complete resolution
Head & Neck Assessment
Head
Cranial bones- not fused to allow to engage in birth process
Sutures:
Posterior fontanele- close by 2nd month of life
Anterior fontanele- close at age of 2 yrs
**fontanele should be about same level of cranial bones; not depressed this incidates dehydration
-bulging indicates increases pressure of skull; for example meningitis produces increased fluid on brain
Facial bones:
Facial Muscles:
Salivary Glands
Submandibular- jaw line and underneath chin
Parotid- along side of jaw
SublingualNeck
-neck muscles:
-anterior and posterior triangle:
-thyroid gland:
Lymph nodes of head and neck
-Preauricular
-Posterior auricular
-Occipital
-Submental
-Submandibular
-Jugulodigastric
-Superficial cervical
-Deep cervical
-Posterior cervical
-Supraclavicular
Function*** Fluid leaves vascular compartment, reabsorb in venous but extra fluid is picked up by lymp nodes
and return to circulatory system
-also, WBC pick up microorganism and lymph system reacts and enlarge to decompose
of organisms
Subjective DataHealth History Questions
1. Headache
2. Head injury
3. Dizziness
4. Neck pain, limitation of motion
5. Lumps or swelling
6. History of head or neck surgery
Head: inspect and palpate skull for size and shape
-normalcephalicin proportion to body
-Hydrocephalus in baby-no longer able to drain cerebral spinal fluid because sutures are not sealed upon birth
head will expand in size
-Acromeagaly- excessive growth hormone; facial features are thicker
Neck:
-Symmetry
-Range of Motion
-Lymph Nodes
-Trachea - midline
-Thyroid Gland
-Posterior Approach
-Anterior Approach
-Auscultate (if enlarged)
Inspect the fair: facial structures
Eyes:
-Transilluminationdarkened environment
-pen light under sinus; if clear sinus light will disperse
Lymphnodes
-Normally not palpable
-Can be small, discrete, moveable (1cm)
-inflammed will still be moveable
-Inflammation
-Juvenile arthritis
-Auto immune body attack muscular skeletal system
-Family history
-Rheumatoid arthritis
-Pagets disease
-Unknown ediology
-Thickening of long bones; prone to fracture
-Osteoporosis
-Decrease in DENSITY of bone
-Social history
-Alcohol or tobacco use
-Work environment: role of repetitious movements
-home environment: physical layout/barriers
-Hobbies/leisure activities
-Exercise Is it F. I. T. ?? (FREQUENCY, INTENSITY, TIME)
-Contact activities risk of injury
-Weight-bearing activities
-Non-weight-bearing activities
-Aerobic activities
-Health maintenance activities
-Sleep
-Use of safety devices
-lumbar support
-Elbow/knee pads
-Health checkups bone density tests
-Diet Intake
-24 recall
-Food frequency
-# of food items eaten
per day/week/month
-Food diaries 3 days
-2 weekdays/1 weekend day
Record after eating
-Direct observation
Assessment
-Equipment
-Goniometer test angle of joint
-Tape measure and felt tip marker
-Sphygmomanometer
-General approach
-Patient comfort
-Compare non-affected to affected - symmetry
-Proceed in cephalocaudal (head to toe) order
-Overall appearance
-Posture
-Gait and mobility
-Weight-bearing status
-Gait patterns
-Transfer ability
-Sitting to standing
-Sitting to sitting
-Laying to sitting
-Normal findings
-Height and weight are proportionate
-Full ROM
-Ambulate independently
-No structural defects
-Shoulders and hips are level
-Head and torso are upright
-Stable gait
-Transfers independently
Inspection
-Muscle size and shape
-Hypertrophy muscle size grows
-Atrophyloss of muscle size due to non use or paralysis of muscle; flaccid
-Involuntary muscle movements
-Tics, tremors
-Limb circumference
-Joint contour and peri-articular tissue
-Surround actual joint
-Normal findings
-Symmetrical muscle contour
-No involuntary muscle movements
-Bilateral limb circumference is within 13 cm of each other
-Joints are flat when extended, and smooth/rounded during flexion
-No joint enlargement or deformity
Palpation
-Muscle tone
-Slight resistance to passive stretch
-Hypotonity (flaccid) no resistance!
-Muscle strength
-Spasticity Muscle strength much resistance, unable to extend muscle
-Scale 0 to 5
Joints to Assess
-head to toe approach
-Check symmetry
-Do painful ones LAST
-Apply light pressure with fingerpads
-Start in the periphery of the joint and move to center of the joint
-Move it through the ROM
-Note swelling, pain, tenderness, warmth, nodules, erythema, ecchymosis
-ecchymosis: bleeding into tissue due to injuries
Range of Motion
-Active ROM performed independently by the patient
-Passive ROM performed by the examiner
Tempromandibular joint TMJ
-Articulation between mandible and temporal bone
-Open and close jaw
-Protraction and retraction
-Side to side movement
Flexion--fold fingers
Radiocarpal Joint Radius Thumb Side and Row of Carpal Bones
Midcarpal Two rows of carpal bones
Fingers and Hands
Abduction- tight fist
Opposition- touch thumb to each finger and be able to grasp
Grip Strength
-Roll B/P cuff up
-Inflate to 20 mm Hg
-Have patient squeeze
-Normal: 150 mm Hg
-Check for symmetry
Carpal Tunnel Syndrome
2 tests:
Tinel- stimulate medial nerve by percussing it/tapping
-should haven no tingle or burn
Phalen-place hands at 90 degree angle for 60 seconds
Osteoarthritis
2 types:
Bouchard- proximal interphalangeal joint inflammation.. Closer to hand
Heberden- distal interphalangeal joint.. Tips of finger
Rheumatoid Arthritis
Develop swans neck, boutinere, severe ulnar deviation
Osteoarthritis- pain after actvity of joint
Rheumatoid- wake up in pain , more flexible as use joint
Fractured Hip
-Pain
-Inability to bear weight
-Affected leg is shorter
-Affected leg:
-Internal rotation
-External rotation
-Any physical deformities in hip area?
-can measure affected and injured leg.. From ankle to hip
-should be no more than 3cm diff between 2 legs
-If fall forward- causes inward rotation and vise versa
Knee Joints
-Complex joint!!
-Patella, femur and tibia
-Extension
-Flexion - 130
Common Knee Disorders
-Younger adult Ligament tears
-Traumatic
-Athletes female (?)
-Ideal weight?
-100 + 5 pounds per inch = 120 pounds
-What is hip to waist ratio?
-Waist circum/hip circum = 1.14 high because > .8 for woman
-% of Ideal body weight
-135%
-What is her BMI?
-Ideal = 19, hers is 27.8 so she is OVERWEIGHT
-Health risks?
-diabete, cardiovascular, hypertension, lower back pain, at risk for osteoarthritis
-What would you ask about life style ?
-Ask her typical die, FIT test for fitness
Nervous System
-Central Nervous System
-brain
-spinal cord
-Peripheral Nervous System
-12 pairs of cranial nerves
-31 pairs of spinal nerves and their branches
Central Nervous System
-Cerebral Cortex-cerebrums outer layer of nerve cell bodies or which looks like gray matter because it lacks myelin
-The cerebral cortex is the center for humans highest function and governs thought, memory, reasoning,sensation
and voluntary movement
-Each half of the cerebrum is a hemisphere
-Each hemisphere is divided into four lobes
Hemisphere4 lobes
-Frontal brain tumor- not able to make sense of world; cognitive issue
-Parietal- somatic body senses, make sense of sensory input
-Temporal- hearing, memory, speech perception and specialized wernike: auditory comprehension (listen to
what people say and articulate and make sense of it could lead to receptive aphasia)
-expressive aphasia able to process information, but cant clearly express themselve..make no sense
Occipital area- vision
Cerebrum
-ability to think and reason
-enclosed by 2 membrane layers called MENINGES
-Under dura meter there is cerebral spinal fluid
-under arachnoid mater is another space for fluid and place for blood to enter if there is trauma
-pia meter
Increased intracranial pressure (icp)
-If blood or fluid accumulates between these layers, pressure builds inside the skull and compromises brain
function.
-Can also occur with tumor growth or fluid build-up in brain tissue
-Increasing intercranial pressure only occurs in infant when fontanelle have closed
-may experience motor weaknesses depending upon where defecits are occuring
Damage to any of these specific cortical areas produces a corresponding loss of function
-such as motor weakness
-loss of sensation
-seizure
-syncopeloss of consciousness
-pain
-parasthesia: lack of feeling in body
-gait disturbance
-visual changes
-memory disorder
-difficulty with speech or swallowing
Neuro exam sequence
-mental status
-crainial nerve
-sensory system
-motor system
-reflexes
Mental status
-level of consciousness
-awake, alert and oriented x3
-place, person, time
-Who they are, where they are, general time of year
**first thing you lose is SENSE OF TIME, then PLACE, then WHO you are
Changes in loss of consciousness
-confusion
-lethargy.. require stimulus to be aroused
-stupor.. need vigorous stimulation
-coma
-varied responses to painful stimuli only
-thumb in notch between eyebrows or pinch trapezius muscle, pressure on mandible, sternal rub with knucles,
nail bed perfussion
-brain death
-require 2 people to determine if withdraw life support
** LOC is the most sensitive indicator of a change in neurological status
-person who is confused, lethargic and start to deteriate
-test oxygen level, then glucose level (because brain cant store energy or oxygen)
Mental status
-Attention ability to repeat info or perform
-Memory short-term/long-term
-Judgment safety issues
-Insight realistic perception of self
-Spatial perception - draw objects
-Calculation ability to calculate
-Abstract reasoning underlying meaning
-Thought process & Content logical/coherent
-Suicidal ideation
Mini mental status screening
-Assesses cognitive functioning
-Assists in identification of delirium/dementia
-Score: 24-30 Normal
< 24 impaired functioning
Cranial nerves
-Olfactory- I
-Eyes closed
-Block one nostril
-Inhale deeply
-Present one odor at a time
-Compare both nares
-Then introduce another scent
-Optic - II
-Oculomotor III
-Most eye movement, pupillary constriction, upper eye lid elevation
-Trochlear IV
-down and in eye movement
-Trigeminal V
-Sensory: Facial sensation
- ophthalmic
- maxillary
- mandibular
- corneal reflex
-Motor: Chewing
-Sense stimulation by whisp of cotton brush across face w. eyes closed
-Cornial reflex- see if person blink when rub cotton over side of cornea
-if lose, at risk for corneal abrasion
-Ability to chew food
-assess by having person frown
-Abducens VI
-lateral eye movement
-Facial VII
-Motor: Expressions frown, raise eyebrows, wrinkle forehead, smile show teeth, whistle, puff out cheeks,
close eyes tight against resistance
-Bells Palsy
-Paralysis of the Facial Nerve
-Note the asymmetry of the palpebral fissures and the nasolabial folds
-unilateral paralyzation
-asymmetry in bindings
-if only in facial area and no weakness in side of body, this of bells palsy rather than stroke
-Chvosteks sign
-Neuro excitability of the facial nerve
-Normal: no twitching when it is stimulated
-If twitch/muscle spasm present hypocalcaemia or tetanus
-check stability of facial nerve
-determine calcium balance determined by parathyroid gland
-low calcium level cause muscle twitching, externally stimulate 7th cranial nerve by tapping on
side of head
-patient will twitch if not enough calcium to stabilize
-occurs after someone who has thryoid surgery
-calcium balance affects cardiac function as well as neurological function
-Sensory taste
-Sweet/Salty tip of the tongue
-Sour - tip of tongue & borders
-Bitter - back of tongue
-Acoustic VIII
-hearing and balance
-Glosopharyngeal IX
-swallowing, salivating and taste
-open mouth and place tongue stick on tongue.. Say ah and watch symmetric movement upward of uvula
-lose function and at risk for aspiration
-Vagus X
-Swallowing, gag reflex, talking, pharyngeal movement, activities of the thoracic and abdominal viscera, such as
heart rate and peristalsis
-say ah
-gag reflex.. Tongue blade to back of pharynx
-during anesthesia, loose gag reflex and cant feed until gag reflex has returned
-Spinal Accessory XI
-shoulder movement and head rotation
-place hand on side of face and ask to laterally rotate head against resistance
-shrug shoulder against resistance
-Hypoglossal - XII
-tongue movement
-tongue is midline and not deviated to one side
-articulate words light, tight and dynamite
-Cranial Nerve Names
-On Old Olympus Towering Tops A Fin and German Viewed Some Hops
-Cranial Nerve Function (sensory, motor, both)
-Some Say Marry Money But My Brother Says Bad Business Marry Money
Dermatomes
-spinal nerves innervate different part of body
-spinal cord injury may impact person to feel diff parts of body
Sensation
Pain & temp- tells us later spinal thalmic tract is sending senses to thalamus and connecting over to cerebral cortex and
able to respond to sensations
Discrimination- test integrity of dorsal column, thalamus and into sensory cortex
Exteroceptive sensation
-Light Touch - wisp of cotton
-Patients eyes closed
-Distal to proximal
-Check for symmetry
-Superficial pain safety pin
-Dull vs sharp
-Temperature hot/cold
**people with diabetes have nerve endings not sensitive to fine touches
Proprioceptive sensation
-motion and position
-vibration sense (distal to proximal)
-stike in palm of hand and then place on bony prominance (hand or foot)
-feel when vibration begins and ends
-neuropathy and diabetes may lose sensation
Cortical sensation
-Stereognosis
--feel something in environment and with eyes closed, actually identify common object
-graphesthesia
-Asterophoresis- absense of feeling
-Graphesthesisa- draw something in palm of hand and person will identify .. draw number 8.. Need to be
orientation to person
-Two-Point Discrimination
-Lips/finger tips = 2-4 mm
-Palms- 8-15mm
-Shin, back = 30-40 mm
-Extinction ability to feel two points simultaneously and feel when one was removed
-Extinction- When stimulus is removed
Decerebrate rigidity (positioning)
-Ominous Sign brainstem, midbrain, upper pons lesion
-Arms stiffly extended, adducted, internal rotation, palms pronated
-Legs stiffly extended, plantar flexion
-Teeth clenched, back hyperextended
-lower portion of brainstem involved in trauma so person is in position that arms are stiff, extended and abducted into
body
-palms pronation
-feet are plantar flexion
-teeth clenched tight and hyperextended neck
-can start unilateral and move bilateral as pressure increases inside head
-Cerebral Cortex hemisphere lesion
-Flexion of Arms, Wrist, Fingers
-Adduction of arms
-Legs extension, internal rotation, plantar flexion
-can survive because vegetative functions are preserved in lower area of brain stem..
-arms abduct into body and elbows flex
Pronator drift
-weakened side falls down and palm rotates up
Coordination
-Test of the integration of the pre-motor cortex, basal ganglia, cerebellum, vestibular system (ear), posterior column,
and peripheral nerves
Romberg test
-Patient stands erect w/ feet together, hands at side, and eyes open
-Then patient closes their eyes
-Note ability to maintain balance
-Normal: Maintains balance with minimal swaying for 20 seconds
Reflexes
-Reflex action
-Automatic response to an adequate stimuli
-Types:
-Muscle stretch
-Deep tendon
-Superficial
-Pathological
Deep tendon reflex
-Biceps
-C 5 & C 6
-Contraction of biceps
-Flexion of elbow
-biceps contraction and cause arm to flex a tiny bit telling us deep tendon reflex is intact.. Test this with
someone who has neck pain or trauma
-Brachioradialis
-C 5 & C 6
-Flexion and supination of forearm
-Triceps
-C 7 & C 8
-Contraction of triceps and extension of arm
-striking back of elbow and feel contraction of biceps and arm will extend a bit
-Patellar
-L 2, L 3, L4
-Contraction of quadriceps and extension of leg
-Achilles
-L 5, S 1, S 2
-Contraction of calf muscles and plantar flexion of foot
-Magnesium sulfate given to pregnant women can cause person to loose deep tendon relfex
Plantar vs babinski
Babinski- Pathological Upper neuron disease condition in adults.. Okay in infants up to age 2
Normal- big toe curves in toward stimulus
Babinski- big toe dorsiflex upward
Superficial reflexes
Abdominal-contraction of umbilical area.. Demonstrate innervation of t2-t12
Cremastic- spinal cord injury.. Take stimulus and stroke inside of thigh and watch for testicle to rise away from stimulus
bulbocavernosus-squeeze glands on top of penis and they will contract
plantar
meningeal irritation
-Nuchal Rigidity resistance w/ neck flexion
-Kernigs Sign resistance to leg extension and pain after the knee was flexed
-Brudzinski Sign legs flex with deliberate neck flexion
Increased intracranial pressure (ICP)
-Change in LOC - **initial sign**
-Cushings Reflex (late signs):
-Elevated systolic pressure
-Widening Pulse pressure
-Bradycardia
-Apnea Spells
-= impending brain stem herniation
-Change in level of conciousness is most important indicator of neuorlogical problem
-increase pressure in head so heart has sytolic pressure increasing while diastolic remain same
-stimulate parasymp and heart rate drops
Glasgow coma scale
-Middle layer
-Choroid
-Lens
-Iris
-Pupil
-Inner Layer
-retina
-optic disc
-macula
-fovea centralis
-cones
-rods
-Visual pathway
-Sensory neurons in the retina
-Optic disc
-Optic nerve
-Optic chiasm
History of eye problems
-Age
-Children
-Amblyopia- brain partially or entirely ignores input from eye due to srabismus (lazy eye) and eye will
wander when not focused need to strengthen extraocular muscles
-Middle age
-Presbyopia impaired near vision age 45
-Retinopathy HTN, Diabetes Mellitus due to intraocular pressure.. Deteriation of arterial beds, can
lead to blindness
-Elderly
-Cataract - with UV light exposure
-Glaucoma - IOP destroy optic nerve; result in blindness
-Macular degeneration - central vision
Macular degeneration
-loss of central vision
-tested by Ampsler grid.. see if distortion within lines
Health History of Eye
-Common chief complaints
-Changes in visual acuity
-Blurred vision
-Diplopia Double vision
-Visual field loss
-Blindness
-Floaters clumps of vitreous humor
-clump if vitreous humor can become aggitated with quick movement and float up into field of
visionsee bright sparkly lights
-Drainage
-Itching
-Dryness
-Medical will discuss common ones
-Eye Surgeries
Inspection
-position
-if ear displace on head; diagnose with chromosomal abnormality
-coloreven tone
-size
-shape
-inflammation
-indicate rheumatoid arthritis on inner helix of ear due to gout
-pain/tenderness
-drainage
Auditory screening
-whisper test
-Patient occludes on ear
-Examiner stands 2 ft. behind patient
-Examiner whispers 2 syllable word
-Have patient repeat it
-weber test
-Place vibratory Tuning Fork on center of head
-Sound lateralizes to both ears equally
-rinne test
-Place vibrating tuning fork on mastoid process
-When patient no longer hears it, place in in front of the ear
-Normal: AC > BC
-Air conduction 2 x bone
-tuning fork used to detect tone
Conductive hearing loss
-dysfunction of sound transmission
-unable to oscilate bones in middle ear or external ear and communicate to inner ear
-can be result of serumen (ear wax)
-otitis media-- inflammation of middle ear
- injury of tympanic membrane
- oto sclerosis-- bone in middle ear fuse together so dont oscilate
-foreign object in ear canal
-Weber test on center of head will lateralize to fore ear
-Rene test air conduction time will = bone conduction time
-complete occlusion of ear canal there is no air conduction
Sensorineural hearing loss
-inner ear problem in vesibu cochlear ear
-Weber test in center of forehead will lateralize to good ear
-Rene test is normal finding: air conduction > bone conductions
Anterior structures
-Look for opacities in vitreous or lens
-Vitreous floaters: dark specks or strands
-Cataracts: densities in lens
-Optic Disc: observe
-Border: blurred nasally
-Color: yellowish orange to creamy pink
-look at this area for integrity of vessels
-lesions
-fovea and macula
-Rings or crescents:
-Physiologic cup
-yellow-white
-< diameter of disc
-Symmetry
Arteries and veins
-Arteries
-Color: Light red
-Size: smaller (2/3 to 4/5 of veins)
-Light reflex: Bright
-Veins
-Color: Dark red
-Size: Larger
-Light reflex: absent
Macula and foveatoward nasal side
-Very last step
-Direct light laterally or ask patient to look at light
-Inspect Fovea
-High concentration of cones for central vision and high resolution vision
-very painful for light to be shined at fovea
-Inspect Macula distinct darker pigmentation
-macular degeneration common in people over 50