health assessment exam 2

nociceptive pain

• nociceptors detect painful sensations and transmit them to the CNS

• examples: mechanical, thermal, chemical trauma to tissue (smashing finger in car door, touching hot stove)

• typically predictable, acute

neuropathic pain

• abnormal processing of of the pain message due to injury to nerve tissue

• ex. phantom limb pain, shingles, multiple sclerosis

• less predictable, can become chronic

visceral pain

• originates from internal organs

• described as dull, squeezing, cramping

• often accompanied by diaphoresis, vomiting, pallor

somatic pain

• originates from musculoskeletal tissues or the body surface and is easy to localize

• can cause nausea, tachycardia, hypertension

• deep somatic pain: aching or throbbing

• cutaneous pain: superficial, sharp, or burning

referred pain

• felt in an area away from the source

• ex. pain from a cardiac episode may cause referred pain in the arm or neck

age related perceptions of pain

• babies: infants can experience pain even before birth, infants born premature can have low level of inhibitory neurotransmitters which help block pain

• aging adults: pain is not a normal process of aging, older adults need adequate pain relief too!!!, pain is a signal that something is wrong

• men have been raised to be more stoic about pain, women have higher sensitivity to pain (women tend to have more reported migraines)

RUQ

• liver

• gallbladder

• ascending colon

LUQ

• stomach

• descending colon

• spleen

RLQ

• appendix

• ovaries and fallopian tubes

LLQ

• descending colon

• ovaries and fallopian tubes

peritoneum

• double layer of membrane that lines the abdominal cavity and supports and stabilizes the organs within it

solid viscera (organs)

• maintain their characteristic and shape

• liver, spleen, kidneys

hollow viscera

• may change shape according to current contents

• bladder, stomach, intestines

anorexia

a loss of appetite for any reason

dysphagia

difficulty swallowing

hematemesis

vomiting with blood

pica

eating non-foods such as grass, dirt, paint chips

constipation

<3 stools per week, straining, or hard stools

helicobacter pylori

a bacteria that commonly causes stomach ulcers

melena

occult GI bleeding that can cause tarry stools

what is it important to do during the physical exam of the abdomen

INSPECT and THEN auscultate

• auscultate prior to percussion or palpation

auscultation, percussion, and palpation of the abdomen

• auscultation: begin in the RLQ, normal bowel sounds are gurgling, high pitched, irregular

• percussion: tympanic percussion tones over much of the abdomen, dull percussion tones over organs such as the liver, or full bladder, hyperresonance is present with excess gas, if kidney infection present percussion may cause costovertebral (CVA) tenderness

• palpation: pt supine w a pillow supporting knees, begin w light palpation to assess tissues (1 cm), then do deep palpation to assess organs or masses

infants and children abdominal assessment findings

• inspect umbilical cord at birth, should have 2 arteries and 1 vein

• infants and young children usually have protuberant abdominal profile, scaphoid shape can be present with dehydration

• organs easier to palpate bc of less developed abdominal profile

aging adult abdomen assessment findings

• both males and females tend to accumulate fat deposits as they age

• liver size decreases with age so they cannot metabolize medications as quickly as young adults

• constipation is a common complaint

hepatitis health promotion

• hepatitis A: liver infection caused by a virus that is transmitted via contaminated food or water or person to person contact

  • symptoms: fatigue, nausea, abdominal pain, loss of appetite, fever, maybe jaundice

  • vaccine available

• hepatitis B and C: liver infection caused by viruses, transmitted via blood and body fluids during sexual contact, sharing of contaminated needles

  • can be short term or chronic

  • effective vaccine available for hepatitis b

types of mental disorders: organic

• have a specific known cause (alcohol and drug intoxication, high fever, strokes, brain tumors)

types of mental disorders: psychiatric

• those for which an organic cause has not yet been established

• ex. major depressive disorder, bipolar disorder, schizophrenia

glasgow coma scale

• quantitative tool with scores ranging from 3-15 to describe level of consciousness

• higher score means higher level of consciousness

• tests eye opening response, motor response, verbal response

delirium

• sudden (develops over hours to days)

• trouble with attention or awareness

• usually reversible when trigger is treated

• alertness fluctuates widely throughout the day

• this is a medical emergency

dementia

• gradual (develops over months to years)

• trouble with memory and cognitive decline

• generally irreversible and progressive

• alertness usually steady until late stages

• this is a long-term chronic condition

suicide screening

• the Ask Suicide-Screening Questions (ASQ) is available free and has been validated in people 8 years and older. The ASQ can be administered in 20 seconds and consists of 4 screening questions

• In the past few weeks, have you wished you were dead?

• In the past few weeks, have you felt that you or your family would be better off if you were dead?

•  In the past week, have you been having thoughts about killing yourself?

• Have you ever tried to kill yourself?

If the person answers yes to any of the questions or refuses to answer any question, consider it a positive screen. Anyone who has a positive screen should be asked: “Are you having thoughts of killing yourself right now?” If the answer is yes, an immediate full safety/mental health assessment is required. If the person answers no, a brief safety assessment is done to determine if a full mental health workup is needed. In either case, the person should not be allowed to leave until evaluated for safety.

dermatome

• area of skin that is innervated mainly by a particular spinal nerve

important dermatome landmarks

• thumb at C6

• axilla at T1

• nipple at T4

• umbilicus at T10

• groin at L1

• knee at L4

cranial nerves in order

1. olfactory

2. optic

3. oculomotor

4. trochlear

5. trigeminal

6. abducens

7. facial

8. acoustic

9. glossopharyngeal

10. vagus

11. spinal accessory

12. hypoglossal

olfactory nerve - 1

• function: smell

• type: sensory

optic nerve - 2

• function: sight, vision

• type: sensory

oculomotor nerve - 3

• function:

  • motor: most extraocular movement, opening of eyelids

  • parasympathetic: pupil constriction, lens shape

• type: sensory and motor

trochlear nerve - 4

• function: down and inward movement of eye

• type: motor

trigeminal nerve - 5

• function:

  • motor: muscles of mastication

  • sensory: sensation of face and scalp, cornea, mucous membranes of mouth and nose

• type: mixed

abducens nerve - 6

• function: lateral movement of the eye

• type: motor

facial nerve - 7

• function:

  • motor: facial muscles, close eye, labial speech, close mouth

  • sensory: taste (sweet, salty, sour, bitter) on anterior 2/3 of the tongue

  • parasympathetic: parotid gland, carotid reflex

• type: mixed

acoustic nerve - 8

• function: hearing and equilibrium

• type: sensory

glossopharyngeal nerve - 9

• type: mixed

• function:

  • motor: pharynx (phonation and swallowing)

  • sensory: taste on posterior 1/3 of tongue, pharynx (gag reflex)

  • parasympathetic: parotid gland, carotid reflex

vagus nerve - 10

• type: mixed

• function:

  • motor: pharynx and larynx (talking and swallowing)

  • sensory: general sensation from carotid body, carotid sinus, pharynx, viscera

  • parasympathetic: carotid reflex

spinal accessory nerve - 11

• function:

  • movement of trapezius and sternomastoid muscles

• type: motor

hypoglossal nerve - 12

• function:

  • movement of tongue

• type: motor

frontal lobe function

personality, behavior, emotions, intellect (includes broca’s area for motor speech)

parietal lobe function

sensation

occipital lobe function

visual reception center

temporal lobe function

• auditory reception center plus hearing, taste, and smell

• includes wernicke’s area for language comprehension

basal ganglia function

initiates and coordinates movements (such as the arm swing)

thalamus function

relay station for sensory pathways

hypothalamus function

regulates functions such as breathing, temperature, appetite

cerebellum function

coordinates and smooths movement, balance, muscle tone

brainstem function

core of the brain includes autonomic center (for respiration, heart, GI function)

stroke signs

• B: balance

• E: eyes (losing vision, seeing double)

• F: face (if smile is crooked)

• A: arm (close eyes hold arm out, if drifting down, stroke indicated)

• S: speech (slurred, sounding strange)

• T: time (do not waste time, call 911)

gait abnormalities: spastic hemiparesis

• characteristic appearance: arm is immobile against the body, with flexion of the shoulder, elbow, wrist, and fingers and adduction of shoulder; does not swing freely. leg it stiff and extended and circumducts with each step (drags toe in semicircle)

• possible causes: upper motor neuron lesion of the corticospinal tract (e.g. stroke, trauma)

gait abnormalities: cerebellar ataxia

• characteristic appearance: staggering, wide-based gait; difficulty with turns; uncoordinated movement with positive Romberg sign

• possible causes: alcohol or barbiturate effect on cerebellum; cerebellar tumor; multiple sclerosis

gait abnormalities: parkinsonian

• characteristic appearance: posture is stooped; trunk is pitched forward; elbows, hips, and knees are flexed. steps are short and shuffling. hesitation to begin walking, and difficulty to stop suddenly. person holds the body rigid, walks and turns body as one fixed unit, difficulty with any change in direction

• possible causes: parkinsonism

gait abnormalities: steppage

• characteristic appearance: slapping quality - looks as if walking up stairs and finding no stair there, lifts knee and foot high and slaps it down hard and flat to compensate for footdrop

• possible causes: weakness of peroneal and anterior tibial muscles; caused by lower motor neuron lesion at spinal cord (e.g. poliomyelitis)

stage 1 pressure ulcer

• non-blanchable erythema

• skin intact

stage 2 pressure ulcer

• partial thickness skin loss including epidermis and dermis

• presents clinically as a blister, abrasion, or shallow crater

stage 3 pressure ulcer

• full thickness skin loss including subcutaneous tissue

• presents as a deep crater

stage 4 pressure ulcer

• full thickness skin loss including muscle and bone

• sinus tracts may be involved

warning signs of skin cancer

• A: asymmetry (two halves look different)

• B: border irregularity (notching, scalloping, ragged edges)

• C: color variations (areas of brown, black, red, blue, white)

• D: diameter greater than 6 mm

• E: elevation or evolution (sudden appearances or recent changes of a mole)

• F: funny looking - “ugly duckling” different from others

macule lesion

• define: solely a color change, flat, or circumscribes, of less than 1 cm

• example: freckles, hypopigmentation, petechiae, measles, scarlet fever

vesicle lesion

• define: elevated cavity containing free fluid, up to 1 cm. clear serum flows if wall is ruptured

• example: herpes simplex, early chickenpox, shingles, contact dermatitis

wheal lesion

• define: superficial, raised, transient, and erythematous; slightly irregular shape from edema

• example: mosquito bite, allergic reaction

pallor

• a white color of the skin due to anxiety or fear bc of the peripheral vasoconstriction from sympathetic nervous system stimulation

erythema

• intense redness of the skin from excess blood in the dilated superficial capillaries

• expected with fever, local inflammation, or blushing in cheeks, neck, and upper chest

cyanosis

• bluish mottled color from decreased perfusion; tissues have high levels of deoxygenated blood

• best seen in lips, nose, cheeks, ears, and oral mucous membranes

jaundice

• yellowish skin color indicating rising amounts of bilirubin in the blood

• first noted in the junction of the hard and soft palate in the mouth and in the sclera, then the eyes appear yellow

• as levels of serum bilirubin rise, jaundice is evident in the skin over the rest of the body

priority setting

• first-level priority problems: airway, breathing, circulation

• second-level priority problems: mental status changes, acute pain, infection risk, abnormal lab values, elimination problems

• third-level priority problems: lack of knowledge, mobility problems, family coping

infant skin presentations

• skin color: mongolian spot, cafe-au-lait spot

• skin color change: harlequin color change, erythema toxicum

• temporary cyanotic conditions: acrocyanosis, cutis marmorata

• hair and nails: lanugo and presence of cyanosis in newborn

• physioligic jaundice

• carotenemia

• moisture, texture, thickness, mobility and turgor

• vascularity or bruising - nervus simplex

flexion

bending a limb at the joint

extension

straightening a limb at the joint

abduction

moving a limb away from the midline of the body

adduction

moving a limb toward the midline of the body

pronation

turning the forearm so the palm is down

supination

turning the forearm so the palm is up

circumduction

moving the arm in a circle around the shoulder

inversion

moving the sole of the foot inward at the ankle

eversion

moving the sole of the foot outward at the ankle

rotation

moving the head around a central axis

protraction

moving a body part forward and parallel to the ground

retraction

moving a body part backward and parallel to the ground

elevation

raising a body part

depression

lowering a body part

carpal tunnel syndrome

• symptoms and signs: pain, nighttime pain, burning and numbness, positive findings on phalen test, and positive tinel sign, atrophy of thenar muscles

• phalen test: person holds both hands back to back while while flexing wrist 90 degrees, in a pt w carpal tunnel this will produce numbness and burning

• tinel sign: directly percuss the location of the median nerve at the wrist, in pt w carpal tunnel this will produce burning and tingling

osteoarthritis

• noninflammatory condition, involving deterioration of cartilage at joints

• joint involvement is often asymmetric or unilateral (due to overuse or overweight)

• signs and symptoms: stiffness, swelling, pain with movement, limited ROM, bony nodules

rheumatoid arthritis

• chronic inflammatory condition

• autoimmune disease

• joint involvement is bilateral and symmetric

• signs and symptoms: redness, swelling, heat, pain, limited ROM, deformities

how many bones in an adult body

206

cardiac and smooth muscle

• involuntary

skeletal muscle

voluntary

tendons

strong fibrous cords that connect muscle to bone

ligaments

fibrous band connecting bone to bone

joints

connection points between bones (can be synovial or non-synovial)

active ROM

modeling the move for the patient and having them perform it themselves

passive ROM

if active ROM is limited, support the weight of the limb as you move it through the expected ROM

scoliosis

• abnormal C or S curvature of the spine

• can cause a difference in shoulder elevation and in level of scapulae and iliac crests

• segments of spine involved: thoracic and lumbar segments of spine