NR 304- Health Assessment II Final Exam

grading pulse

3+ full bounding

2+ normal

1+ weak

0 absent

brachial pulse

palpate this pulse if you suspect arterial insufficiency

temporal artery

palpated in front of the ear

carotid artery

palpated in the groove b/t the sternomastoid muscle and the trachea

brachial artery

major artery supplying the arm

radial artery

lies medial to the radius and wrist supplies blood to the hand

ulnar artery

lies lateral to the ulna. Deeper and often difficult to feel. Supplies blood to the hand

femoral artery

major artery in the leg. Palpated in the inguinal area

popliteal artery

artery in the knee. Located posterior to the patella. Divides into the anterior and posterial tibial artery

anterior tibial

travels down the front of the leg on to the dorsal of the foot becomes the dorsalis pedis.

carries blood to the anterior compartment of the leg and dorsal surface of the foot

dorsalis pedis

a blood vessel of the lower limb that carries oxygenated blood to the dorsal surface of the foot

claudication distance

the number of blocks walked or stairs climbed to produce pain

peripheral perfusion

checking for capillary refill by blanching the nail beds and noting the time for color return

normal is less than 1-2 seconds

doppler

used if pulses are too weak to detect by palpation, monitor blood pressure in infants or children, measure low blood pressure or blood pressure in the lower extremities

A noninvasive test using sound waves to detect blood flow through blood vessels

ex. competent valves (varicosities)

PVD

circulation disorder in which narrowed blood vessels reduce blood flow to the limbs. Caused by arteriosclerosis (hardening of arteries caused by plaque build up)

Inspect skin for ulcers, temperature and color

lymphedema

swelling in the arms or legs caused by a blockage of the lymphatic system , causes a build up of lymph fluid in tissues

intermittent claudication

a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries

5 P's

Pain

Pulselessness

Pallor

Parasthesia (can't feel)

Paralysis (can't move)

Grading Edema

+1 mild pitting, no swelling

+2 moderate pulling, indentation goes away quickly

+3 deep pitting, swollen

+4 very deep pitting, indentation stays, very swollen

Arterial Occlusion

-5 P's

-Mottling

- Bluish/cyanosis

- decrease capillary refill

- cold temperature

arterial insufficiency

NOT ENOUGH BLOOD TO TISSUES.

Location: Calves, Thighs

skin is cool, pale

-skin is thin and shiny

- no edema

-no hair growth

- decreased pulses

-yellow toenails

-elevated pallor

Pain with walking, relieved by rest (claudification)

venous insufficiency

Location: Lowers legs + Ankles

normal temperature

-normal pulse

-flaky, dry, thick skin

-skin tears easily- friable

-edema

-hyperpigmentation (brown)

- Aching heaviness worse with standing

Nursing priority: Elevate legs

arterial ulcers

-intermittent claudication pain

-no edema

-no pulse or weak pulse

-no drainage

-round smooth sores

-black eschar

-location on toes and feet

venous ulcers

-dull achy pain

-lower leg edema

-pulse present

-drainage

- sores w/ irregular borers

- yellow slough or ruddy skin

-location on ankles

vascular bruit

an audible vascular sound associated w/ turbulent blood flow

heaves

lift, a sustained forceful thrusting of the ventricle during systole. Occurs w/ ventricular hypertrophy as a result of increased workload

right ventricular is seen at the sternal border

left ventricular is seen at the apex

thrill

palpable vibration. Feels like the throat of a purring cat.

Signifies turbulent blood flow and directs you to the location of the origin of loud murmurs

S1

Lub. Closure of the AV valves. Heard at the apex of the heart, correlation w/ the carotid artery, signified that systole is starting

S2

Dub. Heard at the base of the heart. closure of the semilunar valves. Indicates that diastole is starting and systole is ending

AV valves

tricuspid and mitral valves. Close during systole to prevent regurgitation of blood back up into the atria. Filling phase during diastole

Semilunar valves

pulmonic and aortic valve. Opens during systole to allow blood to be ejected from the heart

systole

S1 close of AV valves

S2 openof the semilunar valves

base

top of the heart

apex

bottom of the heart

S3

Lub-dupPA heart murmur, occurs when the ventricles are resistant to filling during the early rapid filling phase.

occurs after S2 during rapid filling phase when the AV valves open and atrial blood first pours into the ventricle

(heard at the apex, low pitch, heart failure, heart overload)

S4

fourth heart sound. DaLub-dup. occurs at the end of diastole at pre-systole (before S1) when the ventricle is resistant to filling

A stiff wall (outflow stenosis, HTN, stiff ventricle)

murmurs

turbulent blood flow/ collision current caused by increased blood velocity, decreased blood viscosity and structural defect

varicosities

enlarged, incompentent valves (varicose veins)

reflex grading

0 absent

1 hyporeflexive, diminished

2 normal

3 hyper-reflexive, may indicate disease

4 abnormally reflexive, indicates disease

level of consciousness

a change in the level of consciousness. note person, place time

spinothalamic tract

originates in the spinal cord, transmits impulses from the spine to the thalamus on pain, temperature, itch, vibration and crude touch

sensory

lateral spinothalamic tract

pain, temperature

anterior spinothalamic tract

crude touch

posterior (dorsal column) spinothalamic tract

fine touch, sensations of position, vibration

corticospinal tract

conscious control of movement, discrete voluntary skilled movements, such as precise movement of the fingers and toes

Moro reflex

startling the infant, the baby should look as if its hugging a tree (symmetric abduction and extension of the arms and legs, fanning fingers, curling of the index finger , thumb in C position)

present at 1-4 months

abnormal: absence of reflex or presents after 5 months indicates severe CNS injury

plantar grasp

touch your thumb at the ball of the baby's foot, note the toes curl down tightly, reflex present at birth and disappear at 8-10 months

palmar grasp

offer finger from the baby's ulnar side away from the thumb, tight grasp of the baby's fingers

present at birth, strongest at 1-2 months and disappears at 3-4 months

abnormal- reflex absent w/ brain damage and local muscle or nerve injury, after 4 months indicates frontal lobe lesion

tonic neck reflex

when you turn the baby head to the side and the arms and legs will extend and the opposite will flex. Appears at 2-3 months and disappears at 4-6 months

abnormal- indicates brain damage

Babinski reflex

take the baby foot and make a upside down J,baby toes should go in a fanning motion (+ test in infants)

present at birth and disappears by 24 months

abnormal- present at 2 years occurs w/ pyramidal tract disease (motor) , in adults

spinothalamic test

pain

light touch

vibration

position (kinesthesia)

tactile discrimination (fine touch)

stereognosis

graphesthesia

two point discrimination

extinction

point location

conscious

promptly and spontaneously to state their name, location, date , time are said to be oriented to self, place and time ability to interact appropriately w/ in the context of the immediate environment

confused

does not respond quickly w info about their name, location and the time

poor attention

delirious

restless

agitated

hallucinations

somnolent

excessive drowsiness, mumbles

obtunded

decreased interest in surrounding, slowed response

stuporous

unresponsive and requires vigorous stimulation (painful) for arousal; once aroused the patient may be confused, agitated, unable to follow commands

comatose

does not make this response to stimuli, have no corneal or gag reflex, and they may have no pupillary response to light

CN I

olfactory nerve, smell

CN II

optic, sensory, visual acuity, pupillary reflex ocular fundus

test: Snellen Chart,

CN III, IV, VI

EOM

-oculomotor (superior rectus, inferior rectus and oblique, medial rectus)

-Trochlear (superior oblique)

-Abducens (lateral rectus)

CN VII

facial, sensory and motor

motor: smile, tightly close eyes, lift eyebrows, puff out cheeks, frown

sensory: taste buds

CN VIII

acoustic, sensory

whisper test, rinne test, weber test, equilibrium (romberg)

corneal light reflec

CN IX

glossopharyngeal, sensory and motor

motor: soft palate and uvual rise in midline, and phonation, swallowing

sensory: gag reflex

CN X

vagus, sensory and motor

motor: phonoation, swallowing, gag reflex

sensory: sensation from the carotid body (lowers heart rate, pharynx, GI secretions)

CN XI

spinal accessory, motor

turn head against resistance, shrug shoulders against resistance

CN XII

hypoglossal (motor)

tongue protrusion, tongue retraction, lingual speech (light, tight, dynamite)

CN V

trigeminal , sensory and motor

sensory: facial sensations, corneal reflex

motor: blinking, clenching teeth, movement of jaw

cerebellar tests

Romberg

Pain

spinothalamic test, sharp and dull

hypoalgesia

decreased pain sensation

analgesia

absent pain sensation

hyperalgesia

increased pain sensation

light touch test

spinothalamic test, apply a wisp of cotton to the skin ask person to say yes when the touch is felt. CN V, VII (if on face, corneal reflex)

hypoesthesia

decreased touch sensation

anesthesia

absent touch sensation

hyperesthesia

increased touch sensation

vibration

spinothalamic test, tests the persons ability to feel vibrations of a tuning fork over bony prominences. Ask pt when the vibrations starts and stops

abnormal- unable to feel vibrations, loss of vibration sense occurs w/ peripheral neuropathy (diabetes, alcoholism)

position (kinesthesia)

tests the persons ability to perceive passive movements of the extremities. move a finger or big toe up and down and ask pt to tell you which way it is moved

abnormal- loss of position sense

tactile discrimination

fine touch test, measured the discrimination ability of the sensory cortex

abnormal: lesions of the sensory cortex or posterior column

stereognosis

tests the persons ability to recognize objects by feeling their forms, size and weights.

place a familiar object in the person hand and ask pt to identify it.

abnormal: asterognosis

asterognosis

inability to identify object correctly occurs in sensory cortex lesions (stroke)

graphesthesia

the ability to "read" a number by having it traced on the skin. A good measure of sensory loss if the person cannot make the hand movements needed for sterognosis

two point discrimination

tests the persons ability to distinguish the separation of two simultaneous pin point on the skin.

Apply two point of an opened paper clip to the skin note the distance which the person no longer perceives two separate points

mental status exam

measures appearance, behavior, thought process and cognition

parathesia

numbness, losing ability to feel

cerebellar test

-rapid alternating movements (RAM)

-finger to finger test

-finger to nose test

-heel to shin test

-gait

-Romberg test

-heel to toe (tandem walking)

rapid alternating test

cerebellar test, ask the person to pat the knees w/ both hand and turn over and pat knees . should be done with equal turning and a quick, rhythmic pace

abnormal- lack of coordination, slow, clumsy and sloppy response

finger to finger

w/ persons eyes open, ask the he or she use the index finger to touch your finger and this their own finger should be smooth and accurate

abnormal- lack of coordination, dysmetria, past pointing

dysmetria

clumsy movement w/ overshooting the mark and ccurs w/ cerebellar disorders or acute alcoholism

past pointing

a constant deviation to one side

papilledema

abnormal CN II inspection increased intracranial pressure

Babinski adults

abnormal plantar reflex test. Dorsiflexion of the big toe and fanning of the toes

cerebrovascular accident (CVA)

stroke, occurs when the blood flow is interrupted to a part of the brain

ischemic stroke

most common, occurring when a blood clot blocks a blood vessel in the brain

hemorrhagic stroke

less common stroke, occurs when a blood vessel in the brain ruptures and causes bleeding

symptoms of a stroke

-weakness or numbness in the face, arms or legs

-confusion

-changes in vision

-trouble walking, dizziness, loss of balance, coordination

-severe headache w/ no reason or explanation

recognition of a stroke

Face- are they equal on both sides (facial droop)

Arms- can client raise both arms equallt (arm drift)

Speech- slurred speech or inappropriate words or mute

Time- EMERGENCY

Parkinson's disease

death of dopamine generating cells in midbrain

symptoms of Parkinson's disease

-slow rigid movement

-dementia

-stoop posture

-shuffling gait

-pill rolling

-tremors

-bradykinesia

-rigidity

-impaired balance

-small handwriting