Health Assessment Exam 2

Neurological System (Ch 24), Musculoskeletal (Ch 23), Skin (Ch 12), Nutrition (Ch 13), Abdomen (Ch 22), HEENT (Ch 14-17)

CN I

Olfactory

• Smell

• Test: Identify familiar scents

CN II

Optic

• Vision

• Test: Snellen chart (central vision), visual fields (peripheral)

CN III

Oculomotor

• eye movement, pupil constriction

• Test: PERRLA, extraocular movements

CN IV

Trochlear

• downward & inward eye movement

• follow finger down toward nose (eyes only)

CN V

Trigeminal

• facial sensation, chewing

• Test: light touch on face, clench teech (TMJ test)

CN VI

Abducens

• lateral eye movement

• Test: move eyes side to side

CN VII

Facial

• facial expression, taste (ant. 2/3)

• Test: Smile, frown, puff cheeks, taste test

CN VIII

Vestibulocochlear

• hearing/balance

• Test: whisper test, tuning fork, balance

CN IX

Glossopharyngeal

• taste (post 1/3), swallowing, gag

• Test: gag reflex, assess swallowing

CN X

Vagus

• speech swallowing, autonomic control

• Test: say “ahh”, observe uvula rise midline

CN XI

Spinal accessory

• shoulder & neck movement

• Test: shrug shoulders, turn head

CN XII

Hypoglossal

• tongue movement & articulation

• Stick out tongue, note deviation

PERRLA

Pupils Equal Round and Reactive to Light and Accomodation

• should constrict w/ light outside —> in

• accommodation: focusing on a object near/far

Anisocoria

unequal pupil —> stroke, brain bleed, intracranial pressure

PNS

12 cranial nerves

31 spinal nerves

connects body to the CNS

Somatic system (PNS)

controls voluntary skeletal muscles

Autonomic system (PNS)

controls smooth muscle, cardiac muscle, and glands

• works unconsciously

• maintains homeostasis

Primitive Reflexes

should disappear by 1 year

• if over 1 year —> may be indication of CNS dysfunction

Stereognosis

ability to identify/recognize shape, form, and texture of 3D structure

• Ex. giving a pt a random object to identify while eyes closed

Graphesthesia

ability to recognize numbers, letters, or symbols traced or written on skin

• Ex. tracing a number on the palm of pt hand

Muscle size

atrophy vs hypertrophy

Muscle strength

test resistance against force in various muscle groups to detect weakness or asymmetry

• Graded 0-5

Grade 0 muscle strength

no movement

• pt shows complete paralysis with no muscle movement or twitch upon palpation

Grade 1 muscle strength

flicker of contraction

• pt cannot move arm but the nurse can feel slight muscle twitch under the skin when palpating

Grade 2 muscle strength

movement with gravity eliminated

• pt cannot lift their leg up off the exam table against gravity but when supported in a side-lying position, they can sweep their leg across the surface

Grade 3 muscle strength

movement against gravity only

• pt raises their arm straight up in the air but as soon as the nurse applies light pressure the arm collapses

Grade 4 muscle strength

slight weakness

• pt raises their arm in the air against gravity and holds it up against moderate downward pressure applied by the nurse, but the muscle gives way under maximal force

Grade 5 muscle strength

normal strength

• pt raises their arm against gravity and holds it steady even when the nurse pushes down with force

Muscle tone

checks for abnormalities such as

• limited ROM

• flaccidity (decreased resistance, hypotonia)

• spasticity

• rigidity (indicates CNS dysfunction)

Involuntary movements

tics, tremors, fasiculations, myoclonus, chorea, pronator drift

Tics

sudden, brief and repetitive movements

• Ex. blinking

Tremors

rhythmic shaking

• common in parkinsons

Fasiculations

small muscle twitches seen under the skin

• ALS

Myoclonus

sudden quick jerks

Chorea

irregular jerky, dance-like movements

• huntingtons

Pronator drift

upper extremities slowly drift inward when pt eyes are closed and arms extended

• may show subtle weakness

Stroke

FAST

• Facial dropping

• Arm weakness

• Speech difficulty

• Time to act

WHOL

also known as thunderclap

• indicative of arteriovenous malformation

• tangled connection of arteries and veins that bypass capillaries

Neurological changes requiring immediate attention

Stroke

Headache (WHOL)

Consciousness (acute deterioration in orientation, alertness, or GCS score)

Sharp vs dull sensation

evaluates pain perception and sensory nerve function

light touch

uses a wisp of cotton to lightly touch the skin in multiple dermatomes to assess the patient’s ability to perceive gentle tactile stimuli

Vibration sense

apply a tuning fork over bony prominences using lower pitch frequencies (128 Hz or 256 Hz) to assess vibration sense as these have a slower decay

Genu varum (bowlegs)

Persistent space > 2.5 cm between knees when ankles are together

• normal for about 1 year after learning to walk

Genu valgum (knock knees)

Persistent space >2.5 cm between ankles when knees are together

• normal between ages 2 and 3

Scoliosis

common in preadolescence

• S shaped cervature of the spin

• Forward bend test: looks for uneven shoulder hiehgt, asymmetric iliac crests, or rib hump

Kyphosis

common in older adults

• outward curvature of the thoracic spine

• gradual height loss due to loss of water content and thinning of intervertebral discs

• compounded by osteoporosis

Lordosis

common in pregnancy

• exaggerated inward curvature of the lumbar spine

• develops to adjust center of gravity and maintain balance as the fetus grows

Ortolani maneuver

Hip dysplasia screening for infants

• checks for hip dislocation

• a positive result is a palpable click as the femoral head pops back into socket

Allis test

Hip dysplasia screening for infants

• compares knee heights when the infant lies supine with feet flat on the table

• uneven knee heights indicate hip dislocation

Growth plates

epiphyseal growth plates close around age 20

trauma or infection risks permanent bone deformity

Spinal Curve in infants

C-shaped at birth

• cervical curve develops around 3-4 months when the infant raises their head

• lumbar curve develops around 1-18 months when standing

Glasgow Coma Scale (GCS)

Eye opening response (1-4)

Motor response (1-6)

verbal response(1-5)

Rheumatoid arthritis

Autoimmune, systemic inflammatory disease causing symmetrical joint pain and swelling with morning stiffness lasting >1 hour and systemic fatigue

Osteoarthritis

• Non-inflammatory breakdown of joint cartilage, usually asymmetrical/unilateral, with pain and stiffness that worsens at the end of the day after activity

• Characterized by Heberden’s and Bouchard’s nodes

Gout

• Acute joint inflammation from uric acid accumulation, typically affecting the great toe 

• Triggered by purine rich foods, red meat, and alcohol

Osteoporosis

Net bone loss occurring when bone resorption exceeds bone deposition 

Age-related musculoskeletal changes

Peak bone density

• max is mid 20s

Bone remodeling

• post-peak bone remodeling is a c cyclic process of bone resorptions and deposition for skeletal maintenance and repair

Osteoporosis risk

• boens become porous and fracture-prone; females have greater bone loss

Height loss

Fall prevention

Timed Up and Go (TUG) test

stand, walk 10 ft, turn, walk back, and sit down

should be able to do in under 12 seconds

assess for fall risk

DXA scan

tests for bone density

• females > 65

• males > 70

• high-risk > 50

Phalen test

tests for carpel tunnel

• pt holds hands back to back at 90 degree wrist flexion for 60 seconds

• positive if produces burning or numbness

Abduction

moving away from midline

adduction

moving toward midline

pronation

palm down

• “pour soup”

Supination

palm up

• “hold soup”

Dorsiflexion

toes pointing up toward shin

• “off the gas”

Plantar flexion

toes pointing down

• “push the gas”

Inversion

soles toward inward

eversion

soles turned outward

Crepitus

Abnormal ROM finding

• audible/palpable crunching sound felt as joints rub together 

Contracture

Abnormal ROM finding

• permanent shortening of a muscle and tendon leading to a restricted joint movement or fixation

Ankylosis

Abnormal ROM finding

• severe joint stiffness, immobility, or complete fixation/fusion of a joint

Dislocation

Abnormal ROM finding

•  complete loss of anatomical contact between two bones forming a joint

Subluxation

Abnormal ROM finding

• partial dislocation or alignment loss where two bones in a joint remain in partial contact

Joint Effusion

Abnormal ROM finding

• fluid accumulation within the joint causing swelling, a “boggy” or doughy feel, and restricted movement

Sudden locking

Abnormal ROM finding

•  inability to fully extend or flex a joint

Pain & muscle spasms

Abnormal ROM finding

• resistance or muscle guarding during movement

Primary Lesions

traumatic or pathologic changes in previously unaltered skin

Examples of Primary Lesions

Macule patch - flat, non-palpable

Papule - elevated, solid

Plaque  - elevated, disk-shaped

Nodule - elevated, solid, deeper into dermis

Wheal Urticaria - erythematous, edematous elevation, hives

Vesicles Bulla - clear fluid

Cyst - encapsulated fluid/semi-solid

Pustule - pus-filled

Secondary Lesions

lesion changes over time

Examples of Secondary Lesions

Crust - dried exudate 

Scale - compact flakes 

Fissure - cracks 

Erosion -shallow depression w/o bleeding

Ulcer - deeper depression

Excoriation - abrasion from scratching

Scars - skin depression from tissue loss

Keloid - excessive hypertrophic scar tissue

Lichenification - thick skin from scratching

Annular

circular

Confluent

lesions run together

Discrete

individual lesions

Target

concentric rings

Zosteriform

linnear arrangement along a nerve dermtome

Polycyclic

annular lesions grow together

Stage 1 Pressure injury

non-blanchable erythema

• does not turn white/pale when pressure applied

• skin is intact

Stage 2 Pressure Injury

partial-thickness skin loss

• shallow open ulcer or blister

Stage 3 Pressure Injury

Full-thickness skin loss

• can see sub q fat

Stage 4 Pressure Injury

Full-thickness skin/tissue loss

• can see exposed muscle, tendon, ligament, or bone

Normal Color and Pigmentation of Skin

• consistent w/ ancestral descent

• Cherry angiomas (senile, small, smooth red papules) in older adults

Abnormal Color & Pigmentation of Skin

pallor, cyanosis, erythema, jaundice, vitiligo

Normal Moisture, Texture, Turgor, & Vascularity of Skin

Smooth, soft, uniform, prompt return of skin turgor

Abnormal Moisture, Texture, Turgor, & Vascularity of Skin

Xerosis (excessive dryness)

Seborrhea (excessive oilness)

Decreased turgor/tenting

Edema

Petechiae

Hematoma

Melanoma Screening

ABCDEF Danger for abnormal moles

• Asymmetry

• Border irregularity

• Color variation

• Diameter (>6mm)

• Elevation/Evolution

• Funny looking

Normal hair

full distribution, smooth texture, and clean scalp

Normal Nails

Smooth, slightly convex, firm, pink nail beds, capillary refill < 2 seconds

Abnormal hair

dull, dry, coarse, sparse, brittle, alopecia (hair loss), hirsutism (excess body hair), seborrhea, lice

Abnormal Nails

brittle, ridged, splinter hemorrhages, abnormal shape/contour/consistency

Expected Skin Conditions in Infants

Mongolian spots - hyperpigmented, blue/black/purple (dark skin)

cafe au lait spots - flat, light-brown coffee w/ milk color

erythema toxicum - tiny red macules/papules 

Acrocyanosis - bluish discoloration

cutis marmorata - transient, reticulated, red/blue pattern

physiologic jaundice