Physical Assessment Exam 2

What is inspected in the Musculoskeletal system?

sym, size, contour, color, alignment, ROM, swelling, deformity, atrophy, masses, tissue condition, abnormalities

What is palpated in the Musculoskeletal system?

temp, tenderness, strength, tone, edema, crepitus, nodules, abnormalities

How do you assess muscle tone?

Tone- passive ROM, muscle tension at rest

Hypertonia- spasticity

Hypotonia- weak

Flaccid

How do you assess strength?

Strength- grip, hand, foot strength

MUSCLE TESTING SCALE

5 Full ROM against gravity, full resistance

4 Full ROM against gravity, some resistance

3 Full ROM with gravity

2 Full ROM with gravity eliminated (passive motion)

1 Slight contraction

0 No contraction

Posture expected and unexpected

+ upright, erect, comfortable

- slumped, abnormal curves

How do you assess gait?

walk if stable, inspect base of support, weight bearing strength, stride length, cadence, arm swing, posture

What is active vs passive ROM?

Active- moves with visual and verbal direction

Passive- nurse moves pt

Jaw ROM

protract/retract

lateral

open wide

Cervical Spine ROM

flexion/hyperextension

lateral

rotation

Lumbar Spine ROM

flexion/hyperextension

lateral

rotation

Shoulder ROM

flexion/hyperextension

abduct/adduct

internal/external rotate

Elbow ROM

flexion/extend

supination/pronation

Wrist ROM

flexion/hyperextension

ulnar/radial deviation

Hip ROM

flexion/hyperextend

adbuct/adduct

internal/external rotation

Knee ROM

flex/extend

ankle ROM

dorsiflexion/plantar

eversion/inversion

abduct/adduct

Toes ROM

flex/extend

Osteoporosis risk factors, manifestations, assessment, priorities

Risk factors- low activity/Ca/estrogen, high caffeine/alc/P/steroids, age, woman, white/asian,thin, fam history

manifestation- fracture

assess- decr height, pain w/ activity, decr ROM, spine deformed, fractures, kyphosis

priorities- mobility risk, increase Ca/D, exercise, home safety

Osteoarthritis risk factors, manifestations, assessment, priorities

Risk factors- age, genes, joint injury, obesity, metabolic disorders

manifestation- aches, pain, “grating” move, decr mobility

assess- joint pain, mobility, ROM, crepitus, Herberden’s & Bouchard’s nodes

priorities- pain, mobility, ass devs

Rheumatoid arthritis risk factors, manifestations, assessment, priorities

Risk factors- smoke, high sugar, obese, woman, horm imbalance, fam history

manifestation- joint pain/swell, hot hand/ft, weight loss, anemia, anorexia, weak, LATER: joint deformity, decr ROM, elbows affected

assess- sym, swell/reed/warmth/pain of joints, pallor, vasculitis lesion, mesc strength, ROM, immobility, boutonniere deformity

priorities- mobility risk, pain, prevent deformity, educate (warm showers, ROM exercise, ass devs)

Bone Fracture risk factors, manifestations, assessment, priorities

Risk factors- osteoporosis, trauma to bone, sub use, bone cancer, Paget’s, lact intolerance, age

manifestation- pain, deformed limbs, ecchymosis, swell, muscle spasm

assess- sym, skin temp, cap refill, pulses, movement, pain

priorities- ABCs, mental status, Circulation Sensation Movement assessment, proper alignment, pain

How does nurse assess level of consciousness?

call pt name, louder, shake, painful stimuli (sternum rub)

awake/alert, lethargic, obtunded, stuporous, comatose

Lethargic

sleepy

Obtunded

responds to loud noise

Stuporous

respond to shake/pain

Glasgow Coma Scale

Assesses mental status

Decorticate vs decerebrate

everything flexed to core vs flexed but with arms to side

Speech expected vs unexpected

clear and coherent

garbled dysarthria- distorted, hard to und

dysphagia- hard to speak

Geriatric mental status variations

slow thoughts, decr short term memory, wanders from topic

>80 yrs should be able to recall 2-4 words after 5 mins

CRANIAL NERVES

Oh Oh Oh To Touch And Feel Virgin Girl Vaginas And Hymen

Some Say Marry Money But My Brother Says Bad Business Marry Money

(S = sensory, M = motor, B = both)

Nerve 1

Olfactory- sensory (afferent)

smell

Nerve 2

Optic- sensory

vision

Nerve 3

Oculomotor- motor

eye movement, pupils, eyelids

Nerve 4

Trochlear- motor

eye movement (inferomedial)

Nerve 5

Trigeminal- sensory and motor

facial sensation, biting, chewing

Nerve 6

Abducens- sensory and motor

lateral eye movement

Nerve 7

Facial- sensory and motor

facial expression

Nerve 8

Vestibulocochlear- sensory

hearing and balance

Nerve 9

Glossopharyngeal- sensory and motor

oral sensation, taste, salivation, gag reflex

Nerve 10

Vagus- sensory and motor

innervation of organs in thorax (parasympathetic)

Nerve 11

Spinal Accessory- motor

shoulder shrug and head turning

Nerve 12

Hypoglossal- motor

tongue movement

Spinal Nerves

8 thoracic, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal

Dermatone

skin that rely on specific nerve connections on the spine

Autonomic Nervous Sys function

sympathetic- fight or flight, T1-L2

parasympathetic- rest and digest, arise from S1-S4 and cranial nerves 3, 6, 9, 10

• constrict pupil and airways

• stim saliva

• slow heart

• stim stomach, int, gallbladder

• inhibit insulin release

• contract bladder

Deep tendon reflexes, Grade DTR and what they mean

invol muscle contractions in response to sudden stretch of muscle cause by tap on its tendon

+4 very brisk w/ clonus (hyperactivity) → upper motor neuron (CNS) injury

+3 more brisk than avg → upper motor neuron (CNS) injury

+2 expected

+1 diminished → lower motor neuron (PNS) injury (diabetes, hypothy, spinal shock)

0 no response → lower motor neuron (PNS) injury (diabetes, hypothy, spinal shock)

Reflex Arc

sensory neuron → motor neuron → reflex

Quadriplegic

paralysis on all 4 extremities

Paraplegic

lower portion of body

hemiplegic

one side of the body, stroke

Neuralgia

pain occurring along a nerve (like mom’s arm)

Aura

sign of oncoming seizure/ migraine (banana taste, lightning spots)

Subj data collected for Neurologic system

visit reason

Hx of illness- pain/headache, numb/weakness/paralysis, tremor, aura, speech/swallow problems, faint, memory loss, bowel/urinary control

Past med hist- head injury, meningitis, encephalitis, seizures

Fam Hx- HTN, CVA (cerebrovascular accident), epilepsy, brain cancer, Huntington Chorea

Lifestyle- meds, lead exposure, insecticides, pollutants, chems, ETOH use, drugs

Obj data collected for Neurologic system

A & O

GCS

Gross cranial nerves- speech, vision, smell, gag reflex

Move, strength, muscle tone, sensation, symm, gait and balance, nuchal rigidity (neck stiff)

How to assess Gross cranial nerves

facial symm, speech, vision/hearing in conversation

How to assess Muscle Move & strength

symm, extra movements, grip strength, plantar flexion

How to assess Gait & Balance (cerebellar function)

Balance (ROMBERG TEST)

• remove shoes, stand w/ eyes closed, push lightly

• + is bad

Gait

• walk and note posture, rhythm and steadiness

How to assess Nuchal Rigidity

If suspect meningeal irritation/infl from infection or hemorrhage

1. ensure no cervical vertebrae/ spinal cord injury

2. chin tuck → if not…

3. help pt with chin tuch

4. If painful → meningitis

Neuro Check (just think of clinical)

LOC, pupils, movement, strength of extremities, sensation, vital signs

MENINGITIS dis process, risk factors, manifestations, assessment, priorities

Dis process- viral is most common, bacterial is infectious (MEDICAL EMERGENCY)

Risk factors- viral/fungal/bacterial infection, immunosuppression, spinal fluid contaminated, wound to skull, overcrowded living

Manif- nuchal rigidity, headache, photophobia, fever, ALOC

Assess- + Romberg Test, + Kernig’s sign (pain knee extension), + Brudzinski’s sign (when flex neck, knees also flex), red macular rash

Priorities- ABCs, PLACE IN ISO, neuro checks, HOB 30, antibiotics/viral/pyretic

SEIZURES dis process, risk factors, manifestations, assessment, priorities

Dis process- uncontrolled neuron firing

Risk factors- acute febrile illness (sudden fever onset- Anozie daughter), cerebral edema, infection, acute substance (alc) withdrawal

Manif- tonic-clonic, clonic, myoclonic movements, Loss of consciousness, postictal phase: confusion, muscle sore

Assess- movements, Loss of consciousness, postictal phase: confusion, fatigue, headache, injuries

Priorities- ABC, don’t leave pt, clear area, pad and raise rails, place them on side

CEREBROVASCULAR ACCIDENT (stroke) dis process, risk factors, manifestations, assessment, priorities

Dis process-

• Ischemic from thrombus/embolus

• Hemorrhagic

Risk factors- aneurysm, older than 65, diabetes, obesity, HTN, atherosclerosis, hyperlip, sickle cell anemia, heart dis

Manif- headache, ALOC, hemiparesis, vision changes, aph/dysphasia, dysphagia

Assess- LOC, facial sym, flat affect, dysarthria (slurred speech), strength/move/senses sym

Priorities- ABCs, NEURO CHECKS q15 in acute phase, HOB 30, seizure precautions