Clinical Skills Midterm

Wound

break in the skin surface due to trauma or surgery

Lesion

structural abnormality (loss of tissue continuity, structure, and function) of surface of the skin

Infection

Invasions and multiplication of microorganisms capable of tissue destruction and invasion, accompanied by local or systemic symptoms

Cellulitis

Bacterial infection of connective tissue of the skin

Inflammation

Defensive reaction to tissue injury involving increased local blood flow and capillary permeability that facilitates normal wound healing

5 Cardinal Signs of Inflammation

• Heat

• Redness/Erythema

• Swelling/Edema

• Pain

• Loss of Function

Infection Characteristics

Color: erythema with poorly defined borders, larger than expected, may have “streaking”

Temperature: moderate to severe in surrounding area (may have a fever)

Pain: Excessive

Swelling: Moderate to severe + disproportionate

Drainage: thick, cloudy, pus-like consistency, may be yellow, green, or white with odor

Healing: healing ceases, wound increases in size, granulation tissue bright red

Function: may feel globally ill, malaise

Granulation Tissue

A gel-like matrix of vascularized connective tissue with “beefy red” epithelial buds in a healing wound bed

• What you WANT TO SEE

Maceration

Softening of intact skin due to prolonged exposure to fluids

• Clinical: incontinence in hospital bed, sit too long

• think: sking after being in bath too long

Necrotic

Devitalized tissue that often is adhered to a wound bed

Trophic

Skin changes that occur due to inadequate circulation, including hair loss, thinking of skin, and ridging of nails

• skin may feel very cold

Tunneling

Tissue destruction along wound margins in a narrow area that may extend parallel to the skin surface or deeper into the body

Undermining

Area of tissue under wound edges that become eroded; results in a large wound beneath a smaller wound opening

Exudate

fluid accumulation in a wound bed; mixture of high levels of protein and cells

Serosanguinous

Combination of serous drainage and blood (serous fluid becomes pink)

Purulent Drainage

thick, yellow, green, or brown wound drainage that often has a foul odor, typically a sign of infection

Serous Drainage

thin fluid that is clear or yellow

Slough

Nonviable tissue found in wound bed, typically appearing as a moist, yellow, tan, green, or gray, stringy or mucinous material

• needs removed for healing

Induration

Firm edema with a palpable/definable edge

• Really hard

General Integumentary Symptoms

• Rash

• Itching

• Lumps, nodules

• Skin Pain

• Numbness/tingling

• Diaphoresis (sweating)

• Fever

General Integumentary Health History

• Post-operative incisions

• Prolonged bed rest

• neurological impairment

• vascular injury

• burns

• drug/latex allergies

• long term corticosteroid use

• peripheral vascular disease

• diabetes

• history of cancer

Skin Color Observation - White, Pale

Pallor

• Interruption of diversion of local blood flow

• Decreased red blood cells or blood volume

Skin Color Observation - Blue

Cyanosis

• Decreased oxygen in the blood, decreased local blood flow

• Pulmonary blue

Skin Color Observation - Red

Erythema

• Increased blood flow

• UV exposure, Pulmonary red/pink

Skin Color Observation - Yellow

Jaundice

• Localized to a wound = infection

• liver/gall disease, increased carotene

Skin Color Observation - Brown

Hyperpigmentation

• UV radiation induced = protective melanin response

• Adrenal hormones disturbances

Skin Color Observation - Purple/Brown

Hemosiderin Staining

• Deposition of iron pigment (hemosiderin) in skin/tissue

• Underlying systemic/vascular hypertension (usually distal/lower extremity)

Pressure Ulcers

localized areas of soft tissue necrosis from prolonged pressure over bone

• higher risk for morbidity and mortality

• many are preventable and treatable

Risk Factors:

• decreased mobility

• shear forces

• impaired sensation

• moisture

• malnutrition

• advanced age

• poor nutrition

• history of previous pressure ulcer

Predicting Pressure Ulcers

most common predictor of where pressure ulcer will develop is the position in which the patient remains for prolonged periods of time 

• can develop within hours

• can be from anything causing too much pressure (ex: ankle brace)

Locations for Pressure Ulcers - Position Dependent

Supine: occiput, scapulae, medial humeral epicondyle, spinous processes (thoracic, sacrum/coccyx, posterior/inferior heel

Seated: thoracic sp. processes (esp. if patient is thin), sacrum/coccyx, ischial tuberosities, greater trochanters (if in w/c w/ a sling-like seat)

Side-lying: ear, lateral humeral epicondyles, greater trochanters, medial and lateral femoral condyles, lateral malleoli

Prone: anterior superior iliac spine (ASIS), anterior knee, anterior tibia

First Aid Management of Ulcers

• relieve pressure to that area

• avoid further trauma and friction

• keep area clean and dry

• do NOT massage area

• do NOT apply donut/ring-shaped cushion (decreases blood flow to that area)

The Three “T’s” of Skin

Temperature

• technique: use open surface of your palm or back of your hand

• local: increased heat or decreased temperature

• use thermometer if suspect systemic

Texture

• Technique: palpation of kin surface - esp. over lesions + scars

• S/S: moist, dry, clammy, rough, thickened, thin/fragile, shedding/scaling

Turgor/Tension

• Technique: palpate elasticity, easy of motion of dermal/epidermal layers over underlying fascia

• S/S: reduced pliability, enlarged nodules, skin stays elevated/”tented” >3 seconds

Arterial Insufficiency

Cause: Impaired arterial blood flow

Prevalence: ~5-10%

Location: Distal lower extremities

Pathophysiology: ischemia from narrowed/blocked arteries

Associated Signs: cool skin, hair loss, diminished/absent pulses, dependent rubor (redness/pinkness)

Risk Factors: Atherosclerosis, smoking, diabetes, hypertension

Venous Insufficiency

Cause: Impaired Venous return

Prevalence: ~70-90%

Location: Distal Lower extremities

Pathophysiology: venous hypertension, valve incompetence, edema

Associated Signs: edema, varicosities, hemosiderin staining, lipodermatosclerosis

Risk Factors: DVT, varicose veins, obesity, prolonged standing/sedentary lifestyle

Pulse Characteristics to Check

Rate

• number of times the heart contracts in a given period

• typically beats per minute (bpm)

Rhythm

• regularity of contractions

Force

• strength of left ventricle contraction

• indicates the volume of blood in the peripheral vessels

Arteries for Pulse

Carotid (most common)

Radial (most common)

• Brachial

• Ulnar

• Femoral

• Popliteal

• Posterior Tibial

• Dorsalis Pedis

Estimated Maximal Heart Rate

HRmax v1 = 206.9 - (0.67 x age)

HRmax v2 = 220 - age

Target exercise rate - btwn (0.6 x HRmax) and (0.8 x HRmax)

*Use with individuals expected to have normal HR response to exercise

Recovery HR: two minutes after strenuous but submaximal exercise has ceased, pulse rate should be at least 22 bpm less than maximal pulse rate achieved

Respiration Vital Signs

Rate:

• number of times the chest rises and falls in a given period of time

• typically breaths per minute 

Rhythm:

• regularity of respiratory cycles

Depth

• Much less than the full capacity of the lungs to expand

Systole

arterial pressure when LEFT VENTRICLE contracts

Diastole

arterial pressure when the heart is at REST between contractions

Orthostatic Hypotension

Drop in systolic pressure by greater than or equal to 20 mmHg or diastolic pressure by greater than or equal to 10 mmHg within 2-5 minutes of changing position

• typically moving from lying to seated or seated to standing

Symptoms include lightheadedness, dizziness, syncope (fainting), nausea, blurred or dimmed vision, or numbness, or tingling in the extremities

Edema

Observable Swelling from fluid accumulation, outside of joint capsules

• accumulates in interstitial spaces

  • between cells, vessels, and other structures

• Effusion

  • fluid accumulation within a joint capsule or cavity

  • injury or inflammation 

Types of Edema

Pulmonary Edema

• accumulation of fluid in the interstitial air spaces (alveoli) of the lungs

Ascites

• accumulation of fluid in the cavity of the abdomen (peritoneum)

Peripheral Edema

• fluid accumulation in the periphery of the legs or feet (due to gravity), commonly caused by systemic diseases like heart failure or kidney and liver disease

Oxygen Saturation

Degree to which hemoglobin is bound to oxygen circulating in the blood

• corresponds with many conditions that require hospital admission

• measured via arterial gas analysis or pulse oximetry

*not a core vital sign taken with every pt. 

Dysarthria

slowed or slurred speech due to impaired motor control

Dysphonia

Difficulty with voice production (hoarse, raspy, strained, weak, etc.)

Aphasia

Language comprehension/production issue

Wernicke’s Aphasia

Receptive aphasia

• rapid, effortless speech

• language comprehension is lost

• lesion at temporal lobe

Broca’s Aphasia

Expressive aphasia

• short, effortful phrases

• language comprehension preserved

• lesion at frontal lobe

Global Aphasia

Both receptive and expressive difficulties

• more common

Contractile Tissue: Strong and Pain Free

Suggests no lesion present in the contractile unit

Contractile Tissue: Strong and Painful

suggests a local lesion of the muscle or tendon

Contractile Tissue: Weak and Painful

Suggests a severe lesion around the joint associated with the contractile tissue being tested

Contractile Tissue: Weak and Pain Free

Suggests complete rupture of the muscle, tendon, or its attachment, or injury to the peripheral nerve or nerve root supplying the muscle

Contractile Tissues

muscle/tendon can be diagnosed if there is pain during contraction (AROM or RROM) AND when it is stretched (AROM or PROM)

• brining muscle into shortened position (PROM) should NOT elicit any symptoms of pain

Inert Tissues

ligaments can be diagnosed if there is pain when it is stretched to end ranges of motion (AROM or PROM)

• there will be NO pain during active contraction into shortening

Snellen Eye Chart

Tests optic n. (CN 1)

• 20 ft from chart

• cover one eye, read smallest line accurate 

Confrontational Test

CN 1 - Optic

• pt covers one eye

• PT holds up random amount of fingers in various parts of visual field

• abnormal: unable to detect parts of the visual field

Left Side homonymous hemianopia

loss of vision of the left side of the visual field in each eye

Smooth Persuits

CN III, IV, and VI

• draw and H with your finger

• abnormal: uncoordinated eye jerks, absent movement, or visual disturbance (ex: double/blurred vision)

Convergence

CN III, IV, and VI

• ask pt to focus on object (finger, pencil eraser, tongue depressor, etc)

• patient reports when they see double

• Abnormal: double vision when object is significantly further away, eyes may not move in and down

Pupillary Light Reflex

CN II (detect light) and III (constrict pupil)

• shine light directly into eye and observe puliary reaction in both eye

• abnormal: no constriction of the pupil in response to light, asymmetry between slides

Trigeminal (SE vs SA)

SE: clench jaw, feel masseter and temporalis

SA: swipe along upper, middle, and lower face for sensory feeling

Facial N. Testing

• make facial expressions

• blow air bubble in cheeks and poke

• close eyes against resistance

Cochlear Testing in CN VIII

rub fingers near both ears bilaterally

• abnormal: unable to hear, asymmetry between sides

Rhinne’s Test

• tuning fork on mastoid process

• move to ear when stop hearing at process

• should hear longer at ear

Webber’s Test

• tuning fork on forehead

• should hear same in both ears

• Abnormal: asymmetry - sound heard LOUDER in affected ear

Vestibular Testing for CN VIII

Gaze stability

• hold object in front of patient

• have them focus on it while turning head side to side

• abnormal: unable to maintain gaze, asymmetrical eye movement. Changes in vision (blurry/double)

Taste Test

• Glossopharyngeal N. 

• sour stimulant (ex: lemon juice) on posterior 1/3 tongue

• abnormal: can’t taste sour

Vagus Test

• Pt opens mouth and says AHHHHH

• Abnormal: asymmetry of soft palate or uvula, hoarse voice, bovine (breathy) cough

Hypoglossal Test

• protrude tongue

• move side to side

• Abnormal: tongue deviates toward involved side

Upper Motor Neuron

• cell body in cerebral cortex or brainstem motor nuclei

• axons: travel ENTIRELY within CNS and synapse at LMN

• DO NOT LEAVE CNS

Lower Motor Neuron

• cell bodies located in ANTERIOR horn of spinal cord (spinal nerves) or in cranial nerve motor nuclei of brainstem

• Axons: exit the CNS as spinal nerves or cranial nerves and synapse directly onto skeletal muscle

• Final common pathway to muscle

UMN Lesion Symptoms

• Location: cortex, brainstem, descending fibers

• Muscle tone: increased

• Reflexes: hyperreflexia, presence of pathological reflexes

• Muscle spasms, clonus

• paresis/paralysis, global distribution

• Muscle bulk: disuse atrophy: variable, widespread distribution, especially anti-gravity

LMN Lesion Symptoms

• Location: cranial nerve nuclei, ventral horn of spinal cord, peripheral nerves

• Muscle tone: decreased or absent (flaccid/floppy)

• Reflexes: decreased or absent

• denervation: fasciculations (muscle twitches under the skin)

• Paresis/paralysis - limited distribution (specific area)

• Neurogenic atrophy: rapid, focal distribution, severe muscle wasting

UMN Tests

Deep Tendon Reflexes

• hyperreflexive response due to impaired modulation of the normal synaptic response

Clonus Testing:

• normal to have 2-3 beats (children), 4+ is pathological

Pathological Reflexes

• Babinski’s Test

• Hoffman’s Test

Clonus Testing

• gently move pt foot PF/DF several times

• rapidly DF ankle

Fatigable = stops on own

Non-Fatigable/Sustained = doesn’t stop on own (more than 10 beats)

Nerve Root Compression

Sensory loss in a dermatomal pattern

• muscle weakness in corresponding myotome

• reduced DTR

Non-Dermatomal Sensory Loss

Caused by peripheral nerve compression or injury

• symptom are localized with likely limited functional loss

• ex: carpal tunnel, crush injury, surgical incision

Non-Selective Nerve Damage

Sensory loss is bilateral and symmetrical, NOT dermatomal

• presents as “stocking-glove” distribution on hands and feet

• Common in: diabetes, MS, Guillain-Barre, alcoholic neuropathy, Lyme disease

Dorsal Column System

• Light touch, fine sensation, vibration

• aDORable (fuzzy, soft)

Test distal to proximal:

UE: PIP → MCP → Ulnar styloid → olecranon → acromion

LE: 1st MCP → medial malleolus → tibial tuberosity → ASIS

*If distal is in tact - DON’T need test proximal

Spinothalamic Pathway

Sharp/Dull, Hot/Cold (Temperature)

Dermatomes

Assesses sensory component of a nerve root

• Area of skin supplied by a single nerve root

• Considerable Overlap

Myotomes

Assesses motor component of a nerve roots

• group of muscles supplied by a single nerve root

• muscles may be supplied by multiple nerve roots

• damage to one nerve root may cause weakness

Deep Tended Reflexes

Assesses integrity of nerve pathway in the peripheral and central nervous system

• monosynaptic reflex pathway = afferent (Ia muscle spindle) → efferent (alpha motor neuron)

Myotome Weakness (C7 vs Radial N.)

C7 Nerve Root Compression:

• elbow extension weakness given it is a major source of tricep inn. 

• However, triceps also inn by C6, C8, and T1 = some ability to produce weak force

Radian N. Lesion:

• Peripheral branch formed by C5-8 and T1

• Sole nerve supply of triceps

• Injury to proximal radial nerve would likely lead to total triceps paralysis

DTR Grading Scale

0: No reflex

1+: minimal or depressed response

2+: Normal Response

3+: Overly brisk response

4+: extremely brisk response with clonus

Hypotonic

PNS Dysfunction

• injury or compression along the nerve pathway, including nerve root

• normal transfer of the reflex message prohibited

• usually unilateral (ex: lumbar radioculopathy)

Hypertonic

CNS Dysfunction

• diminished modulating influence from supraspinal centers → Spinal Cord

• exaggerated reflex response

• Usually bilateral (ex: spinal cord injury)

Coordination

Primary responsibility of the CEREBELLUM

• should perform UE, LE, and postural control screen if cerebellar dysfunction is suspected

Ataxia

“without coordination”

• lack of smooth movement and fine motor control

Tremor

Occurs at terminal end of limb movement (intention) or during maintenance of head/trunk posture (postural)

• ex: tremor reaching for object, right before grab it

Hypotonia

decreased muscle tone → not common symptom for CNS

Dysarthria

Poor control of syllable/word coordination

• trouble putting words together

• I….want….to…

Eye Movement Abnormalities

nystagmus (abnormal eye mvmt.), impaired smooth pursuits, saccades (rapid eye mvmt., divert visual attention)

Dysdiadocokinesia

abnormal coordination

• struggle to alternate rapid movements

Dysmetria

abnormal coordination

• trouble with gauging distance or force of movements

TUG Values

<10 sec = normal

> 14 sec = fall risk

>20 sec = impaired functional mobility

Sit-To-Stand Values

Men:

• 64-69 years = 12-18 stands

• 70-74 years = 12-17 stands

• 80-84 years = 10-15 stands

Woman:

• 64-69 years = 11-16 stands

• 70-74 years = 10-15 stands

• 80-84 years: 9-14 stands