University:
University of Alberta
Course:
NURS 125 | Nursing Practice - Health Assessment
Academic year:

2024
Views:

468

Pages:

65
Author:

Ali O

Hand Hygiene: pg. 56 Documentation Formatting pg. 80-84 Percussion Sounds: Note Intensity Pitch Duration Quality Location Hyperresonant V Loud Low Long Boomlike Emphysematous Lungs Resonant Loud Low Long Hollow Healthy Lung Tympanic Loud High Moderate Drumlike Gastric bubbles (stomach) Dull Moderate High Moderate Thud Liver Flat Soft High Short Dull Bone Auscultation Sounds: Focus Intensity Pitch Quality Frequency loud High course/ tubular Inspiration Bronchial expiration Vesicular Over most lung fields Intro to Health Assessment : Chapter 1-3 RN’s: - - - Self regulated health care professionals - Alberta: CARNA - Canada: CNA Guided by Code of Ethics - Providing save, compassionate, competent and ethical care - Promoting health and wellbeing - Promoting and respecting informed decision-making - Preserving Dignity - Maintaining privacy and confidentiality - Promoting Justice - Being Accountable Collaborate with clients to optimise health Promote health and wellness of individual, families, and communities, mitigate suffering Engage in Health Promotion: - Primary Prevention: strategies aimed to prevent health concerns; Immunizations, health teachings, safety precautions… - Secondary Prevention: early diagnosis of health issues to prevent complications; vision screening, Pap smears, hearing testing… - Tertiary Prevention: preventing complications of an existing disease or condition, promoting health to highest possible level; diet for diabetics, inhaler for lung disease… Providing care across lifespan from before birth to death Also develop policy, drive change, coordinate teams, teach, conduct research and lead organizations Advocate for patient, environment, health and the profession Health Assessment: - Subjective Data (based on patient experience & perception) & Objective Data (measurable data & nurse assessment) Collection via. - General Survey + Initial Data Collection + Health History + Physical Examination = Health Assessment Nursing Process: 1. Assessment a. Nurses collect data, and may provide educational or emergency interventions simultaneously b. Nurses also evaluate care during assessment, such as checking for side effects to meds. c. Nurses set outcomes collaboratively with patients 2. Diagnoses a. Clustering of data to make a judgement or statement about the patient’s condition. b. Seven axes of nursing diagnosis: i. The diagnostic concept ii. Subject (individual, family, community) iii. Judgement (impaired, ineffective) iv. Location (anatomy) v. Age (infant - elderly) vi. Time (chronic, acute, intermittent) vii. Status of diagnosis (actual, risk, wellness, health promotion) 3. Planning a. Outcome identification includes the formulation of specific, measurable, realistic, attainable, tim-oriented, and most importantly patient-centred goals. b. In addition to standard care and physicians orders, the patient care plan requires analysis about individual patient needs, to promote individualized and more holistic care. c. Care planning may be documented as care plan, care map, case notes, clinical pathway, teaching plan, or discharge plan. 4. Intervention a. “Any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient outcome.” b. Nursing interventions include: therapeutic communication, assessment, education, supervision, coordination, referral, support, and application of technical skills. 5. Evaluation a. Judgement of the effectiveness at meeting the patients goals and outcomes based upon the patients responses to the interventions Critical Thinking: ➢ Purposeful, outcome-directed/result-oriented thinking ➢ Driven by patient, family, group, and community needs ➢ Based on the nursing process, evidence informed thinking, and scientific method ➢ A result of specific knowledge, skills, and experience ➢ Guided by professional standards and codes of ethics ➢ Constant reevaluation, self-correction, and striving to improve Types of Health Assessment a. Emergency: (for life-threatening, unstable situations) i. A --- Airways (with C-spine protection if any injury is suspected) ii. B --- Breathing (rate, depth, use of accessory muscles) iii. C --- Circulation (pulse rate, rhythm, skin colour) iv. D --- Disabilities (LOC, pupils, movement) 1. Priority Setting: issues are addressed according to severity and acuity of the situation. Nurses use knowledge, clinical experience, expertise, and professional judgement to determine priorities. And top importance to patients should be considered top priority to nurses. b. Comprehensive i. Includes a complete health history (includes patients perception of health, strengths, risk factors, functional abilities, coping methods, & support systems) and physical examination ii. A complete physical examination includes all systems and regions, usually in a head-to-toe format. c. Focused (based on patient’s issues) i. In depth about the specific issue, health history focuses on the symptoms (10 factors of symptoms), physical examination includes general survey, selected vital signs,and inspection, palpation, auscultation, percussion of specific areas that may relate to symptoms. Guiding Frameworks: 1. Functional Assessment: focuses on the functional patterns all humans share, assessed during health history interview: health- perception/management activity/exercise, nutrition/ metabolism, elimination, sleep/rest, cognition/perception, roles/relationships, sexuality/reproduction, coping/stress tolerance, self-perception/self-concept, values and beliefs. 2. Head to Toe: used for physical assessment; most organized system for gathering comprehensive physical data starting at the head to the feet. 3. Body systems: logical tool for organizing data when documenting and communicating findings. Clustering similar data in order in respect to a body systems that are afflicted. Documentation: - Recording both objective and subjective data for legal purposes & for communicating findings with others Cultural Competence: refers to complex combination of knowledge, attitude, and skills that health care providers use to deliver care that considers total contexts of the patient's situation across cultural boundaries. Frequency of Assessment:Varies with the patient’s needs, purpose of assessment, and health care setting ● ● ● ● ● Long-term care setting Intensive care setting Outpatient setting Focused assessments following treatments Periodic health assessment focuses on screening and prevention guidelines for age and risk factors (See Current Canadian Screening Guidelines). ● Regular health assessment for people living with chronicity may focus on their unique health issues (e.g. Spina Bifida Clinic). Nursing Communication: Therapeutic Communication: basic tool nurses use in caring relationship with patients, focusing on patient and patient’s concerns ➢ Caring: encompasses nurse’s empathy, compassion, sensitivity & patient-centred care, showing warmth, caring, interest, and respect and values patient unconditionally and nonjudgmentally. ➢ Empathy: ability to perceive, reason, communicate understanding of another person’s feelings without criticism. Non-Verbal Communication: ● Physical appearance, facial expression, posture & positioning in relation to patient, gestures, eye contact, voice, and use of touch are all important components. Verbal Communication ● Active Listening: focus on patients & their perspective. ● Restatement: repeating patient in order to encourage patient to elaborate. ● Reflection: restatement that identifies the main theme of communication and how the patient may be feeling. ● Facilitation: encourage the patient to say more and continue the conversation. ● Silence: purposeful to allow patients to gather their thoughts and provide accurate answers. ● Focusing: address areas of concern related to current issue by redirecting conversation or keeping conversation on topic. ● Clarification: questions prompting the patient to give more information to better understand the previous statement. ● Summarizing: restating the condensed important info at the end of interview to ensure the patient is clearly understood. Non-Therapeutic Responses: ● ● ● ● ● ● ● ● False Reassurance Sympathy Unwanted Advice: nurses perspective & opinions are unwanted Biased Questioning Changing Subject Distractions Technical / Overwhelming Language Interrupting Phases of Interview 1. Pre Interaction Phase a. Collecting data from health records prior to meeting the patient 2. Beginning Phase a. Introductions b. Building Rapport c. Asking what they want to be referred to by. 3. Working Phase a. Collecting data by asking both open & close ended questions b. Recording data, and always maintain eye contact 4. Closing Phase a. End interview by summarizing main points, thank you for the time and tell them what will be the next steps. (pg. 126-144) Pain: Acute Pain: (short and normally associated with tissue damage) Chronic Pain: (last longer than 3-6 months, may not have identifiable cause) Neuropathic Pain: (form damage to nerves in PNS or CNS) Nociceptors: carry pain to the CNS via. fast delta A fibers and slower C fibers. 3 Components: 1. Sensory Discriminative (severity and location of pain) 2. Affective motivational (emotional aspect) 3. Cognitive evaluative (meaning attributed to pain) 4 steps of Nociception: 1. Transduction: noxious stimuli -> nerve impulse (free nerve ending) 2. Transmission: signal -> CNS 3. Perception: CNS identifies pain 4. Modulation: Inhibitory & facilitating input from the brain Responses to painful Stimuli: - Neuronal plasticity: ability of nervous system to change and alter its function - Windup: enhanced response to pain due to prolonged exposure - Peripheral sensitization: inflammation causes sensitivity to touch or pressure - Central sensitization: pain stimuli can persist in spinal never even; after peripheral stimulation is removed Week 2: Analysis of a Sign or Symptom, Anatomical Position, Skin Hair and Nails Red flags: Pressure Ulcers ◦Braden Scale Acute dehydration Cyanosis Melanoma Acute trauma and burns Expected Findings: Skin evenly coloured, smooth, soft, consistently warm, with intact turgor. No suspicious lesions. Nails smooth and translucent, lateral and proximal folds without swelling or erythema. Hair smooth texture, symmetrically distributed over the scalp, consistent coloration and hydration, without evidence of excessive breakage or loss. No evidence of breakage. Scalp has consistent pigmentation, no lesions. (290) Signs vs Symptoms Signs Symptoms Action of physical manifestation -sensation, emotion perceived or experienced -objective data -subjective data Usually collected during physical exam -usually collected during interview -observable through senses -not observable by others 10 Attributes of Signs and Symptoms Location Quality Severity/Quantity Timing Aggravating Factors Alleviating Factors Associated Signs and Symptoms Environmental Factors Significance to Client Client Perspective Anatomical Position Anatomical surfaces Anatomical terms of comparison Anatomical quadrants Anatomical Lines Integumentary system •Vital information about the patient’s health status •Reflects the patient’s hydration, nutrition, emotional status and systemic illness (all systems!) Skin ◦ Epidermis ◦ Dermis ◦ Subcutaneous layer Hair ◦ Vellus hair- short, barely noticeable. Little ◦ Terminal hair- hair on head etc ◦ Nails Epidermal appendage ◦ ◦ ◦ Sweat glands Eccrine glands- sweat Apocrine glands- ear wax Sebaceous glands- oil on skin Fitzpatrick Skin Type Health History: Skin Hair and Nails Risk Factors ◦Risk Factors vs Protective Factors ◦Modifiable vs Non modifiable (i.e. for Skin Cancer Courseware p. 77) “Tell me about your concern” ◦Rash ◦Pruritus ◦Bruising ◦Redness/inflammation/discharge ◦Specific Lesions ◦Cutting ◦Tattoos/Piercing ◦Hair Nails Physical Assessment: Skin Inspection ◦Colour – Natural or halogen lamp (not fluorescent), sun exposed vs not exposed, assess mucus membranes and conjunctiva as well! Uniformity of colour too. ◦Hygiene ◦Lesions/rashes/erythema/swelling/discharge/odour Palpation ◦Temperature – use dorsal surface of hands ◦Moisture ◦Texture ◦Thickness ◦Turgor Skin lesions/ Rashes Inspect and Palpate ◦Size ◦Shape ◦Colour ◦Texture ◦Exudate ◦Tenderness ◦Configuration ◦Location and distribution ◦Vascular = Check also for pulsations and blanching Location and Distribution Single of multiple Particular body parts Random or patterned Symmetric/asymmetric Sun exposed or protected (pg. 278) ABCD’S A: Asymmetry B: Border C: Colour D: Diameter E: Evolution Physical Assessment Hair & Scalp Inspection ◦Quality ◦Distribution (gender, age, genetics) ◦Puberty = onset of pubic hair growth and increased hair on legs & face & chest (male sex) ◦Pattern of Loss (smooth skin vs stubble) ◦Colour (a few illnesses affect hair colour per se. e.g. flag sign) ◦Texture (has there been a change: dry and coarse or fine and silky) ◦Scalp Palpation ◦Light palpation ◦Scalp mobile and non-tender Physical Assessment: Nails Inspect ◦Colour (pink to light brown) ◦Shape Palpate ◦Capillary Refill <3 seconds Clubbing: Normal finger: 160 or less Clubbing: 180 or more Week 3 : Assessment of Vital Signs Expected findings: (111) T 37 degrees celsius orally. R radial P 68 bpm, regular, elastic 2+/4+. R- 14 breaths per min, regular, no use of accessory muscles, ro retrationts. SPO2 98.BP 118/64. (111) Red flags: (92) -Acute change -stridor -respirations < 10 breaths/ min, greater and 32 -increased effort to breathe -oxygen saturation < 92 -Pulse < 55, > 120 bpm - Systolic BP < 100, greater and 170 - Temp < 35, >39.5 -New onset of chest pain -agitation or restlessness - Oral T>37.5-38 in neutropenic patients/transplant Temperature (pg.98-99) 1. 2. 3. 4. 5. Oral: 36.5-37.5 Axillary: 35.9-37.2 Rectal: 37-37.5 Tympanic: 36-37.5 Temporal: 36.5-37.5 Respiration: (12-20breaths/min) (pg.103-104) - Tachy: >24 - Brady: <10 Pulses (60-100bpm) (pg.102-103) Blood Pressure (< 120/80) (pg. 105-107) - Brady (slower) <60 - Tachy (faster >100 Diabetic BP: 130/80 Hypoventilation: slow and shallow Hyperventilation: fast and deep Resp. rate 65 and older: 12-24 Diurnal pattern: varies .1 temp through day, low in morning, high in afternoon Week 4: Head, Neck, Lymphatics, Nose, Sinuses, Mouth and Throat Expected findings head: The scalp is symmetrical, intact without tenderness, masses, lesions or differences in firmness. The skull shape is normocephalic and intact. Infant: i.e. Anterior fontanelle soft and flat, slightly pulsatile Expected Findings Carotid Arteries/neck: -no bruits bilaterally, pulse regular, 2+, equal bilaterally, elastic Expected Findings Lymph Nodes: Non palpable, < 1 cm, mobile, non tender Expected Findings Thyroid: if palpable: symmetrical, rubbery, non tender, barely palpable Parathyroid non palpable Nose Expected Findings: Symmetrical, midline and proportionate to facial features -smooth skin, no lesions -coloration consistent with facial skin -no drainage -no pain/tenderness -internal mucosa is pink and moist -airflow good Sinus expected findings symmetrical, no redness or swelling, non tender Mouth expected findings -Lips are pink, moist, no lesions -Bruccal mucosa, soft & hard palates pink with no lesions -Gingiva is pink and moist without inflammation -Breath has no foul odor -Tongue is smooth and midline -Teeth are well aligned, no decay -Uvula rises symmetrically with ah. -No swelling, pain, tenderness Throat Expected findings -tissue is pink and moise with symmetrical margins -no enlargement or lesions -tonsils are present with no obstruction of midline evident (0-25%) Major Mouth Red Flags -Oral growth/path/sore that wont heal -Impaired swallowing -Hoarseness or change in speech -Numbness -Persistent lump or feeling like something caught in throat -Epiglottitis Lymphatics Red Flags Virchow Node (Sentinel Node) ◦Left Supraclavicular ◦Associated with abdominal cancer ◦ Right Supraclavicular ◦Thoracic malignancies ◦Hodgkin’s lymphoma Overall Huge Red Flags Head injury ◦assess breathing, strength, sensation C spine injury Pain ◦Headache ◦Neck pain/ neck movement Fontanelles ◦Depressed (dehydration?), bulging Lumps/ masses ◦Lymphatic (>1 cm, fixed, irregular, hard/rubbery), thyroid, other? Remember: skin assessment HNEET Homeostasis and Regulation ◦Gas exchange ◦Perfusion ◦Fluid and electrolytes ◦Nutrition Protection and Movement ◦Sensory Perception ◦Mobility ◦Tissue Integrity ◦Pain ◦Immunity ◦Inflammation FAST Face, arm, speech, time Focused Health History Assessment of risk factors ◦Risk assessment and health promotion ◦Reducing the risk of injury ◦Preventing complications ◦Promoting the early detection of masses or lymph nodes Personal history Medications Family history Surgical History Review of Systems (Common head and neck symptoms) •Headache •Facial pain •Neck pain •Limited ROM •Lumps or masses •S&S of hypo/hyperthyroidism Head Physical Assessment Gather equipment (gloves, stethoscope, glass of water) Ensure patient comfort, dignity, and safety Have client sit at the edge of the examining table facing you with head at eye level Have client remove wig/hairpiece/head covering as appropriate Instruct patient about the assessment procedures and to tell you if anything is uncomfortable Physical examination ◦Inspection ◦Palpation ◦Auscultation Infants (posterior fontanelle closes by 2 months, anterior by 24 m) Inspection & Palpation: Head Inspect: Skull, Scalp and Face ◦Shape ◦Size ◦Profile ◦Symmetry ◦Swelling ◦Scars ◦Hair Distribution Palpation ◦Nerve distribution (numbness, tingling, pain) ◦Lumps and bumps Facial Dermatomes & CN 7 branch Inspection & Palpation: The Neck Inspection ◦Flexibility ◦Shape ◦Size ◦Symmetry ◦Swelling Palpation •Carotid Artery (note: auscultate before palpate) one at a time!! •Lymph nodes (size, shape mobility) •Thyroid (consistency, size, lumps goiter, nodules) Auscultation •Carotid arteries for bruits (prior to palpation) •Enlarged thyroid for bruits (continuous sound over isthmus) Posterior Neck: C7 should be most prominent. Lymphatics: inspect and palpate ◦Systematically ◦Preauricular ◦Posterior auricular ◦Occipital ◦Tonsillar ◦Submandibular ◦Submental ◦Anterior cervical ◦Posterior cervical ◦Supraclavicular Menginism Signs of Meningeal Irritation ◦Headache (+/- Nausea & Vomiting) ◦Photophobia ◦Nuchal Rigidity Summary: Head and Neck Ask about: ◦Smoking, diet, other risk factors? ◦Headaches/migraines, syncope, seizures, pain Vitals/Weight Assess (inspect, palpate): ◦Range of motion ◦Palpate Head, Face, Nose, Lymph nodes, Thyroid, Carotid Pulses, Cervical Spine ◦Ask about pain/tenderness during palpation Look for symmetry, intactness, bilateral movement, normal placement (eg. Thyroid gland), masses?, lacerations?, bruising?, rashes Physical Assessment, Mouth, Throat, Nose Equipment needed: Penlight, tongue depressor, nasal speculum/otoscope, appropriate “liquid” for swallowing study. Preparation: patient comfort, dignity, and safety Physical examination, Nose, Sinuses, Mouth, Throat, Swallowing evaluation Techniques: ◦Inspection ◦Palpation Percussion Nose Inspect (observe external structures) ◦Check for patency ◦Note discharge Can visually inspect internal canal bilaterally (otoscope) Note: congestion, bleeds, polyps?, allergy s&s Test smell (not peppermint!) Palpate external structures Sinuses Inspect: redness, swelling, discharge from eyes/nose Palpate: frontal, ethmoid & maxillary sinuses Percuss: Direct over sinus areas to inspect for pain Mouth, Tongue, Throat (430, 431, 433) Extraoral Assessment (Head and Neck!) ◦Inspect: symmetry/swelling ◦Palpate: Masseter muscle, Parotid Gland/Lymphatics Intraoral Assessment (Lips, Cheeks, Gingiva, Tongue, Salivary Glands & Ducts, Hard & Soft Palate, Throat) ◦Inspect: colour, size, ◦Palpate: texture / masses/ tenderness Tonsils Expected and unexpected findings, nose, sinuses, mouth, throat (437) Area of assessment Expected findings Unexpected findings nose Mucosa dark pink, septum midline, nontender, intaced Septum appears eroded, purulent discharge noted Turbinates Mucosa pink, moist, no lesions bilaterally Mucosa swollen, reddened bilaterally Smell Correctly identifies coffee (left nare) and cinnamon (right nare) Unable to distinguish odors bilaterally Paranasal sinuses (frontal and maxillary) Nontender on palpation bilaterally Tenderness over right maxillary sinus lips Pink, moist, intact Circumoral pallor, cracking at corners Mouth (oral mucosa) Buccal mucosa pink and moist, no lesions Mucosa grey, red, open. Lesions. Gums and hard palates Gingiva pink, firm upper and Bleeding from lower gums, lower palate rough, painful to touch Teeth White, 32, inact, no debris Mottled yellow, broken, plaque evident Tongue Midline, no tremors, no lesions Thick white coating, nodules noted on upper surface Uvula Midline, gag reflex intact bilaterally Deviates right, no gag reflex bilaterally Pharynx Pink, no exudates bilaterally White patches on pharynx, tonsils red and swollen. Week 5: Cranial Nerves, Eyes Ears Cranial Nerves Expected findings: Sense of smell intact bilaterally. Optic disc visualized with crisp margins. Pupils are equal, round and briskly responsive to light and accommodation (PERRLA), gaze is purposeful and conjugate. Masseter and temporal muscle strength equal bilaterally, temperature/pain, light touch, discrimination to opthalmic, maxillary and mandibular regions intact bilaterally. Facial movements symmetrical at rest and on command. Hearing intact to whisper test bilaterally, lateralize bilaterally and AC>BC (Rinne test positive). Voice and swallowing intact, uvula midline, soft palate intact and rises symmetrically with vocalization. Shoulders equal bilaterally at rest and with shrug. Tongue midline, strength equal bilaterally. Eyes Expected Findings: Visual acuity 20/20 bilaterally. Accurately reads the newsprint. Identifies colour bars on Snellen chart correctly. Patient sees finger at about 50 degrees superior, (0 degrees temporal and 60 degrees nasal. Alignment is symmetrical/ corneal light reflex. Gaze fixed and steady Extraocular movements intact. Eyebrows full and appropriate to age. Eyelashes evenly distributed. Blinking every 203 s. Eyes are symmetrical, and in parallel alignment. Lacrimal apparatus not enlarged or tender. Conjunctiva with small vessels visible. Sclera clear and white. Ears Expected Findings: (404) Right Pinna intact, canal well aerated., TM translucent with visible bony prominence of the malleus and sharp cone of light. Left pinna intact, calal well aerated, TM translucent with visible bony prominence of the malleus and sharp cone of light. Hearing intact bilaterally with whisper test. Rinne AC > BC in both ears. Weber test heard equally in both ears. Red Flags Trauma to eyes or ears Sudden changes in vision or hearing Raccoon eyes/Battle Sign Fluid leaking from the ears following head trauma Cranial Nerves (701) Cranial Nerve Motor vs sensory Physiology Assessment 1 Olfactory Nerve (I)- Sensory Smell and smell interpretation, including peristalsis, salivation, emotional and behavioural responses Smell test 2 Optic (II) Sensory Vision, including visual acuity and peripheral vision Visual Acuity Field of Vision Visualization of the Fundus Pupillary Light Response Funduscopic examination 3 Oculomotor (III) motor Extraocular eye movements: Upward Medial Downward Up and in Pupillary Light Response Eyelid raising and pupil constriction Cardinal directions PERRLA Eyelid inspectoin 4 Trochlear (IV) motor EOMs down and in Cardinal directions 5 Trigeminal (V) Sensory and motor Ophthalmic branch: sensation to the cornea, conjunctiva, upper eyelid, eye brows, nasal mucosa, forehead, nose Maxillary branch: sensation to the skin of cheek and nose, lower eyelid, upper jaw, teeth, palate, mouth mucosa, part of pharynx Mandibular Branch: sensation to the lower jaw, including the gums, ◦Ask to open mouth and observe for jaw deviation ◦Palpate masseter & temporalis muscles & ask patient to clench jaw. ◦Move jaw side to side & examiner attempts to push midline in each direction. ◦Jaw Jerk – motor reflex Corneal reflex (with VII) teeth, lips, palate, and part of tongue and motor function to muscles of mastication Conjunctival reflex (with VII) 6. Abducens (VI) motor EOMS; lateral Cardinal Directions 7. Facial (VII) Sensory and motor Taste and sensation for the anterior two thirds of the tongue and soft palate, serves as the primary motor nerve for facial expression Look at facial movements! Motor: ◦Raise Eyebrows ◦Close Eyes Tight ◦Close Lips Tight/Puff Cheeks ◦Show teeth Sensation Taste Anterior 2/3 (IX Posterior 1/3): ◦External Ear Sensation – rarely detected ◦Function of Stapedius Muscle – hyperacusis Parasympathetic Function ◦Lacrimal Glands– just ask! ◦Hypolacrimia (Schirmer’s test) ◦ Salivary Glands – just ask! Corneal reflex (with V) Conjunctival reflex (with v) Acoustic reflex (with VIII) 8. Acoustic (VIII) Sensory Hearing, equilibrium Vestibular Nerve ◦Observe eyes for nystagmus ◦https:// www.youtube.com/ watch? v=phpe_RVGqcA ◦Romberg Test ◦Requires proprioception, vision and vestibular function Hearing ◦Whisper Test ◦Conductive hearing loss vs Sensorineural hearing loss? ◦Rinne Test ◦AC>BC ◦Weber’s Test Acoustic reflex (with VII) 9. Glossopharyn Sensory and motor geal (IX) Pharyngeal muscle for swallowing and speech; parotid salivary gland Test with X Swallowing Gag reflex secretion, general sensory 10. Vagus (X) Sensory and motor Provides most parasympathetic innervation to a large region: digestions, stimulation of defecation, slowed heart rate and reduced contraction strength and constriction of bronchioles Test with IX, swallowing and gag reflex -palatal arches (look to see if they’re flattened, or arched( 11, Spinal accessory (XI) Motor Swallowing and Check for shoulder speaking; innervates drug, turning head the muscles that turn the head and elevate the shoulders (shrug) 12. Hypoglossal (XII) Motor Provides voluntary tongue movement Check tongue movements Dermatomes dermatome is the area of the skin of the human anatomy that is mainly supplied by branches of a single spinal sensory nerve root. These spinal sensory nerves enter the nerve root at the spinal cord, and their branches reach to the periphery of the body. Dermatome maps estimate sensation from dorsal horn cells and single level spinal nerve roots. ◦There are a few different maps out there! Peripheral nerve plexuses and thus peripheral nerves are mixtures of fibres arising from several nerve roots. Visual Acuity Test Visual Acuity Test of Macular Function. ◦Macula gives rise to the majority of optic nerve fibers logMAR ◦Logarithmic scale, uniform progression of letter size ◦5 letters per row Snellen’s Test: Distance Visual Acuity ◦Distance from the Chart/What you read on the chart (Distance people with “normal vision” can read at 20 feet). = Index of Refraction. ◦20/20 Limit of “Normal Vision” ◦Legal blindness is best corrected vision 20/200 ◦Trivia: in England use 6m ◦ ◦Jaegar Test: Near Vision ◦14 inches from eye ◦Read to smallest letter (i.e. 14/14) Myopia: Nearsightedness (myopia) is a common vision condition in which you can see objects near to you clearly, but objects farther away are blurry. Hyperopia: far away things clear, close things blurry Visual Field Testing Visual field: refers to what in the environment is visible when the eye fixates on a stationary object (361) ◦ Static confrontation (363): stand approx 60-90 cm (arms length) directly in front of the patient. Your eyes and their eyes should be on the same level. Ask the patient to cover his left eye. Close your right and instruct the patient to look only at your open eye at all times. Present one to four fingers midway between yourself and the patient in each of the 4 quadrants of the visual field. Ask the patient to report the number of fingers *the patient accurately reports the number of fingers presented in all 4 quadrants with each eye.* Kinetic Confrontation (363): eyes must be on the same level. Instruct the patient to say now when the fingers first come into view. Wiggle your fingers from a far distal point and then move them toward the center of each quadrant. Your fingers should not be immediately visible (except in inferotemporal quadrant) test the other eye. Patient sees his finger at about the same time as the nurse if the peripheral visual field is as expected in that quadrant!* ◦Perimetry: Precise measures by eye care professionals Cardinal Directions Corneal Light Reflex (364) - Instruct the patient to stare straight ahead at the bride of your nose. Stand in front of the patent and shine a penlight at the bridge of the patient’s nose. Note where the light reflects on the cornea of each eye. Light reflection is in exactly the same spot in both eyes. Rinne test (399-400) Examines the differentiation between BC and AC -Ac less resistant to BC -Normal = AC AC, conductive hearing loss is in place 1. Hit the tuning fork 2. Place the base of the handle on patients mastoid process, note time on the second hand of your watch 3. Instruct the patient to tell you when he or she no longer hears the sound of the fork. Note the number of seconds 4. Once the patient no longer hears the sound through the mastoid process, move the tip of the tuning fork to the front of the external auditory meatus, again note the time on the second hand of your watch 5. Instruct the patient to inform you when he or she no longer hears the sound. Weber test (401) Helps to differentiate the cause of unilateral hearing loss. -After activating the fork, place its handle on the midline of the parietal bone in line with both ers. The patient hears the sound in both ears or in the midline at equal intensity. Sinusoral hearng loss: unilateral identification, in ear that the patient did not hear or has reduced perception Conductive: louder on the affected side. Weber and Rinne together Acoustic Reflex: VII and VIII Complex pathway but in essence: ◦Contraction of the stapedius muscle (CN VII) with loud noise or person’s vocalizations (CN VIII). ◦Ipsilateral stimulus causes bilateral contraction Tested with tympanometry Drops tension to 50% after a few seconds CN VII damage proximal to the stapedius muscle = Hyperacusis Sensorineural hearing loss = diminished reflex Eye Issues Eyes turned in esotropia Eye turned out exotropia Blepharitis inflammation of the eyelid Conjunctivitis inflammation of the conjunctiva keratitis inflammation of the cornea Episcleritis inflammation of the outermost layers of the sclera Scleritis inflammation of the sclera Anterior uveitis inflammation of the iris and ciliary body Posterior uveitis inflammation of the choroid Miosis constricted pupils Mydriasis dilation of the pupil Anisocoria unequal pupil size Cataract clouding of the lens of the eye exophthalmos abnormal protrusion of the eyeball Arcus senilis gray-white arc or circle around the limbus of the iris that is common with aging Ears Health History Earaches (otalgia) Infections/Discharge (otorrhea) Hearing Loss Environmental noise Tinnitus Medications Vertigo Self-Care Behavious (Health Promotion Opportunity) External ear Two types of cerumen 1. dry, light and flaky 2. wet, brown/yellowish and smellier Tympanic Membrane ◦Colour ◦Position ◦Integrity of membrane How to tell if it’s left or right: (402) Cone of light is visible in the inferior quadrant (5 o'clock in right ear, 7 o'clock in left) Week 6 + 7: CNS PNS Health History Neurologic Vertigo Headache Sleep Syncope Seizures Paralysis Paresthesia Pain Loss of consciousness Memory Loss Falls Trauma Weakness Tremor Speech disorders Cognitive disorders Abnormal vision Hearing loss Loss of mobility Bowel and bladder Neurologic Physical Exam Level of consciousness Vital Signs/Height/Weight Gait Cognitive function • Mini-mental State Examination • Clock Drawing Communication (speech/language) Cranial nerve function & reflexes Motor Function ◦Cortical ◦Cerebellar Sensory Function §Pain & Temperature §Light touch §Motion and Position §Stereognosis, Graphesthesia, Two Point, Extinction Reflex Testing ◦Deep tendon reflexes ◦Superficial Reflexes Level Of Consciousness Alert ◦person, place, time Confused ◦slow thinking, perhaps memory loss, does not respond correctly/quickly to person, place or time Delirious ◦restless or agitated and marked loss of attention Drowsy Lethargic ◦drifts off frequently, must be aroused (sedated?) Obtunded ◦frequent sleep, difficult to arouse, incoherent speech Stupor ◦responds only to pain, groans and mumbles Coma ◦unconscious with little or not response to stimuli Gait After assessing gait and while a patient is still standing you could also assess: Walk toward you with eyes closed Walk heel to toe and on heels and on toes Romberg test (725) Check for pronator drift and tremor Vision Vestibular Sense Proprioception NOT A CEREBELLAR TEST! -ask patient to stand with feet together and arms at sides for 20 seconds. Maintains posture with eyes open and closed. Pronator Drift (724) Palms up Hold the position Observe eyes open then closed Forearm Pronates (with or without downward movement) ◦Contralateral pyramidal tract: Muscle weakness Slow pronation with upward movement ◦Ipsilateral cerebellar (rebound test accentuates) ◦Dorsal column (including parietal lobe): More of a searching movement Mental Status Exam Orientation Receptive Language Expressive Language ◦Dysarthria – difficulty producing sounds ◦Dysphasia – disorder in language use Memory Reading Writing Calculations Following complex commands Rapid Neuro Assessment 1) LOC 2) Vital Signs, Pupillary light response 3) GCS (<8=endotracheal intubation = severe TBI!) 4) Gross assessment of extremity strength (if patient can follow commands!) 5) Gross assessment of sensation – light touch bilaterally, head to toe 6) Other cranial nerve reflexes prn Neuro Vital Signs Vital Signs – in a format to observe changes Pupils Motor – Handgrip and leg movement Glasgow Coma Scale Glasgow Coma Scale ● If patient intubated, 10, B/c Verbal will be removed (: 10t. Benefits: ◦Fast ◦Good for monitoring progress ◦Good predictor of prognosis and outcome acutely ◦Mild 13-15 ◦Moderate 9-12 ◦Severe <8 ◦*This can change rapidly as the brain swells!* Disadvantages •Results can be confounded by things like sedation, intubation, or alcohol intoxication •Large inter-rater variability •Not great for long-term predictability Assessment: Motor Inspection and Palpation ◦Symmetry ◦Tone (Atony Hypotonic, Spasticity/Hypertonic ) ◦Strength ◦Coordination ◦Involuntary Movements AHS Spinal Signs 6 = Normal strength against resistance 5= Moderate strength against resistance 4= Full ROM against gravity only 3= Partial ROM against gravity only 2= Gravity eliminated 1 = Flicker 0 = Absent Shoulder (CN XI)…but actually testing adduction in diagram (C5,6) Elbow Flexion (C5 – biceps) Elbow Extension (C7 – triceps) Wrist (C6) Handgrip (C6-8) Hip Flexion (L2) Knee Extension (L3) Ankle Dorsiflexion (L4/5) Ankle Plantarflexion (S1) Toes (L5, S1) Muscle Power Testing 5 = Normal 4 = Weakness 3 = Movement against gravity 2 = Definite muscle contraction but no power against gravity 1= Flicker 0 = None **Important muscles are triceps, wrist extensors, hamstrings, tibialis anterior and extensor halluces longis. Coordination Cerebellar Examination Need to assume conscious proprioception and no major paresis! 1. Finger to nose/heel to shin (dysmetria) 2. Rapid alternating movements (dysdiadochokinesia) 3. Axial stability & heel to toe walking 4. Scanning Speech (dysarthria) Involuntary Movements Spasm Fasciculations https://www.youtube.com/watch?v=u421daHAgpY Tremor At rest Intention Sensation: Paint and Temperature Pain discrimination ◦Compare sides (Sharp vs Dull) Temperature ◦Test using cold/warm tuning forks ◦Cold and warm water in test tubes Crude touch= anterior spinothalamic pathway Sensation Most Touch Sensations: ◦Light touch (Spinal thalamic and posterior column) ◦ ◦Two point discrimination ◦ ◦Proprioception ◦Vibration (decreased in older adults) ◦ ◦Stereognosis ◦ ◦Graphesthesia Sensation Table: (726-729) Sensation Procedure Expected Finding Light Touch Pull the end of the cotton Light touch intact over lower swab so that it is wispy. Ask extremities the patient to close the eyes and apply light touch to the skin with the swab. Comparing sides, test most dermatomes over upper and lower extremities. Ask patient to state when he or she feels the sensation Superficial Pain Sensation Break a tongue blade so that Pain sensation intact over the end is sharp. Demonstrate lower extremities sharp versus dull sensation. Ask the patient to close the eyes, lightly touch the skin with the sharp end. Stimulate similar dermatomes as for light touch. OCcasionally substitute the dull end of the stimulus to check the patient’s reliability. Ask the patient to state when he or she feels dull or sharp Temperature sensation Test temp. Sense only if pain is not intact! Temperature sensation is in tact over upper extremities Use test tubes containing warm and cold water. Ask patient to close eyes. Touch the skin with warm or cold objects. Ask the patient to identify when he or she feels the warm or cold stimulus. Again, over most dermatomes. Motion and Position Sense Demonstrate up and down positions in toes and fingers. Ask the patient to close the eyes. Grasp either side of one of the patient’s fingers or toes and move it up or down, avoiding contact with adjacent digits. If the patient cannot identify the direction of movement, test the next most proximal joins. Test both sides Motion and position sense of the upper extremities is intact Discriminative Sensation Point localization, Vibration sensation. na -require intact touch and position sense and intact sensory cortex as the sensations require analysis and interpretation Point localization Ask the patient to close the eyes, using a finger, gently touch the patient on the hands, lower arms, abdomen, lower legs and feet. Ask the patient to identify where the sensation is felt, but avoid cueing the patient by asking “do you feel this?” Observe areas of sensation loss. Point localization is intact Vibration sensation Strike low pitched tuning fork Vibration sense is intact in the (128 Hz). Ask the patient to great toe bilaterally close eyes. Holding the fork at the base, place it firmly over bony prominences, beginning at the most distal location. The toes, ankle, shin, anterior superior iliac spine, finger joints, wrist, elbow, shoulder, sternum can all be tested. If the sensation is felt at the most distal point, no further testing is necessary. Ask the patient to state what sensation is felt, where and when it disappears. Stereognosis This test evaluates cortical Stereognosis intact bilaterally sensory function. Ask the patient to close the eyes and identify a familiar object placed in each palm in turn. The patient must manipulate the object only in the hand it’s in. Two Point discrimination Ask the patient to close the Generally there is ore yes. Holed the blund end of discrimination distally than two cotton swabs approx 2 centrally. inch apart and move them together until the patient feels them as one point. The fingertips are most sensitive, with a minimal distance of 38 mm, while the upper ars and thighs are least sensitive, with a minimal distance of 75 mm. Extinction Ask the patient to close the eyes. At the same time, touch the same body area on both sides. Ask the patient to state where he or she perceives the touch Sensations are felt on both sides. Grapesthia This test also evaluates cortical sensory function. Ask the patient to close the eyes. Use a blunt object to trace a number on each of the patients palms in turn. Change the number. Ask the patient to identify which object has been traced Grapesthia intact bilaterally. DEEP TENDON REFLEXES : 731 4+: very brisk, hyperactive with clonus 3+: brisker than average 2+ Average, expected 1+; diminished 0: no response, zero Clonus: 730 Characterized by alternating flexion/extension movements (jerking) in response to a continuous muscle stretch. Deep Tendon Reflexes Palpate the tendon. Watch for symmetry of response. Hold your hammer loosely. Test: FIND ON 731 §Brachioradialis (C5 & C6) §Biceps (C5 & C6) §Triceps (C6 & C7 – mostly C7) § §Patellar (L2-L4) §Achilles (S1-S2) Superficial Reflexes Above Umbilicus: T8 – T10 Middle: T9-T11 Below Umbilicus: T10-T12 Babinski sign Week 8: Thorax, Lungs & Breast with Lymphatics Gas Exchange - Ventilation - Transport - Perfusion Anterior Thoracic Landmarks - 12 pairs of ribs - 1-7 true ribs - 8-12 false ribs - 11-12 floating ribs - Visceral pleura ● lines lungs Parietal pleura ● lines thoracic wall ● Mediastinum ● Diaphragm Pleural space ● Trauma can cause lung collapse (eg. pneumothorax, hemothorax) Lobes of Lungs: - Oblique Fissure: runs from 6th rib MCL (anterior) to T3 spinous process (posterior) - Horizontal Fissure: between RUL & RML - RML: extends from 4th rib sternal border, to 5th rib MAL - - Can only be auscultated anteriorly (difficult in woman) Right lung is approximately 2.5 cm higher than left lung Apex (top): - 2-4 cm above the inner third of the clvicle (anteriorly) - Near C7 (posteriorly) Base (bottom): - 6th rib MCL & 8th rib MAL (anteriorly) - T10 (posteriorly) (3 rib spaces inferior to scapula) may extent to T12 on deep breaths Lower Respiratory Tract - Smoking Cessation (5 A’s) - Pack Years: # of years x # of packs Ask about smoking Advice patient to stop smoking Assess patients readiness to quit Advice patient set stop dates & education Arrange follow up to monitor and support patient Trachea bifurcates @ sternal angle (ant.) & T4 spinous process (post.) Narrowed bronchioles may lead to wheezing Excess mucus production may result in crackling or gurgling breath sounds Alveoli exchange O2 % CO2 Fluid filled alveoli sound like fine crackles in auscultation Excess fluid might cause airways to collapse and decreased breath sounds Diaphragm contracts, pulls down to breathe Common Respiratory Signs & Symptoms - Chest Pain/Discomfort - - Dyspnea: laboured breathing/breathlessness - Signs of resp. Distress - Pursed lips, nasal flaring, mouth breathing, use of accessory muscles - Leaning forward, tripod - Irritability, LOC altered Orthopnea: difficulty breathing lying down Cough Sputum - Mucoid, purulent, hemoptysis Wheezing/Tightness of chest Change in functional ability With hypoxemia, cyanosis (blueish) may occur centrally or around mouth, pallor (pale) greyish tones indicate poor oxygenation Chronic resp disease may lead to rubor (reddish-purple) or erythema (flushed) Barrel Chest (sagittal diameter > transverse diameter) may indicate COPD Physical Assessment: Inspection: - Posterior: - Shape and configuration of thoracic cage Palpation - Superior to inferior - Left and right sides consecutively - Anterior & Posterior assessment - Note tenderness, masses, lesions, crepitus - Crepitus = bubble wrap sensation = air trapping Tactile fremitus - Ulnar surface of hand - Patient Repeats “99” - Variations in findings usually reduced at the bases Chest Expansion: ● Posterior ○ Place hands at level of T9 & T10 posteriorly ○ Slide thumbs medially to raise a skin fold between ○ Ask the patient to inhale deeply ○ Skin fold should expand/disappear ○ Note symmetry ● Anterior ○ Hands at costal margin - Low/asymmetrical = abnormal - Assess for: muscle weakness, fracture, infection, respiratory disease Percussion: ● Percuss from lung apex to lung base ● Compare side to side ● Anterior and posterior assessment ○ Expected finding: Resonance Throughout ○ Abnormal: Hyper resonance (air trapping, e.g. COPD) Dullness (e.g. fluid) ● Diaphragmatic Excursion ○ Ask patient exhale and hold breath ○ When sound changes from resonant to dull mark with pen ○ Inhale and hold breath (mark where it goes from resonant to dull) ○ Difference should be 3-5cms, 7-8 cms in well conditioned adults. Auscultation: ● Tips: ○ Not over clothing ○ Diaphragm of stethoscope ○ Ask the patient to breath a little more deeply than normal, through their mouth ○ Listen to one full breath per location ○ Move side to side to compare symmetry ● Assess ○ Intensity and Pitch ○ Quality ○ Duration ○ Adventitious Sounds ○ Ask patient to say “99”, sound should be muffled ■ If sound is clear its bronchophony ○ Ask patient to say “ee”, sound should be muffled ■ If sounds clear its egophony ○ Ask to whisper “1-2-3”, should be faint, muffled ■ If it's louder clearer than whispering it’s called whispered pectoriloquy Breath Sounds Adventitious Lung Sounds