N317-Exam #3 + Genito-Urinary System and Breast Assessment for Final Exam

exotropia

-outward turning of eye

think like a nurse: observation/general survey

-overall body structure -position -posture -gait/mobility -use of assistive devices -manipulation of small objects (pen) -muscle symmetry & strength -fall risk

cartilage

-provides cushion and smooth surface for opposing bones

PERRLA

-pupils equal: difference should be less than 1 mm if have difference -round: not irregular edges, uneven shape -react to light: CN II and III --direct --consensual -accommodation: ability of eye to look far away then look at thing in near vision

entropion

-rolling inward of eyelid

ectropion

-rolling out of eyelid (excessive tearing, dry eyes)

pupil

-round, symmetrical

bursa

-sac filled with vicious synovial fluid in areas of potential friction (help muscles and tendons glide smoothly over bone)

prespiqusis

-sensorineural hearing loss -can be expected

joint cavity

-space where the bones are enclosed: filled with synovial fluid

presbyopia

age related farsightedness -lens less flexible

inspection and palpation: head and face

cranial nerve V: trigeminal nerve -motor: clench teeth to test masseter & temporal muscles -sensory: light wispy touch to four areas of face with cotton cranial nerve VII: facial nerve -motor: smile, frown, raise eyebrows, puff out cheeks -sensory: only if suspect damage, test sense of taste by applying solution of sugar, salt, or lemon juice to tongue and identify

ptosis

drooping

plane of movement

horizontal, vertical, rotary, or combination

summary checklist: eye examination

•Test visual acuity •Snellen eye chart •Test visual fields •Confrontation test •Inspect EOM function •Corneal light reflex, cover test, diagnostic positions test •Inspect external eye structures •Inspect anterior eyeball structures •Inspect ocular fundus •Optic disc, retinal vessels, general background, and macula

headaches

(9% are benign)

visual reflexes

-Pupillary light reflex (direct, consensual) -Fixation -Accommodation -check CN II (optic nerve), CNIII (ocular motive nerve)

wrist and carpals (radiocarpal joint): metacarpophalangeal & interphalangeal joints

-ROM: flexion (point down), extension (straight outward), hyperextension (bend upward) -ulnar and radial deviation -abduction (spread fingers apart) -make a fist -thumb movement to base of little finger -30 degree angle hyperextending fingers

spinal movement

-able to do because of intervertebral discs (cushion vertebrae) -elasticity allows compression on one side of spine, compensatory expansion on other side

hip joint: ball and socket joint

-articulation between acetabulum and head of femur -ball and socket -stability for weight bearing function -ROM: flexion, extension, hyperextension (behind you backward) -internal (move knee in and out) and external rotation, abduction (away from body) and adduction (towards other leg)

knee joint

-articulation of femur, tibia, patella -large and complex -hinge joint --two sets of ligaments for stability ---cruciate ligaments (stabilize inside) ---collateral ligaments (stabilize outside of knee joint) -ROM: flexion and extension of lower leg

shoulder-glenohumeral joint

-articulation of humerus with glenoid fossa of scapula -rotator cuff: group of four muscles and tendons support and stabilize shoulder -ball & socket: allows mobility on many axes -ROM: flexion, hyperextension, abduction, adduction, internal & external rotation circumduction -flexion: move all way up to sky (arm) -circumduction: make entire circle with arm -internal rotation: reach behind back and try to touch opposite scapula -external rotation: reach behind head and try to touch same scapula -hyperextension: arm by side, move it back -abduction: toward body, arm straight out

temporomandibular joint (TMJ)

-articulation of mandible and temporal bone -can feel it in depression anterior to tragus of ear -TMJ permits jaw function of speaking and chewing -allows three motions: --hinge action to open and close jaws --gliding action for protraction and retraction --gliding for side to side movement of lower jaw

ankle and foot (tibiotalar joint)

-articulation of tibia, fibula, talus -hinge joint -ROM: -plantar flexion (pointing toes forward) -dorsiflexion: pulling toes toward nose -inversion: rotate foot inward -eversion: rotate foot outward (20-30 degrees)

exophthalmos

-bulging of eye (hyperthyroidism)

loss of visual acuity is best explained by:

-cataract -glaucoma -macular degeneration -diabetic retinopathy

conjunctiva

-clear transparent mucous membranes

cataracts

-clouding of lens -primary risk factor: age (by 80, most have some form of cataract)

xanthelasma

-collection of fatty deposits

retina

-cones: see color, rods -change color, light impulses

spinal curves:

-convex: (thoracic) -concave (lumbar) -convex (sacrum)

myopia

-diminished far vision -type of presbyopia

ligaments

-fibrous bands that connect bone to bone: provide joint stability

tendons

-fibrous bands that connect muscle to bone

amplitude

-fine, medium, or coarse

skeletal muscle movements

-flexion and extension -abduction & adduction -pronation & supination -circumduction -inversion & eversion -rotation -protraction & retraction -elevation & depression

inspection and palpation-head

-general appearance -head/skull -scalp -temporal arteries -palpate TMJ

arcus senilis

-grey/blueish ring

focused history questions (subjective data): head and face

-headaches (any unusually frequent or severe headaches) -head injury (describe exactly what happened (symptom analysis) -dizziness (describe what feels like) -seizures (frequency, warning signs, what happens in their body) -jaw or facial pain

elbow joint

-hinge joint -three bony articulations: humerus, radius, ulna --hinge action moves radius and ulna on one plane, allowing flexion (short) and extension (long) -radius and ulna articulate with each other at two radioulnar joints, (one at elbow and one at wrist) --permit pronation (palm down) and supination (palm up) of hand and forearm

palpable fisher

-how open between upper and lower lid

(stroke): central facial palsy

-in CNS -supranuclear lesion -preservation of forehead and brow movements -loss of nasolabial folds and drooping lower lip -can still raise eyebrows -slurred speech -trouble talking

cluster

-intermittent, excruciating, unilateral with autonomic signs -always one-sided -continuous, burning, piercing, excruciating -abrupt onset, peaks in minutes, last 45-90 mins -severe, stabbing -occurs in clusters -1-2/day lasting 1/2-2 hours for 1-2 months -exacerbated by alcohol, stress, daytime napping, wind or heat

nystagmus

-involuntary rapid eye movements -pendular movement or jerk

esotropia

-inward turning of eye

morse fall risk assessment

-is there a history of falling? -does the person have more than one medical diagnosis? -does the person use ambulatory aids? -does the person have an IV or saline lock? -is gait impaired? transferring? -what is the person's mental status? -high, mod, low risk other risk factors: -age >65; living alone -impaired balance -decreased muscle strength -polypharmacy -pain -alcohol use in the home: -area rugs -pets -poor lighting -stairs

diabetic retinopathy

-living with increased bg over long period of time -retina affected: -microhemorrhages -newly formed bv's -detachment/damage to tissue -25-74: leading cause of blindness

macular degeneration

-loss of central vision -increased risk of with age -not able to see faces as well or read books as well

tension

-musculoskeletal origin -mild to mod -location: on both sides -bandlike tightness, nonthrobbing/ no pulsatile -gradual onset: last 30 minutes to days -diffuse, dull aching pain -situational, in response to overwork, posture -triggers: stress, anxiety, depression, poor posture

peripheral facial palsy (Bell's palsy)

-neuropathy of facial nerves (CN 7) -cannot close eye on affected side -lesion in facial nerve -loss of forehead and brow movement -loss of nasolabial folds and drooping lower lip

miosis

-not a lot of pupil change with light or accommodation

tosis

-one eye closed and drooping

cornea

-outermost layer

vision assessment-distance vision

-snellen standard eye chart -place chart at eye level in well-lit spot -position person on a mark exactly 20ft from chart -use card to shield one eye, if wears glasses, leave on -ask person to read chart to the smallest line of letters possible -then encourages to try next smallest line -success=missing only 1-2 letters in a line (20/20 line)

inspection and palpation-face

-symmetry -facial expression (affect) -skin -involuntary movements -TMJ: temporal mandibular joint -palpebral fissures (should be symmetrical on both sides) -nasolabial fold (depressed with stroke/cerebral palsy)

muscle strength

-test major muscle groups for each joint -apply opposing force -should be equal bilaterally grading scale: +5 full ROM against gravity-full resistance +4 full ROM against gravity-some resistance +3 full ROM with gravity +2 full ROM without gravity-passive ROM +1 slight contraction +0 no contraction: paralyzed or not able to move

pinguecula

-thickening of conjunctiva -exposure to wind, sun, dust over LPOT -changes in coloring of sclera

skeletal muscle

-under conscious control; produce movement when they contract; composed of bundles of muscle fibers (fasciauli)

migraine

-vascular origin -genetically transmitted -HA + prodrome, aura -commonly one-sided, but may occur on both sides -throbbing, pulsating -rapid onset, peaks 1-2 hrs, lasts 4-72 hours or longer -moderate-severe -2/month lasting 1-3 days -1/10 patients=weekly -hormonal, foods, hunger, weather, sleep deprivation

focused history questions (subjective data): eyes

-vision difficulty: decreased acuity, blurring, blind spots -pain: (relate to trauma glaucoma (frequent infections) -strabismus (both eyes are not fixating on same thing), diplopia (double vision) -redness, swelling -watering, discharge -history of ocular problems -glaucoma -use of glasses or contact lenses -self care behaviors -medications: ex: digoxin toxicity (altered color vision, yellow hue (circle)

the aging adult

-visual acuity: changes in how well lens can accommodate -ocular structures --eyebrows --cornea --pupils --lens

midrasis

-when pupils do not change a lot when doing accommodation

sclera

-white color, eye structure/shape

purpose of musculoskeletal system:

1. support: bones, ligaments, tendons, cartilage 2. movement: joints, muscles 3. encase & protect: bones, muscles 4. hematopoiesis: bones (white, red blood cells, platelets) 5. storage of essential minerals: bones -joints are the functional units of the musculoskeletal system because they permit the mobility needed for activities of daily living

spine:

33 connecting bones stacked in a vertical colummn -7 cervical -12 thoracic -5 lumbar -5 sacral -3-4 coccygeal

inspection-extra ocular muscle function

CN III: ocular motor nerve Corneal light reflex (Hirschberg) -shine light on nose bridge, see bright sparkle/reflection on cornea Diagnostic positions test: -six cardinal positions of gaze -tests CN-III, IV, VI (oculomotor, trochlear, abducens) -hold finger up, have them follow finger up/down/side to side, switch to fingers on other hand -might see flicking when go to far reaches of vision

inspection and palpation-eyes

General inspection Eyebrows Eyelids Eyelashes Eyeballs Conjunctiva and sclera Cornea and lens Iris and pupil

inspection-ocular fundus

Normal fundus-sharp optic disk, only place in the body where you can view blood vessels directly, general background may vary according to person's skin color, macula is pale pink area in center of fundus.

pseudoptosis

Upper lid of the eye resting on the lashes

developmental competence

aging adult -ear changes shape as the lobe elongates, linear wrinkling -may have coarse hair on the helix, anti helix, and tragus; skin may be dry -may have dry earwax. the tympanic membrane may be whiter, duller, or translucent, and the light reflex may be diminished. -often have generalized loss of hearing. it first occurs in the high frequency sounds and then progresses to include all frequencies (presbycusis) -cilia become coarse and stiff -loss of hearing causes social isolation

developmental competence: eye

aging adult -lens of eye naturally loses some ability to accommodate to near objects. diminished near vision is known as presbyopia. -decline in color vision, especially the ability to see purples and pastels -decrease in periorbital fat may give eyeballs a sunken appearance (can lead to ectropia) -lower lids may sag; skin folds are prominent in the upper lids -conjunctivae may be pale or have slightly yellow tint due to fat deposits -arcus senilis (white, gray or blue opaque ring in the corneal margin) is normal variant -pigment degeneration may cause the iris to be pale with brownish discoloration -pupil reaction may be slower but should be symmetrical -accommodation may be slow -ectropion: dry eye, moisture loss with increase tear production

developmental competence: head and face

aging adult: -facial bones more prominent and sagging facial skin due to loss of elasticity, decreased subcutaneous fat and decreased moisture in skin -temporal arteries may look twisted and prominent -senile tremors are benign and include nodding and tongue protrusion

ankle & foot assessment and potential abnormal findings

assessment: -compare both feet -position of feet & toes -contour/stability of joints -skin & nails -longitudinal arch -note locations of calluses or bunions -ROM -muscle strength potential abnormal findings: -hallux valgus: distal part of great toe is directed away from midline (partly crosses 2nd toe) (RA) -calluses/ulcers -bunion: inflamed bursa formed at pressure point -hammertoe: hyperextension of metatarsophalangeal joint with flexion of proximal interphalangeal joint: toes 2-5 -gout (excess uric acid in blood with crystals in joint space of first toe-painful)

wrist & hand: assessment and potential abnormal findings

assessment: -hands, wrists, metacarpophalangeal joints on dorsal and palmar sides -contour and shape -thenar eminence: pad of hand (palm), atrophy with carpal tunnel) -ROM -muscle strength possible abnormal findings: -ulnar deviation (RA) -swan-neck or boutonnier deformity (RA) -ankylosis (RA) -bouchard nodes (proximal) (with RA, bony overgrowth on jts (muscles) and herberden nodes (distal) (OA) -carpal tunnel: thenar eminence atrophy

knee: assessment and potential abnormal findings

assessment: -lower leg alignment with thigh -shape & contour -swelling --differentiate soft tissue vs. fluid in joint -quadriceps atrophy -ROM -muscle strength -concavities should be on each side of knee possible abnormal findings: -genu varum (bowlegs): ankles touch, but knees do not when stand up -genu valgum (knock-knees): knees touch but ankles do not/won't (standing straight upright) -swelling -tenderness -injury: ligaments, bones, tendons -crepitus/pain

TMJ: assessment and possible abnormal findings

assessment: -place tips of first 2 fingers in front of ear -palpate contracted temporalis and master muscles as person clenches teeth -compare sides for size, firmness, strength, tenderness -ask person to open mouth, protrude lower jaw, move jaw side to side possible abnormal findings -pain -swelling -crepitus (audible and palpable)

spine: assessment and potential abnormal findings

assessment: -posterior spine (and hips) -note position of shoulders, scapulae, iliac crests, and gluteal folds -four natural curves -palpate spinous processes/muscles -ROM -muscle strength -gluteo folds: should be symmetrical, where butt meets leg) potential abnormal findings: -scoliosis: lateral curative of spine -kyphosis: outward curvature of spin (thoracic) -limited ROM -muscle spasm -herniated nucleus pulposus

hip: assessment and possible abnormal findings

assessment: -symmetry of iliac crests (note with spine assessment) -assess gluteal fold symmetry and equally sized buttocks -joint symmetry, with crepitus or tenderness -ROM -muscle strength -assess standing and lying down in supine position possible abnormal findings: -limited ROM -pain -asymmetric iliac crests/buttocks in scoliosis of spine -greater trochanter is where ball and socket hip joint is, palpate there

cervical spine

assessment: -alignment of head and neck -palpate spinous processes and sternomastoid, trapezius, and paravertebral muscles -ROM -muscle strength potential abnormal findings: -asymmetry of muscles -muscle spasm -limited ROM -pain

elbow: assessment and possible abnormal findings

assessment: -size & contour in flexed & extended positions -deformity, redness, swelling -olecranon bursa -lateral epicondyles of humerus -nodules -tenderness -ROM -muscle strength: offer resistance possible abnormal findings: -"tennis elbow": inflammation & tenderness of epicondyles, head of radius and tendons -subcutaneous nodules (RA): palpate tender, size, contour -olecranon (rounded area right at elbow tip) bursitis (trauma, gout, rheumatoid arthritis)

shoulder: assessment and possible abnormal findings

assessment: (compare side to side) -size -symmetry -contour -swelling -heat -tenderness -ROM -muscle strength possible abnormal findings: -atrophy/asymmetry -redness -swelling -dislocation: loss of rounded shape -pain/crepitus -muscle spasm -rotator cuff lesions: limited ROM

optic disk

blind spot

fluid on knee

bulge sign: -for swelling in supra patellar pouch, bulge sign confirms presence of fluid as you try to move fluid from one side of joint to other. -firmly stroke up on medial aspect of knee two or three times to displace any fluid; tap lateral aspect and watch medial side in hollow for distinct bulge from a fluid wave; normally none is present ballottement of the patella: -use left hand to compress supra patellar pouch to move any fluid into knee joint -with right hand, push patella sharply against femur; if no fluid is present, patella already snug against femur

functional assessment: objective #4

categories: -bathing: in & out of tub; turning faucets -toileting: on/off toilet; peri-care, continence -dressing: buttons, zippers, pulling clothing over head; shoes/socks -grooming: shaving, brushing teeth, hair care, makeup as desired -eating: preparing meals, during liquids, bringing food to mouth; drinking -mobility: walking, up/down stairs, getting in/out of bed, transferring IADL's: instrumental -communicating: talking, using phone, writing, shopping, housekeeping, money management -medication management -assess any self-care deficit and develop individual plan of care: promote independence -identify relevant from irrelevant problems -prioritize

lens

clear, flexible

frequency

constant, or fades after a few beats

degenerative conditions

degenerative conditions: much more localized -osteoarthritis (degenerative joint disease): hips, knee joints because you use them more -noninflammatory, localized -joints stiff, painful, increases throughout day -swollen with hard, bony protuberances -osteoporosis -decrease in skeletal bone mass -increases risk for fracture -risk factors: elderly, postmenopausal women, genetics, alcoholism, aging, sedentary lifestyle, smoking -feel better with rest

glaucoma

increased intraocular pressure results in damage to the retina and optic nerve with loss of vision -peripheral vision impaired

inflammatory conditions

inflammatory conditions: (more systemic, involving other systems) -rheumatoid arthritis: autoimmune, chronic -symmetric and bilateral joint involvement -joints warm, tender, swollen, painful, erythematic -fatigue, weakness, anorexic, weight loss, low grade fever, lymphadenopathy -joint pain/stiffness worse after rest; improves with activity -ankylosing spondylitis -form of RA -chronic progressive inflammation or spine and sacroiliac joints -kyphosis

summary checklist: head and face examination

inspect head -symmetry, size, shape, and position inspect face -symmetry, facial movements, expression, lesions palpate head -massess, tenderness, scalp mobility palpate face -symmetry, tenderness, muscle tone, and TMJ function

focused musculoskeletal assessment: for people with articular disease, a+ history, or problems with ADLs

inspect: -joints: -size and contour -symmetry -skin & tissue --color, swelling, masses, deformity palpate: -joints: -skin temp-heat -tenderness-try to localize -swelling/fluid-try to localize -masses -muscles: -tenderness -swelling -symmetry -strength

musculoskeletal assessment: subjective

joint: -pain, stiffness, swelling, heat, redness, limited ROM muscles: -pain, cramps, weakness bones: -pain, deformity, trauma functional assessment (ADLs) patient-centered care

mature cataract

lens is completely opaque

nonsynovial vs. synovial joints

nonsynovial: -united by fibrous tissue or cartilage -unmovable or slightly movable -skull -vertebrae synovial: -freely movable -bones separated from each other -bones enclosed in a joint cavity -cavity filled with synovial fluid -cartilage (vascular (does not receive any blood supply, receives nourishment from synovial fluid)) (slow cell turnover) covers surface of opposing bones -cushions -smooth surface

hearing

pathways of hearing -air conduction: sound comes as waves to tympanic membrane (vibrates) moves little bones to cochlea -bone conduction hearing loss -conductive -sensorineural: hairs on nerves affected

head and face examination

preparing for exam: -quiet, comfortable room -warm, clean hands -equipment: non-latex gloves assessment techniques: -inspection -palpation

eye examination

preparing for the exam -quiet, comfortable room -warm, clean hands -equipment -snellen eye chart -jaegar card (handheld card to check near vision)/rosenbaum eye chart -index card -penlight -ophthalamoscope (not routine) assessment techniques -vision assessment -distance -near -color -peripheral extra ocular movements (EOMs) -inspection -PERRLA -palpation -ophthalamoscopy

ophthalmoscope assessment

red reflex: like red reflection of retina when take photo with flash optic disc retinal vessels general background macula: darker area on back on retina

musculoskeletal changes with aging

•Gradual loss of bone density •Postural changes—decreased height •Kyphosis •Redistribution of subcutaneous fat •Bony prominences more marked •Loss of muscle mass •Decreased balance •Increased risk for falls -decreased fat in periphery, more over abs, hip -shortening in truck, lose height, arms appear longer

musculoskeletal assessment: objective

•Inspection •Palpation •Auscultation (?) (crepitus: grading sound, hear and feel->degenerative joint disease (bone grading on bone)) •ROM Muscle Strength (a new scale! 0-5)