Assessments Exam 3

AV node

(atrioventricular node) region of the heart between the right atrium and right ventricle from which electrical impulses spread to the ventricles during a heartbeat

SPICES

- Skin impairment - Poor nutrition - Incontinence - Cognitive impairment - Evidence of falls or functional decline - Sleep disturbances

older client minimum caloric intake

1200 - 1600 cal a day

Major causes of abdominal distention

6Fs: Fluid Fat Flatus Feces Fetus Fatal tumors

Systole

Av valves shut, ventricles contract (isometric contraction) pushing open the aortic and pulmonic valves pressure in ventricles is higher than in atria

Stroke FAST

Face - ask pt to smile, notice any drooping? Arms - ask pt to raise both arms, does one arm drift downward? Speech - ask pt to repeat a simple phrase, is speech slurred or strange? Time - if you observe any of these, CALL 911 ASAP!

Jugular veins

Internal and external veins internal lies deep and medial to the sternocleidomastoid muscle external more superficial - lateral to the sternocleidomastoid muscle and above clavicle return blood to the heart from head, neck by the superior vena cava

neuro check

Level of Consciousness (LOC) Pupillary Checks Movement and Strength of Extremities Sensation in Extremities Vital Signs

parietal pain

POINTY parietal peritoneum becomes inflamed (appendicitis or peritonitis) - Localized to source - Severe steady pain

SA node

Sinoatrial node: pacemaker of the heart located on the posterior wall of the R atrium near the junction of superior and inferior vena cava

SLUMS

St. Louis University Mental Status Assessment - used to assess signs of dementia in clients who seem confused or reports inability to recall short-term or long-term information - score 27-30 w HS edu normal - score 20-30 w/out HS edu normal

Positive Romberg test

Swaying and moving feet apart to prevent fall is seen with disease of the posterior columns, vestibular dysfunction, or cerebellar disorders.

stroke volume

The amount of blood ejected from the heart in one contraction.

Afterload

The force or resistance against which the heart pumps.

visceral pain

VAGUE hollow abdominal organs become distended or contract forcefully or when capsules of solid organs are stretched - dull aching burning cramping colicky pain - poorly defined or localized and intermittently times

Cullen sign

a bluish or purple discoloration around the umbilicus indicates intraabdominal bleeding

cardiac catherization

a diagnostic procedure in which a catheter is passed into a vein or artery and then guided into the heart - groin, wrist, arm - goes in arteries circling the heart not a chamber - chest pain/angina rule out MI - it will be painful BUT - if a pt is allergic to shrimp that indicates an iodine allergy so that is important info

Kernig's sign

a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down

subarachnoid space

a space in the meninges beneath the arachnoid membrane and above the pia mater that contains the cerebrospinal fluid - cushions brain and spinal cord - nourishes CNS - removes waste materials

graphesthesia

ability to "read" a number by having it traced on the skin

hallux vagus

abnormality in which the great toe is deviated laterally and may overlap the second toe

palpitations

abnormality of the heart's conduction systemm

analgesia

absence of pain sensation

anesthesia

absence of touch sensation

abnormal percussion of abdomen

accentuated tympany or hyperresonance is heard over a gaseous distended abdomen

joint or muscle pain

aching

presbycusis

age related hearing loss

Right Lower Quadrant

appendix, ascending colon, cecum, Right kidney, Right ovary and tube, Right ureter, Right spermatic cord *Appendicitis pain felt here*

precordium

area of the chest wall overlying the heart and great vessels

Right upper quadrant

ascending and transverse colon, duodenum, gallbladder, hepatic flexure of colon, liver, head of pancreas, pylorus (small bower -or ileum transverses all quadrants), Right adrenal gland, Right kidney, Right ureter

Rheumatoid Arthritis

autoimmune worse in the morning, gets better with activity -bilateral -worsens when sitting for long periods of time

urinary bladder

bladder filled with urine may be palpated in the abdomen above the symphysis pubis

ischemic stroke

blood vessel carrying blood to the brain is blocked by a clot

osteoporosis

bones demineralize and become porous and fragile, making them susceptible to fractures

hemorragic stroke

brain aneurysm bursts or a weakened brain vessel leaks - less common, more fatal

Diastasis recti

bulge between a vertical midline separation of the abdominis rectus muscles - little significance

angina

cardiac chest pain squeezing around heart steady severe pain and a sense of pressure Cardiac pain is often seen with exertion and relieved with rest

Transient Ischemic Attack (TIA)

causes no damage but indicates a stroke risk - disappears within 24 hours - no long term damage

calcified tenditis

chronic pain and severe limitation of all shoulder motions

chronic rheumatoid arthritis

chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints, limited range of motion and finger deviation toward the ulnar side

S1

closure of Av valves (mitral and tricuspid) beginning of systole "LUB" best heard at apex sound is softer at the base louder at the apex

S2

closure of semilunar valves(pulmonic and aortic) beginning of diastole best heard at base

arterial insufficiency

cold, pale, clammy skin on the extremities and thin shiny skin with loss of hair, especially on lower legs

CAM

confusion assessment method - used to distinguish delirium from dementia "CAM has double D's"

perforator (communicator) veins

connecs the superficial veins with deep veins

medulla oblongata

contains nuclei for CN's and controls respiratory function, HR and force, BP

Cushing's syndrome

dark bluish-pink striae

hypoalgesia

decreased sensitivity to pain

hypesthesia

decreased sensitivity to touch

peripheral neuropathy can result from?

deficiency in niacin, folic acid, or vitamin B12

loss of physiologic reserve

defined as the aging body's inability to make an appropriate adaptation to environmental challenges (they get tired easily, they decompensate quicker)

Osteoarthritis

degenerative worsens w activity throughout the day -unilateral -worsens in rainy weather

P wave

depolarization of the atria 0.0.8-0.11 s

QRS complex

depolarization of the ventricle <0.1 s

dysphasia

difficulty speaking

frontal lobe

directs voluntary, skeletal actions influences communication (talking and writing), emotions, intellect, reasoning ability, judgement, and behavior Broca area - speech "you have to walk to the front of the room to communicate your feelings to Mr. Broca"

Positive Babinski sign

dorsiflexion of the big toe and fanning of all toes

bone pain

dull deep throbbing

bunion

enlarged painful inflamed bursa

keloids

excess scar tissue results from trauma or surgery more common in african americans and asians

S/S of illness in the older client

falls incontinence increased weakness and lethargy loss of appetite weight changes confusion changes in sleep and level of alertness

cardiac cycle

filling and emptying of the heart's chambers

spleen

filters blood of cellular debris normally not palpable

kidneys

filtration and elimination of metabolic waste products right kidney slightly lower bc of liver palpable anteriorly on thin patients tenderness felt at the costovertebral angle

abdominal border

flanks- laterally pubic symphysis - inferiorly costal margins - superiorly

boutonniere deformity

flexion of proximal interphalangeal joint and hyperextension of the distal interphalangeal joint

swelling of knee

fluid in knee join or thickening of synovial membrane

knock knees

genu valgum

bowed legs

genu varum

lumbar lordosis

hip flexion contracture and hip extensor weakness drive the lumbar spine into increasing lordosis to balance head over pelvis

borborygmus

hyperactive bowel sounds

hammer toe

hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint - occurs with the second toe

swan neck deformity

hyperextension of the proximal interphalangeal join with flexion of the distal interphalangeal joint

presbyopia

impaired vision as a result of aging

asterognosis

inability to recognize objects by sense of touch

lesion of cranial nerve XI

inability to shrug shoulders

hyperalgesia

increased sensitivity to pain

hyperesthesia

increased sensitivity to touch

occipital lobe

influences the ability to read with understanding and is the primary visual receptor center "Once I read the book I was able to visualize the assessment"

transverse abdominis

innermost abdomen layer

endocardium

innermost, think layer of endothelial tissue and is continuous with the endothelial lining of the blood vessels

normal auscultation of abdomen

intermittent, soft clicks and gurgles 5-30 bowel sounds per minute High pitch

parietal lobe

interprets tactile sensations (touch, pain, temperature, shapes and two point discrimination) "Your parents teach you to sense"

ataxia

lack of muscle coordination unsteady gait

Wernicke's area

language comprehension

liver

largest solid organ palpable

Left Upper Quadrant

left adrenal gland, left kidney, left ureter, pancreas (body and tail), spleen, splenic flexure of color, stomach , transverse descending colon

Left Lower Quadrant

left kidney, let ovary and tube, left ureter, left spermatic cord, descending and sigmoid colon

solid viscera

liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus

Carotid artery

located in the groove between the trachea and the sternomastoid muscle supply the neck, head and brain with oxygenated blood

superficial veins

located near the body surface great and small saphenous veins

deep veins

located within the tissues and away from the body surface femoral and popliteal

small intestine

longest portion of digestive tract not normally palpable

associated factors of geriatric syndromes

malnutrition eating and feeding problems sleeping problems dizziness syncope self neglect

frailty syndrome

manifests as fatigue, weakness, decline in physical activity, appetite

flattening of lumbar curve

may be seen with herniated lumbar disc or ankylosing spondylitis

Brainstem

midbrain, pons, medulla oblongata

internal abdominal oblique

middle abdomen layer

myocardium

middle layer of the heart; thickest layer of the heart, made uo if cintractile cardiac muscle cells

retraction

moving backward

protraction

moving forward

calluses

non painful thickened skin that occurs at pressure points

ganglion

nontender, round, enlarged, swollen, fluid-filled cyst - commonly seen at the dorsum of the wrist

pancreas

normally not palpable endocrine gland and accessory organ of digestion

external abdominal oblique

outermost abdominal layer

epicardium

outermost, covers outer surface of the heart

Referred pain

pain at different site that are innervated at same labels - travels/refers - highly localized

Brudzinski's sign

pain with resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine

rotator cuff tear

painful and limited abduction accompanied by muscle weakness and atrophy

arterial disease ulcers

painful and often located on toes foot or lateral ankle

corns

painful thickening of the skin over bony prominences and at pressure points

venous ulcers

painless, occur on the lower leg or medial ankle

ascites

pale, taut skin may be seen

flat feet

pes planus

verruca vulgaris

plantar warts; under a callus

Geriatric Syndromes

pressure ulcers, incontinence, falls, functional decline, delirium

hernia

protrusion of the bowl through abdominal wall - if you cannot push back hernia = emergency b/c of decreased blood supply

grey-turner sign

purple discoloration at the flanks indicated bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis

Fasciculation

rapid continuous twitching of resting muscle without movement of limb

temporal lobe

receives and interprets impulses from the ear. Contains Wernicke area, which is responsible for interpreting auditory stimuli "You go to temple to listen to Mr.Wernicke"

hypothalamus

regulates water balance, appetite, vital signs, sleep cycles, pain perception, and emotional status

T wave

repolarization of the ventricles <0.20 s

tremors

rhythmic oscillating movements

parietal pericardium

secretes a small amount of pericardial fluid allows for smooth, friction-free movement of the heart

spider angioma

seen with liver disease or portal hypertension

rotator cuff tendinitis

sharp catches of pain when bringing hands overhead

fractures

sharp, knife life and INCREASES with motion

Dysarthria

slurred speech

Broca's area

speech production

hollow viscera

stomach, gallbladder, small intestine, colon and bladder

gallbladder

store bile not normally palpable

stomach

store, chum and digest food not usually palpable

scaphoid

sunken abdomen may be seen with severe weight loss or cachexia related to starvation or terminal illness

gouty arthritis

tender, painful, reddened, hot, swollen metatarsophalangeal joint of the great toe

synovitis

tenderness and warmth w BOGGY

Cardiac output

the amount of blood pumped by the heart per minute determined by stroke volume CO = SV x XR normal adult CO: 5-6 L/min

Diastole

the av valves are open, ventricles are relaxing higher pressure in the atria than in the ventricles so blood passes from atria into the ventricle

sarcopenia

the loss of muscle mass, strength, and function that comes with aging

arteriosclerosis

the thickening and hardening of the walls of the arteries, occurring typically in old age.

ST segment

time during which ventricles are contracting and emptying <0.12 s

PT interval

time of heart activity 0.12-0.20s

dorsiflexion

toes draw upward to ankle

plantar flexion

toes point away from ankle

pericardium

tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart

colon

transverse and descending colon may be felt on palpation

murmurs

turbulent blood flow in which swooshing or blowing sound may be auscultated over the precordium or heart valves

tic

twitch of face, head or shoulder

cerebellum

two hemispheres, coordination, smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone - gait and balance - tandem walk - Romberg test - RAM - heel to shin - finger to nose

Glasgow Coma Scale (GCS)

useful for clients who are unresponsive or are not responding to questions - eye-opening response - verbal response - motor response Best response: 15 Comatosed < 8 Unresponsive: 3

intermittent claudication

usually first - weakness, cramping, aching, fatigue, frank pain with activity located in calves, thigh, or buttocks quickly relieved with rest other Sx: burning/aching pain in feet and toes while resting (esp. at nigh supine)

three mechanism to help propel blood back to the heart

valves muscular contraction - squeeze blood to heart through valves pressure gradient created through breathing - inspiration decreases intrathoracic pressure while increasing abdominal pressure

Raynaud's disease

vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes, characterized by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, and coldness - bilateral

QT interval

ventricular depolarization and repolarization <0.38 s

abdominal aortic aneurysm

vigorous wide exaggerated pulsations

osteomalacia

vitamin D deficiency may result in recurrent injuries

preload

volume of blood in ventricles at end of diastole

venous insufficiency

warm skin, edema and brown pigmentation around the ankles are associated with venous insufficiency

fibromyalgia

widespread musculoskeletal pain fatigue, sleep, memory, mood changes, cognitive disorders Hard to diagnose

Fatigue from compromised CO

worse in the evening or as the day progresses