UMHB Nursing Blueprint Module Exam C

If a patient is having a stroke, what can the nurse observe of the patient?

(FAST) Face Drooping Arm Weakness Slurred Speech Time

Scoring Deep Tendon Reflexes

0 No response 1+ Sluggish/Diminished 2+ Active/ Expected 3+ Slightly Hyperactive, more brisk than normal (not necessarily pathologic) 4+ Brisk, hyperactive with intermittent clonus associated with disease.

Expected Response of Reflex

2+ active/expected response

Pathologic/Spontaneous Fracture

A break in the continuity of bone resulting from weakness in bone such as osteoporosis/neoplasm. Findings: Pain from muscle spasm. Deformity and loss of function caused by shortening of tissue around bone and localized edema.

Guillain-Barre Syndrome

Acute syndrome characterized by a widespread demyelinization of nerves of the peripheral nervous system. Affects motor component of peripheral nerves. Caused by a cell-mediated autoimmune response to a viral infection. Patients may have a respiratory or GI viral infection before onset. Findings: Ascending paralysis that begins weakness and paresthesia in the lower extremities and ascends to upper extremities and face. Ascending may result in respiratory depression. Decreasing variation may occur. Deep tendon reflexes are absent.

Bell's Palsy

Acute unilateral paralysis of the facial nerve. 80% of patient recover fully after a few weeks to months. Findings: History of pain behind ear or on the face a few hours or days before onset of paralysis. On the affected side the eye does not close, the forehead does not wrinkle, and the patient is unable to whistle or smile.

Cupping

Alternative medicine therapy for arthritis, stomach aches, bruises, and paralysis. Glass cups with negative pressure created with heat. Practiced by Latin American and Russian Cultures.

Temporal Lobe

Auditory complex. Wernicke's area (comprehensive of spoken and written language), interprets auditory, visual, and somatic sensory input that are stored in thought and memory.

Epidermis

Avascular. Go under keratinization and melanin.

Triceps Reflex

Back of elbow

CNA CNX Vagus Nerve

Voluntary muscles of phonation (guttural speech sounds) and swallowing sensation behind ears and part of external canal, secretion of digestive enzymes, peristalsis carotid reflex, involuntary action of heart, lungs, and digestive tract.

Spinal Cord

Carry information and reflex

Osteoarthritis

Caused by degenerative changes of articular cartilage. Affects weight-bearing joints and fingers. As cartilage wears away, the bones rub causing joint inflammation. Unilateral and bilateral. Findings: Edema and aching pain. Joint deformity.

Cerebrovascular Accident (stroke)

Cerebral blood vessels become accluded by a thrombus/embolus or when intracranial hemorrhage occurs. Brain tissue becomes ischemic resulting in CVA/Stroke. Caused by hypertension/cerebral aneurysm. Findings: Manifestations based on area of ischemic. Sudden unilateral numbness/weakness of face, arm, or leg. Trouble walking, dizziness, or loss of balance/coordination. Severe headache. Sudden confusion, dysphagia (difficulty swallowing), Aphasia (difficulty speaking/understanding speech), or partial loss of vision.

Normal Spine Curvature

Cervical concave, thoracic convex, lumbar concave

Relative data that are included in a Comprehensive health history (refer to pages 343 and 344)

Chronic illnesses, medications, history of head injuries and residual effects, history of surgeries on the brain, spinal cord, or nerves, seizures, and family history of strokes.

Rheumatoid Arthritis

Chronic, autoimmune inflammatory disease of connective tissue. Onset is gradual, with fatigue, morning stiffness lasting more than an hour, diffuse muscle ache, weakness. Synovial lining becomes inflamed leading to deterioration of cartilage and erosion of surfaces, causing bone spurs. Ligaments and tendons become fibrotic and shortened causing partial dislocation of joints.

Cerebellum

Coordinating movement equilibrium, muscle tone, and proprioception.

Biceps Reflex

Crease inside elbow, Brachial vein

Parkinson's Disease

Develops slowly due to degeneration of Thedopamine-producing neurons in the substantia nigra of basal ganglia. Findings: Resting tremor, bradykinesia, and rigidity. Masklike faces, trunk-forward flexion, muscle weakness, shuffling gait, and finger pill-rolling tremor.

Dysphagia

Difficulty swallowing

Aphasia

Defective or absent language function

CNA CNIV Trochlear Nerve

Downward, inward eye movement

CNA CNVII Facial Nerve

Facial expression (except jaw), close eyes, labial speech sounds, taste (anterior 2/3 tongue), sensation to pharynx, secretion of saliva and tears.

Hair

Epidermal Cells in the dermis form hair. Root, shaft, and follicle.

Nails

Epidermal cells converted to hard plates of Keratin.

Crepitus

Grating, crackling/popping sounds and sensations experienced under the skin and joints/crackling subcutaneous tissue

Common Problems (refer to pages 344-346)

Headaches (Migraine, cluster, tension), Dizziness, vertigo, seizures, loss of consciousness, changes in movement/sensation, and difficulty swallowing/ communicating.

CNA CNVIII Acoustic/Vestibulocochlear Nerve

Hearing and Equilibrium.

Trigeminal Neuralgia/Tic Douloureux

Intense paroxysmal pain along one ot all three of the branches of the trigeminal nerve (CN V). Factors include trauma to the face or head and infection of the teeth or jaw. Patient can identify trigger points in small areas on the cheek, lip, gum, or forehead that initiate pain when stimulated. Findings: Abrupt, intensive unilateral pain along the tissues innervated by CN V that lasts a few seconds.

Achilles Reflex

Heel

Diencephalon:Subthalamus

Helps Basal Ganglia

Diencephalon:Epithalamus

Helps with sleep schedule and regulate endocrine function.

Basal Ganglia

Helps with smooth coordinated voluntary movements, balances production of Acetylcholine and Dopamine.

Gout

Hereditary disorder. Increase in serum uric acid. Caused by either increased production or decreased excretion of uric acid and urate salts. Affects wrists, hands, ankles, and knees. Findings: erythema and edema. Painful to move and thus limited ROM. Tophi-round, pealike deposits of uric acid in ear cartilage/large, irregularly shaped deposits in subcutaneous tissue. Kidney stones from uric acid crystals can cause manifestations of flank pain and CVA tenderness.

Subcutaneous Layer

Hyperdermis. Loose connective tissue. Fatty cells retain heat, provide protective cushion, and provide calories.

Dysphasia

Impairment of speech not as severe as aphasia

Receptive Aphasia

Inability to comprehend speech of others and of oneself. Also termed fluent aphasia. Associated with lesions in Wernicke's area in the Temporal Lobe.

Expressive Aphasia

Inability to spontaneously communicate or translate ideas into meaningful speech or writing. Also termed as nonfluent aphasia. Broca's area is affected in the Frontal Lobe.

Alzheimer's Disease

Incurable, degenerative neurologic disorder that begins with a decline in memory. MOST COMMON CASE OF DEMENTIA in western countries. Cause is unknown. Findings: 3 stages. Early satge lasts 2 to 4 years when the patient's memory (e.g., forgetting names and misplacing items) begins to fail. The second stage lasts from 2 to 12 years when the patient experiences progressive memory loss and has difficulty with ADLs. Language skills deteriorate, and the patient becomes disorientated and confused with poor concentration. The final stage requires the patient to have total care and they are unable to communicate.

Encephalitis

Inflammation of brain tissue and meninges. Caused by bacteria, viruses, fungi, and parasites. Findings: Onset is gradual/sudden, with symptoms of a headache and nausea and signs of a fever, lethargy, irritability, and vomiting. Decreased consciousness, motor weakness, tremors, seizures, aphasia, and positive Babinski's sign.

Bursitis

Inflammation of bursa, connective tissue structure surrounding a joint by constant friction. Caused by arthritis, infection, injury, or excessive exercise. Findings: Painful, limited ROM; edema; tenderness; erythema.

Meningitis

Inflammation of meninges that surround the brain and spinal cord. Caused by invasion of bacteria, viruses, fungi, parasites, or toxins. Findings: Severe headache, fever, and malaise (weakness). Nuchal rigidity/stiff neck. Level of consciousness may decrease with drowsiness and reduced attention span, can lead to stupor and coma. Confusion, agitation, and irritability.

Craniocerebral Injury (Head Injury)

Injury to scalp, skull, or brain that is sufficient to alter normal function. Findings: Closed head injuries produce cerebral concussion or contusion. Residual deficits in memory, cognition, and motor sensory abilities.

Spine Abnormalities: Scoliosis; S-shaped deformity

Involves lateral curvature, spinal rotation causing rib asymmetry, and thoracic kyphosis. Findings: Uneven shoulder and hip levels. Curvature btw 10% and 20%=mild variation. Rotation deformity causes rib hump and flank asymmetry on forward flexion. Depending on severity of curve, physiologic function of lungs, spine, and pelvis.

CNA CNV Trigeminal Nerve

Jaw open and clench and chewing and sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, and facial skin.

R.A. Findings

Joint involvement is bilateral, localized pain, edema, stiffness, low-grade fever and fatigue, ulnar deviation, swan-neck deformity, and boutonniere deformity

Inspection and Palpation of the joints and muscles

Joints: Increased vs decrease ROM c use of Goniometer Musicles: Scale % of normal Zero (O) 0 0% Trace (T) 1 10% Poor (P) 2 25% Fair (F) 3 50% Good (G) 4 75% Normal (N) 5 100%

Patellar Reflex

Knee

Apocrine Sweat Glands

Larger and deeper glands found only in the axillae, nipples, arelae, anogenital area, eyelids, and external ears. Secretion at puberty. Influenced by hormones. Response to emotional stimuli, glands secrete odorless fluid containing protein, cabs, and other substances. Production of BO due to the bacteria that feed off secretion.

CNA CNVI Abducens Nerve

Lateral eye movement

Osteoporosis

Loss of bone density (osteopenia) and decreased bone strength. Bone mineral density (BMD)>2.5 standard deviations below the mean for young health adult women. Causes: aging with decline in estrogen and calcium deficit and lack of weight bearing exercise. Use of immunosuppression therapy such as glucocorticoids Findings: Silent disease. Loss of height, spontaneous fracture/kyphosis

Myasthenia Gravis

Neuromuscular disease characterized by weakness of voluntary muscles that improves with rest and administration of anticholinesterase drugs. The Acetylcholine receptor sites are destroyed by autoantibodies, causing muscle weakness. Can have tremors of the thymus gland. 3 types: 1) ocular, 2) bulbar, which affects swallowing, and 3) general, which affects arms, legs and trunk. General also affects breathing.

Diencephalon:Hypothalamus

Maintaining homeostasis, body temperature, hunger, and thirst, formation of ANS responses, and storage and secretion of hormones.

Carpal Tunnel Syndrome

Median nerve is compressed btw the flexor retinaculum (carpal ligament) and other structures within the carpal tunnel. Caused by repetitive movements. Findings: Burning/numbness, tingling in the hands, often at night. During Phalen's sign/Tinel's sign Pt. report numbness, pain, and paresthesia.

Expected Findings

Normal muscle strength=5. Normal flexion or extension; full range of motion actively and passively with joint stability but without tenderness, heat, etc. Always compare sides. Dominant side would be stronger. Ability to follow gait with stance and swing. Symmetrical spine.

Spine Abnormality: Herniated Nucleus Pulposus/ Herniated Disk/ Slipped Disk

Normally in lumbar spine due to lifting heavy objects. Findings: Complaints of numbness and radiating pain in affected extremity. Straight leg raises cause pain by putting pressure on spinal nerve. In Cervical, causes arm pain and paresthesia. Deep tendon reflexes may be depressed or absent, depending on the spinal nerve involved.

Types of Joints: Slightly Moveable Joints

Or amphiarthrodial: symphysis pubis

Types of Joints: Freely Moveable Joints

Or diarthrodial: knee and distal interphalangeal (DIP)

Types of Joints: Immovable Joints

Or synarthrodial; suture of the skull

Mental Status and level of consciousness (LOC) is tested by

Orientation X3 (person, place, and time), memory, calculation ability, Communication skills (naming, repeating, writing, and copying), judgment and reasoning, and abstract reasoning.

Expected/Normal findings in an exam

Oriented to person, place, and time. Speech understandable and of sufficient volume. Cranial nerves II to XII grossly intact. Balanced gait with upright pressure. Muscle strength 5/5 and movement coordinated bilaterally; negative Romberg sign. Peripheral sensation intact. Deep tendon reflexes 2+ bilaterally. No clonus present.

Abnormal Findings

Pain, tenderness, heat, abnormal gait, asymmetry, weakness, uneven leg length, difficulty opening mouth, impaired ROM, and Crepitus

Fracture

Partial/complete closed=Skin Intact Open=Skin broken Most likely to occur in children and older adults. Forearm in children, Hip in older adults. Findings (found under spontaneous Fracture)

Melanin

Pigment for the skin and hair and serves as a shield against UV radiation.

Frontal Lobe

Primary Motor, Voluntary motor activity. Broca's area, intellectual function, awareness of self, personality, and emotion.

Multiple Sclerosis

Progressive demyel-inaction of nerve fibers of the brain and spinal cord. Auto immune disorder from a virus that attacks myelin of CNS. Findings: fatigue, depression, and paresthesias, focal muscle weakness, ocular changes (diaplopia, nystagmus), bowel, bladder, and sexual dysfunction, gait instability, and spasticity.

Keratin

Protein that is deposited causing the cells to become flat, hard, and water proof.

Related System Disorders with Carpel Tunnel

RA, gout, hypothyroidism with fluid retention that occurs with pregnancy and menopause.

CNA CNIII Oculomotor Nerve

Raise eyelids, eye movement, pupillary constriction, change in lens shape.

Eccrine Sweat Glands

Regulate temperature by water secretion through the surface of skin. Distributed almost everywhere throughout surface of skin. Found more on hands, soles of feet, and forehead. Controlled by nervous system.

Diencephalon:Thalamus

Relay and integration station from spinal cord to cerebral cortex

Brainstem

Relay stimuli for muscle movement

Coordination Assessment

Romberg Test (for balance, stand feet together and arms at side. Eyes open then closed), Stand on one foot, Tandem (walking heel-toe pattern), Hop on one foot, Knee bends (shallow/deep), walking on toes, walking on heels.

Sebaceous Glands

Secrete lipid-rich substance call sebum. Keeps hair and skin lubricated. Located all over the body but mostly on face and scalp, with an exception of palms and soles of feet. Sebum secretion, stimulated by sex hormone activity, accelerates during puberty and varies throughout life span.

Parietal Lobe

Sensory input of position, sense of touch, shape and texture of objects.

Paronychium

Skin tissue adjacent to nails.

Landmarks

Spinous Processes Posterior Iliac spine Sternum Joints Thoracic Spine

Upper Extremities Assessment

Tap thighs (rapid pronation and supination), touch nose (arms stretched, eyes closed), thumb to fingers rapidly, and Nose to finger (ability to use index finger to touch self nose and assessor's index finger with eyes open)

Cranial Nerve Assessment CNI Olfactory Nerve

Test for smell

CNA CNII Optic Nerve

Test sight and visual fields

Brachioradialis Reflex

Thumb side of wrist

Types of Joint Movement: Lateral Flexion

Tilting head as far as possible toward each shoulder

CNA CNXII Hypoglossal Nerve

Tongue movement for speech sound articulation (l, t, n) and swallowing

Types of Joint Movement: Opposition

Touch thumb to each finger of the same hand

Spinal Cord Injury

Traumatic disruption. Cervical Spinal Injury = quadriplegia. Thoracic and Lumbar Spinal Injury = paraplegia. Findings: complete spinal cord transection includes parethesia/anesthesia and signs are paralysis below level of injury with loss of bowel and bladder control. Damage upper motor neurons, causing spastic paralysis. Incomplete is variable in signs.

Coining

Treatment practice by Cambodians and Vietnamese. The body is rubbed vigorously with a coin exerting pressure until red marks appear over bony prominence of rib cage on back and chest. Have been mistaken as signs of abuse/mistreatment.

CNA CNXI Spinal Accessory Nerve

Turn head, shrug shoulders, some actions of phonation.

Dermis

Vascular connective tissue. Contains sensory nerve fibers that react to touch, pain, and temperature.

Occipital Lobe

Visual Cortex. Responsible for interpreting visual information.

Babinski's Reflex

is one of the normal reflexes in infants. The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out.

Lower Extremities Assessment

knee to shine slide (with heel of one foot on knee of the opposite leg, and slide heel down shin) and Gait (walking smooth, balanced with upright posture, opposing arm swing).

CNA CNIX Glossopharyngeal Nerve

swallowing and phonation sensation of nasopharynx, gag reflex, taste (posterior 1/3 of tongue), secretion of salivary glands, carotid reflex.