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