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66 Cards in this Set
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- Back
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How to assess nutritional status |
mid-arm circumference, BMI,( assess skin, hair and nails), waist to hip ratio(p229), triceps skinfold thickness(p231). For hydration: I/O, BP, turgor, palpate eyeball, edema, lung sounds, eye position and color of surrounding skin (p. 223) |
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Purpose of nutritional status assessment |
provides insight into the client's overall health status. Identifies risk factors for obesity and nutritional deficits. (p. 211) |
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objective vs. subjective data for nutritional assessment |
Subjective: questions regarding dietary habits such as average daily intake of food, types and quantities consumed, where and when food is eaten, and conditions or diseases that affect intake or absorption. *food consumed in the last 24 hrs Objective: physical examination including body weight, build, taking anthropometric measurements, and assessing hydration. |
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indicators for BMI |
weight, height less than 18.5 = underweight 25.0-29.9 = overweight greater than 30 = obese. Over 40 = extremely obese(p 218). |
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changes for older adults nutrition |
minimum caloric intake decreases (1200-1700 cal/day) Need nutrient dense food. poor oral health=discomfort=interferes with chewing and digestion decreased thirst sensation (drugs also contribute to dehydration) |
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definition of malnutrition |
undernutrition lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat. |
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assessing fluid status (how does this affect nutrition) |
Imbalances suggest impaired organ function and fluid overload, or inability to compensate for losses, resulting in dehydration. ( also affects elimination. Water is necessary for many chemical reactions in the body- water soluble vitamins ) |
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how to assess patients typical nutrition |
24 hour recall |
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vessels anatomy |
Superior and inferior vena cava return blood to right atrium from upper and lower torso pulmonary artery leaves right ventricle and carries blood to lungs Pulmonary veins return oxygenated blood to left atrium aorta transports oxygenated blood from the left ventricle to the body |
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anatomy of layers |
epicardium-outer surface of heart myocardium-thickest middle layer of heart endocardium-thin innermost layer |
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valve anatomy |
Tricuspid valve:between right atrium and ventricle bicuspid (mitral) valve: between left atrium and ventricle pulmonic valve:entrance of pulmonary artery as it exits right ventricle aortic valve: beginning of the ascending aorta as it exits left ventricle (TRI to do right or you MIT get left behind) |
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how to assess apical pulse |
Fifth intercostal space, left midclavicular line |
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COLDSPA |
Character - What kind of pain Onset - When did it begin Location - Where is it? Does it radiate? Does it occur anywhere else? Duration - How long does it last?Severity - How bad is it? Pattern - What makes it better or worse? Associated Factors - Any other symptoms occur with it? How does it affect you? |
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Where to auscultate heart sounds |
Aortic - Second intercostal space at the right sternal border - base of the heart Pulmonic - second intercostal space at the left sternal border Erb’s point - Third to fifth intercostal space at the the left sternal border Mitral (apical) - Fifth intercostal space near the left mid-clavicular line - apex of the heart Tricuspid area - fourth or fifth intercostal space at the left lower sternal border |
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how to assess heart sounds |
first heart sound (S1) second heart sound (S2) S1 best heard at the apex, S2 best heard at base |
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where to locate pulses and how to assess |
carotid: medial to sternocleidomastoid muscle on neck radial pulse: against radius, ulnar pulse: medial aspects of inner wrists brachial pulse: groove between bicep and tricep femoral pulse: medial aspect of leg popliteal pulse: deep in the bend of the knee, dorsalis pedis: along foot by big toe posterior tibial pulse: behind and below medial malleolus Pulse amplitude scale: 0-absent, 1+=weak, 2+=normal, 3+=increased, 4+=bounding |
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what is capillary refill? How to assess? |
It’s a way to assess circulation; you press on the nail-beds and see how fast it refills; should be less than 3 seconds longer than this may indicate vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia. |
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how to assess for varicose veins |
Ask client to stand because varicose veins may not be visible when supine. appear as distended, nodular, bulging, and tortuous, result from incompetent valves in veins, weak vein walls, or obstruction above varicosities |
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indications for arterial insufficiency |
Pain: intermittent claudication to sharp, unrelenting, constant Pulses: quick or diminished Skin: dry, shiny, loss of hair over toes and foot, nails thickened and ridged, cool to cold temperature, pallor of foot, dependent rubor Ulcers: very painful, deep often involving joint space, circular shape, minimal leg edema, located on tips of toes, toe webs, heel or other pressure areas if confined to bed, pale black to dry and gangrene ulcer base |
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indications for venous insufficiency |
Pain: aching, cramping Pulses: present but may be difficult to palpate through edema Skin: thickened and tough, reddish blue in color, associated with dermatitis, pigmentation in gaiter area (area of medial and lateral malleolus) Ulcer: medial malleolus or anterior tibial area, minimal pain if superficial, superficial depth, irregular border, moderate to severe leg edema, granulation tissue of ulcer base (beefy red to yellow) |
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indications for intermittent Claudication |
weakness, cramping, aching, fatigue, frank pain located in calves, thighs, or buttocks symptoms relieved by rest but reproducible with same degree of exercise |
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Proper order for assessing the abdomen |
inspection, auscultation, percussion, palpation |
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how and where to assess the bladder |
start at symphysis pubis and move outward to estimate borders; percussion (distended has dull percussion); palpated as smooth, round, and somewhat firm, extends as far as the umbilicus when distended Usually not palpable if recently voided. |
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how to assess for appendicitis |
McBurneys point: rebound tenderness-sharp, stabbing pain as pressure is released from abdomen |
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How to assess gallbladder |
Murphey's sign: press fingertips under the liver border and the right costal margin and ask the client to inhale deeply- accentuated pain that causes the pt to hold his breath is a positive sign”p 499. |
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signs of peptic ulcer disease |
abdominal pain, feeling of fullness, mild nausea, chest pain, fatigue, weight loss, black or tarry stools, vomiting |
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assess from least painful to most painful |
p 501 box 23-2 perform light palpation before deep |
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age related changes to GI system |
liver decreases in size after age 50 p 491 higher fat-to-lean muscle ratio causes risk for complications with diarrhea (like fluid volume deficit, dehydration and electrolyte and acid-base imbalances) |
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proper procedure for listening to bowel sounds |
use the diaphragm of the stethoscope (make sure it isn’t cold), apply light pressure or simply rest it on a tender abdomen, begin in RLQ and proceed clockwise, covering all quadrants; listen for at least 5 min before determining that there are no sounds present |
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indications for hyper, hypo or active or absent bowel sounds |
Hyperactive: rushing, tinkling, and high pitched; indicate rapid motility heard in early bowel obstruction, gastroenteritis, diarrhea, or with use of laxatives; loud, prolonged gurgles characteristic of “stomach growling” Hypoactive: indicate diminished motility; common causes include paralytic ileus following abdominal surgery, inflammation of the peritoneum, or late bowel obstruction, may occur in pneumonia Normal: series of intermittent, soft clicks and gurgles heard at a rate of 5-30 per minute |
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sounds to be heard when percussing |
dull over organs like spleen and liver (or full bladder) tympany around hollow areas |
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what to do for tickelish patients when assessing ABD |
place the client’s hand under your own for a few moments, keep your hands warm |
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what affects changes in ROM |
Limited ROM seen with osteoarthritis, spondylosis, disc degeneration. Decreased ROM against resistance is seen with joint or muscle disease. |
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how to assess TMJ or results of TMJ |
index and middle fingers anterior to external ear opening, ask client to open mouth, move jaw from side to side, protrude and retract jaw, snapping and clicking may be felt abnormal findings include decreased ROM, swelling, tenderness, or crepitus TMJ dysfunction associated with clicking, popping, or grating sound, muscle and joint disease includes decrease muscle strength |
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how to document muscle strength (indications 1-5) |
5 active motion against full resistance-normal 4 active motion against some resistance-slight weakness 3 active motion against gravity-average weakness 2 passive ROM (gravity removed and assisted by examiner)-poor ROM 1 slight flicker of contraction-severe weakness 0 no muscular contraction-paralysis |
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what is the snuff box? |
Hollow area on the back of the wrist at the base of the fully extended thumb. |
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medications which put patients at risk for bone loss |
steroids (pg. 514) |
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risks for bone loss |
decreased calcium and vitamin D intake, no weight bearing exercise, smoking, heavy drinking, caffeine. |
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how to assess cerebellum and why assess cerebellum |
coordination and muscle tone 545-546 Muscles are symmetric, muscles contract and are equally strong against resistance, no tics or tremors noted. Romberg test, assessing the gait and balance 563-564. |
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phalens test |
rest elbows on a table and place the backs of both hands against each other while flexing the wrists 90 degrees with fingers pointed downward and wrists dangling for 60 seconds Tingling, numbness and pain may indicate carpel tunnel syndrome |
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first thing to assess for MS system |
observe gait |
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Changes in gait |
Toddlers have a wide-based gait and are usually bow-legged. Children aged 2-7 are usually knock-kneed. Older adults may have a wider and shorter gait with the hips and knees flexed for a bent-forward appearance. |
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how to assess reflexes (where, grading, documenting) |
Document from 1+ to 3+, no response is abnormal. 1+ present but decreased 2+ normal 3+ increased or brisk, but not pathologic Reflex locations-Biceps, brachioradialis, triceps, patellar, Achilles. |
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how to trouble-shoot assessing reflexes |
Clenching the teeth when testing arm reflexes Interlocking hands when testing leg reflexes |
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Assessing CN I |
Olfactory (s) Identify scented object with eyes closed and obstructing one nostril |
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Assessing CN II |
Optic (s) Snellen chart/ newspaper or magazine (near vision) |
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Assessing CN III |
Oculomotor (m) inspect margins of eyelids, extraocular movements, pupillary response to light |
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Assessing CN IV |
Trochlear instruct the pt to follow your finger while you move it down toward his nose. |
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Assessing CN V |
Trigeminal (M) Clench teeth, and palpate temporal/masseter for contraction; (S) forehead, cheeks and chin with sharp/dull object w/clients eyes closed |
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Assessing CN VI |
Abducens inspect margins of eyelids, extraocular movements, pupillary response to light |
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Assessing CN VII |
Facial (m) smile/frown/show teeth/puff cheeks/purse lips/raise eyebrows/close eyes tightly (S) Taste |
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Assessing CN VIII |
Acoustic/Vestibulocochlear (S) whisper test (Weber/Rinne test) |
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Assessing CN IX |
Glossopharyngeal (M) cough, swallow, (S) gag reflex |
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Assessing CN X |
Vagus check uvula rise (have pt open mouth and say “ah”) and gag reflex (pg. 562) |
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Assessing CN XI |
Spinal Accessory shoulder shrug |
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Assessing CN XII |
Hypoglossal (M) protrude tongue then side to side and against resistance |
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how to assess bells palsy vs stroke |
Bells palsy (pt will not have altered LOC, no arm drift, no paralysis of other limbs, pupils are PERRL) Stroke (altered LOC, arm drift, paralysis of other limbs, pupils are not PERRL) |
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what is graphesthesia |
ability to recognize writing on the skin |
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what is the romberg test |
tests pt balance; pt stands with feet together and hands to side |
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changes in neurologic status - ?? |
Some older adults’ sense of smell and taste may be decreased. May normally have hand or head tremors or dyskinesia (repetitive movements of the lips, jaw, or tongue). Rapid alternating movements may be difficult because of decreased reaction time and flexibility. Light touch and pain sensations may be decreased. Vibratory sensation at ankles may decrease after 70. The sense of position of great toe may be reduced. Decreased reaction time with reflexes. (Achilles reflex and flexion of toes absent/difficult to elicit) |
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indications for changes in pupils (constricted, dilated) - ?? |
Illuminated pupils constrict simultaneously. Pupils constrict when bringing an object close to the face. (accommodation) |
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changes in gait - Cerebellar ataxia |
(wide-based, staggering, unsteady) seen in cerebellar diseases and alcohol or drug intoxication; romberg tests are positive |
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changes in gait- Parkinsonian Gait |
(shuffling, turns accomplished in very stiff manner, stooped over, flexed hips and knees) seen in parkinsons and drug-induced parkinsonian; effect on the basal ganglia |
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changes in gait- Scissors Gait |
(Stiff, short gait, thighs overlap each other with each step) seen in partial paralysis of the legs |
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changes in gait- Spastic Hemiparesis |
(Flexed arm held close to body while client drags toe of leg or circles it stiffly outward and forward) seen with lesions of the upper motor neurons in the cortical spinal tract, (stroke) |
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changes in gait- Footdrop |
(client lifts foot and knee high then slaps foot down, cannot walk on heels) Diseases of lower motor neurons |
