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179 Cards in this Set
- Front
- Back
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Central Nervous System
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Brain: cerebrum, brainstem, cerebellum
Sinal Cord |
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Peripheral Nervous System
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Cranial nerves
Spinal nerves |
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Sensory system
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afferent
-transmits information from periphery to the CNS -contains receptors |
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Motor system
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efferent
-transmits infromation from CNS to the rest of the body -sends motor information to effectors |
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Cerebrum
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functions: movement, LOC, ability to speak and write, emotions, memory
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Brainstem
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-consists of midbrain, pons, medulla oblongata
-most cranial nerves originate in brainstem -regulation of HR, BP, and breathing |
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Cerebellum
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-posterior part of the brain
-responsible for equilibrium, muscle tone, adn coordination |
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Cerebellar lesions cause:
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-loss of coordination (ataxia)
-tremors -distrubances in gait and balance |
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Somatic sensory
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receives sensory information from:
- Skin - Fascia - Joints - Skeletal muscles - Special senses |
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Visceral sensory
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receives sensory informatioin form viscera
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Somatic motor
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"voluntary"
nervous system innervates: - Skeletal muscle |
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Autonomic motor
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"involuntary"
nervous system innervates: - Cardiac muscle - Smooth muscle - Glands |
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Spinal cord
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-from base of the brain down to L1(45cm)
- connects brain to the body of motor and sensory function -31 spinal nerves *C1-C8, T1-T12, L1-L5, S1-S5, one coccygeal *Posterior (dorsal) roots = sensory * Anterior (ventral) roots = motor - Herniated vertebral disk is the most common spinal nerve root pathology -Involvement of multiple nerve roots *Guillain-Barre - Phrenic nerves arise from spinal root C3 to C5 * Damage can result in diaphragmatic paralysis |
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Patients with high cervical cord lesions (C1-C4)
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seldom survive without immediate ventilatory support
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Patients who survive a lesion above C7 usually:
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remain dependent on others for daily care
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Sparing of the C7 segment retains
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elbow and writs extension and enables transfer from wheelchair to bed, providing a degree of independence
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Patients with thoracolumbar injuries
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usually regain full independence
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A mixed cord and lumbar root lesion may occur at this level.
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roots are more resistant to injury- "root escape" adn the outlook is more favorable
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Mental Status and LOC
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-LOC and mentation: most important parts of the neurologic exam
-changes due to CNS dysfunction -initial goal of exam is to determine pt's awareness *starts with patient encounter -compromise of LOC may be due to: *Generalized dysfunction (overdose) *Abnormality in specific area |
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Full consciousness:
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pt is alert, attentive, follows commands, responds promptly to external stimulation if asleep, and once awake, remains attentive.
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Lethargy:
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pt is drowsy but partially awakens to stimulation; pt will answer questions adn follow commands but will do so slowly and inattentively
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Obtundation
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pt is difficult to arouse and needs constant stimulation to follow a simple command. Although there may be verbal response with one or two words, the pt will drift back to sleep between stimulation
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Stupor
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pt arouses to vigorous and continuous stimulation; typically, a painful stimulas is required. The only response may be an attempt to withdraw from or remove the painful stimulus
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Coma
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pt does not respond to continuous or painful stimulation. There are no verbal sounds and no movement, except possibly by reflex.
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Glasgow Coma Scale (GCS)
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most widely used instrument to quantify neurologic impairment
-Test *motor response *verbal response: poorly suited for pt's with impaired verbal response (e.g. aphasia, hearing loss, tracheal intubation) *eye opening Scale goes from 3 (deep coma) to 15(fully awake) - 12-15 = non ICU observation - 9-12 = significant insult -<9 = severe coma = req. ETT |
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Mini-Mental State Examination
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MMSE or Folstein test
- 30pt ? to assess cognition - samples various functions *arithmetic, memory, orienta. - score interpretation *>27/30 = normal * 20-26 = mild dementia * 10-19 = mod. dementia * <10 = severe dementia |
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Sedation and Delirium in the ICU
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Delirium occurs in 60-80% of MV pt's
Associated with: - longer hospital stay -higher mortality -poor long-term cognitive function Richmond Agitation Sedation Scale (RASS) +4 to -5 - titrate sedation Sonfusion Assessment Method for the ICU (CAM-ICU) -evaluates delirium |
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Cranial Nerve Exam
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12 cranial nerves = sensory and motor function
-midbrain (CN III, IV) -pons (CN VIII) -medulla (CN IX to XII) |
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Acoustic problem
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CN VII, VIII
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Pupillary response
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CN II, III
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Corneal reflex
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CN V, VII
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Gag reflex
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CN IX, X
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Sensory Exam
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somatosensory pathways
-spinothalamic (ST)= pain, temp. - dorsal column medial lemniscus (DCML)= vibration, position sense (proprioception) Evaluates ability to perceive sensations with eyes closed Assessment of light touch, pinprick, and temp. |
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Motor Exam
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pt's ability to move on command
motor strenght and range of motioin scale from 0 to +5 unconscious = response to pain upper motor neuron (UMN) - Babinski's sign, hyperreflexia, clasp knife -Decorticate and decebrate posture Lower motor neuron (LMN) -loss of strength, tone and reflexes, muscle wast and fasciculations |
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Person laying down with hands on chest:
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Decorticate
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Person laying down with hands to side turned outward:
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Decerebate
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Westphal's sign
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absense of patellar reflex
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Superficial reflexes
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plantar reflex
Tested when suspected L4-L5 or S1-S2 injury |
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Babinski's sign
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dorsiflexion of the great toe with fanning of remaining toes
Normal in children 12 to 18 months of age |
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Cough reflex
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CN X
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Anisocoria
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one pupel larger than other
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Myosis
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pontine hemorrhage, narcotics
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Mydriasis
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brain injury, anticholinergics
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Mid-position fixed pupils
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severe cerebral damage
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Corneal reflex
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CN V, VII
No orbicularis oculi contraction in response to corneal stimulation |
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Dysmetria
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under and overshooting of goal directed movements
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Romberg test
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balance
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Cheyne Stokes respiration
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Intracranial cause, hypoxemia, cardiac failure
Lesions from cerebrum to cervical cord cause changes of breathing patterns |
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Ataxic breathing
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marker of brainstem dysfunction
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Cushing's triad
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increased ICP
-hypertension, widening pulse pressure, bradycardia, bradypnea |
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Indications Intracranial pressure monitoring
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-monitor pt's at risk for life-threatening intracranial hypertension.
-monitor evidence of infection -assess effects of therapy for reducing ICP |
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Although hyperventilation decreases ICP, what is the most critical element to monitor
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cerebral perfusion pressure (CPP)
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Primary symptoms of cardiopulmonary disorders
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cough
sputum production hemoptysis shortness of breath (dyspnea) chest pain |
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Cough
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protective reflex
stimulation of receptors - pharynx, larynx, trachea, lg bronchi, lung and visceral pleura caused by: inflammatory, mechanical, chemical, or thermal stimulation of cough receptors * key to determine etiology is careful history, physical exam, and CXR |
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Possible causes of cough receptor stimulation
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inflammatory
mechanical (inhaled dust) - obstructive - airway wall tension chemical temperature ear |
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Afferent pathway
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Vagus, phrenic, glossopharyngeal, trigeminal nerves
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Efferent pathway
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smooth muscles of larynx and tracheobronchial tree via phrenic, spinal nerves
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Phases of Cough
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inspiratory
compression expiratory |
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Reduced effectiveness of cough
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-weakness of inspiratory or expiratory muscles
-inability of the glottis to open or close correctly -obstruction, collapsibility, or alteration in shape or contours of the airways -decrease in lung recoil (emphysema) -abnormal quantity or quality of mucus production (thick sputum) |
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Acute causes and clinical presentation of cough
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sudden onset; severe, short course, self limiting
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Chronic causes and clinical presentation
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persistent > 3 weeks
postnasal drip, asthma, COPD exacerbation, allergic rhinitis, GERD, chronic bronchitis, bronchiectasis, left heart failure |
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Paroxysmal causes and clinical presentation
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periodic, prolonged, forceful episodes
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Associated symptoms Cough
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wheezing
stridor chest pain dyspnea |
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Complications of Cough
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torn chest muscle
rib fractures disruption surgical wounds pneumothorax or pneumomediastinum syncope arrhythmia esophageal rupture urinary incontinence |
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Sputum
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secretions from tracheobronchial tree, pharynx, mouth, sinuses, nose
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Phlegm
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secretios from lungs and tracheobronchial tree
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Sputum Production Components
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mucus, cellular debris, microorganisms, blood, pus, foreign particles
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Normal sputum production
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100ml/day
-upward displacement via wavelike motion of cilia until swallowed |
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Abnormal Sputum Prodcution
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Excessive production by inflamed glands
-infection, cigarette smoking, allergies |
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How should you describe sputum
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colr
quantity consistency odor time of day presence of blood |
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black sputum
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smoke or coal dust inhalation
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brownish sputum
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cigarette smoker
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frothy white or pink
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pulmonary edema
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Sand or small stone sputum
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aspiration of foreign material, broncholithiasis
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Purulent sputum
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infection, pneumonia
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Mucoid
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emphysema, pulmonary TB, early chronic bronchitis, neoplasms, asthma
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Mucopurulent
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infection, pneumonia, cystic fibrosis
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Hemoptysis
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expectoration of sputum containing blood, varies in severity from slight streaking to frank bleeding.
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Causes of Hemoptysis
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bronchopulmonary
cardiovascular hematologic systemic disorders TB or fungal infections |
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massive hemoptysis
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400ml/3h or 600 ml/24h
emergency condition cancer, TB, bronchiectasis, trauma Streaky: pulmonary infection, lung cancer, thromboemboli odor, color, acuteness |
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Hematemesis
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vomited blood
determine source - oropharynx: swallowed from respiratory tract -esophagus or stomach: alcoholism or cirrhosis of liver |
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Characteristics of Hemoptysis
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cardiopulmonary disease
coughed up from lungs/chest dyspnea pain or trickling sensation in chest alkaline (blood pH) mixed with sputum Froth may be present color bright red |
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Characteristics of Hematemesis
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Gastrointestinal disease
vomited from stomach nausea, pain referred to stomach acid (blood pH) mixed with food froth is absent color dark, clotted, "coffee grounds" |
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Shortness of breath
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most distressing symptom of respiratory disease
-single most important factor limiting ability to function |
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Dyspnea
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subjective experience of breathing discomfort
Breathless, short-winded, feeling of suffocation |
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Dyspnea Scoring Systmes
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scale of 0 to 10
visual analog scales modified Borg scale ATS SOB scale UCSD SOB questionaire |
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Causes, types, and clinical presentation of dyspnea
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WOB abnormally high for the given level of exertion
-asthma and pneumonia Ventilatory capacity is reduced -neuromuscular disease Drive to breath is elevated -hypoxemia, acidosis, exercise |
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Cardiac and circulatory related dyspnea
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inadequate supply of oxygen to tissues
primarily during exercise |
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Psychogenic dyspnea
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panic disorder
not related to exertion |
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Hyperventilating
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rate, depth exceeds body's metabolic need
results in hypocapnia and decreased cerebral blood flow |
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Acute dyspnea
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children: asthma, bronchiolitis, croup, epiglotitis
adult: pulmonary embolism, asthma, pneumonia, pneumothorax, pulmonary edema, hyperventilation, panic disorder |
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Chronic dyspnea
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COPD and CHF most common causes
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Paroxysmal nocturnal dyspnea (PND)
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sudden dyspnea when sleeping in recumbent postition
associated with coughing sign of left heart failure |
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Orthopnea
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dyspnea when lying down
associated with left heart failure |
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Trepopnea
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dyspnea when lying on one side
unilateral lung disease, pleural effusion |
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Platypnea
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dyspnea in upright position
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Orthodeoxia
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hypoxemia in upright postion, relieved by returning to a recumbent position
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Platypnea and orthodeoxia
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seen in patients with right to left intracardiac shunts or venoarterial shunts
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Causes of Chest Pain
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cardiac ischemia, angina
inflammatory disorders of thorax, abdomen musculoskeletal disorders, trauma, anxiety referred pain from indigestion, dissecting aortic aneurysm |
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Cardinal sypmtom of heart disease
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angina
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Pulmonary Causes of Chest Pain
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involvement of chest wall or parietal pleura
Pleuritic pain -inspiratory, sharp, abrupt onset -worsens with insp., cough, sneeze, hiccup, or laughter -increases with pressure and movement Chest wall pain -intercostal and pectoral muscles -well localized |
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Syncope
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dizziness and fainting
temporary loss of consciousness: from reduced cerebral blood flow and oxygen |
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Causes of Syncope
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thrombosis, embolism, atherosclerotic obstruction
Pulmonary: embolism, bouts of coughing, hypoxia, hypocapnia |
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Vasovagal
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most common type of syncope
-loss of peripheral venous tone vagus nerve controls HR which decreases. Bareing down |
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Orthostatic hypotension
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-sudden drop in BP when person stands up
-dizziness, blurred vision, weakness, syncope -elderly, vasodilators, dehydration |
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Carotid sinus syncope
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-hypersensitive carotid sinus
-slows pulse rate, fall in blood pressure, syncope |
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Tussive syncope
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-syncope due to strong coughing
-seen most often in men with COPD, obesity, a positive smoking history, and frequent use of alcohol |
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Edema
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soft tissue swelling from abnormal accumulation of fluid
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Bilateral peripheral edema
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-most often occurs in ankles and lower legs
-most often caused by right or left heart failure -right heart failure often caused by cor pulmonale |
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Right heart failure is often caused by:
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cor pulmonale
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Euthermia
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Normal temperature
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Pyrexia
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fever, hyperthermia
-sustained: cond. present -remittent: cond. elivated -intermittent: over and over -relapse: occurs several days |
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Causes of fever
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hot environment, dehydration, reaction to chemicals, drugs, hypothalamic damage, infection, malignancy
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Pulmonary infections
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-lung abscess, empyema, TB, pneumonia
-remittent fever in mycoplasma pneumonia, legionnaire's disease, acute viral infections |
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Infection with no fever
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-high dose corticosteroids
-immunosuppressants -immunocompromised (leukemia, AIDS) |
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Snoring
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serious concern when associated wth apnea
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Incidence and causes of snoring
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-10% to 12% of children
-10% to 30% of adults Peak at age 50 to 59 (male) 60 to 64 (female) -obesity is one of the most common causes |
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Gastroesophageal reflux
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heartburn and regurgitation
extraesophageal manifestation -laryngitis, asthma, chronic and nocturnal day cough, chest pain, dental erosion -GER mor than twice a week = GERD |
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Risk factors of gastroesophageal reflux
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obesity, cigarette smoking, pregnancy
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Nerves that control your breathing
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phrenic nerves
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Nerve that control coughing
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vagus (X)
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Nerves that control gag reflex
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glossopharyngeal (IX) and vagus (X)
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Hemoptysis
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coughing of sputum containing blood
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Excessive hemoptysis
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400ml/3h or 600ml/24h
cancer, TB, bronchietasis, trauma |
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Hematemesis
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vomited blood
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SOB
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-most distressing symptom of respiratory disease
-cardiac disease |
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Dyspnea
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subjective experience of breathing discomfort "breathless"
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Paroxysmal nocturnal dyspnea
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sudden dyspnea when sleeping in recumbent position
-sign of Lt heart failure |
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Orthopnea
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dyspnea when lying down
-assoc. w/ Lt heart failure |
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Trepopnea
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dyspnea when lying on one side
-sign: unilateral lung disease, pleural effusion |
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Platypnea
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dyspnea in upright position
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Orthodeoxia
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hypoxemia in upright position, relieved by returning to a recumbent position
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Radiograph best for lesions
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computed tomography
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Radiograph best for tumors
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computed tomography
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Radiograph best for embolism
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radionuclei lung scanning
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Radiograph best for V/Q abnormalities
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lung scanning
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Neuromuscular disease that involves multi nerve roots
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Guillain Barre
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Define GERD
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gastroesophageal reflex more than 2x a week
-heartburn or regurgitation |
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What is the Pwave?
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depolarization of the atria
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Small square on ECG paper
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.04 sec
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Lg. square on ECG paper
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0.2 sec
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PR interval
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less than 0.2sec
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QRS complex
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less than 0.12sec
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Normal Sinus Rhythm
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-HR: 60-100 bpm
-Pwave present for each QRS complex -PR interval: less than 0.2sec -QRS less than 0.12sec |
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Atrial Flutter
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-atrial rate: 250-300/min
-ventricular <180 -no identifiable P waves -Saw tooth QRS < .1sec -atrial rhythm = reg -ventricular = reg/irregular |
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Atrial Fibrillation
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-atrial rate >350-400
-irregular ventriular -no id of P waves, erratic baseline -QRS <0.1 sec and not reg |
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Ventricular Tachycardia
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-3 or more PVC's
-wide QRS complexes w/no preceding P waves -ventricular rate 100-250/min -progresses into V-fib -tx: cardioversion or meds. |
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Ventricular Fibrillation
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-most life threatening arrythmia
-erratic quivering of the ventricular muscle mass -cardiac output = 0 -tx: cardioversion, CPR, O2, and antiarrhythmic meds |
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CPP
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cerebral perfusion pressure
-most critical element to monitor -a result of the MAP-ICP |
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PEA
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pulseless electrical activity
-no mechanical response -treat like asystole |
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What factors may lead to a weak cough?
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reduced lung recoil
bronchospasm weak inspiratory muscles |
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A cough described as being persistent for more than 3 weeks would be called?
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chronic cough
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A patient's complaint of breathlessness or air hunger would be defined as?
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dyspnea
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what term is used to describe shorteness of breath in the upright position?
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Platypnea
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Dyspnea may vary from pt to pt depending on the underlying pathophysiology.
(true or false) |
true
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Chest pain associated with inspirationi is termed pleuritic
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true
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What causes syncope?
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severe coughing
pulmonary embolism hypovolemia |
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Chronic pulmonary hypertension may lead to which of the following clinical findings?
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pedal edema
hepatomegaly |
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Which of the following is associated with night sweats?
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pneumonia
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In what decade of life is snoring most likely to be present in adult males?
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50 to 59 years
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What is a radiograph density?
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water
air fat |
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An item that is white on the radiograph would be called radiopaque.
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true
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What is the standard distance between the x-ray source and the film for a posteroanterior x-ray?
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6ft
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Which of the following views helps to evaluate for the presence of small amounts of free pleural fluid?
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lateral decubitus
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What problems may be associated with a portable (anteroposterior) chest x-ray?
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poor radiographic exposure
pt is not centered on the film artifactual shadows may be present on the film |
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What film is helpful in indentifying a pneumothorax?
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expiratory
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Correct positioning of an endotracheal tube is confirmed if the tip of the tube is approximately _____ cm above the carina on the chest x-ray.
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3-5cm
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Tomography is especially useful in visualizing masses in the mediastinum and chest.
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true
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What is true regarding the use of MRI in lung disease?
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it is better than CT in evaluating the hilar areas for lymph node and vascular enlargment.
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What is the best method to evaluate the presence of a thromboemobolism?
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angiography
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What is the significance of the silhouette sign?
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it allows differentiation between alveolar and interstitial infiltrates
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What is a radiographic sign of atelectasis?
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hemidiaphragm elevation
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What could be seen on a chest x-ray of a patient with congestive heart failure?
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increased retrosternal airspace on a lateral film
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Chest x-ray findings consistent with pleural effusion?
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blunted costophrenic angle
meniscus sign partially obscured and elevated hemidiaphragm |
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The brainstem consists of midbrain, pons, medulla oblongata.
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true
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LOC and mentation are the most important parts of the neurologic exam.
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true
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Kerly B lines are indicative of which disease pathology:
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pulmonary edema
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Empyema
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is pus that builds up in the pleural space
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Name the four different tissue densities that are visible on the normal chest radiograph:
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air
water bone fat |
