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145 Cards in this Set
- Front
- Back
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Assessing orientation
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Person—ask their name
Place—do they know where they are? -Country/state/city -Building/floor Time -Month, day and year -Season Situation -Current circumstance (know that they had for breakfast) -General (life/work/family, etc.) |
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Level of Consciousness (LOC) assessment
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Alert
Drowsy Lethargy: Person can be aroused with little difficulty Obtundation: Person cannot be fully aroused (difficult to be aroused) Stupor: person can only be aroused by vigorous physical stimulation OR unable to be aroused from a sleep-like state (not unconscious) Comatose: person is unable to make any purposeful response to stimuli |
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Objective Measures of LOC
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Glasgow Coma Scale (GCS)
Less confusing than terms requiring definitions ACDU (Alert, Confused, Drowsy, Unresponsive) AVPU (Alert, Responds to Voice, Responds to Pain, Unresponsive) -The ACDU and AVPU are both simpler to use than the Glasgow Coma Scale, but not as precise. -Notice that the ACDU identifies confusion as a Level of Consciousness, whereas others speak of confusion as part of a person's orientation |
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Glasgow Coma Scale
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Glasgow Coma Scale is widely used and recognized as it is less confusing, more precise, and more objective
Does take more skill to assess than ACDU or AVPU Score range is from 3-15. No "zero." Generally a patient who scores below 8 is considered to be comatose and at significant risk of mortality. Comatose generally has a 3 |
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Delirium characteristics
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Sudden onset
Causes fluctuations in mental function Mainly affects attention Usually reversible Delirium is a acute process and they are at a high risk for death If not diagnosed early enough, delirium can lead to stupor and death, especially in older adults |
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Delirium risk factors
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Can affect anyone but most common in older patients
Dementia Stroke Dehydration Neurodegenerative disorders- Parkinson's disease Illness- UTI (common in men), pneumonia, meningitis Sleep deprivation Drugs- illicit drugs, antipsychotics, sedatives (especially benzodiazepines), anticholinergics. Polypharmacy increases risk.Abrupt drug cessation (alcohol, sedatives) ICU |
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Dementia characteristics
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Gradual onset
Mental function declines slowly Mainly affects memory Usually irreversible Dementia slow chronic process Dementia pt remember something from a long time ago but don't remember five minutes ago (pt who learn English late could forget) |
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Confusion assessment method (CAM)
Feature 1: Acute Onset and Fluctuating Course |
Evidence of an acute change in mental status from the patient's baseline
Behavior fluctuates during the day, or increases and decreases in severity |
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Feature 2: Inattention
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Difficulty focusing attention
Distractibility Trouble keeping track of what was being said |
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Feature 3: Disorganized thinking
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Rambling or irrelevant conversation
Unclear or illogical flow of ideas Switching subjects unpredictably |
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Feature 4: Altered Level of consciousness
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Vigilant [hyperalert]
Lethargic drowsy, easily aroused stupor [difficult to arouse] coma [unarousable] |
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Mini Mental State Exam (MMSE)
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-Commonly used to screen for dementia
-Advantages Widely used and recognized Brief—takes about 10 minutes to complete Simple enough to be used by non-professionals -Limitations Somewhat culture-specific Communication difficulties Learning disabled or other disabilities |
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Montreal Cognitive Assessment (MoCA)
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Similar to the MMSE in terms of what it measures
Not as commonly used May be more sensitive in identifying Mild Cognitive Impairment (MCI) than MMSE and other similar tests Sensitivity to MCI is important for early treatment, as this is when it will be most effective. Treatment may mean the individual is able to live independently, or in the community with help, instead of being placed in a nursing home. Key point: don't delay referral for memory assessment and treatment because the results may be "expected" for an older adult, or if they appear to be coping well! This is the group that is most likely to benefit from therapeutic intervention! |
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Clock Drawing Test
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Assesses visual/spatial and constructive deficits as well as problems with executive functioning
The patient is asked to draw a clock face showing a predetermined time (ex: 10 after 11) Scoring is based on deviations from the norm done to evaluate Alzheimer, brain injury, after a stoke |
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Mental status can also be affected by
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Hypothyroidism
Depression/Anxiety Stress Medications Others? |
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Wernicke's area
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in temporal lobe is associated with language comprehension
Damage results in receptive aphasia (person hears sound but it has no meaning) |
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Broca's area
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in frontal lobe mediates motor speech
Damage results in expressive aphasia (person cannot talk). Can understand but only produces garbled sound -can point to what they want to say |
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Basal ganglia
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Control automatic associated movements of the body, e.g. the arm swing alternating with the legs during walking
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Hypothalamus
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controls vital functions such as temperature, heart rate, blood pressure, sleep, ant and post pituitary gland, coordinator of autonomic nervous system activity and emotional status
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Cerebral cortex
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gray matter
Center for humans' highest functions-governing thought, memory, reasoning, sensation and voluntary movement |
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Cerebellum
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located under occipital lobe concerned with motor control of voluntary movements, equilibrium, and muscle tone such as playing piano, swimming, and juggling
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Midbrain
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the most anterior part of the brain—contains many motor neurons and tracts
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Reflex arc
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deep tendon reflexes--patellar
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superficial reflexes
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corneal reflex, abdominal reflex
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visceral reflexes
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pupillary response to light and accommodation
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Pathologic reflexes
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Babinski or extensor plantar reflex
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CN I
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Olfactory: Sensory: smell
test sense of smell one nostril at a time |
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CN II
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Optic: Sensory: vision
Visual acuity and visual fields by confrontation (peripheral vision) |
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CN III
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Oculomotor: Motor: EOM movement, raises eyelids/ parasympathetic: pupil constriction, lens shape
PERRLA (shine a light) |
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CN IV
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Trochlear: Down and inward movement of the eye
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CN V
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Trigeminal: Motor: muscles of mastication/Sensory: sensation of face and scalp
Palpate jaw/ test sensory of three facial tracts, and corneal reflex (see if can clench jaw) |
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CN VI
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Abducens-lateral movement of the eye
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CN VII
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Facial: Motor: facial muscles/ sensory: taste on anterior two-thirds of tongue
Test facial expressions, sweet or sour anterior two-thirds of tongue |
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CN VIII
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Acoustic: Sensory-hearing and equilibrium
Test hearing acuity, Weber and Rinne |
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CN IX
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: Glosspharyngeal: Motor-pharynx-phonation and swallowing/ sensory-taste on posterior one-third of tongue
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CN X
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Vagus: Motor: pharynx and larynx/ sensory: sensation from carotid body, pharynx, viscera
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CN XI
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Spinal: movement of trapezius and sternomastoid muscles
Check shoulder shrug, head rotation against resistance |
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CN XII
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Hypoglossal: movement of tongue
Inspect tongue: say "light, tight, dynamite" (stick out tongue) |
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Dermatomes
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Dermal segmentation is the cutaneous distribution of the spinal nerves
(our ability to feel) Useful landmarks: Thumb, middle finger, fifth finger: C6, C7, C8 Nipple at level of T4 (is paralyzed below t4) Umbilicus at level of T10 Groin in region of L1 |
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Neuro developmental consideration for infants
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Infants: myelination follows a cephalacaudal and proximodistal order (head, neck and extremities)
Movements are directed by primitive reflexes which disappear at predictable times during the first year - Proximodistal: inside out: gross to fine motor |
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Neuro dev consideration for aging adults
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steady loss of neurons with aging-by age 80, brain weight 15% less: signs include impaired fine coordination and agility, loss of vibratory sense at the ankle, loss of position sense at the big toe, irregular pupil shape and decreased pupillary reflexes
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History for neuro assessment in aging adult
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Aging adult:
Dizziness? (Men) Faint while standing to urinate? Decrease in memory Tremor? Relieved with alcohol, activity, rest? Fleeting blindness, weakness, loss of consciousness? (screen for stroke) |
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CN III,IV,VI
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Cardinal field of gaze
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CN IX, X
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Watch uvula rise midline with "Ahh"
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physical exam cerebellar function
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Balance tests: gait, tandem walking, Romberg test (time for 20 seconds), shallow knee bend
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Deep tendon reflexes
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reveals intactness of the reflex at specific spinal levels:
4+ very brisk 3+ brisker than average (pre seizure activity) 2+ average, normal 1+ diminished, low normal 0 no response |
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Infants: reflexes
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II, III, IV, VI: Optical blink reflex
V: Rooting reflex VII: facial movements VIII: Moro reflex IX, X: swallowing, gag reflex XII: pinch nose, mouth will open and tongue rise in midline |
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synovial joints
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freely moveable-separate bones from each other and are enclosed in a joint cavity
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nonsynovial joints
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united by fibrous tissue or cartilage and are immovable (e.g. joints in the skull)
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ligaments
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fibrous bands that connect bone to bone
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Circumduction
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moving the arm in a circle around the shoulder
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Extension
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straightening a limb at the joint
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Supination
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turning the forearm so that the palm is up
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Pronation
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turning the forearm so the palm is down
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Adduction
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moving a limb toward the midline of the body
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Abduction
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Moving a limb away from the midline of the body
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Flexion
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bending the limb at the joint
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extension
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straighten the limb at the joint
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rotation
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moving the head around a central axis
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dorsiflexion
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moving the foot upward and back toward the body
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plantar flexion
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moving the foot away from the body (pushing on gas pedal)
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Eversion
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moving the sole of the foot outward toward at the ankle
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Inversion
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moving the sole of the foot inward at the ankle
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Protraction
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moving a body part forward and parallel to the ground
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Retraction
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moving a body part backward and parallel to the ground
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Elevation
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raising a body part
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Depression
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lowering a body part
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Glenohumeral joint
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articulation of the humerus with the glenoid fossa of scapula-together called rotator cuff
-Rotator cuff injury: you can get it from distention, the most common way is reaching into the back seat to get something |
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Large subacromial bursa
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helps during abduction of arm
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Hip joint
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articulation between acetabulum and head of the femur: great stability due to weight-bearing function
-Hip fracture can lead to tremendous blood loss, and pt can go into shock |
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dev consideration infants and muscle skeletal
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Fetus has skeleton at 3 months gestation made up of cartilage
Long bones grow in dimensions of width or diameter and lengthening occurs at epiphyses, or growth plates Any trauma or infection at this location puts the child at risk for bone deformity—closure of epiphyses occurs about age 20 Muscles vary in size and strength due to genetic programming, nutrition, and exercise |
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dev consideration for pregnant women in muscle skeletal
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Pregnant female: increased circulating hormones cause increased mobility in the joints
Lordosis compensates for the enlarging fetus which produces strain on the lower back muscles, felt as low back pain in late pregnancy Aching, weakness and numbness in upper extremities Carpal Tunnel syndrome more common due to swelling in center of wrist |
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dev consideration aging adult muscle skeletal
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Aging adult: loss of bone matrix (resorption) faster than new bone growth (deposition): net effect is osteoporosis
Postural changes and decreased height occur: significant after age 60 (starts at age 40: so check a height on them) Kyphosis increases; deposition of fat in abdomen and hips Loss of subcutaneous fat makes bony prominences more marked; loss of muscle mass occurs Physical activity delays muscle mass loss and prevent osteoporosis |
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Osteoporosis
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greatest potential in Chinese, Japanese and Inuits, less in whites, lowest in blacks
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Rheumatoid arthritis Vs Osteoarthritis
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Rheumatoid arthritis worse in a.m., gets better with movement
Osteoarthritis worse later on in the day |
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Tendonitis
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worse in the morning, improves during the day
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Self-care behaviors
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Occupational hazards, e.g. risk for carpal tunnel syndrome
Exercise program warm-up etc and pain during exercise Recent weight gain? Meds for musculoskeletal system: ASA muscle relaxant, pain reliever, NSAID's Chronic disability: interaction with family, with friends, self-image |
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RICE
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Rest: 24-48 hours prior to rehabilitation
Ice: for days; recommended 20 minutes on then off; decreases pain by promoting vasoconstriction, controls hemorrhage and edema Compression: leave in place 72 hours after acute injury-limits swelling Elevation: reduces internal bleeding |
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ROM
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Check active ROM while stabilizing body area proximal to area being moved—note limitation or increase in ROM, use goniometer if indicated
-Can chart full ROM. It limited then chart limited with the number of degrees it is limited -Goniometer: shows how many degrees, but you can estimate |
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Synovial membranes
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should not be palpable: abnormal if boggy or doughy
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Phalen's test
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: flex wrists 90 degrees—numbness and burning positive in Carpal Tunnel Syndrome
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Tinel's Sign
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Directly percuss median nerve: burning and tingling positive for Carpal Tunnel Syndrome
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physical exam knee
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inspect shape and contour
Bulge sign: confirms presence of fluid Check for crepitus by holding hand on patella as knee is flexed and extended |
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physcial exam spine
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check for scoliosis age 12; pronounced lumbar curve common with obesity
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Ortilani Maneuvar
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congenital dislocation: adduct then abduct flexed legs;feel for hip instability (pops into place)
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Allis test
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for infants and children
hip dislocation: compare leg length (look for symmetry of fat folds) |
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Check back in infant and children
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tuft of hair in midline may indicate spina bifida
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Bowlegged stance
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genu varum): WNL at 1 year
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A functional assessment is the basis for
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Care Planning
Goal setting Discharge planning Eligibility for service like Rehabilitation Units and DME (durable medical equipment) Long term care placement, Home Health or Hospice |
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Instrumental Activities of Daily Living (IADL)
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Tasks necessary for independent living
Shopping, meal preparation, taking meds, |
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mobility (a domain of functional assessment)
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Fine and coarse motor skills, balance, coordination, endurance
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Considerations to functional Assessment
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May tire easily
Medication side effects Glasses, hearing aides Face client Speak slowly and clearly Lower pitched voice Use simple terms Room comfort Privacy Close to bathroom Pain will affect the quality of your assessment Cultural considerations |
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Katz Index of Independence in ADL
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Measures physical function in the older adult and the chronically ill
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Lawton Instrumental Activities of Daily Living
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Self report measure of performance rather than ability
Cultural and gender biases Women score in all 8 domains Men score on 5 Omit laundry, housekeeping and preparing food |
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Cognitive Impairment
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Poses unique challenges to assessment
Do not assume that patient cannot answer questions Individualize your questions to your patient Perhaps yes and no questions suit best The home is often the best place for assessments - may not be possible |
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Caregiver Assessment
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social worker could do this
Demands can be overwhelming Assess ability to cope and handle stress as well as the caregiver's perception of strain The situation is far from static and may change quickly. Good days/bad days Older persons need for institutional care is largely based on caregiver's status and perceived burden Respite care: caregiver takes a break |
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Assessing for Elder Mistreatment
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Ask simple, direct questions
Be nonjudgmental, nonthreatening Interview patient and caregiver separately Look for inconsistencies, delay in treatment for injuries, poor hygiene, reluctance of caregiver to leave elder alone with care provider 'Red Flags' suggestive of abuse p. 863 of text suspect with caregiver hovers |
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Environmental Assessment
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Home visit is best but not always possible
Is there access to basic services? Environmental hazards Lighting Floor - throw rugs, electrical cords Toilet/bath facilities Steps Fire safety |
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Hospice
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Philosophy of care that focuses on comfort care versus cure of illness
All-encompassing, treating pain and physical symptoms as well as emotional, social, and spiritual symptoms. Multidisciplinary Eligible if doctor certifies that a person has a terminal illness and has 6 months or less if the disease runs its normal course 90% of people will die of a chronic illness versus an acute episode |
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hospice count..
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Provided in patient's home, assisted living and nursing homes
Some in-patient units Medicare benefit Pays for Doctor services, Nursing care, Medical equipment and supplies, Drugs for symptom control and pain relief, hospice aide, social worker services, bereavement Less than 40% are cancer diagnosis End stage cardiac, pulmonary, dementia, stroke |
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Erik Erikson
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described the growth of the ego-conscious rational part of the personality
Eight stages of ego development. Each stage characterized by conflict or crisis relating to the maturation and societal expectations of that age and each has generally positive or negative outcome. Crisis must be resolved in order for the person to continue to the next stage. |
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Jean Piaget
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described stages of cognitive development.
Piaget described child's thinking from simple reflex behavior to complex, logical and abstract thought Four definite sequential stages Each builds on foundation of previous stages Sensorimotor, preoperational, concrete operations, formal operations |
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Infant
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Core issue: trust vs. mistrust
-through relationship with primary caregiver, the infant learns to trust -this sense of security extends to self and others -abusive, unresponsive or unpredictable caregiver results in mistrust Sensorimotor intelligence: learn through action |
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infant physical dev
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Major milestones:
-growth is cephlocaudal and proximal to distal -6 months-sitting; pincer grasp -9 month-search for hidden object -1 year-6 words -foundation for receptive language Periodic Health Exams Major health problems: infections and illnesses (especially if not breast fed) |
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toddler
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Core issue: automony vs. shame & doubt
-if successfully navigated, child is able to differentiate self from others, and can: -tolerate separation -delay gratification -control body functions -acquire verbal functions Can locomote, wants it all, but lacks judgment (say no all the time) (Origins of negativism) Parent must be firm, consistent, allow appropriate, safe explorations, but remain available Loves rituals |
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toddler health care
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Health care: yearly check ups; safety & preventing accidents
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preschooler
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Core issue: Initiative vs. guilt
-sense of initiative is tied up in fine & gross motor & cognitive advances -realizes separateness -development of gender identity & conscience -great energy -experiences world and copes through play & fantasy (lie a lot b/c don't know the difference) -cognitive development is preoperational, meaning thinking is concrete & literal -does not make logical connections -reasons from particular to particular (transductive) -language becomes tool for social interaction (3-4 word sentences; 5-6, 6-8 word sentences) |
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preschooler health care
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Health care: yearly checkups, watch for developmental problems, safety issues
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school age
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Core issue: industry vs. inferiority
-approval comes from others outside home -continued growth & independence -success at task mastery increases sense of self esteem -concrete thinker, but begins to use logic in manipulation of symbols, hence can think through simple problems -can use numbers, read, classify, and conserve |
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school age health care
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health problems may go undetected unless acute
-contacts with health care may drop off |
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Preadolascence/ adolescence
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Core issue: identity
-many physical changes -analytical thinking (can think about thinking, solve problems mentally, and consider multiple aspects of a problem) -personal fable (i can hitch hike and no one will hurt me) Imaginary audience |
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preadolascence/adolescence health care
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-mva #1 cause of death/morbidity
Other problems: poor nutrition and emotional problems Contact with health care provider may be episodic Teaching (breast/testicular exam; risk reduction) -ask about drug, sex, seat beat use |
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early adulthood
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Core issues: Intimacy vs. isolation; generativity vs. stagnation
-hinges on secure personal identity -develop meaning/philosophy of life -physically, maximum potential for growth & strength reached -cognitively, reality based and uses abstract thinking, based in part on increased life experiences from work, school -review Levinson in Jarvis (20's home base; 30's transition/self reflection/ settling down |
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early adulthood health care
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-usually a healthy group
-risks: learning limitation resulting in problems with completing education/employment -need to be aware of impact of family history |
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middle adulthood
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Core issue: generativity vs. stagnation
-need to invest in others outside self -Physical changes -Reviewing career; career transitions & role realignment -sandwich problems (aging parents and adolescent/young adult children) -empty nest -death of peers -females transition a little earlier than males, to midlife |
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middle adulthood health care
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-frequently depends upon personal resources
-family history may begin to play out -focus on checkups & prevention |
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late adulthood
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Core issue: integrity vs. despair
-everyone must confront despair and eventuality of death -decreased strength and health -new roles -adjustment to losses -life review -cognitively, may have decreased ability for complex decision-making, slower reaction time, and short term memory changes |
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infants growth
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Double birth weight by 4-6 months (a lot of variation)
Triple birth weight by one year (variation) 90% brain growth by two years Visual acuity-from 20/150 to 20/40 at two years Explores, stands, use spoon, plays, speaks (1 to 4 words) by one year |
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toddler growth
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Growth decelerates
Language development Motor development Control of bodily functions Social skills Tolerating separation |
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preschooler growth
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Gains 4.5 lbs and 3 inches
Baby face matures Legs elongate More graceful Muscles growing Developing conscience Identification of sex role Separateness as individual |
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middle childhood growth
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Physical growth steady
6.5 lbs and 2 inches/year Mastering skills Approval seeking Self-esteem development Friend development Moral standards |
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adolescence growth
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Tremendous physical growth
50% of all weight In one year 3-4" and 20 lbs Skeletal structures/glands double in size Secondary sex characteristics Growing independence Identity search Achievements Peer relationships Analytical and abstract Value system development Sexual Identity Choosing a career |
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young adult growth
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Peak physical condition
Maximal muscle coordination, strength and tone High energy level Risk-taking Optimal mental powers Emancipation Establishing career Forming intimate bond Marriage Managing own household Social connections Parenting Philosophy of life Civic responsibility |
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middle adult growth
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Physical changes/Decline of bodily functions
Climacteric (menopause) Adjustment/Life review Career achievements Developing hobbies Caregivers of children, aging parents Changing roles/Developing relationships |
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older adult growth
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Decreased physical functional
Peak problem solving Wisdom Forming new family roles Affiliation with peers Adjusting to retirement Physical living arrangements Life review Preparation for life and death |
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Denver II Developmental Screen
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Age range: birth to 6 years
Time required: 10 to 25 minutes Screening tool designed to detect developmental delays in infants and preschoolers Tests four functions: gross motor, language, fine motor-adaptive and personal-social skills. Not an intelligence test Does not predict intellectual ability Identifies children slow in development Used for early detection to facilitate effective treatment |
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Montgomery's glands
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cover the areola and secrete a protective lipid material during lactation
-let soapy water run over when cleaning |
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tanner's staging
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Stage I—preadolescent
Stage II—breast bud stage Stage III—nipple flush w/ breast Stage IV—areola and nipple form a secondary mound Stage V—mature breast: only nipple protrudes, areola flush with breast |
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Gynecomastia
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may be physiologic in the adolescent male
May occur in the older adult male d/t changing hormonal levels May be caused by medications or medical problems that alter hormone levels |
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breast cancer risk factors
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Advancing age is the most important risk factor
Other factors: genetic predisposition, estrogen exposure, high BMD, high breast tissue density on ultrasound, Caucasian race, higher socioeconomic status |
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BRCA1 & BRCA2
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mutations account for approximately 5% of all breast cancers, + mutation confers lifetime risk of 65-85%
Half of hereditary breast cancer occurs under age 50 |
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cryptorchidism
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Failure of testes to descend into scrotum (cryptorchidism) is present in <6% of term male infants—decreased fertility and increased risk for cancer with this condition
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Hypospadias
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is a congenital defect—urethral meatus opens on ventral side of penis
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Tanner maturity ratings for males
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1st sign is enlargement of testes, then pubic hair appears, then increase in penile size (table 24-1)
Takes 2-5 yrs (3 yrs is average) |
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Inguinal area physical assessment
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palpate for hernia: ask client to strain down
Palpate inguinal lymph nodes |
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Testicular Self Exam
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T: Timing once a month
S: Shower warm water E: Examine, report changes immediately |
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tanners staging females
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8½-13 yrs)—1st signs of puberty
breast and pubic hair development lastly menses—takes 3 years to complete Menses may be irregular in teenagers and in the 40's-50's |
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Goodells' sign
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cervical softening
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Chadwick's sign
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cervix looks cyanotic
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Hegar's sign
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softening of lower uterine segment
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Bimanual examination
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Palpate vaginal wall
Assess cervix for tenderness, consistency, mobility, contour Uterus for size, tenderness, position Position: anteflexed, anteverted, midline, retroverted, retroflexed Adnexa: size, mobility, tenderness Rectovaginal examination |
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Screening—Colorectal Cancer
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Colorectal cancer is the third most common cancer among men and women in the United States
There are 4 basic tests for colon cancer: a stool test, sigmoidoscopy, colonoscopy, and double contrast barium enema These tests are effective in catching cancers in the early stages, when treatment is most beneficial |
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pack years
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One ''pack year'' is 20 cigarettes smoked/day for one year
Quantification of pack years smoked is important in clinical care because lungs are eroding all that time Degree of tobacco exposure is closely correlated to risk of disease. Smokers suffer an irreversible forced expiratory volume in one second (FEV1) loss of 4.4-10.4 ml per pack year smoked There is a strong dose-response relation between the number of pack years smoked and the risk, severity and mortality of chronic obstructive pulmonary disease and the risk of lung cancer |
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Alcohol consumption of 4 drinks per day is associated with increased risk of
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Deaths from cirrhosis and alcoholism
Cancers of the mouth, esophagus, pharynx and liver Heart disease including cardiomyopathy Injuries Hypertension, tachycardia and atrial fibrillation Breast cancer in women starting at 2 drinks per day |
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Assessment for Alcohol Use Criteria-Standard Clinical Diagnostic Criteria
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Relationship trouble
Risk for bodily harm Role failure Run-ins with the law |
