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Nursing 3120 Midterm

Course Intro, Health Hx, Communication, Assessment Techniques

Health Assessment
-systematic way of collecting data about a client/patient for purpose of determining the clients health status
-patient interview subjective
-physical examsubjective/objective
-lab/diagnostic testingobjective
Therapeutic Communication
-all about CONTEXT
Communication- no just words
-very dynamic process behavior is > words
-behaviors, verbal and nonverbal, intended or perceived
Personal variables
Age, gender, language, preferences, experiences, personality, self concept, values, cultural background, religion
Communication impacted by
Aspects to consider in a message
-What is in the mind of the sender?
-What does the sender chose to send?
-How is the message sent?
-What is received by the receiver?
-What does the message bring to mind in the receiver?
Goals of effective communication
-send CLEAR, HELPFUL messages to our patients
-INTERPRET ACCURATELY what our patients are communicating
Verbal Communication
-denotation : concrete definition of a word
-connotation: personal interpretation of word
-speed or rate at which a message is delivered
-includes the use of pauses between important idea or concepts
Theurapeutic communication
-goal focused

-different perspective
-needs of patient
-focus on problem solving
-encourage a patient to express feelings and concern
-nurse terminates
-genuineness: there for the patient, not about you
-respect: address patient by name and tone of voice
-empathy: recognize what patient is going through.. make connection, more willing to share info
Social communication
-needs of both
-mutual sharing
-both parties express naturally
-reciprocal approval
-terminates spontaneously
Patient interview
-based on trust
-cant promise info patient shares is strictly confidential; only share w. people that need to know
-do not react, use eye contact
-writing; need to be aware how much time spent
-electronic health records
Stages of an interview
Stage 1- introduction
-purpose of interview
State 2- working
-collect data
Verbal techniques
-best way = open ended to allow patient to tell story in their own words
Closed questionFacilitation
Silence- facilitate conversation
Reflection- pick up on emotion they are expressing and reflect back on patient
Summary-theurapeutic approach
ConfrontationInterpretationExplanationSummaryNon verbal techniques
Professional appearance
Posture- keep self open
Gestures and facial expressionEye contact-

VoiceTouch- need to first develop relationship

-do not tough psychiatric patient
-too touchy can cause patient to withdraw
Stage 3- closing
-thank and aknowledge; summarize what will do with info
Non therapeutic techniques
-requesting an explanation .. why?
-puts patient on defense
-If patient refuses need to provide why you are collecting information
-never leave a blank, interpreted as a health provider did not ask Q
-offering false reassurance
-if patient is stress, reflect back saying you would be stressed too therapeutic approach
-if you were me, what would you do?
response: pros and con from their stand point.. they need to make OWN decision
problematic questioning
-Posing leading questions
-you dont smoke, do you?
-Interrupting the patient
-Engaging in talkativeness
-Using multiple questions
-Using medical jargon
-talk at patient level
-Being authoritative
-dont act as a boss, your there to help
Interviewing the patient with special needs
-Hearing Impaired
-Visually Impaired
-Speech Impaired
-Non-English speaking
-Low level of understanding
Tips for using an interpreter
-Use trained medical interpreter not family or significant other
-Allow time for the patient and interpreter to converse prior to interview
-Request sentence by sentence translation
-Allow extra time
-Use brief questions
-Maintain eye contact with the patient
-Observe patients nonverbal response
-Use preprinted questions if available

Health History
*basis to use when you plan care
*need to judge how reliable the information given is
-Subjective information
-Database of persons health status including social, emotional, physical, cultural, and spiritual wellbeing
-Serves as a basis for planning care
-Reliability of informant
Types of Health History
Complete- only when general check up, not for a specific problem
-essential: co morbidity, medications, allergies, past health history
EpisodicInterval or follow upEmergencyComponents of a health history
-Biographical Information
-Patient or significant other
-Reliability of informant
-Reason for seeking health care- Chief Complaint
Characteristics of chief complaint
-Radiation: does it spread?
-Quality: what does it feel like .. open ended
-Quantity (severity): scale 1-10
-Associated symptoms
-aggravating factors: what makes it worse?
-alleviating factors: what makes it best?
-timing (when, duration)
C- Character: how does it look, feel, sound, smell
O Onset
L Location: where, ? Radiation
D Duration
S Severity
P Pattern: what makes it worse/better
A Associated manifestations
M What Meaning does this have for you
-Region & Radiation
-Understanding Patients Perception

Past health history

-Medical History
-Surgical History
-Psych/Mental Health History
-Medications prescribed, over the counter
-Communicable Diseases
-Allergies drug, food, allergens reaction
-true allergy: allergic response rash, throat close vs someone getting nauseas
**need to know exact reaction
-Childhood Illnesses
-Immunization History
Family Health History
-identify genetic patterns
-immediate blood relatives
Social history
-Alcohol Use
-type, amount, frequency, CAGE
-Drug Use
-Type, amount, frequency
-Tobacco Use pack yr history
-higher pack yr= increased risk for pulmonary, cardiovascular and cancer
-1 pack a day for 20 yrs = 20 pack yr history
-Sexual practices
-Travel History military history
-important for ENDEMIC disease
-Roles and Responsibilities
-Domestic Violence
-ever felt need to cut down?
-are people around you annoyed with your drinking?
-ever felt guilty after drinking?
-ever need an eye opener to start day?
Health maintenance
-Stress Management
-Safety Devices
-Health Check-ups
-Traditional & Alternative Medicine
Review of systems
-subjective responses to series of body systems questions
-this is not the physical assessment; comes later
Purpose of physical assessment
-Screening of general well-being

-Validation of complaints that caused the patient to seek health care

-Monitoring of current health problems
-Formulation of diagnoses and treatments
Assessment Technique
I- Inspection-sense of sight
-sense of smell
P-Palpation- act of touching the patient in a therapeutic manner
Light palpation- superficial, delicate, gentle
-use finger pads or the back of your hand
-provides info on skin texture, moisture, temp, superficial pulsations and tenderness
Moderate palpation- superficial, delicate, gentle
-use finger pads
-depress 1 cm below surface
-provides info on skin texture, moisture, masses, fluid, muscle guarding, pulsations and tenderness
Deep palpation- provide info about position of organs, masses, size, shape, mobility and consistency
-use hands
-depress 4-5 cm below skin surface
-most commonly used for assessing abdominal and reproductive structures
-Wash hands before and after the exam
-Wear gloves if indicated
-Warm hands
-Fingernails short and clean
-Inform the patient when, where, and how you will the touch will occur
-Striking one object against another to cause vibrations that produce sound
-Analyze sounds by intensity, duration, pitch
-Any part of the body can be percussed
-Most commonly used for abdomen and thorax
Direct- feel sinuses
Indirect- place finger on chest and touch finger
Direct fist- slap finger place on kidney
Indirect fistQuality of sounds
Flatness- skull
Dullness- nose
ResonanceHyperresonanceTympany- over cheek or abdomen; gas filled
-Clean earpieces
-Point earpieces towards the nose
-Quiet room
-Diaphragm with pressure
-Bell without pressure

P- PercussionA-Auscultation-follow this order for most, except ABDOMEN, use IAPP

Nursing Process
Assessment- determine treatment
Goal setting
General survey, VS, Pain Assessment
General Survey
-Physical Appearance
-Assess patients:
-stated age. Vs apparent age
- health care issues aging to the person
-general appearance
-symmetry of findings via shoulders
-body fat
-central obesity due to endocrine problem contribute to elevated BMI eg. cushing disease
-limbs proportional
-upright stature
-motor activity
-gait is smooth and stable
-able to bear own weight
-purposeful motor activity
-body and breath odors
-physically capable of proper hygiene
-neglect for caring in older persons
-psychological presence
-observe the patients:
-dress grooming, personal hygiene
-mood and manner
-moody can indicate psychological issue
-slurring indicate toxicity or neurological impairment eg. stroke
-rapid indicate anxious or hyperthyroid
-expressive aphasia unable to articulate words indicate a neurological defecit
-facial expressions
-asses for:
-labored breathing, wheezing, cough and labored speech
-painful facial expressions, sweating, guarding,
-serious or life-threatening complication
-emotional distress or anxiety
***if distress, do not assess for patient history
Body Shape
Mesomorphic- average height, well develop muscle curvature

Endomorphic- short and stalky, apple or pear shape

Pear- weight in hip and upper thigh
Apple- weight in chest/abdominal area .. risk for cardiovascular diease
Ectomorphic- taller, lanky and fat/muscular curvature distribution not well developed
Eg. marfan syndromepredispose for cardiovascular events

Vital Signs
-equivalent to 5/9 x Temp in Farenheight 32 degrees
-Average: 37 C or 98.6 F
-Range: 36-38 C or 96.8-100.4 F
-Advantages: MOST COMMON
-convenient and accessible
-safety, physical abilities, accuracy
-Average: 0.7 C or 0.4 F higher than oral
-Range: 36.7-38.5 C or 98.0 101.6 F
-Advantages: MOST ACCURATE
-rounded bulb doesnt injur rectal mucosa
-Disadvantages: INVASE
-if immunesuppressed, not enough platelet and can rectally bleed co agulation
-average: .6 C or 1 F lower than oral
-range: 35.4-37.4 C or 95.8 -99.4 F
-advantages: safe, noninvasive
-under armpit child doesnt fight
-disadvantages: accuracy? Length of time to obtain measurement 6-8 min
-average: calibrated to oral or rectal scales
-range: same as oral/rectal
-advantages: convenient, fast, safe
-calibrate to oral or rectal scale
-Accuracy? Technique affects reading
-in adult; take pinna of ear and pull it up and back to straighten ear canal, place snuggly in ear
and hear beep
-in child; take pinna of ear and pull it up and back; need for infrared to hit tympanic
membrane to get an accurate temperature
**if hypothermic, may just be temp of ear canal; not tympanic membrane
-thermal artery thermometer
-As accurate as rectal and pulmonary artery temps
-More accurate than tympanic
-Press and run across forehead and temporal artery

-helpful in pediatric client

-not good if person is sweaty
-variable affecting body temp
-Circadian rhythms
-Highest temperature in later afternoon and early evening
-temp difference in regard to menstrual cycle due to secretion of progesterone
-infants run higher temp; 99.6 rather than 98.6 for adult.. Elderly run temp of 96
-patients immunosupressed due to steroids for inflam or arthritis will NOT see rise in
body temperature
-temperature variations
-Hyperthermia- above 101. 5 farenheight
-hypothermic- below 98.2 far
-induced into hypothermic to decrease oxygen in body so cellular activity goes down to
decrease basal metabolic rate
-A febrile- no temperature
-radial: thumb side
-4 point scale: absent to bounding
-normal range for adults: 60-100
Factors affecting heart rate:
-age, gender, activity, emotional status, pain, environmental factors, stimulants and medications
Age variations in heart rate
Newborn: 100-170 bpm
1 yr: 80-160 bpm
3 yr: 80-120 bpm
6 yr: 70-115 bpm
10 yr: 70-110 bpm
14 yr: 60-110 bpm
Adult: 60-100 bpm
Apical Pulse:
-angle of Louis (2nd intercostals space) and move 3 down
-near nipple in men, under boob in women
-listen to closure of AV valves
-s1 and s2 in cardiac cycle
Pulse deficit:
-apical pulse rate- peripheral (radial) pulse rate
-should equal ZERO
-cardiac dysrhythmias: people with irregular in conduction system will have extra beat in heart, but
volume of blood is minimal so doesnt reach radial pulse
R- respirations

-rise and fall of chest indicating inspiration and expiration

-diaphragm movement of abdomen
-count for 1 full movement
-female and children thoracic movement
-maleabdomen movement
-higher than woman
-pain, anxiousness, heat and stimulants cause increased heart rate
-should be effortless and unconscious
Eupnea- normal
Tachypnea- fast
Bradpnea- slow
Apnea- absence of
Dyspnea- difficulty breathing, labored or short of breat
Orthopnea- positional breathing problems
-seen in edema patients due to fluid ingested in pulmonary organs
Age Respiration rates:
Infat: 30-40/min
1 yr: 20-40/min
4 yr: 22-30/min
10 yr: 20-26/min
16 yr: 16-20/min
Adult: 10-20/min
B/P-blood pressure
-Force exerted by the flow of blood pumped into the large arteries
Korotkoff sounds
Phase 1- 1st sound hear
-most accurate way: insert catheter into large artery; sense pressure and through transducer
on outside; give digital read out
Phase 2- indicate highest systolic pressure.. Amount of force left ventricle have to resort to overcome
pressure from cuff wrapped around arm
-change in quality of sound
Phase 3- intense tapping
Phase 4- sound muffles
Phase 5- sound dissapears
Phase 6- recorded as diastolic pressure (bottom #)
99% of time see phase 1/phase 5
Factors that determine Blood Pressure
-cardiac output: how strong is muscle to exert enough contract to push blood into larger arteries of
-PVr: how dilated/constricted arteries are influence pressure
-if dilate down; increase.. If dilate up; lower
-Volume: if hypovolemic (low volume; decrease volume)
-Viscosity: thicker blood; draw more fluid in vascular compartment cause BP to rise
-elasticity of wall: young; vessels are elastic and constrict rapidly and BP is maintained
-hardening of arties increase BP because no dilating out so pressure inside vessel will increase
Measuring Blood Pressure

-Systole Contraction
-Diastole Relaxation
-Pulse pressure
-difference between systolic and diastolic pressurev
-Mercury sphyg: eye needs to be eye level w. mercury because visual perception will change
-Aneroid manometer: measure in ml/mercury pressure
-thigh **difficult to auscultate due to lots of movement and adipose tissue
-avoid AV shunts or fistulas, affect arm of postmastectomy patient
-position of patient
-location where taken
-Normal findings
-prehypertension = 120-140/80-90
-hypertension= >140/90
Pulse pressure- systolic diastolic
-average = 40
-average < 40 indicate not profusing blood throughout body
-average > 40 indicate neurological damage in the brain
Common error in blood pressure measurements
-incorrect cuff size
-if too largefalsely low
-if too small falsely high
-unrecognized ausculatory gap
-not testing by palpation before auscultating
-common in people w. hypertension
-incorrect cuff placement
Factors influencing B/P
-age: male > female
-race: African American high BP.. prone to cardio vascular
-weight: increase BMI, more force heart has to use to contract to spread blood throughout whole
-diurnal rhythm: BP decrease during sleep
-white coat syndrome: when practioner come in, BP elevated because nervous
-Hypervolemia: increase blood volume
-Hypovolemia: decrease in blood volume
Age variations in B/P
-newborn; 80/46
-infant: 90:61
6 yr: 100/56
14 yr: 118/61
Adult: 120/80
Elderly: 130/80

P-pulse oximetry
-measurement of oxygen saturation of hemoglobin molecule
-normal: > 95%
-dark nail polish, ambient lighting will interfere w. reading, hypothermic or low BP
-interpert reading w. blood count and hemoglobin level
-indicate percent of oxygen breathing at a time: normal is 20.8%.. The other percentage is nitrogen
P-pain assessment
-subjective feeling and an individual response
-need to asses, treat and evaluate pain

Pain Characteristics
-associated manifestation
-aggrevating factors
-alleviating factors
-meaning and impact

What effect does pain have on vitals?

-BP, pulse rates, respiratory rates increase/breathing more shallow because deep breath may increase
pressure on area of pain
-not a normal affect in facial expression, begin to sweat
-mood becomes irritable or quiet and withdrawn
-position: keeled over, cluthing/protecting area of pain

Pain Scales
- Wong baker scale: 4-5 yr range understand scale of faces to communicate level of pain; severity scale --- FLACC: used in infants and adults in ICU; look at behavioral cues indicating pain (face, legs, activity, cry and
-PAINAD Scale: pain assessment in Advanced Dementia

Mrs. Samuels is admitted to the hospital with a diagnosis of Right Middle Lobe pneumonia. Her vital signs are
Temp 101.7 F, Apical pulse 112, radial pulse 104 BPM +2, Resp 28 and shallow; B/P 132/84; pulse ox on AA = 88%.
-Respiration: Tachypnea
-Apical pulse rate: tachycardia
-Pulse pressure: 48 (systolic/diastolic)
-Pulse defecit: 8 (apical/radial).. Indicates extra beats ..not enough contraction to push blood through
-Pulse oximetry reading: need 95% or abovehypoxnea: low blood oxygen level
-AA: indicates use of ambiant air; source of aid
A 28 year old male is brought to the ED by a friend who found him outside on the sidewalk. He is unresponsive,
Temp 94F rectally; apical pulse 48 BPM & irregular; Resp 5 and shallow; B/P 82/42; pulse ox 74% on AA.
Vital signs:
-hypothermic, bradycardic, bradypnea, hypotensive, hypoxemic b/c < 95% on AA

Skin, Hair, Nails Assessment

Importance as a System
-Largest organ system
-Guards from trauma, pathogens, and extreme temperature
-Barrier to keep fluids in and pathogens out
-Sensory contact with environment
-Vital organ system
Information from Assessing skin
-general health
-presence of infection, fluid imbalance, and electrolye imbalance
-rashes/lesions indicate presence of lesions
-fluid overlead if skin is puffy; if skin is dry and sunken in, indicate fluid defecit
-pinkish tone reflective of oxygenation status
-tissue perfusion/oxygenation status
-activity, sleep/rest
-self care ability
-systemic disease manifestation
- reflective of problem within another organ system and show up in skin system
Structures of Skin
-epidermis: outer, highly differentiated avascular layer
-dermis: inner, supportive, vascular layer
-subcutaneous tissue: layer of adipose tissue
Structural of Epidermal Appendages
-nails: keratinized appendage of epidermis; hardened
Vellus-short, fine, non pigmented
Terminal- thicker, coarse, pigmented.. develop as go through puberty
-sebaceous glands
-Sensory fibers- interpret outside worlds
-Sebaceous glands- produce sebum which lubricates the skin and makes it soft and elastic
Sweat glands-eccine: control body temperature, if hot you will sweat
-apocrine: found in axilla and gentile area which function after puberty and are responsible for
body odor
Functions of Skin
-Sensory perception
-Synthesizes Vit. D
-Repair surface wounds
-Stores blood & fat
-Identification of individuals
-Communicate emotions
-Protects internal structures
-older people lose adipose tissuelose cushioning, prone to injury
-Protects against heat/ultra violet rays
-Barrier to microorganisms
-Absorption of medication
Functions of the Glands
-Excrete metabolic waste

-Regulate temperature through evaporation

-Resist water loss in low humidity
Health HistorySubjective Data
-Previous skin diseases
-Change in skin color or pigmentation
-indicate disease process
-Varies from person to person
-Ask the person about their usual skin coloring
-Dependent on race
-Exposed vs. non exposed areas
-Change in a mole
-Change in feel of your skin temperature, moisture, texture, excess dryness
-feel hot or cold, excessive dryness or sweating, hard or leathery skin
-Itching - pruritis
-Excess bruising
-muscoskeletal problem; coagulation
-physchosocial issue- violence
-Rash or Lesion
-Impact and coping with
-dermatological side effect
-rash or hives due to allergies to medicine
-Hair Loss
-Change in nails
-Environmental or occupational hazards
Transcultural Considerations
-Melanin located in epidermis, produced by melanocytes.
-All people have same number of melanocytes; amount of melanin
produced varies with genetics, hormonal status, and environmental
-Melanin protects against ultraviolet rays
-When assessing dark skin, observe color changes in mucous membrane conjunctivae, earlobes,
nailbeds, palms & soles.
-Pallor can appear as greyish/dull tones or yellowish/brown tinges.
-Pallor is identified in dark skin as absence of underlying red tones.
-A normal Bluish tone of lips found in dark skinned Mediterranean population.
Skin Color changes
Cyanosis- oxygenation status and cardio respiration system.. Deoxygenated
blood in system?
Jaundice- biliary tract disease; something wrong with liver, gallbladder or
-not allow of excretion of bile from liver and bile has yellow tint that is
reabsorb into circulatory system and enimate in skin
-normal for infants upon birth .. Too high can cause permanent
neurological problems but usually dissipates in a few days
-in adult; more of a path physiological issue

Pallor- paleness to skin due to anemia, blood loss, not sufficient amount of RBC produced from bone
Erythema- redness of skin; reflect dermatitis or some inflammatory disorder
Ecchymosis- type of bruising of skin due to bleeding into subcutaneous layer
-body reabsorb bleeding skin changes yellow
Vitigo- complete absence of melanin
-patchy areas
-occurs in all races
-auto immune test: attacks own melanocytes
-hypopituitary: lack of melanocytic stimulating hormone
-body image disturbance
Albinism- total body depigmentation; white cast to the skin
-easily sunburned
-increase risk for skin cancer
Hyperpigmentation of skin
-sun exposure; tan lines
-over production of melanocytic stimulating from:
-pituitary tumor
-adrenal insufficiency
-renal disease
-birthmarkpink/purple markings
Discrete- distinct; isolated
Confluent- run together
Annular- circular
Generalized- trunk or extremity where is located
Grouped- clustered together
Linear- scabies, creases of fingers
Target- bullseye rash
Zosterform- follow nervepath, very painful .. Herpes zoster
-can develop shingles
-Macules and patches
-flat lesion w. a change in pigmentation
Eg. freckle or nevus
-Papules and Plaque
-solid, elevated lesion
-papules < .5 cm
-plaques > .5cm
-Blisters vesicles and bullae
-sharply delineated elevation filled w. clear fluid
-< 1 cm = vesicle
-> 1 cm= bullae
Eg. chicken pox or small pox
-Pustules and Abscess
-vesicles or bullae filled with pus
Eg. acne or abcess in deeper layers
-Nodules and Tumor
-elevated lesion under the skincan be moved over the lesion
-0.5-2cm = nodule
-> 2cm = tumor

-localized swelling in the epidermis

-irregular elevation
-red or pale
-antibody reaction to medication develop patches in skin
-treat w. bendaryl which is an ANTIHISTAMINE
eg. hives
-patchy, flaking of the skin surface
Eg. dandruff, psoriasis
-dried serum, blood or pus on the skin surface of the skin
-eschar: black leathery scab on healing wound
-skin is attempting to repair and if infected, will see drainage
-layer of skin becomes thickened and rough as a result of rubbing
-superficial wound with loss of epidermis or mucosa
-risk if deepens can cause infection
Skin Changes
-scar: lack melanocyte
-keloid formation: over production of scars
-staie: stretch marks pink initially then silvery white
Vascular Lesions
-capillary hemangiomas
-spider angioma
-hormonal contraceptives
-liver disease: high levels of hormones due to lack of drainage
-venous star
-engorgement of veins: venous insufficiency due to circulatory problem manifesting self onto
Changes in skin w. aging
-Decreased skin elasticity, increased wrinkling
-Skin thinner, drier, more fragile
-Decreased sweat gland activity
-Fewer hair follicles
-Decreased vascularity in dermis (pale)
-Medication based skin changes
-steroid causes skin to thin
-seborrheic keratosis
-skin tags: excess skin most commonly found under armpits
-senile lentigo: liver spots uneven pigmentation
-ability of melanocyte to produce even igmentation
-cherry angiomas: vascular arterial; benign
Danger Skins in pigmented lesions of the skin
A Asymmetry

B Border irregularcancer?
C Color variedcancer?
D Diameter larger than 6 mm
E - Elevation
Basal cell carincoma-waxy translucent appearance; sharply defined border
Squamous cell carcinoma- rough, elevated, irregular
-doesnt metastasize and spread cancer beyond lesion
Malignant melanoma- uneven surface, irregular outline, varying pigmentation
-will metastasize can result in death
Palpation of the Skin
-Moisture dry, diaphoretic
-Influenced by environment, muscular activity, body temp., stress
-Temperature warm bilaterally
-Hands & Feet can be cooler but =
-Palpate using back of hands/fingers
-No Tenderness
-Texture smooth, even, firm
-skin tugor; skin doesnt go back; not well hydrated or loss of adipose tissue
-Fluid build-up in intercellular spaces
- 0 no pitting
-+1 0 - 1/4 (mild)
-+2 - (moderate)
-+3 - 1 (severe)
-+4 - > 1 (severe)
Alopecia; Hair loss
-male pattern baldness
--loss 15 -40 hairs a day
-male pattern baldness assoc with genetics and testosterone
-known as alopecia.. Can develop to medical therapies as well
-hair will come back, with diff texture or color
-Trichotillomania- psych disorder manually pull hair out to scope w. stress
-Female baldness- hormonal imbalance often during pregnancy
-can reflect vitamin/defic or interraction w. medication
-inability for women to break down testerone into DHT
-develop hair follicle atrophy
-can be due to hot comb or traction (corn row)
Excess hair; Hirsutism
-drug induced
-over production of adrenal glands
-hormonal imbalance
-Nails should be pink, adherant to nail bed
-Surface of nail bed- smooth and flat
-Nail bed perfusion can reflect cardiovascular perfusion

-blanch out nail bed and determine how long reperfussion takes (should be less
than 3 sec)
-160 degree angle .. If greater indicate systemic illness
-90% of black individuals
Nail Growth
-Rapid every 6-8 weeks
-12-16 weeks
-26-32 weeks
Beau Lines- transverse growth arrest lines
-generalized serious illness
-Distal finger becomes rounded drumstick
-Nail angle > 180
-Birds beak
-reflect pulmonary and cardiovascular
-diamond shape should form when nails together
-fungal infection of nail bed
-common in toenails
-dark, warm, most envioment
-common in people with diabetes
--difficult to treat; nails are keratinized so difficult to get medication down to where the infection is
-oral antifungal medications interact w. liver
-takes 6-8 months for complete resolution
Head & Neck Assessment
Cranial bones- not fused to allow to engage in birth process
Posterior fontanele- close by 2nd month of life
Anterior fontanele- close at age of 2 yrs
**fontanele should be about same level of cranial bones; not depressed this incidates dehydration
-bulging indicates increases pressure of skull; for example meningitis produces increased fluid on brain
Facial bones:
Facial Muscles:
Salivary Glands
Submandibular- jaw line and underneath chin
Parotid- along side of jaw
-neck muscles:
-anterior and posterior triangle:

-thyroid gland:
Lymph nodes of head and neck
-Posterior auricular
-Superficial cervical
-Deep cervical
-Posterior cervical
Function*** Fluid leaves vascular compartment, reabsorb in venous but extra fluid is picked up by lymp nodes
and return to circulatory system
-also, WBC pick up microorganism and lymph system reacts and enlarge to decompose
of organisms
Subjective DataHealth History Questions
1. Headache
2. Head injury
3. Dizziness
4. Neck pain, limitation of motion
5. Lumps or swelling
6. History of head or neck surgery
Head: inspect and palpate skull for size and shape
-normalcephalicin proportion to body
-Hydrocephalus in baby-no longer able to drain cerebral spinal fluid because sutures are not sealed upon birth
head will expand in size
-Acromeagaly- excessive growth hormone; facial features are thicker
-Range of Motion
-Lymph Nodes
-Trachea - midline
-Thyroid Gland
-Posterior Approach
-Anterior Approach
-Auscultate (if enlarged)
Inspect the fair: facial structures
-Transilluminationdarkened environment
-pen light under sinus; if clear sinus light will disperse
-Normally not palpable
-Can be small, discrete, moveable (1cm)
-inflammed will still be moveable

-enlarged, firm, tender, mobile

-Possible malignant
-hard, nontender, nonmobile
Thryroid Goiter-nodules can be benign or malignant
Musculoskeletal Assessment
Long Bones
-humerus, femur and tibia
Short bones
-carpals, tarsals
Flat bones
-ribs, sternum
Irregular bones
-pelvis and hip vertebrae
Skeletal muscles
Elongated muscle cells or fibers in striated bands
Mostly voluntary, under conscious control
Provide for movement
Maintain posture
Generate heat
>600 muscles in body
-attach bone to bone
-strong bands
-maintain joint in normal ROM
-attachs muscle to bone or muscle to muscle
-muscle contraction; tendon pulls on bone
-tendon sheath: tendonitis inflammed pain
-important in muscular move
-bursa are fatty pouches that facilitate movement of body to decrease frictions
-fluid filled cavities located at tissue sites where tendons or muscles pass over bony prominences near joints
-facilitate movement
-reduce friction
-bursitis: caused by overuse
Articulation: point where 2 bones meet
Fibrous- joined by fibrous tissues joints in head
Cartilaginous- cartilage to vertebrae
Synovial- bones separated by a fluid filled sac
-freely movable.. cushion that protect joint
Common chief complaints

-pain: most common complaint

-chronic vs acute
-where is it? Scale 0-10, what does it feel like, when does it occur? Assoc with other manifestations?
Characteristics of chief complaint
-Associated manifestations
-Aggravating factors
-alleviating factors
-Meaning/Impact on ADLs and QOL
Medical History
-Musculoskeletal specific
-Joint disorders
-Bone or skeletal disorders - fractures
-Neuromuscular disorders
-Nonmusculoskeletal specific
-Infections: lyme disease
-Blood disorders: hemopheliablood into joint; limitation of motion
-Peripheral vascular disorders
**cancer may metastasize to bone
-Surgical History
-Arthroscopy Joint examination of
-Arthroplasty Joint repair/reconstruction
-Diskectomy or Laminectomy surgical fixation
-Internal fixation
-External fixation
-Reattachment of a limb
-Common medications
-Anti-inflammatory agents - NSAIDS
-Analgesics: narcotic or non-narcotic
-Muscle relaxants
-Calcium supplements
-Biphosphonates Fosamax - Evista, Boniva - inhibit osteoclastic activity
-Protect bone
-Hormone therapy used less for bone health
-Special needs
-Use of assistive devices
-Hemiplegia, quadriplegia, paraplegia
-Plegia = paralysis
-Childhood illnesses
-Polio post polio syndrome
-Loss of muscular activity

-Juvenile arthritis
-Auto immune body attack muscular skeletal system
-Family history
-Rheumatoid arthritis
-Pagets disease
-Unknown ediology
-Thickening of long bones; prone to fracture
-Decrease in DENSITY of bone
-Social history
-Alcohol or tobacco use
-Work environment: role of repetitious movements
-home environment: physical layout/barriers
-Hobbies/leisure activities
-Exercise Is it F. I. T. ?? (FREQUENCY, INTENSITY, TIME)
-Contact activities risk of injury
-Weight-bearing activities
-Non-weight-bearing activities
-Aerobic activities
-Health maintenance activities
-Use of safety devices
-lumbar support
-Elbow/knee pads
-Health checkups bone density tests
-Diet Intake
-24 recall
-Food frequency
-# of food items eaten
per day/week/month
-Food diaries 3 days
-2 weekdays/1 weekend day
Record after eating
-Direct observation
-Goniometer test angle of joint
-Tape measure and felt tip marker
-General approach
-Patient comfort
-Compare non-affected to affected - symmetry
-Proceed in cephalocaudal (head to toe) order
-Overall appearance
-Gait and mobility
-Weight-bearing status
-Gait patterns
-Transfer ability
-Sitting to standing
-Sitting to sitting
-Laying to sitting

-Normal findings
-Height and weight are proportionate
-Full ROM
-Ambulate independently
-No structural defects
-Shoulders and hips are level
-Head and torso are upright
-Stable gait
-Transfers independently
-Muscle size and shape
-Hypertrophy muscle size grows
-Atrophyloss of muscle size due to non use or paralysis of muscle; flaccid
-Involuntary muscle movements
-Tics, tremors
-Limb circumference
-Joint contour and peri-articular tissue
-Surround actual joint
-Normal findings
-Symmetrical muscle contour
-No involuntary muscle movements
-Bilateral limb circumference is within 13 cm of each other
-Joints are flat when extended, and smooth/rounded during flexion
-No joint enlargement or deformity
-Muscle tone
-Slight resistance to passive stretch
-Hypotonity (flaccid) no resistance!
-Muscle strength
-Spasticity Muscle strength much resistance, unable to extend muscle
-Scale 0 to 5
Joints to Assess
-head to toe approach
-Check symmetry
-Do painful ones LAST
-Apply light pressure with fingerpads
-Start in the periphery of the joint and move to center of the joint
-Move it through the ROM
-Note swelling, pain, tenderness, warmth, nodules, erythema, ecchymosis
-ecchymosis: bleeding into tissue due to injuries
Range of Motion
-Active ROM performed independently by the patient
-Passive ROM performed by the examiner
Tempromandibular joint TMJ
-Articulation between mandible and temporal bone
-Open and close jaw
-Protraction and retraction
-Side to side movement

-No crepitis bone on bone; not cushioned

-33 Irregular bones--vertebrae
-7 Cervical
-12 Thoracic articulate with ribs
-5 Lumbar
-Sacrum shapes the posterior wall of the pelvis
Inspection and palpation of the spine
-Note curvature
-Check symmetry
-Check alinement by Palpating spinous processes
Kyphosis- increase convexity
-displace center of gravity
Lordosis concave lumbar
-obesity; large abdomen; pregnant woman
Scoliosis- Screening is positive.. Refer to orthopedist
Range of Motion
Abduction-Arm over head
Adduction-Arm across body straight
Horizontal Flexion-Arms up like a dive
Horizontal Backward Flexion--Like on blocks for swim start
External Rotation--Hands behind head
Internal Rotation--Hands behind back
Inspection and palpation of shoulder
-Shoulders = in height
-No swelling
-No tenderness
-No crepitus
-Full ROM
Rotator Cuff Tear
-Arm extended and abducted from the body
-Instruct patient to slowly lower the arm while maintaining arm extended
-Arm quickly drops
-Severe pain
-ask someone to extend out, abduct away from body, slowly lower to side of body
-if rip, will have pain trying to abduct
Palpation of elbow
-Palpate for warmth, swelling, tenderness, nodules, crepitus
-Tennis Elbow: Lateral epicondylitis
-Golfers Elbow: Medial epicondylitis
Wrist and Elbow
206 Bones in Body--1/2 in hands and feet
Extension flat out

Flexion--fold fingers
Radiocarpal Joint Radius Thumb Side and Row of Carpal Bones
Midcarpal Two rows of carpal bones
Fingers and Hands
Abduction- tight fist
Opposition- touch thumb to each finger and be able to grasp
Grip Strength
-Roll B/P cuff up
-Inflate to 20 mm Hg
-Have patient squeeze
-Normal: 150 mm Hg
-Check for symmetry
Carpal Tunnel Syndrome
2 tests:
Tinel- stimulate medial nerve by percussing it/tapping
-should haven no tingle or burn
Phalen-place hands at 90 degree angle for 60 seconds
2 types:
Bouchard- proximal interphalangeal joint inflammation.. Closer to hand
Heberden- distal interphalangeal joint.. Tips of finger
Rheumatoid Arthritis
Develop swans neck, boutinere, severe ulnar deviation
Osteoarthritis- pain after actvity of joint
Rheumatoid- wake up in pain , more flexible as use joint
Fractured Hip
-Inability to bear weight
-Affected leg is shorter
-Affected leg:
-Internal rotation
-External rotation
-Any physical deformities in hip area?
-can measure affected and injured leg.. From ankle to hip
-should be no more than 3cm diff between 2 legs
-If fall forward- causes inward rotation and vise versa
Knee Joints
-Complex joint!!
-Patella, femur and tibia
-Flexion - 130
Common Knee Disorders
-Younger adult Ligament tears
-Athletes female (?)

Older adults Osteoarthritis

-Wear and Tear
Hallux Valgus & Hammertoes
-shoe is too small, forces bone to be squished
-callous form and act as median for infection.. Osteomyolitis
Hammertoes- pronounce flexion of metatarsal
Anthropometric Measurements
-best time is weight in morning and under same conditions
-Waist to Hip Ratio
-Body Proportions
-Growth Patterns in Children
-Changes in Nutritional Status in Adults
Ideal Body Weight
-Female: 100 Lb for 5 feet then add 5 Lb for every inch above 5 feet.
+ or 10% for small or large frame
-Male: 106 Lb for 5 feet then add 6 Lb for every inch over 5 feet
+ or 10% for small or large frame
-Actual Wt IBW x 100 = % IBW
-70-80% IBW moderate malnutrition
-< 70% IBW severe malnutrition
-110% IBW overweight
->120 % IBW obesity
Waist to Hip ratio
-males are apple shape :thoracic and abdominal
-female are pare shape: weight aaaround hip and thigh
Risk for obesity related diseases
-Waist to Hip Ratio
-Waist Circumference Divided by Hip Circumference
Body Mass Index
-Formula R/T Height & Weight
-Associated with Body Fat Content
-Higher BMI associated with disease risk
-Weight (Kg)
Height (m)2
-Weight (Lbs) x 704.5
Height (inches)2
Body Mass Index
< 18.5
- Underweight
18.5 24.9 - Normal
25.0 29.9 - Overweight

30.0 34.9 - Obesity Class I

35.0 39.9 - Obesity Class II
- Obesity Class III
Skin Fold thickness
-Determines Body Fat Stores & Nutritional Status
-Triceps Skin Fold (TSF)
Mid arm circumference
-Skeletal Muscle Mass
-Measure in mm
-Normal: 5-95th% tile based on age/gender
-Used to calculate the Mid-Arm Muscle Circumference
Mid arm muscle circumference
-Measure of skeletal muscle mass and fat stores
-Calculated using the TSF & MAC
-MAMC (cm) = MAC (cm) (0.314 x TSF)
-Normal: 5-95th tile for age & gender
Gerontological variations
-Bone density decreases
-Increased risk for osteoporosis
-Muscle atrophy
-Decreased muscle strength
-Deterioration of articulating cartilage
-Vertebral inflexibility
-Thoracic kyphosis
-Decrease in height
Neuro & mental Status Exam
-What would you ask mrs peters?
-Did you slip? Conscious? What made you fall? What pain do you feel?
-What assessments would you perform?
-Pain radiating, quality, moving make it worse
-Set of vital signs
-Neurological assessment pupils, hand grasps
-Basic inspection for wound, bruises, deformities
-Palpate neck, head, joints for fractures
-What possible risk factors might exist for this patient?
-Post menopausal
-Caucasian female
-What would indicate to you a possible fracture?
-External rotation of fit indicate hip fracture
-Unable to bear weight
-Difference in leg length (shorter b/c femur bone rise up)
-Ms jones is 35 yr old
-5 foot 4, 162, bmi = 27.8, hip = 35 inches and waist = 40 inches

-Ideal weight?
-100 + 5 pounds per inch = 120 pounds
-What is hip to waist ratio?
-Waist circum/hip circum = 1.14 high because > .8 for woman
-% of Ideal body weight
-What is her BMI?
-Ideal = 19, hers is 27.8 so she is OVERWEIGHT
-Health risks?
-diabete, cardiovascular, hypertension, lower back pain, at risk for osteoarthritis
-What would you ask about life style ?
-Ask her typical die, FIT test for fitness
Nervous System
-Central Nervous System
-spinal cord
-Peripheral Nervous System
-12 pairs of cranial nerves
-31 pairs of spinal nerves and their branches
Central Nervous System
-Cerebral Cortex-cerebrums outer layer of nerve cell bodies or which looks like gray matter because it lacks myelin
-The cerebral cortex is the center for humans highest function and governs thought, memory, reasoning,sensation
and voluntary movement
-Each half of the cerebrum is a hemisphere
-Each hemisphere is divided into four lobes
Hemisphere4 lobes
-Frontal brain tumor- not able to make sense of world; cognitive issue
-Parietal- somatic body senses, make sense of sensory input
-Temporal- hearing, memory, speech perception and specialized wernike: auditory comprehension (listen to
what people say and articulate and make sense of it could lead to receptive aphasia)
-expressive aphasia able to process information, but cant clearly express themselve..make no sense
Occipital area- vision
-ability to think and reason
-enclosed by 2 membrane layers called MENINGES
-Under dura meter there is cerebral spinal fluid
-under arachnoid mater is another space for fluid and place for blood to enter if there is trauma
-pia meter
Increased intracranial pressure (icp)
-If blood or fluid accumulates between these layers, pressure builds inside the skull and compromises brain
-Can also occur with tumor growth or fluid build-up in brain tissue
-Increasing intercranial pressure only occurs in infant when fontanelle have closed
-may experience motor weaknesses depending upon where defecits are occuring
Damage to any of these specific cortical areas produces a corresponding loss of function
-such as motor weakness
-loss of sensation

-impaired ability to understand and

process language
**due to loss of blood supply
-brains cant store o2 and glucose; needs a ready supply at all times for neurological functioning
-when blood supply is deminished, cells are oxygen deprived and cause neuorological defecits because can not
aerobic or cellular metabolism
Components of the CNSdivisions of the cerebrum
Basal ganglia- coordinate automatic muscle movement of body
-involved in cognitive and emotional functioning in body
Thalamus- relay motor and sensory signals for processing
-regulate conciousness, sleep patterns, and how alert we are
Hypothalamus- connection between NS and endocrine
-regulated by pituitary gland
Cerebellum- involved in motor control and coordination
-how precise we are w. movement
-tested by police when suspected of DUI
-Central Core of the brain
-Consists of 3 areas
-Medulla oblongata
-Complex network of sensory fibers that control:
-able to lose upper brain functions but still have heart working but the person may not be sane
Cross representation
-Notable feature of nerve tracts
-Left side of body controlled by right side of the brain
-Right side of the body controlled by left side of brain
Peripheral Nervous System
-carries sensory messages to the CNS from sensory receptors, motor messages from the CNS out to muscles and glands,
as well as autonomic messages that govern the internal organs and blood vessels
-The peripheral nerves carry input to the CNS via sensory fibers (called afferent fibers)
- deliver output from the CNS via fibers (called efferent fibers).
-cranial nerves exit the BRAIN rather than the SPINAL CORD
-Spinal Nerves- 31 pairs of nerves which arise from the length of the spinal cord and supply the rest of the body.They
are named for the region of the spine from which they exit- they are:
-8 cervical
-12 thoracic
-5 lumbar
-5 sacral
-1 coccygeal
Subjective data

-syncopeloss of consciousness
-parasthesia: lack of feeling in body
-gait disturbance
-visual changes
-memory disorder
-difficulty with speech or swallowing
Neuro exam sequence
-mental status
-crainial nerve
-sensory system
-motor system
Mental status
-level of consciousness
-awake, alert and oriented x3
-place, person, time
-Who they are, where they are, general time of year
**first thing you lose is SENSE OF TIME, then PLACE, then WHO you are
Changes in loss of consciousness
-lethargy.. require stimulus to be aroused
-stupor.. need vigorous stimulation
-varied responses to painful stimuli only
-thumb in notch between eyebrows or pinch trapezius muscle, pressure on mandible, sternal rub with knucles,
nail bed perfussion
-brain death
-require 2 people to determine if withdraw life support
** LOC is the most sensitive indicator of a change in neurological status
-person who is confused, lethargic and start to deteriate
-test oxygen level, then glucose level (because brain cant store energy or oxygen)
Mental status
-Attention ability to repeat info or perform
-Memory short-term/long-term
-Judgment safety issues
-Insight realistic perception of self
-Spatial perception - draw objects
-Calculation ability to calculate
-Abstract reasoning underlying meaning
-Thought process & Content logical/coherent
-Suicidal ideation
Mini mental status screening
-Assesses cognitive functioning
-Assists in identification of delirium/dementia
-Score: 24-30 Normal
< 24 impaired functioning

Cranial nerves
-Olfactory- I
-Eyes closed
-Block one nostril
-Inhale deeply
-Present one odor at a time
-Compare both nares
-Then introduce another scent
-Optic - II
-Oculomotor III
-Most eye movement, pupillary constriction, upper eye lid elevation
-Trochlear IV
-down and in eye movement
-Trigeminal V
-Sensory: Facial sensation
- ophthalmic
- maxillary
- mandibular
- corneal reflex
-Motor: Chewing
-Sense stimulation by whisp of cotton brush across face w. eyes closed
-Cornial reflex- see if person blink when rub cotton over side of cornea
-if lose, at risk for corneal abrasion
-Ability to chew food
-assess by having person frown
-Abducens VI
-lateral eye movement
-Facial VII
-Motor: Expressions frown, raise eyebrows, wrinkle forehead, smile show teeth, whistle, puff out cheeks,
close eyes tight against resistance
-Bells Palsy
-Paralysis of the Facial Nerve
-Note the asymmetry of the palpebral fissures and the nasolabial folds
-unilateral paralyzation
-asymmetry in bindings
-if only in facial area and no weakness in side of body, this of bells palsy rather than stroke
-Chvosteks sign
-Neuro excitability of the facial nerve
-Normal: no twitching when it is stimulated
-If twitch/muscle spasm present hypocalcaemia or tetanus
-check stability of facial nerve
-determine calcium balance determined by parathyroid gland
-low calcium level cause muscle twitching, externally stimulate 7th cranial nerve by tapping on
side of head
-patient will twitch if not enough calcium to stabilize
-occurs after someone who has thryoid surgery
-calcium balance affects cardiac function as well as neurological function
-Sensory taste
-Sweet/Salty tip of the tongue
-Sour - tip of tongue & borders
-Bitter - back of tongue

-Acoustic VIII
-hearing and balance
-Glosopharyngeal IX
-swallowing, salivating and taste
-open mouth and place tongue stick on tongue.. Say ah and watch symmetric movement upward of uvula
-lose function and at risk for aspiration
-Vagus X
-Swallowing, gag reflex, talking, pharyngeal movement, activities of the thoracic and abdominal viscera, such as
heart rate and peristalsis
-say ah
-gag reflex.. Tongue blade to back of pharynx
-during anesthesia, loose gag reflex and cant feed until gag reflex has returned
-Spinal Accessory XI
-shoulder movement and head rotation
-place hand on side of face and ask to laterally rotate head against resistance
-shrug shoulder against resistance
-Hypoglossal - XII
-tongue movement
-tongue is midline and not deviated to one side
-articulate words light, tight and dynamite
-Cranial Nerve Names
-On Old Olympus Towering Tops A Fin and German Viewed Some Hops
-Cranial Nerve Function (sensory, motor, both)
-Some Say Marry Money But My Brother Says Bad Business Marry Money
-spinal nerves innervate different part of body
-spinal cord injury may impact person to feel diff parts of body
Pain & temp- tells us later spinal thalmic tract is sending senses to thalamus and connecting over to cerebral cortex and
able to respond to sensations
Discrimination- test integrity of dorsal column, thalamus and into sensory cortex
Exteroceptive sensation
-Light Touch - wisp of cotton
-Patients eyes closed
-Distal to proximal
-Check for symmetry
-Superficial pain safety pin
-Dull vs sharp
-Temperature hot/cold
**people with diabetes have nerve endings not sensitive to fine touches
Proprioceptive sensation
-motion and position
-vibration sense (distal to proximal)
-stike in palm of hand and then place on bony prominance (hand or foot)
-feel when vibration begins and ends
-neuropathy and diabetes may lose sensation

Cortical sensation
--feel something in environment and with eyes closed, actually identify common object
-Asterophoresis- absense of feeling
-Graphesthesisa- draw something in palm of hand and person will identify .. draw number 8.. Need to be
orientation to person
-Two-Point Discrimination
-Lips/finger tips = 2-4 mm
-Palms- 8-15mm
-Shin, back = 30-40 mm
-Extinction ability to feel two points simultaneously and feel when one was removed
-Extinction- When stimulus is removed
Decerebrate rigidity (positioning)
-Ominous Sign brainstem, midbrain, upper pons lesion
-Arms stiffly extended, adducted, internal rotation, palms pronated
-Legs stiffly extended, plantar flexion
-Teeth clenched, back hyperextended
-lower portion of brainstem involved in trauma so person is in position that arms are stiff, extended and abducted into
-palms pronation
-feet are plantar flexion
-teeth clenched tight and hyperextended neck
-can start unilateral and move bilateral as pressure increases inside head
-Cerebral Cortex hemisphere lesion
-Flexion of Arms, Wrist, Fingers
-Adduction of arms
-Legs extension, internal rotation, plantar flexion
-can survive because vegetative functions are preserved in lower area of brain stem..
-arms abduct into body and elbows flex
Pronator drift
-weakened side falls down and palm rotates up
-Test of the integration of the pre-motor cortex, basal ganglia, cerebellum, vestibular system (ear), posterior column,
and peripheral nerves
Romberg test
-Patient stands erect w/ feet together, hands at side, and eyes open
-Then patient closes their eyes
-Note ability to maintain balance
-Normal: Maintains balance with minimal swaying for 20 seconds
-Reflex action
-Automatic response to an adequate stimuli
-Muscle stretch
-Deep tendon

Deep tendon reflex
-C 5 & C 6
-Contraction of biceps
-Flexion of elbow
-biceps contraction and cause arm to flex a tiny bit telling us deep tendon reflex is intact.. Test this with
someone who has neck pain or trauma
-C 5 & C 6
-Flexion and supination of forearm
-C 7 & C 8
-Contraction of triceps and extension of arm
-striking back of elbow and feel contraction of biceps and arm will extend a bit
-L 2, L 3, L4
-Contraction of quadriceps and extension of leg
-L 5, S 1, S 2
-Contraction of calf muscles and plantar flexion of foot
-Magnesium sulfate given to pregnant women can cause person to loose deep tendon relfex
Plantar vs babinski
Babinski- Pathological Upper neuron disease condition in adults.. Okay in infants up to age 2
Normal- big toe curves in toward stimulus
Babinski- big toe dorsiflex upward
Superficial reflexes
Abdominal-contraction of umbilical area.. Demonstrate innervation of t2-t12
Cremastic- spinal cord injury.. Take stimulus and stroke inside of thigh and watch for testicle to rise away from stimulus
bulbocavernosus-squeeze glands on top of penis and they will contract
meningeal irritation
-Nuchal Rigidity resistance w/ neck flexion
-Kernigs Sign resistance to leg extension and pain after the knee was flexed
-Brudzinski Sign legs flex with deliberate neck flexion
Increased intracranial pressure (ICP)
-Change in LOC - **initial sign**
-Cushings Reflex (late signs):
-Elevated systolic pressure
-Widening Pulse pressure
-Apnea Spells
-= impending brain stem herniation
-Change in level of conciousness is most important indicator of neuorlogical problem
-increase pressure in head so heart has sytolic pressure increasing while diastolic remain same
-stimulate parasymp and heart rate drops
Glasgow coma scale

-Eye Opening 1-4

-Eyes Open
-4 Spontaneous
-3 To speech
-2 To pain
-1 Absent
-Best Verbal Response 1-5
-Verbal Response
-5 - Converses/oriented
-4 Converses/disorient
-3 Inappropriate
-2 Incomprehensible
-1 - Absent
-Best Motor Response 1-6
-Motor Response
-6 Obeys Commands
-Response to pain
-5 Localizes pain
-4 Withdraws(flexion)
-3 Decorticate
-2 Decerebrate
-1 - Absent
-Normal: Score 15
-Below 8: Coma
-External structures
-Palpebral: pink, moist mucous membrane seen when pull skin below eye down
-reflective of HCT, will be pale if anemic
-Bulbar: clear transparent over entire eye
-vessels should not be engorged
-Inner: inside of eye (where eye goop is)
-Lacrimal apparatus: upper outer quadrant for TEARS.. Clense front of eye to prevent microorganism enter
mucous membrane
-Extraocular muscles
-Internal structures
-Outer layer
-Sclera: white with few small superficial vessels
-moist and shiny
-in Arican American, can see yellow streaking as normal variant
-if YELLOWjaundice due to biliary tract malfunction
-Cornea: should be clear, moist and shiny
-NO discharge, cloudiness, opacities
1. corneal laceration- foreign object that cuts cornea
2. acrus senilis- loss of pigmentation in IRIS, if in younger personcan be due to high lipid level

-Middle layer
-Inner Layer
-optic disc
-fovea centralis
-Visual pathway
-Sensory neurons in the retina
-Optic disc
-Optic nerve
-Optic chiasm
History of eye problems
-Amblyopia- brain partially or entirely ignores input from eye due to srabismus (lazy eye) and eye will
wander when not focused need to strengthen extraocular muscles
-Middle age
-Presbyopia impaired near vision age 45
-Retinopathy HTN, Diabetes Mellitus due to intraocular pressure.. Deteriation of arterial beds, can
lead to blindness
-Cataract - with UV light exposure
-Glaucoma - IOP destroy optic nerve; result in blindness
-Macular degeneration - central vision
Macular degeneration
-loss of central vision
-tested by Ampsler grid.. see if distortion within lines
Health History of Eye
-Common chief complaints
-Changes in visual acuity
-Blurred vision
-Diplopia Double vision
-Visual field loss
-Floaters clumps of vitreous humor
-clump if vitreous humor can become aggitated with quick movement and float up into field of
visionsee bright sparkly lights
-Medical will discuss common ones
-Eye Surgeries

-Medications eye drops

-Injuries foreign bodies, trauma
-Family History of eye disease
-genetic predisposition for development of cataracts
-Work environment-exposure to toxins, chemicals, infections, allergens
-Health maintenance activities
-Use of safety devices - goggles
-Eye exams, Glaucoma check
Visual Acuity
-Cranial nerve II
-Distance vision
-Myopia near sighted, can be corrected
-Near vision
-Hyperopia - far sighted
Eye Tests
-Snellen Eye chart: distant vision
-standing 20 ft away
-test each eye individually
-which eye read completely correct is recorded
-if visual acuity is 20/30 or >, referred
-green and red line is screening for color blindness
-E chart: distant vision
-Used with individuals who do not know the alphabet
-Note the green and red line for gross check of color vision
-Rosenbaum Card: near vision
-handheld card
-14 inches away
-20/20 vision is NORMAL
-20/80 vision means a patient can read at 20 feet away what a patient with 20/20 can read at 80 feet
-blind no light perception
-legally blind varies state to state
-corrected vision is 20/200 or worse
-color blindness
-inheritred recessively x linked trait
Males: 8% white; 4% black
Females: .4% *RARE*
-test with Ishihara Plates
Visual fields
-Confrontation technique
-Assess all fields
-Types of defects
-determine if any problems with visual field
Hemianopsia-lose peripheral vision on sides, top or bottom of eye
Circumferential blindness-see in center, not peripheral
Unilateral blindness-blind in 1 eye, no visual field perception

External eye and lacrimal apparatus

-ptsosis: uneven eyelids.. can be reflection of cranial nerve #3 disfunction
-exophthalmos: can be due to hyperthyroid
-bulging of eye, bilateral in nature
-hordeolum (stye)- infected hair follicle mostly due to staph aureus
-treat with warm, moist soaps
-chalazion: infection of the eye lid
-warm water will treat, otherwise will need to be everted with staph aureus
-lacrimal apparatus:
-check for swelling, drainage, erythema (redness), excessive tearing
Extraocular muscle function
-Corneal Light Reflex (Hirschberg test)
-Focus penlight 12-15 inches away from eyes
-Note the reflected light it should be symmetrical
-Cardinal Fields of Gaze - Cranial nerves III, IV, VI
-tested in DUI; unable to control extraocular muscles while intoxicated to keep focus
-Cover/Uncover Test (remain focus, or start to deviate?)
-Focus in distance
-Cover one eye
-Note any movement in uncovered eye
-Remove the cover
-Note any movement in the eye being uncovered
Pupil Check
-Cranial Nerve III
-Normal Size 2mm 6 mm
-Note speed of constriction with light
-darken room, shine light, pupil constrict should be BRISK.. but can be sluggish or absent
-Note consensual response in other eye
-when one pupil constrict, the other will constrict
-accommodation: focus on object in distance, pupils will dilate and when object gets closer, pupils will bilaterally
constrict and converge
-PERRLA- pupils are equal, round, reactive to light and accommodation
Change in pupil response
-Pinpoint small and fixed
-Miotic drops
-Brain Lesion
-Mydriatric drops
-Head trauma
-Brain Stem infarct
-Cardiac Arrest after 4-6 minutes
Cranial Nerve III intact?
-Check Dolls Eyesvestibular ocular reflex
-Hold eyes open
-Briskly turn head to one side

-if intact, maintain image on back of retina

-if damage, eyes follow in same direction of turning
-Note movement of the eyes
-Positive = intact
-Negative = brain Stem injury
Clinical case
18 yr old with 2 day history of malaise(depression), loss of appetite, fever and aching muscle
-subjective info?
-self diagnose self (exposures, congregate housing)
-what has she been doing to treat self
-life style behaviors (decrease in frequency in eating and pain)
-location of achy muscles
-key physical assessments
-vital signs
-palpate lymph nodes (movable, enlarged, tenderness)if tender and non movable, indicate cancer
-past medical history (co morbities)
-on medication.. esp steroid
-dizzy, lighthead, headache, signs of rash, photophobia (bright lights), vomiting,drowsiness
Vital signs:
-temp = 102.7 (every degree of farenheight above normal, see cardio vascular response increase by 10
beats per minute)
=pulse 128 bpm 3+
-respiration 28/minute
-bp = 118/72
Clinical case
-82 yr old, fall on ice and strike side of head 6 hras ago, slurred speech, difficulty swallowing and right arm/leg weakness
-cranial nerve
-visual inspection
-loss of consciousness (lose time first because most abstract)
-vital signs
-range of motion
-examine hip fracture for muskoskeltal
-assess strength.. squeeze hand, push against hand
-as more pressure inside of head, heart needs to pump more forcefully to get blood into cranial.. systolic
increase, diastolic stay same and as pressure increase, baroreceptors in carotid arteries recognize this and increase
parasympathetic stimulation
Assessment of ear
Subjective data
-change or loss of hearing
-drainagewhat type?
Blood- rupture ear drum
Clear- make sure not cerebral spinal fluid; test by glucose dipstick
-tinnitus; ringing in the ears
-indicate fluid behind tympanic membrane
-vertigo, dizziness indicate vestibular problems
-frequent ear infections common in pediatric because eutheschian tube is shorter and horizontal; easy for
microorganisms from back of pharynx is easily travel because direct pathway and close

-if ear displace on head; diagnose with chromosomal abnormality
-coloreven tone
-indicate rheumatoid arthritis on inner helix of ear due to gout
Auditory screening
-whisper test
-Patient occludes on ear
-Examiner stands 2 ft. behind patient
-Examiner whispers 2 syllable word
-Have patient repeat it
-weber test
-Place vibratory Tuning Fork on center of head
-Sound lateralizes to both ears equally
-rinne test
-Place vibrating tuning fork on mastoid process
-When patient no longer hears it, place in in front of the ear
-Normal: AC > BC
-Air conduction 2 x bone
-tuning fork used to detect tone
Conductive hearing loss
-dysfunction of sound transmission
-unable to oscilate bones in middle ear or external ear and communicate to inner ear
-can be result of serumen (ear wax)
-otitis media-- inflammation of middle ear
- injury of tympanic membrane
- oto sclerosis-- bone in middle ear fuse together so dont oscilate
-foreign object in ear canal
-Weber test on center of head will lateralize to fore ear
-Rene test air conduction time will = bone conduction time
-complete occlusion of ear canal there is no air conduction
Sensorineural hearing loss
-inner ear problem in vesibu cochlear ear
-Weber test in center of forehead will lateralize to good ear
-Rene test is normal finding: air conduction > bone conductions

Opthalmoscopic and otoscopic examinations

-Diopter: Unit that measures power of lens to converge or diverge light
-0 lens clear for perfect or corrected vision
-20/20 vision
-Red: Myopic (nearsighted) Minus numbers
-Black: Hyperopic (farsighted) Plus numbers
Lens: get largest diameter of light in order to look through the pupil
-3 different lights of different size depending on size of pupil to maximize light
How do you see through iris?
-need to dilate pupils as much as possible
-darken room
-relax eyes as if gazing into distance
-patient looks in the distance
-Mydriatic Drugs dilate the pupil
-Head injury and coma
-Essential to observe pupillary reactions
-Suspicion of narrow-angle glaucoma
Getting ready
-Examiner removes glasses
-Leave contact lenses in place
-Darken room
-Switch on ophthalmoscope
-Set lens disc to 0 diopters
-Adjust to large round beam of white light
-Keep index finger on lens disc
*LEFT arm, LEFT eye of practitioner and place right arm on shoulder
Opthalmoscopic exam
-Relax eyes as if gazing into distance
-Place your left hand on patients forehead
-Examine right eye
-Right hand holds ophthalmoscope
-Right index finger on diopter adjuster
-Focus light on patients right eye
-Left hand and left eye for patients left eye
- Patient gazes at a specific distant point
-Tilt handle of ophthalmoscope ~ 20 degrees
-Begin 15 inches away, 15 degrees lateral to patients line of vision
-Shine light on pupil: Look for Red Reflex
-Place thumb of other hand on patients eyebrow
-Try to keep both eyes open
-RELAX, gaze into distance
-Move in on 15 degree line toward pupil
-Ophthalmoscope almost touches eyelashes

Anterior structures
-Look for opacities in vitreous or lens
-Vitreous floaters: dark specks or strands
-Cataracts: densities in lens
-Optic Disc: observe
-Border: blurred nasally
-Color: yellowish orange to creamy pink
-look at this area for integrity of vessels
-fovea and macula
-Rings or crescents:
-Physiologic cup
-< diameter of disc
Arteries and veins
-Color: Light red
-Size: smaller (2/3 to 4/5 of veins)
-Light reflex: Bright
-Color: Dark red
-Size: Larger
-Light reflex: absent
Macula and foveatoward nasal side
-Very last step
-Direct light laterally or ask patient to look at light
-Inspect Fovea
-High concentration of cones for central vision and high resolution vision
-very painful for light to be shined at fovea
-Inspect Macula distinct darker pigmentation
-macular degeneration common in people over 50