Peripheral Vascular, Musculoskeletal, and Lymphatic System Assessment

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Why is it important to ask about diabetes during the health history?

because of poor circulation, diabetics tend to have tissue damage in certain extremities that makes their skin very sensitive and can come off when friction is present

Smoking tobacco causes _____________

vasoconstriction

What things effect capillary refill?

cigarette smoking
decrease temp (including room temp)
peripheral edema
anemia

What does it mean if someone has an irregular heartbeat?

they have a conduction problem

Pulses Alternans

pulses that have a regular rate, but alternate from weak to strong

Pulses Alternans is seen in people with what?

heart failure

Bigeminal Pulse

2 rapid beats, followed by a long interval, caused by a premature heartbeat

Bigeminal pulses are seen in people with what?

PVC (Premature Ventricular Contraction)

Labile Pulse

normal pulse at rest but increases when pt stands or sits

Bounding pulses (4+) typically occurs in someone with what?

hyperthyroidism

What is a normal pulse grade?

2+

What should you do before you stick someone in their radial artery?

make sure the Ulnar artery has good blood supply with the Allen Test

Allen Test

used to evaluate adequacy of collateral arterial circulation prior to cannulating the radial artery. Blood should return in 2-5 seconds

You should always document if someone has good circulatory supply before you stick them. True or False

True

Bilateral Edema indicates what?

systemic problems
heart failure

Unilateral Edema indicates what?

local obstruction
inflammation
infection

What is the normal O2 Stat?

95-100%

The Epitrochlear Lymph node is in the ____________

antecubita fossa

What should you always do when measuring edema?

measure the same spot every time

Homan's Sign

Checks for DVT (Deep Vein Thrombus) have pt's knee slightly bent and then sharply dorsiflex the foot. Ask the pt is it elicits calf pain

Why is Homan's Sign not very reliable?

a + homan's sign is only present in about 15% of pt. with DVTs

Brawny Edema

nonpitting, hard to touch

Brawny edema is seen in pts with what?

lymphatic obstruction
deep vein occlusion

Bruit

unexpected swooshing or murmur sound over an artery or organ. Occurs with turbulent blood flow

Bruits indicate what?

partial occlusion

What occurs with a positive Manual Compression Test?

people with incompetent valves, their valves do not stay close, which results and increase pressure of blood flow in veins back to the heart in the lower extremities. Because the valves to not stay close, they blood travels back and creates a wave on your other hand

Bruits are also heard in people that have _________ form in their arteries.

plaques

When assessing peripheral circulation. You should use the 5 P's. What are they?

pain
pulse
pallor
paresthesia
paralysis

Paresthesia and Paralysis occur with what?

acute occlusion of a major artery

Remember that you should not ask questions when assessing peripheral vascular system and the musculoskeletal system. Why and What should you do instead?

Because people tend to just nod, you should always give demands such as "say yes if you feel any pain" or "move your big toe" or "say if the pain is sharp or dull"

When inspecting musculoskeletal, the body parts should be __________

symmetrical

Why is it important to ask a pt to name some of the activities they do daily?

because many pt will say they are capable of doing all ADLs but really just sit on the coach all day

It is very important for adolescence to do what before sports and activities and use what?

warm up
safety equipment

What does Ortolani's Maneuver assess for?

congenital hip dislocation

What indicates a + Ortolani's Maneuver?

clicking and feeling the femur shift

Ortolani's Maneuver is done until a child is what year of age?

1

Allis Sign assess for what?

equal height of knees

What indicates a + Allis Sign?

one knee is shorter than the other

What should a normal gait should be?

smooth, rhythmic and coordinated

What else can be done to assess for gait?

have the pt walk on their heals and toes for leg strength

How do you assess balance?

have a pt walk on a straight line

Active ROM

client performs unassisted, muscle strength is built

Active Assisted ROM

nurse helps client with ROM exercises, but the client still builds muscle strength

Passive ROM

nurse must perform all ROM. no muscle strength is built

What should you do if the pt complains of pain or cramping while doing ROM activities?

stop, reestablish correct body alignment, let the pt rest, and see if they are willing to try again

Why is it important to do Passive ROM for pt that have experienced a stroke?

It does not take long for joints to become frozen. Sometimes if joints become frozen, it is impossible for pt to get movement back. This is why the nurse should perform Passive ROM frequently when a pt is in a bed for a long period of time

Which joint do you assess when assessing the jaw?

Temporomandibular Joint (TMJ)

What is the normal opening for one's mouth?

3-6 cm (3 fingers)

A pt clenches their teeth while you apply resistance on their chin. What cranial nerve are you assessing?

Cranial Nerve V: Trigiminal

Pain or crepitis heard when assessing one's jaw indicates what?

TMJ disfunction

Normally one's head should be __________

erect

How do you assess for Cervical Spine muscle strength?

place hand against side of head or jawline and have pt resist pushing

Kyphosis

hunch back. excessive curvature of cervical vertebrae

Lordosis

swayed back. excessive curvature of lumbar vertebrae

What are two ways to assess Cranial Nerve XI (Assessory Nerve)?

placing your hand on the pt head or jawline and have them resist pushing
placing your hands on pt shoulders and have them lift shoulders against resistance

It is still considered normal if one leg is _________ longer than the other

1 cm

When is LaSegue's Test done?

if someone has lower back pain that radiates downward

A + LaSegue's Test can indicate what?

possible herniated disc

How do you assess muscle strength for upper extremities?

placing hands on shoulders and have the pt shrug up against your hands

Internal rotation of upper extremities is having a pt bring their arms where?

in front of them

External rotation of upper extremities is having a pt bring their arms where?

behind their head

Abduction of upper extremities is having a pt bring their arms where?

above their head

Adduction of upper extremities is having a pt bring their arms where?

across their chest

Having the pt resist pushing of their arms assesses what muscle?

biceps

Having the pt resist pulling of their arms assesses what muscle?

triceps

Phalen's Test

having the pt put their wrist together with their fingers facing the floor at a 90 degree angle

Phalen's Test Tinel's Sign test for what?

CTS

Tinel's Sign

percussing the median nerve

What indicates a + Phalen's Test and Tinel's Sign?

numbness or burning

Limited Internal Rotation and Abduction are both an early sign of what?

hip disease

How do you assess muscle strength in lower extremities?

put your hand on the pt thigh and have them push upward

Bulge Sign

stroke medial aspect of the knee 3 times, tap the lateral side, watch for fluid wave on medial side

Bulge sign test for what?

small effusion of the knee

Ballottement

with knee extended use L hand to compress suprapatellar pouch, use R hand to push patella against femur, release pressure keep fingers in place, with fluid the patella displaces

Ballottement test for what?

large effusion of the knee

McMurray Test

with knee flexed, try to pull leg forward

McMurray Test checks for what?

torn meniscus

When is McMurray Test performed?

with history of trauma or local pain of knee

What happens with a + McMurray Test?

clicking of the knee

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