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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