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Health Assessment Exam 4

Terms in this set (133)

What are cognitive and cultural influences on pain perception?
attention people give to their pain, expectation/anticipation of pain, judgement and explanation of pain
What are the types of pain?
Acute
Chronic
Nociceptive
Neuropathic
Acute Pain
recent onset (less than 6 months)
What are physiological signs associated with acute pain?
increase in BP
increase in pulse
increase in respirations
Persistent (Chronic) Pain
may be intermittent or continuous (lasts longer than 6 months)
What are physiological signs associated with persistent pain?
irritability
depression
insomnia
Types of Nociceptive Pain
Somatic
Visceral
Somatic Nociceptive Pain
superficial (cutaneous) pain comes from skin and soft tissue
comes from sources such as blood vessels, joints, tendons, muscle, and bone
easily localized
How is somatic nociceptive pain described?
sharp
aching
throbbing
Visceral Nociceptive Pain
originates from larger interior organs--kidney, stomach, intestine, gallbladder, pancreas
difficult to describe and localize
How is visceral nociceptive pain described?
cramping
dull
--can also be associated with referred pain
Neuropathic Pain
due to abnormal processing of injury or disease affecting the peripheral portions of CNS--usually chronic
does not adhere to the typical phases of pain
may be perceived long after site of injury is healed
most difficult to assess and treat--often requires adjuvant analgesics
What is neuropathic pain described as?
burning
tingling
electrical
stabbing
pins and needles
Which type of pain is protective?
acute pain
Peripheral Neuropathic Pain
pain is felt along peripheral nerve
When should pain be assessed?
regularly
Should you believe self report about pain?
YES!
What are the characteristics of pain?
Onset
Location
Duration
Characteristics
Aggravating and Alleviating Factors
Related Symptoms
Treatment
Severity
When should pain always be reassessed?
after an intervention
Describe the pain scale
0-5 or 0-10
no hurt to hurts worst
What are the components of the pain process?
Transduction
Transmission
Perception of Pain
Modulation
Transduction
injured tissue releases chemicals that propagate pain message
action potential moves along an afferent fiber to the spinal cord
Transmission
the pain impulse moves from the spinal cord to the brain
Perception of Pain
pain is felt
Modulation
neurons from brainstem release neurotransmitters that block the pain impulse
Pain Threshold
point at which a stimulus is perceived as pain
Does pain threshold vary significantly in a person over time?
No
Pain Tolerance
duration or intensity of pain a person will endure before outwardly responding
What decreases pain tolerance?
repeated exposure to pain
fatigue
anger
boredom
sleep deprivation
What increases pain tolerance?
alcohol consumption
medications
hypnosis
warmth
distracting activities
strong faith related beliefs
Use OLDCARTS for
Symptom Analysis--
Health History
Is there a specific exam for pain?
No
What are the cardinal signs of musculoskeletal disease?
pain
redness (erythema)
swelling
increased warmth
deformity
loss of function
What are the components of the musculoskeletal system?
bones- hard rigid and dense
muscles- fibrous tissue that connects to bone to facilitate movement
joints- places of union of two or more bones
Functions of Bones
support for soft tissues and organs
protection of organs--brain and spinal cord
body movement and hematopoiesis
continual remodeling and changing collagen and mineral composition to accommodate stress placed upon them
What are the two parts of the skeleton?
axial skeleton
appendicular skeleton
Axial skeleton
facial bones
auditory ossicles
vertebrae
ribs
sternum
hyoid bone
Appendicular skeleton
scapula
clavicle
bones of pelvis and legs
Joint
functional unit of the musculoskeletal system permits mobility needed for activities of daily living
Types of Joints
Nonsynovial
Synovial
Nonsynovial Joints
immovable or slightly movable
Synovial Joints
movable
What can rubbing of synovial joints lead to?
osteoarthritis
Ligaments
strong, dense flexible bands of connective tissue that hold bones to bones
Tendons
strong, nonelastic cords of collagen located at the end of muscles to attach them to bones
Osteoporosis
bone disease resulting from bone loss
Risk Factors for Osteoporosis
over 50
female
Caucasians and Asians have higher risk
small boned and thin
family history
smoking, alcohol, low calcium, inadequate weight bearing exercise
glucocorticoids and anticonvulsant medications
low estrogen
low testosterone in men
Prevention of Osteoporosis
Primary
diet rich in calcium and vitamin D
weight bearing exercise
avoid smoking and excessive alcohol use

Secondary
routine screening women age 65+
Health Promotion of Osteoporosis
Encourage Primary and Secondary Prevention
Osteoarthritis
cartilage between bones wears down and can lead to pain, stiffness, and swelling
Risk Factors for Osteoarthritis
age--by 85 a person has a 1 in 2 chance
occurs more in women over 45 and more in men under 45
overweight
joint injury to knee or hip
infection
occupations involving knee bending and squatting
Prevention of Osteoarthritis
Primary
diet rich in calcium and vitamin D
weight bearing exercise
avoid smoking and excessive alcohol use

Secondary
routine screening women age 65+
Health Promotion for Osteoarthritis
Encourage Primary and Secondary Prevention
What is family history a risk for?
vertebral diseases
osteoarthritis
rheumatoid arthritis
gout
Which patient's description of pain is consistent with injury to a bone?
a) "Deep, dull, and boring"
b) "Cramping even when not moving"
c) "Intermittent, sharp, and radiating"
d) "Numbness and tingling with movement"
A
How does the nurse determine if a patient's musculoskeletal examination is normal?
a) By reading the examination findings documented in the patient's chart
b) By comparing findings from other patients in the same age group
c) By reading descriptions in health assessment books
d) By comparing the patient's left side with the right side
D
While testing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform which motion?
a) Extension of the arm
b) Flexion of the arm
c) Adduction of the arm
d) Abduction of the arm
B
The nurse testing the patient's muscle strength finds that the patient has full resistance to opposition. How would this finding be documented?
a) Poor or 2/5
b) Fair or 3/5
c) Good or 4/5
d) Normal or 5/5
D
While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements?
a) Flexion, extension, and hyperextension
b) Circumduction, internal rotation, and external rotation
c) Adduction, abduction, and rotation
d) Flexion, pronation, and supination
A
During an assessment of a young adult, the nurse notes that the patient's shoulders are uneven. Which examination would the nurse perform for further data?
a) Ask the patient to rotate each shoulder to assess for range of motion.
b) Ask the patient to push against the nurse's hands with his or her forearm to test muscle strength.
c) Ask the patient to shrug his or her shoulders while the nurse pushes them down to test the muscle strength.
d) Ask the patient to bend forward at the waist while the nurse checks the alignment of the patient's vertebrae.
D
The nurse is comparing the right and left legs of a patient and notices that they are asymmetric. Which additional data does the nurse collect at this time?
a) Passively moves each leg through range of motion and compares the findings
b) Observes the patient's gait and legs as he or she walks across the room
c) Measures the length of each leg and compares the findings
d) Palpates the joints and muscles of each leg and compares the findings
C
A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for the nurse to use with this patient?
a) Inspecting the musculature of the face and neck for symmetry
b) Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain
c) Asking the patient to move her chin to her chest, hyperextend her head, and move her head from the right side to the left side
d) Asking the patient to open her mouth as widely as possible and inspecting the lower jaw for redness, edema, or broken teeth
B
When a nurse asks a patient to place the right arm behind the head, the nurse is testing for which range of motion?
a) Flexion of the elbow
b) Hyperextension of the shoulder
c) Internal rotation and adduction of the shoulder
d) External rotation and abduction of the shoulder
D
With the patient in a supine position, how does a nurse test the external rotation of the patient's right hip?
a) Asking the patient to move the right leg laterally with the right knee straight
b) Asking the patient to flex the right knee and turn medially toward the left side (inward)
c) Asking the patient to place the right heel on the left patella
d) Asking the patient to raise the right leg straight up and perpendicular to the body
C
How is bone pain usually described?
deep
dull
boring
intense
How is muscle pain usually described?
cramping
Normal Findings for Musculoskeletal Assessment
Coordinated smooth gait, complete range of motion against gravity with full resistance (5/5) in all joints without pain, muscle size symmetric bilaterally, shoulders aligned, and vertebral column straight
Expected Movements
Neck and Cervical Spine--Pivotal
Flexion: Bring chin to rest on chest.
Extension: Return head to erect position.
Hyperextension: Bend head back as far as possible.
Lateral flexion: Tilt head as far as possible toward each shoulder.
Rotation: Turn head as far as possible to right and left.

Shoulder--Ball and socket
Flexion: Raise arm from side position forward to position above head.
Extension: Return arm to position at side of the body.
Hyperextension: Move arm behind body, keeping elbow straight.
Abduction: Raise arm to side to position above head with palm away from head.
Adduction: Lower arm sideways and across body as far as possible.
Internal rotation: With elbow flexed, rotate shoulder by moving arm until thumb is turned inward and toward back.
External rotation: With elbow flexed, move arm until thumb is upward and lateral to head.
Circumduction: Move arm in full circle. Circumduction is combination of all movements of ball-and-socket joint.

Elbow--Hinge
Flexion: Bend elbow so lower arm moves toward its shoulder joint and hand is level with shoulder.
Extension: Straighten elbow by lowering hand.
Hyperextension: Bend lower arm back as far as possible. Not all elbows hyperextend.

Forearm--Pivotal
Supination: Turn lower arm and hand so palm is up.
Pronation: Turn lower arm so palm is down.

Wrist--Condyloid
Flexion: Move palm toward inner aspect of the forearm.
Extension: Move fingers so fingers, hands, and forearm are in same plane.
Hyperextension: Bring dorsal surface to hand back as far as possible.
Radial flexion: Bend wrist medially toward thumb.
Ulnar flexion: Bend wrist laterally toward fifth finger; referred to as radial/ulnar deviation.

Fingers--Condyloid hinge
Flexion: Make fist.
Extension: Straighten fingers.
Hyperextension: Bend fingers back as far as possible.
Abduction: Spread fingers apart.
Adduction: Bring fingers together.

Thumb--Saddle
Flexion: Move thumb across palmar surface of hand.
Extension: Move thumb straight away from hand.
Abduction: Extend thumb laterally (usually done when placing fingers in abduction and adduction).
Adduction: Move thumb back toward hand.
Opposition: Touch thumb to each finger of same hand.

Hip--Ball and socket
Flexion: Move leg forward and up.
Extension: Move leg back beside other leg.
Hyperextension: Move leg behind body.
Abduction: Move leg laterally away from body.
Adduction: Move leg back toward medial position and beyond if possible.
Internal rotation: Turn knee toward the inside.
External rotation: Turn knee toward the outside.
Circumduction: Move leg in circle.

Knee--Hinge
Flexion: Bring heel back toward back of thigh.
Extension: Return heel to floor.

Ankle--Hinge
Dorsiflexion: Move foot so toes are pointed upward.
Plantar flexion: Move foot so toes are pointed downward.

Foot Gliding
Inversion: Turn sole of foot medially.
Eversion: Turn sole of foot laterally.

Toes--Condyloid
Flexion: Curl toes downward.
Extension: Straighten toes.
Abduction: Spread toes apart.
Adduction: Bring toes together.
How to Test Musculoskeletal Strength
Ocular musculature
Lids
Eye muscles
Close eyes tightly.
Track object in six cardinal positions.
Attempt to resist closure.

Facial musculature
Blow out cheeks.
Place tongue in cheek.
Stick out tongue; move it to right and left.
Assess pressure in cheeks with fingertips.
Assess pressure in cheek with fingertips.
Observe strength and coordination of thrust and extension.

Neck muscles
Extend head backward.
Flex head forward.
Rotate head from side to side.
Touch shoulders with head.
Push head forward.
Push head backward.
Observe mobility and coordination.
Observe range of motion.

Deltoid Hold arms upward. Push down on arms.

Biceps Flex arm. Pull to extend arm.

Triceps Extend arm. Push to flex arm.

Wrist musculature
Extend elbow.
Flex elbow.
Push to flex.
Push to extend.

Finger muscles
Extend fingers.
Flex fingers.
Spread fingers.
Push dorsal surface of fingers.
Push ventral surface of fingers.
Hold fingers together.

Hip musculature In supine position raise extended leg. Push down on leg above knee.
Hamstring, gluteal, abductor, and adductor muscles of leg Sit and perform alternate leg crossing. Push in opposite direction of crossing limb.

Quadriceps Extend leg. Push to flex leg.

Hamstring Bend knees to flex leg. Push to extend leg.

Ankle and foot muscles Bend foot up (dorsiflexion). Push to plantar flexion.
Bend foot down (plantar flexion). Push to dorsiflexion.

Antigravity muscles
Walk on toes.
Walk on heels.
Grading Muscle Strength
No evidence of contractility Zero (0) 0 0%

Evidence of slight contractility Trace (T) 1 10%

Complete range of motion with gravity eliminated Poor (P) 2 25%

Complete range of motion with gravity Fair (F) 3 50%

Complete range of motion against gravity with some resistance Good (G) 4 75%

Complete range of motion against gravity with full resistance Normal (N) 5 100%
What are the two components of the nervous system?
Central Nervous System
Peripheral Nervous System
What is the CNS?
Central Nervous System
What is the PNS?
Peripheral Nervous System
What are the cerebral lobes?
Frontal Lobe
Parietal Lobe
Temporal Lobe
Occipital Lobe
Frontal Lobe
Primary motor cortex
functions related to voluntary motor activity
Broca's area (left)
Intellectual function, awareness of self, personality
Parietal Lobe
Primary sensory cortex
Temporal Lobe
Primary auditory cortex
Wernicke's area (left)
Occipital Lobe
Primary visual cortex
Cerebellum
CNS
functions include coordinating movement, equilibrium, muscle tone, and proprioception
Brainstem
CNS
Midbrain, pons, medulla oblongata
contains 10/12 cranial nerves
relay stimuli concerning muscle movement to other brain structures
Spinal Cord
CNS
continuation of the medulla oblongata in brainstem
consists of 31 segments each giving rise to spinal nerve pairs
terminates at L1-L2
grouped in tracts to transmit sensory, motor, and autonomic impulses between brain and body
Pathways of the Spinal Cord
Sensory
Motor
Sensory Pathways of CNS
Ascending tracts
spinothalamic tract (pain, temperature, crude touch)
posterior (dorsal) column (position, vibration, fine touch--stereognosis)
Motor Pathways of CNS
Descending Tracts
corticospinal or pyramidal tract (fine voluntary movements)
extrapyramidal tracts (crude automatic movements)
cerebellar system (balance, coordination)
Peripheral Nervous System
Includes all the nerves outside the brain and spinal cord
12 pairs of cranial nerves and 31 pairs of spinal nerves and all their branches
carries sensory messages to the CNS, motor messages from the CNS and autonomic messages to internal organs and blood vessels
Components of the PNS
Autonomic Nervous System
Somatic Nervous System
Components of the Autonomic Nervous System
sympathetic and parasympathetic
Is the autonomic nervous system voluntary or involuntary?
involuntary
Sympathetic Nervous System
Fight or Flight
Parasympathetic Nervous System
Rest and Digest
Somatic Nervous System
voluntary movement
How many cranial nerves are there?
12
Cranial Nerves
Olfactory - I
Optic - II
Oculomotor - III
Trochlear - IV
Trigeminal - V
Abducens - VI
Facial - VII
Acoustic - VIII
Glossopharyngeal - IX
Vagus - X
Spinal Accessory - XI
Hypoglossal - XII
Cranial Nerve I
Olfactory
sensory
smell and reception interpretation
Cranial Nerve II
Optic
sensory
visual acuity and visual fields
Cranial Nerve III
Oculomotor
motor
raise eyelids, most extraocular movements

(parasympathetic)
(pupillary constriction, change lens shape)
Cranial Nerve IV
Trochlear
motor
downward, inward eye movement
Cranial Nerve V
Trigeminal
motor
jaw opening and clenching, chewing and mastication

sensory
sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin
Cranial Nerve VI
Abducens
motor
lateral eye movement
Cranial Nerve VII
Facial
motor
movement of facial expression muscles except jaw, close eyes, labial speech sounds (bmw)

sensory
taste on the anterior 2/3 of tongue, sensation to pharynx

(parasympathetic)
(secretion of saliva and tears)
Cranial Nerve VIII
Acoustic
sensory
hearing and equilibrium
Cranial Nerve IX
Glossopharyngeal
motor
voluntary muscles for swallowing and phonation

sensory
sensation of nasopharynx, gag reflex, taste on the posterior 1/3 of tongue

(parasympathetic)
(secretion of glands, carotid reflex)
Cranial Nerve X
Vagus
motor
voluntary muscles of phonation (guttural speech sounds) and swallowing

sensory
sensation behind ear and part of external ear

(parasympathetic)
(secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract)
Cranial Nerve XI
Spinal Accessory
motor
turn head, shrug shoulders, some actions for phonation
Cranial Nerve XII
Hypoglossal
motor
tongue movement for speech sound articulation (ltn) and swallowing
How to remember names and order of the cranial nerves
On
Old
Olympus
Towering
Top
A
Finn
And
German
Viewed
Some
Hops
How to remember sensory or motor or both for cranial nerves
Some
Say
Marry
Money
But
My
Brother
Says
Big
Boobs
Matter
More
How are spinal nerves named?
According to where they emerge from the spinal vertebrae
Myotomes
Motor fibers that innervate muscles
Dermatomes
Sensory fibers that innervate skin
C Dermatomes
neck
shoulders
posterior and lateral arms
T Dermatomes
thorax
mid back
anterior and medial arms
L Dermatomes
low back
anterior and lateral legs
most of feet
S Dermatomes
genitalia
buttocks
anus
posterior leg
heels
Reflex Arc
controls autonomic responses (involuntary) to stimuli at level of spinal cord
frees the cerebral cortex from involvement in some muscle movements that occur in the body
provides rapid response from painful stimuli
Four Types of Reflexes
deep tendon
superficial
visceral
pathologic
What is intact when the reflexes are intact?
receptor
stimulus
sensory neuron
motor neuron
response by effector
What level is tested for deep tendon reflexes?
spinal level
Functions of Sympathetic Nervous System
increases BP and HR
vasoconstriction of peripheral vessels
inhibits peristalsis
dilates bronchi
Functions of Parasympathetic Nervous System
deceases HR and force of myocardial contraction
decreases BP and respirations
stimulates peristalsis
CVA
Cerebrovascular Accident (Stroke)
Risk Factors for CVA
older adults
men; women are more likely to die from stroke than men
family history--parent, grandparent, or sibling
African Americans, Hispanics, American Indians, Alaska Natives have greater risk than non-Hispanic whites or Asians
smoking
alcohol
high blood cholesterol
obesity
hypertension
diabetes mellitus
previous CVA, TIA, heart attack
atrial fibrilation
Deficits of CVA
aphasia
changes in memory and cognition
Broca's Aphasia
difficulty speaking
Wernicke's Aphasia
difficulty understanding
Parkinson's Disease
chronic and progressive movement disorder resulting from the degeneration of the dopamine-producing neurons in the substantia nigra of the basal ganglia

characterized by resting tremors of the face, jaw, hands, arms, and legs; bradykinesia; rigidity; and postural instability
Multiple Sclerosis
Progressive demyelination of nerve fibers of the brain and spinal cord

fatigue, depression, and paresthesias, focal muscle weakness; ocular changes (diplopia, nystagmus); bowel, bladder, and sexual dysfunction; gait instability; and spasticity
Myasthenia Gravis
weakness of voluntary muscles that improves with rest and administration of anti-cholinesterase drugs
Seizure
sudden, uncontrolled electrical disturbance in the brain
What can seizures affect a person's ability to do?
activities of daily living such as brushing their teeth and combing their hair
people may become weak, confused, or dizzy after a seizure
Health Promotion for TBI
wear a helmet
wear a seatbelt
avoid distracted/impaired driving
Structures that affect balance
semicircular canals
cerebellum
A change in level of consciousness is the first sign of?
impaired cerebral function
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