258 Nursing SDSU Exam 3 – Flashcards
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Central-CNS
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Brain and Spinal cord
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Peripheral-PNS
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Cranial Spinal ---Functions: Sensory, Motor, Autonomic, Reflexes
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Developmental- Newborns and Infants
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-Brain growth- Cerebral cortex within 1st year -Myelination order: cephalacaudal and proximodistal -----------------------------head, neck, trunk, extremities -*Primitive reflexes:* ---------------------rooting/sucking ---------------------tonic neck ---------------------moro (startle) ---------------------palmer grasp ---------------------planter grasp ---------------------stepping -Underdeveloped senses
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Developmental- Preschool to schoolage
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Assess behavior during play Asses motor by watching Asses gate while walking and running
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Developmental-Aging adult
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-Atrophy- steady loss of neurons in brain and spinal cord -Muscle losses tone and bulk -Slower reactions -Decreased cerebral blood flow
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5 Sections of a completed neuro exam
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Mental Cranial Motor Sensory Reflexes
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Neuro exam types
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-Screening: Well has no findings -Complete exam: For person with signs of dysfunction -Recheck: Person with changes
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Neuro Subjective- Assess
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Headache Head Injury Dizzy Seizures Tremors Weakness Incoordination Numbness/tingling Difficulty swallowing Past History
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Mental Status- Asses
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-*Appearance*: Posture, Body Movements, Dress, Hygiene -*Behavior*: LOC, Facial expression, Speech, Mood -*Mental Status*: Consciousness, Language, Orientation, Attention, Abstract reasoning (process and content), Perceptions
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LOC
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Alert, Lethargic, Obtunded (dull) Stupor or Semi-coma, Coma
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Mood and Affect
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*Mood*-a durable, prolonged expression of emotional state that colors the emotional life- pervasive and sustained *Affect*- A temporary or current emotional state- as expressed in current behaviors *examples* Anxiety, Depression, Euphoria, Rage, Ambivalence, Irritable
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Cognitive Function
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-Orientation to time, place, and person = Oriented x3 -Attention span: Give a sequence of things to -Recent memory: 2 hour recall -Remote memory: Past history, historical events
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Assess Cognitive function
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*Mini Mental State Exam* Supplemental and standard: great with elderly, measures change Max score is 30 Score of 23 or below evidence of impairment and need to refer for further review
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Mini Mental
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-*Orientation*- What is the year, season, date, day, month? Where are we? What street do you live on -*Registration*- Name 3 objects, have patient repeat if they can later in recall -*Attention and calculation*- Serial 7's Spell world backwards -*Recall*- Have patient tell you 3 words from earlier -*Language*- Show 2 objects and ask what they are Have patient follow a 3 step instruction, tell and read Have patient read and follow a command Have the patient copy a design
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Thought process and perception
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Does the person make sense? Is speech consistent and logical? Is the person consistently aware?
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Objective
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Cranial Nerves Motor System Sensory System Reflexes
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I (1)
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-Olfactory- ______________________________-SENSORY- Smell
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II (2)-
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-Optic-_____________________________________-SENSORY- -Acuity Snellen - Letters in front _____normal 20/20 -Visual Fields Confrontation - Peripheral
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III (3) IV (4) VI (6)
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-Oculomotor- -Trochlear- -Abducens-______________________________________-MOTOR- Check Extra Ocular Motor Check pupillary (III) PERRLA
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V (5)
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-Trigeminal-____________________________________-SENSORY/MOTOR- Clinch teeth, Pull down on jaw Close eyes and then Cotton ball on face for sensory Cornea puff of air
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VII (7)
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-Facial-__________________________________________-SENSORY/MOTOR- Smile Frown Puff out cheeks Taste- salty and sweet
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VIII (8)
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-Acoustic-______________________________________-SENSORY- *Whisper test*: stand behind and whisper a word *Rhine test*: Bone conduction and air conduction. Place fork behind ear on bone until they can't hear it and then next to hear until they can't hear it anymore. AC>BC needed *Weber test*: Place fork on top of head...can they hear both sides?
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IX (9) X (10)
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-Glossopharyngeal- -Vagus-_______________________________________-SENSORY/MOTOR- X + XI------Gag reflex and swallow IX-----Move tongue up and down and side to side in mouth X------uvula and soft palate say aaahhh
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XL (11)
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-Spinal accessory-__________________________-MOTOR- Turn head side to side and shoulder up all with resistance Muscle strength?
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XII (12)
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-Hyperglossal-___________________________________-MOTOR- Stick tongue out and move side to side Is tongue midline?
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Muscle strength-
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Inspect and Palpate 5-Normal against gravity 4- Weak against gravity 3- No resistance, but lifts antigravity 2- No lift antigravity, move side to side 1- Trace contraction, no movement 0- No contraction, no movement
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Motor function
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Coordination Balance Gross- motor function
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Cerebral function tests-MOTOR
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-*Gait*: ----------- tandem walking -*Lower extremity*: ------------*Romberg*: feet together and eyes closed ------------Heel to shin -*Higher extremity*: -------------Rapid alternating movements: Flipping hands, finger to nose, finger to finger
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Sensory tests
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-*Spinothalamic Tract*: -------------Pain: tongue blade for dull/sharp -------------Temp: only use if abnormal -------------Light touch: cotton wisp -*Posterior Column Tract*: --------------Vibration: Tuning fork on bony, distal then feet and fingers then knees --------------Position: Finger or toe, move up and down --------------Fine touch: Need normal to near normal
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Stereognosis
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Recognizes objects
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Graphesthesia
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Number traced on skin
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Two point discrimination
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Perceive 2 separate points
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Extinction
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Feel touch on 2 separate points
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Point location
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Recall of sensation
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Reflexes
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Stretch or deep tendon reflexes (DTR's) Stretch receptors, tapping makes the muscles longer and the stretch receptors are stimulated and react to the change/ Look for symmetry and grade -Biceps:: C5-C6 -Triceps:: C7-C8 -Quads (knee jerk):: L2-L4 -Achilles:: L5-S2 -Babinski:: sole of bare foot- dorsiflexion (flare toe) is abnormal except in infant
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Reflex grading
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0- No response 1+ Diminished/low-----hypoereflexia *2+* Average/ normal 3+ Brisker than average 4+ Very brisk-----hyperreflexia (indicative of disease)
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Glasgow Coma Scale
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Best eye opening response Best motor response Best verbal response Score of 15 is fully alert Score of 7 or less is a coma
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Stoke- Warning signs
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-Sudden numbness/ weakness of the face, arm, leg especially if only one sided -Sudden confusion, trouble speaking, or understanding -Sudden vision problems in one or both eyes -Sudden trouble walking, dizziness, loss of balance or coordination -Sudden sever headache with no known cause
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Stroke- Interventions
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-Note time -Call 911 or follow plan -It is a medical emergency -Treatment must be initiated within 3 HOURS of onset
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Mental status
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-Screen for suicide- Evidence of depression or sadness? Ask questions -Warning signs of suicide- Hopelessness in a depressed individual Prior attempts Verbal messages Saying goodbye, giving away prized possessions A given plan
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The head- Infants and Children
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*Fontanels* -Posterior- Triangle, closes by 1-2 months -Anterior- Diamond, closes by 9m - 2y Head is larger than chest at birth and will equal chest by 2 years by 5-7 cm
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Infants
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*Caput succedaneum* Cone head. Swelling and bruising of the presenting portion of head. Birth trauma. NOT suture line related. *Cephalhernatoma* Hemorrhage over one cranial bone Stays within suture portion Absorbed during the first weeks of life. Birth trauma.
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Facial developments
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*Pregnant female* 2nd trimester chloasma may appear (blotchy spots) fades after delivery *Aging adult* Bones more prominent, Sagging skin, Decreased subcutaneous fat and moisture, Sunken look if teeth lost
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Lymph nodes in neck
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Major part of immune Detects and gets rid of foreign substances 10 groups closely packed *Possible infection* Tender Enlarged Moveable Should return to normal after infection is gone *Possible malignancy* Non-tender Firm to hard Not moveable Recheck in 2-4 weeks if still present
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Thyroid Gland
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Endocrine gland secrets T3 and T4 and regulates cellular metabolism Two lateral lobes, Straddles trachea Check for enlargement, consistency, symmetry and presence of nodes. Stand behind person and gently push over trachea to palpate thyroid gland Normal= cant feel Goiter= enlarged thyroid
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Nose
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Hydrates and warms air *Paranasal* Frontal: absent at birth Maxillary: after all teeth Ethmoid: After puberty
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Developmental changes of nose
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*Pregnant women* Stuffiness and epistaxis (nose bleeds) Gums hyperemic and soften and bleed with brushing *Aging adult* Loss of subcutaneous fat makes nose appear larger Nasal hair coarser and stiffer Loss of taste- slow atrophy of tissues
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Teeth and development
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*Children*-all 20 deciduous (baby) teeth by age 2 1/2 *32 permanent teeth* Girls sooner than boys Blacks sooner than whites Adult and elderly: Natural or dentures (remove for exam)
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Hearing
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Is vital to language development Issues cause delay
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Ears
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Adults: Up + back Children: Down + back
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Cerumen
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-Ear wax- Yellow or brown Produced by sweat glands Dry-grey, flaky Wet- honey brown, dark brown + moist Protects the moistens the ear canal. Don't clean unless obstruction is present.
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Tympanic membrane
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-Eardrum- Separate inner and outer Pearly grey, oval, flat, or concave Cone of light- 5 oclock: right and 7 oclock: left
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Middle ear
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Conducts sounds from outer ear from vibrations Reduces amplitude Equalizes pressure on each side
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Eustachian tube
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Connects middle ear and nose....allows air passage Normally closed, unless yawn or swallow Shorter/ wider in children = higher risk of infection
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Inner ear
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Bony labyrinth hold sensory organs
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Air conduction
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normal hearing
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Bone conduction
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Vibrations directly to the inner ear
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Hearing loss
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*Conductive* Mechanical- external or middle ear Decreased amplitude Cerumen impaction Something in ear Tympanic membrane perforated Pus *Sensorineural* Pathological of inner ear Nerve damage *Mixed* Loss of both
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Ears and hearing Developmental
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Second hand smoke Environmental Elderly: ---------Increase cerumen ---------Presbycusis ---------Course/stiff cilia can't vibrate well or at all
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Otoscopic exam
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Looks inside ear canal towards tympanic membrane Up and back for adults Down and back for children
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Whisper test
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Stand behind person and whisper a word Is it equal in both? *Conductive loss* louder in bad ear *Sensorial loss* louder in better ear
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Rhinne test
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-Air conduction should be greater than bone conduction- Place fork behind ear on bone (mastoid process) until the pt can't hear it, then place beside ear until pt can't hear it. If there is conductive loss bone>air
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Weber test
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Bone conduction Place fork on top of head. Is it hear bilaterally?
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Eyes: Infants and Children
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Newborns: -------------limited sight. 80% nearsighted. Periph intact Infants: ------------macula develops by 4 months, fully by 8 months Light perception by Blink and Pupillary reflexes First exam by preschool age
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Eye: Aging adult
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Change in eye structure Decreased tears Atrophy By age 40- presbyopia, cant focus near Slowed focus near to far Need more light Cataracts- lens fogs from clumping of proteins
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Glaucoma
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Increased intraocular pressure *Loss of peripheral* Men>women
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Macular degeneration
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Most common cause of blindness Breakdown of cells of the macula in the retina *Loss of central* Women>men
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Medication Administration
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Log in with ID Don't leave meds alone Watch them take Use clinical judgement Always have someone check your calculations
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SIX rights of medication
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1. Right *medication* 2. Right *dose* 3. Right *patient* 4. Right *route* 5. Right *time* 6. Right *documentation*
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Patients have a right
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To be informed Refuse a med Have a med history To be advised of experimental and research meds To receive safety info To receive support therapy To not receive unneeded meds
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Medication routes
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*Oral*- easiest and most preferred *Topical*- -----skin -----nose (roll to side and head back) ----- eye (avoid cornea) ----- ear ------vaginal ------ rectal- (towards umbilicus) *Inhalation*- *Irrigation*- (usually sterile water) *Parenteral* *Injection*
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Sexual function
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*Newborn + infant*: -------------------- psychosexual development *Toddler/preschooler*: -------------------- explore their body, potty training *School age*: -------------------- adopt roles *Adolescence*: -------------------- hormonal changes, puberty, orientation, relationship conflicts, at risk for abuse *Adult*: -------------------- adult intimate relationship, pregnancy, raising children, infertility *Older adult*: -------------------- menopause, erectile dysfunction
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Factors that affect sexuality
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-Loving and trusting relationship -Emotional state -Values and morals -Self image/ confidence -Pregnancy -Enviroment
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Alterations in sexuality
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-Illness and disability -Medications -Surgery -Infertility -Sexual Abuse -Inhibited sexual desire -------------Physical: meds, neuro, hormonal -------------Psychological: depression, intrapersonal -Impotence (erectile dysfunction) -------------*Primary*: never could achieve erection -------------*Secondary*: could but can't now ----------Psychological- does during sleep ----------Physiological- can't at all -Ejaculation Dysfunction -------------Premature: subjective, sometimes anxiety -------------Inability: (into vagina) ---------Primary- psychological ---------Secondary- intrapersonal, meds, nerves -Orgasmic dysfunction ------------Very common in women: lack of enough stimuli, problems in relationship -Dyspareunia ------------Painful sex -Vaginismus ------------Involuntary contraction of the vaginal muscles
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Breast
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Infants: affected by maternal hormones, symmetrical Adolescents: 8-10 years starts, Asymmetry, Tanner staging, gynecomastia in males Pregnancy: blue vascular patterns, large, nipples increase size, areolae darken, colostrum, engorgement in lactation by day 3 Aging: pendulous, sagging, flattened. nipples may retract, feel granular, gynecomastia can occur in men from reduced testosterone
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Breast exams
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Self- start by age 20 Clinical- Yearly or every 3 years 20-30y old, annually after 40 Mammogram- Finds very small masses, 2 views each breast
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Female reproductive
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Pregnancy: Uterus increases, mucus plug. vaginal secretions more acidic Aging: Ovaries stop producing hormones, uterus shrinks, vaginal secretions more alkaline Pap starts at age 21 21-29 every 3 years 30-65 every 5 years and HPV >65 no testing
