Week 9 (Ch 23-24) - Denver College of Nursing - PDF

11/18/2024 WEEK 9 (CH 23-24) Denver College of Nursing 1 TERMINOLOGY -...

11/18/2024 WEEK 9 (CH 23-24) Denver College of Nursing 1 TERMINOLOGY - tenderness /pan Circumduction- Pronation- palms Supination- Flexion- Bending circular manner down palms up Abduction- Adduction- Extension- Hyperextension: moving away from moving toward straightening past straight line midline midline Internal/medial External/lateral Dorsiflexion: Plantar flexion: rotation- rotating rotation- rotating ankle/toes up point toes down toward midline away from midline 2 2 Medications HEALTH HISTORY Arthroplasty : joint replacement ' Previous or chronic musculoskeletal conditions? PMH: Injuries? Trauma? Surgeries? Arthroplasty = joint replacement Medications? Smoker? E- muscle Myalgia pan Ostealgia - Bone Pan Review of Systems: Arthralgia - joint pain Changes in muscle strength? Health promotion (Calcium/Vitamin D, exercise) OPQRSTU Limitations in ADLs? - bathing, toileting, dressing, grooming, eating, mobility, communicating Functional Assessment: Sports, hobbies, work? Mobility aids? 3 3 1  Hard - washing - Vitals Call 3) watch Apple  11/18/2024 screening inspect palpate : MUSCULOSKELETAL EXAMINATION Inspection & palpation of joints Screening exam integrated with each body region; suffices for most people: observe ROM as person proceeds through general motions Complete musculoskeletal use a cephalocaudal approach, with exam is appropriate for persons with current bilateral comparisons for examining disease or changes in bones, muscles, and joints. functional ability: 4 4 ( more in-depth MUSCULOSKELETAL EXAM OVERVIEW ) ☆ Overall Inspection: posture, gross deformities, atrophy (not used / smaller Inspect for color, swelling, deformities, masses Joints: Palpate for heat, tenderness, crepitus/crepitation Assess active ROM while demonstrating each Range of Motion (ROM): movement ☆ If you see a limitation, gently attempt passive ROM itwaaYg ↳ nurse assists Graded out of 5 Muscle Strength: Test against gravity and resistance 5 5 position alignment : 5 OVERALL INSPECTION [ kyphosisscoliosis , lordosis ? Inspect skeleton by observing posture and extremities for alignment, symmetry, size, and gross deformities Muscle mass Inspect overall musculature for symmetry and muscle wasting Jarvis p. 597 6 6 2  11/18/2024 HEAD, NECK, CERVICAL SPINE ( Ip) Inspect & Palpate Assess Test crepitus , tenderness, heat Inspect & Palpate Assess ROM: lateral Test Muscle Strength: Joint: cervical spine bending; rotation; turn head against Masses and TMJ flex/extend resistance (CN XI) 515 normal 7 7 toffs SPINAL COLUMN Inspect profile first; normal is double ‘S’ shape Inspect posteriorly - have patient bend at waist Assess ROM: flex/extend; rotation; lateral bend L K S 8 8 SPINAL ☆ remember these in CURVATURES Scoliosis Lateral curvature Kyphosis Excessive outward curvature of Lordosis Excessive inward curvature of lumbar spine words not just in pics thoracic spine Back pain Can occur with Can occur with Uneven injury, age, or abdominal shoulder, hip osteoporosis weakness, levels pregnancy, or Rib and flank neuromuscular asymmetry disease 9 9 3  11/18/2024 Heat tenderness crepitus , SHOULDERS , , symmetry Inspect & palpate joints for abnormalities Abduct away body ( body) Adduct Assess ROM: adduct/abduct; external/internal to adding rotation; flex/extend Test muscle strength: abduct against resistance back 10 strength ( hand while on shoulders) 10 ( suponat holding soup) ELBOWS Inspect & Palpate joint for abnormalities pronation (pouring soup out Assess ROM: flex/extend; supinate/pronate Test Muscle Strength: biceps (flexion) and triceps (extension), while stabilizing the person's arm with one hand 11 11 Inspect & Palpate joints Assess ROM: Flexion and extension of wrists Flexion and extension of fingers Hand grip two fingers Test Muscle Strength: Hand grips: offer two fingers WRISTS & HANDS eÑ get 12 12 4  11/18/2024 HIPS Client should be supine for hip assessment Important for older adults as limited ROM and weakness in hips can contribute to falls. Inspect & Palpate joint Assess ROM: flexion/extension; internal/external rotation; abduction/adduction Test Muscle strength ↳ sitting 13 13 LEGS & KNEES Inspect & Palpate knee joints for abnormalities, including fluid accumulation Assess ROM: Flexion, extension hyperextension up to 15° is okay Muscle strength: Hamstrings (flexion) & Quads (extension) Limping gait can indicate limited ROM, pain 14 14 MEASURE LEG LENGTH Jarvis p. 600-601 - growth plate injuries * Indications: back or hip pain, abnormal gait True leg length: anterior iliac spine to medial malleolus True LL discrepancies can be congenital or from injury ☆ Apparent leg length: umbilicus to medial malleolus I Apparent LL discrepancies can be due to spine, hip, or pelvic abnormalities 15 15 > middle 5  11/18/2024 (step on ) petal ANKLES AND FEET gas Inspect & Palpate ankle and toe joints not Assess ROM: dorsiflexion & plantar flexion; eversion and inversion; equal bilateral flexion and extension of ( toes cp) toes ↳ into Body Test Muscle strength: foot pushes & pulls 16 16 ☆ FALL PREVENTION ☆ - - Cau armbands ight Falls can be caused by mobility problems, confusion, musculoskeletal injuries, dehydration. - g⑨ , Alarms , rails per gctdine grippy ' Falls are one of the biggest causes of traumatic deaths. socks Elderly patients have a higher risk of falls and greater morbidity and mortality associated with falls. Falls can result in musculoskeletal injury, head trauma, and emotional stress. 17 17 ☆ $ ☆ Timed Get Up and Go (TUG) test: Time it takes and sit down again Normal = = can't legs can tell some other symptoms , Jarvis p. 677 SPINAL CORD INJURIES Severe spinal cord trauma results in temporary spinal shock: loss of function, sensation, and reflexes below injury. Injury to cervical spine: Injury to thoracic, lumbar, or sacral spine: Quadriplegia Paraplegia Upper extremity DTRs are affected Lower extremity DTRs are affected C3-C5 nerve roots innervate diaphragm (monitor breathing) Injuries at T6 or higher can cause autonomic dysreflexia with noxious stimuli: sudden h/a, flushing, diaphoresis, HTN with reflex bradycardia. 49 49 50 50 CEREBROVASCUL AR ACCIDENT (CVA) AKA” stroke” or “brain attack” Risk factors: HTN, DM, HLD, carotid artery disease, a-fib, smoking S/S depend on severity of ischemia/bleed and the brain area affected, but commonly include aphasia, hemiparesis, h/a, balance or vision problems Large hemorrhagic strokes tend to increase ICP quickly  coma, seizures Acute hyporeflexia, flaccidity Residual hemiparesis results in hyperreflexia, rigidity Neuro Checks q1-2 hr at first 51 51 17  11/18/2024 triad → into cranial Cushing pressure INCREASED INTRACRANIA L PRESSURE Increased ICP can result from tumors, bleeding,TBI, and infections. 52 52 most common in women ÷: 34 0 g.. Autoimmune progressive demyelination of nerve fibers of brain and spinal cord (UMN) S/S vary: MULTIPLE memory spasms Cognitive or mood changes SCLEROSIS (MS) Vision changes; nystagmus Pain: head, eyes Marked fatigue Balance issues - speech , , Paresthesia Difficulty moving 53 53 Dopamine ↓ Resting Tremor worse at rest - : PARKINSON’S DISEASE Rigidity *Resting “pill rolling” ' Develops slowly as brain’s dopamine- tremor balance /coordination : impaired producing neurons in Tremor is worse at rest *Rigidity basal ganglia degenerate *Impaired *Bradykinesia Flat affect balance/coordination slow movement Stooped posture Shuffling gait Cognitive changes 54 54 18  11/18/2024 55 GUILLAIN-BARRÉ SYNDROME Widespread demyelinization of peripheral nerves (LMN) May be preceded by virus or certain immunizations 80-90% recover with few or no residual deficits *Ascending flaccid paralysis begins with weakness in lower extremities and hands and ascends from Clinical findings: there DTRs and superficial reflex absent 56 15% will develop resp depression– monitor closely. 56 Autonomic : extremity DysvefuxiaLower! ! damage to ,↑HR " sweating knows - Body 19