Lungs and Respiratory System
Exam 2 Study Guide and Vocabulary
Module 5: Gas Exchange
Chapter 11: Lungs and Respiratory System
Review anatomy and physiology of the respiratory system
Describe assessment findings associated with respiratory distress
Respiratory Distress
Apprehension with restlessness
Nasal flaring
Supraclavicular or intercostal retractions
Bulging with expiration
Use of accessory muscles
Paradoxical chest wall movement (trauma)
Tripod position
Describe paradoxical chest wall movement and tripod position
Paradoxical chest wall movement may occur after chest trauma when the chest wall moves in during inspiration and out during expiration.
Tripod position (leaning forward with the arms braced against the knees, a chair, or a bed) also suggests respiratory distress in patients with COPD or asthma. Tripod position enhances accessory muscle use.
Compare and contrast eupnea and dyspnea
Sighing
frequently interspersed deeper breath; may indicate fatigue or anxiety
Retraction
chest retraction appears when intercostal muscles are drawn inward between the ribs and indicates airway obstruction that may occur during an asthma attack or pneumonia.
Bradypnea
slower than 12 breaths per minute
Kussmaul's
rapid, deep, labored
Tachypnea
faster than 12 breaths per minute
Biot
irregularly interspersed apnea periods in disorganized sequence of breaths
Hyperventilation
faster than 20 breaths per minute, deep breathing
Cheyne-stokes
varying periods of increasing depth interspersed with apnea
Air trapping
increasing difficulty in getting breath out
Prolonged expiration
asthma?
What conditions may lead to clubbing?
Chronic hypoxia observed in patients with cystic fibrosis or COPD
Describe thoracic asymmetry (normal shape, symmetry and muscle development)
The ribs should slope down at about 45 degrees relative to the spine. The thorax should be symmetric. The spinous processes should appear in a straight line. The scapulae should be bilaterally symmetric. Muscle development should be equal.
Detect thoracic asymmetry by inspection alone is ask the patient to take a full deep breath and look for a local lagging in chest expansion. Skeletal deformities such as scoliosis may limit the expansion of the chest. Patients with emphysema may have a barrel shaped chest due to chronic air trapping in the alveoli.
Describe steps for auscultation of posterior and lateral thorax
Auscultation of Thorax
Have patient sit upright and breath deeply and slowly through mouth
Use symmetrical pattern to auscultate listen for full respiratory cycle (full inspiration/full expiration)
Compare side to side using established landmarks
Ask client to fold arms in front to give better access to lateral sounds
Tips for Auscultation
Bumping stethoscope tubing can cause the sound to be distorted
If patient is cold and shivering sound will be distorted
Excess hair on chest can give false crackle or pleural friction rub sounds
Extraneous noises (gown, drape) sound like crackle or pleural friction rub
Describe the following breath sounds with anticipated locations and characteristics
Describe the following adventitious sounds (include possible illness)
Describe pectus carinatum: ○ or pigeon chest; note prominent sternum
Describe pectus excavatum: ○ or funnel chest; sternum is indented above xiphoid
Describe anticipated anteroposterior diameter: ○ about half the lateral diameter; 1:2 ratio
Describe barrel chest: ○ patients with emphysema may have a barrel shaped chest due to chronic air trapping in the alveoli; increases the costal angle
Describe pattern of auscultation: ○ snake-like pattern?
Describe palpation method
Palpate Posterior thoracic muscles
Use palmar surface of fingers to feel texture and consistency of skin over chest and the alignment of vertebrae
Use both hands to compare the two sides
Expected Findings
Vertebrae should be straight and non-tender
Scapulae should be symmetric and musculature well developed
Unexpected Findings:
Crepitus- crackling sensation under fingers indicates air leak
Pleural friction rub- coarse grating sensation during inspiration (inflammation of pleural surface)
Palpate posterior thoracic wall for expansion
Stand behind patient and place both thumbs on either side of spinal process about level T 9 or T 10
Maintain thumb position extend fingers of both hands laterally
Ask patient to take several deep breaths
Both thumbs should move apart symmetrically
Unilateral movement requires further evaluation
Possible causes include pulmonary disease, fractured rib, chest wall injury, pneumonia and atelectasis
Describe process for assessing vocal fremitus?
Consolidation of lungs- alveolar space is filled with liquid instead of gas
Vocal (tactile) fremitus (Palpation)
Vibration resulting from verbalizations
Use palmar surface of the hand over right/left lung fields
Ask patient to recite “1, 2, 3,” or “99”
Vibrations should be equal
Unequal vibrations- occurs with pneumothorax, pleural effusion, atelectasis, or bronchial obstruction
Decreased fremitus-occurs COPD, pulmonary edema, excess fat
Increased fremitus (enhanced vibrations)- occurs in patients with consolation (pneumonia, tumor)
What is the expected tone, intensity, pitch, duration and quality of percussion?
Percussion over Lung Fields
Sound depends on air-tissue ratio
Perform when suspect overinflated or consolidation of lungs
Have patient sitting position with arms folded in front and head bent forward to move scapula laterally and expose lung field
Percuss between ribs and compare right to left
Use same landmarks as for auscultation
Sounds resonant (loud intensity, loud pitch, long duration, hollow quality)
Hyperresonance is heard in over inflation (emphysema)
Dull tones heard in pneumonia, pleural effusion or atelectasis
Describe process for assessing diaphragmatic excursion
Uses percussion to estimate the location of the diaphragm during inspiration and expiration. This procedure is used when increased downward expansion is suspected (which may be found in patients with emphysema) or when decreased expansion is suspected (which may be found in patients with an enlarged liver)
Describe the following:
Vocal resonance
Bronchophony
Instruct patient to say “99” “e-e-e” or “1,2,3”
Use diaphragm to auscultate response
Expect: muffled tone “nin-nin” or “1, 2, 3” (document as -)
Response is loud, clear consolidation is present (document as +)
Whispered Pectoriloquy
Same process as bronchophony except patient whispers “1, 2, 3” during auscultation
If + advance to next assessment
Egophony
Final test for vocal resonance
Ask patient to say “e-e-e”
Expected response is muffled “e-e-e”
Unexpected finding- sounds like “a-a-a”
What is the significance of tracheal deviation?
One cause of tracheal shift is an increase in lung volume of the contralateral lung and/or pleural space caused by pneumothorax, large pleural effusion, or massive consolidation; OR decrease in volume of the ipsilateral lung caused by atelectasis
Describe the following common lung problems
Acute bronchitis
Inflammation of the mucous membranes of the bronchial tree caused by virus or bacteria
Assessment Findings:
initial non-productive cough progressing to productive, substernal chest pain aggravated by coughing
Fever, malaise, and tachypnea
Rhonchi and wheezing
Nursing Dx: Impaired Gas Exchange R/T inflammation bronchial tree AEB productive cough, tachypnea, rhonchi and wheezing
Pneumonia
Inflammation of the terminal bronchioles and alveoli caused by virus, bacteria, fungi, virus or aspiration
Assessment Findings:
Viral- non-productive cough or clear sputum
Bacterial- productive cough with white, yellow or green sputum
Fever, malaise, pleuritic chest pain, pulmonary consolidation, inspiratory crackles, increased tactile fremitus, egophony and whispered pectoriloquy
Tuberculosis
Contagious bacterial infection caused by mycobacterium tuberculosis and transported by airborne droplets
Lungs, kidneys, bone, lymph nodes and meninges are involved
Assessment Findings:
usually asymptomatic during early stages then develops fatigue, anorexia, weight loss, night sweats and fever
Late disease involves frequent mucopurulent sputum
Pleural effusion
Accumulation of serous fluid in pleural space between visceral and parietal pleura
Assessment Findings:
depends on fluid accumulation and position of patient
If large accumulation rapidly- dyspnea, intercostal bulging, or decreased chest wall movement
Asthma
R/T Chronic respiratory disorder characterized by airway obstruction and inflammation
Triggers include: environmental exposures, viral illness, allergens, and genetic predisposition
Most children develop symptoms in early childhood
AEB: persistent cough that is worse at night, increased respiratory rate, prolonged expiration, audible wheeze, shortness of breath, tachycardia and use of accessory muscles and cough; also may appear anxious
Emphysema
Destruction of alveolar wall → permanent enlargement of the air spaces
Major risk factor is cigarette smoking
Small percentage result from inherited α1 antitrypsin enzyme deficiency
Assessment Findings
underweight with barrel chest, shortness of breath with minimal exertion, pursed-lip breathing, tripod position, diminished breath and voice sounds, possible wheezing or crackles, decreased diaphragmatic excursion
Chronic bronchitis
Hypersecretion of mucus by goblet cells of trachea and bronchi
Results in productive cough for 2 months in 2 successive years
Assessment Findings
Productive cough, increased mucus, dyspnea, rhonchi (sometimes cleared by coughing) crackles when mucus occludes alveoli
Pneumothorax
One of 3 types resulting in air in the pleural space
Closed-spontaneous, traumatic, or iatrogenic
Open- occurs following penetration of chest by injury or surgery
Tension- develops when air leaks into pleura and can not escape
Assessment Findings:
Signs vary depending on amount of lung collapse
Minor collapse- slight shortness of breath, anxiety, chest pain
Large- severe respiratory distress
Hemothorax
Blood in pleural space caused by injury (or thoracic surgery complication)
Assessment Findings:
Similar to pneumothorax with distant muffled breath sounds and dullness with percussion over affected area
Atelectasis
Collapsed alveoli; external pressure from tumor, fluid, or air in the pleural space or lack of air from hypoventilation of obstruction by secretions
Assessment Findings: diminished or absent breath sounds, <90% O2 Sat
Lung cancer
Uncontrolled growth of anaplastic cells caused by tobacco smoke, asbestos and other noxious inhalants
Assessment findings:
Initial symptom is persistent cough, weight loss, congestion, wheezing, hemoptysis, labored breathing and dyspnea
Dullness on percussion, diminished lung sounds
Module 6: Nutrition and Pain
Chapter 13: Abdomen and Gastrointestinal System
What general inspection assessment may indicate abnormal findings?
Contour
Marked Concavity (Abnormal)
Inspection Technique
View from 2 angles
Standing behind head
Squatting at side at eye level
Ask pt. to take deep breath and hold
Contour should remain smooth
Describe the anticipated findings of the abdomen.
Expected
Striae/ scars
Fine vascular network
Central umbilicus
Slightly protruding (overweight)
Abnormal
Jaundice- elevated bilirubin
Erythema-inflammation
Bruising
Displaced umbilicus
Upward, downward, or lateral- hernia
Inverted- ascites/mass
Glistening /taut skin
Prominent venous patterns- portal hypertension
Describe the assessment process for an abdominal hernia.
Hernia
Have pt. cough
Observe for bulging (abnormal)
Describe the seven F's of abdominal distension.
7 F’s of Distension
Fat
Flatulence
Feces
Fibroid tumor
fatal tumor
Fetus
Fluid
What landmark indicates where abdominal girth should be measured?
Measurement is most often made at the level of the belly button (navel).
When auscultating the abdomen for bowel sounds...
Use diaphragm of stethoscope
Press lightly
Follow sequential pattern
Expected
Normoactive bowel sounds should be heard every 5 to 15 seconds
High pitched gurgles or clicks (varies)
What is the significance of marked pulsations in the abdominal area?
Peristalsis x not be visible; upper midline pulsation may be visible in thin people
If pulsations are noted, do not palpate!
Describe the abdominal palpation process.
Light Palpation Process
Access tenderness and muscle tone
Patient bend knees
Use pads of fingers
Depress 1-2 cm
Palpate area of pain last
Reduce ticklishness by sliding hands to position
Or have patient use hand on top of nurse hands
Expected
No tenderness
Relaxed abdominal muscles
Consistent tension
Abnormal
Cutaneous tenderness
Hypersensitivity
Superficial masses
Rigidity
Increased tension
Deep Palpation Process
Use distal flat portion of finger pads
Depress 4-6 cm (1.6-2.4 inches)
Watch patient face for grimace
Ask patient to breathe slowly through mouth (facilitates relaxation)
Expected
No tenderness
No masses
Palpable aorta (at epigastrium above and left of umbilicus)
Rectus abdominis is palpable feces in ascending or descending colon
Abnormal
Pain
Facial grimace
Masses
What is rigidity associated with?
Pain
Should areas of abdominal pain be assessed first or last?
Palpate area of pain last.
What is the anticipated tone heard on percussion of the abdomen? What may dullness on percussion indicate?
Tympany is common percussion tone heard and is caused by the presence of gas
Dullness in a localized area may indicate distention, fluid, or an abdominal mass; the suprapubic area may be dull when the urinary bladder is distended
An enlarged liver, hepatomegaly, is... ○ abnormal and exceeds 3 centimeters in adults
Spleen enlargement may indicate what disease process?
Viral Hepatitis
A palpable gallbladder may indicate what disease process?
Cholecystitis with cholelithiasis
Describe Murphy’s sign.
Cholecystitis with cholelithiasis (Gallbladder stones)
Describe the process for assessing the abdominal reflexes.
Elicit Abdominal Reflexes
Not commonly tested
Stroke each quadrant with end of reflex hammer
Stroke away from umbilicus
Expected finding
Contraction of rectus abdomen toward side stroke
Abnormal finding
Diminished reflexes
Ascites is caused by what disease process? What assessment findings are associated?
Occurs with chronic liver disease
Assess for shifting dullness when fluid in the peritoneal cavity (ascites) is suspected. Assess for fluid wave when ascites is confirmed and the fluid wave resembles fluid moving within the abdomen from one side to the other.
What is McBurney’s sign?
Appendicitis
What is the Iliopsoas muscle test?
This technique is performed when appendicitis is suspected. When the patient reports RLQ pain to pressure against the raised leg, his or her iliopsoas muscle is irritated indicating an inflamed appendix.
What is the obturator muscle test? What is a negative result?
When a ruptured appendix or pelvic abscess is suspected, this technique is performed. Pain in the hypogastric region when the right leg is rotated is a positive sign indicating irritation of the obturator muscle.
How would you document the expected findings?
05/03/2017 @ 13:00 T- 98.6, P-78 rt. Radial, R-12 non-labored, O2 saturation 98% RA, B/P 118/88. Client appears relaxed in the sitting position with slow even respirations, abdomen appears smooth, with very faint vascular network, umbilicus is centrally located, with slightly protruding contour, abdomen moves smoothly with even respirations, normoactive (1 sound every 5-15 seconds) bowel sounds in all four quadrants, no signs of tenderness upon light palpation, LBM 5/3/17 patient states “normal”----J. Crafton MSN, RN
Have a basic understanding of the following common problems and conditions:
Gastroesophageal reflux disease
Gastric secretion in esophagus
Caused by weakening of lower esophageal sphincter or increased intra-abdominal pressure
Heartburn, regurgitation, dysphagia, aggravated by lying down and relieved by sitting up, antacids, and eating
Hiatal hernia
Displaced umbilicus (everted)
Stomach protrudes through esophageal hiatus of diaphragm
Caused by muscle weakness
Manifestations: heartburn, regurgitation, dysphagia
Peptic ulcer disease
Duodenal Peptic Ulcer most common peptic ulcer
Result from helicobacter pylori
Manifestations: burning pain left epigastric and back 1-2 hours after eating, mid morning and mid afternoon and middle of night
Relief with antacids or eating
Crohn’s disease
Chronic inflammatory bowel disease
Aka regional enteritis or regional ileitis
May occur mouth to anus
Common in terminal ileum and colon
Fistulas, fissures, and abscesses
Manifestations: severe pain, cramping, diarrhea, nausea, fever chills, weakness, anorexia and wt. loss
Ulcerative colitis
watery diarrhea with blood, mucus and pus
most common form of IBD worldwide
Inflammatory Bowel Disease
Manifestations: This disorder is characterized by unpredictable periods of remission with relapses. Patients complain of mild to severe crampy abdominal pain, fever, chills, anemia, and weight loss.
Diverticulitis
Inflammation of diverticula (diverticulitis)
Herniation through muscular wall of colon
Fecal material causes inflammation and abscess
Manifestations: LLQ cramping, N/V, altered bowel habits (constipation), distended abdomen, tympanic, dec. bowel sounds, localized tenderness
Viral hepatitis
Inflammation of liver
Different viruses
Manifestations: N/V, malaise, fever, enlarged liver and spleen, jaundice, tan colored stools, dark urine
Cirrhosis
Degenerative disease of liver; destruction and regeneration of hepatic cells
Cobblestone appearance of liver impairs function
Caused by viral hepatitis, biliary obstruction and alcohol abuse
Manifestations: liver becomes palpable and hard, ascites, jaundice, cutaneous spider angiomas, dark urine, tan colored stools, spleen enlargement; End stage: portal HTN, esophageal varices, hepatic encephalopathy and coma
Cholecystitis with cholelithiasis
Inflammation of gallbladder usually caused by gallstones
Obstructed bile duct from edema or gallstones
Manifestations: RUQ colicky pain radiates to mid-torso or rt. scapula, indigestion and mild transient jaundice
Pancreatitis
Acute or chronic inflammation of pancreas; autodigestion of organ
Caused by alcoholism or obstruction of sphincter of Oddi
Gallstone can obstruct digestive enzyme of pancreas
Radiates from epigastrium to back
Manifestations: steady, boring, dull or sharp pain, n/v wt. loss, steatorrhea, glucose intolerance, patients prefer fetal position with knees to chest
Urinary tract infections
Infection of the urethra (urethritis), bladder (cystitis), and renal pelvis (pyelonephritis)
Gram–negative organisms E. coli, Klebsiella, Proteus or Pseudomonas
Fecal material in the urethra to bladder
Manifestations: frequency, urgency, dysuria,
Cystitis same manifestation plus bacteriuria and fever
Older adults- confusion of delirium with or without fever
Nephrolithiasis
Formation of stones in kidney pelvis,
Contributing factors: metabolic, dietary, genetic, or climatic
Manifestations: fever, hematuria flank pain that radiates from to groin and genitals
Module 7: Mobility
Chapter 14: Musculoskeletal System
Review the anatomy and physiology of the musculoskeletal system
Describe the anticipated curvatures for the following: cervical, thoracic, lumbar
Cervical Spine: Concave
Thoracic Spine: Convex
Lumbar Spine: Concave
Expect: slight protrusion at C7 and T1, alignment of iliac crests at L4
Describe the assessment process for determining size and symmetry of the extremities.
BUE and BLE symmetry (no person has perfect symmetry)
Use paper tape to measure baseline and side to side comparison
Record in centimeters above or below joint
Measurements <1 cm variance not significant
Bilateral Atrophy- possible spinal cord injury or malnutrition
Unilateral atrophy- disuse
Localized Fasciculation- possible drug SE
Generalized spasms- variety of causes
Describe the range of motion assessments for the following joints:
Neck and cervical spine
Pivotal Joint
Flexion- chin to chest (45 degree)
Extension- return to erect position (0 degree)
Hyperextension- bend head back as far as possible (55 degree)
Lateral flexion- tilt head toward each shoulder (40 degree)
Rotation- turn head to right and left (70 degree)
Shoulder
Ball and Socket Joint
Flexion- raise arm from side to forward position (180 degree)
Extension- return arm to side of body (0 degree)
Hyperextension- move arm behind body (50 degree)
Abduction- raise arm to side above head with pal away from head
Adduction- place arm across body (50 degree)
Internal rotation- rotate shoulder til thumb turned inward, toward back
External rotation- rotate elbow til thumb upward, lateral to head
Circumduction- move arm in full circle (combines all b and s joint)
Elbow
Hinge Joint
Flexion- bend elbow so lower arm moves toward shoulder and hand is level with shoulder
Extension- straighten elbow
Hyperextension- bend arm back far (not everyone can hyperextend)
Forearm
Pivotal Joint
Supination- palm up
Pronation- palm down
Wrist
Condyloid Joint
Flexion- move palm toward forearm
Extension- fingers, hands, forearm all in same plane
Hyperextension- bring dorsal surface back as far as possible
Radial flexion- bend wrist medially
Ulnar flexion- bend wrist laterally
Fingers
Condyloid Hinge Joint
Flexion- make fist
Extension- straighten fingers
Hyperextension- bend fingers back as far as possible
Abduction- spread fingers apart
Adduction- bring fingers together
Thumb
Saddle Joint
Flexion- move thumb across palmer surface
Extension- move thumb away from hand
Abduction- extend thumb laterally (usually done during abduction)
Opposition- touch thumb to each finger of same hand
Hip
Ball and Socket Joint
Flexion-move leg forward and up
Extension- move leg back and beside other leg
Hyperextension- move leg behind body
Abduction- move leg laterally away from body
Adduction- move leg medially toward body
Internal rotation- turn knee toward inside
External rotation- turn knee toward outside
Circumduction- move leg in circle
Knee
Hinge Joint
Flexion- bring heel back toward thigh
Extension- return heel to floor
Ankle
Hinge Joint
Dorsiflexion- move foot so toes are pointed upward
Plantar flexion- point toes downward
Foot
Gliding Joint
Inversion- turn sole of foot medially
Eversion- turn sole of foot laterally
Toes
Condyloid Joint
Flexion- curl toes downward
Extension- straighten toes
Abduction-spread toes apart
Adduction- bring toes together
Describe the assessment process for the following muscle strength:
Ocular musculature
Patient: Close eyes tightly
Nurse: Attempt to resist closure
Facial musculature
Patient: Blow out check, place tongue in cheek, stick out tongue & move it
Nurse: Assess pressure in cheeks, strength/coordination of thrust/exertion
Neck muscles
Patient:
Extend head backward
Flex head forward
Rotate head side to side
Touch shoulders with head
Nurse:
Push head forward
Push head backward
Monitor mobility and coordination
Observe ROM
Deltoid
Patient: Hold arms upward
Nurse: Push down on arms
Biceps
Patient: Flex arm
Nurse: Push down on arm
Triceps
Patient: Extend arm
Nurse: Push to flex arm
Wrist musculature
Patient: Extend elbow; Flex elbow
Nurse: Push to flex; Push to extend
Finger muscles
Patient:
Extend fingers
Flex fingers
Spread fingers
Nurse:
Push dorsal surface of fingers
Push ventral surface of fingers
Hold fingers together
Hip musculature
Patient: In supine position raise extended leg
Nurse: Push down on leg above knee
Hamstring, gluteal, abductor and adductor muscles of leg
Patient: Sit and perform alternate leg crossing
Nurse: Push in opposite direction of crossing limb
Ankle and foot muscles
Patient: Bend foot up (dorsiflexion); Bend foot down (plantar flexion)
Nurse: Push to plantar flexion; Push to dorsiflexion
Antigravity muscles? Quadriceps and Hamstring
Patient: Extend leg (Q); Bend knees to flex leg (H)
Nurse: Push leg to flex (Q); Push to extend (H)
Describe the criteria of grading and recording muscle strength using the Lovett scale. How would you document muscle strength bilaterally with full resistance.
Lovett Scale
Zero (0)
No evidence of contractility, Grade 0, 0%
Tract (T)
Evidence of slight contractility, Grade 1, 10%
Poor (P)
Complete ROM with gravity eliminated, Grade 2, 25%
Fair (F)
Complete RAM with gravity, Grade 3, 50%
Good (G)
Complete ROM against gravity w/ some resistance, Grade 4, 75%
Normal (N)
Complete ROM against gravity w/ full resistance, Grade 5, 100%
What additional assessment should be completed if unequal leg length is suspected?
Measure from anterior superior iliac spine to medial malleolus
Compare right side to left side
Describe the process to assess musculature of the face and neck for symmetry.
Assessment of the Musculature of the Face and Neck
Do this during interview session
Ask patient to open and close mouth
Ask patient to smile
Use finger to palpate front of tragus to detect smooth movement of temporomandibular joint
Palpate neck for tenderness and lymph nodes
Asymmetry may be caused by...
Facial surgery
Bell’s palsy
Describe the assessment of the temporomandibular joints for movement, sounds, and tenderness. What are some of the symptoms for TMJ.
Use the pads of the first two fingers in front of the tragus of each ear to palpate the temporomandibular joint (TMJ) with the mouth closed and open. The mandible should move smoothly and painlessly. An audible or palpable snapping or clicking in the absence of other symptoms is not unusual
Pain or crepitus of the TMJ with locking or popping may require further evaluation. Difficulty opening the mouth or limited range of motion may result from injury or arthritic changes. Pain in the TMJ may indicate malocclusion of teeth or arthritic changes.
Describe the differences between kyphosis, lordosis, and scoliosis.
Kyphosis-posterior curvature (convexity) of thoracic spine
Lordosis- anterior curvature (concavity) of spine
Scoliosis- lateral curvature of the spine
All of these conditions may create asymmetry of the shoulders and hips
These are some possible causes of inequality of height
How do you assess cranial nerve XI (The spinal accessory). What muscle may indicate compression of this nerve?
Ask the patient to shrug the shoulders while you attempt to push them down.
Weakness of the trapezius muscles may indicate compressed spinal nerve root or compression of spinal accessory CN XI.
Describe Heberden’s and Bouchard’s nodes. What type of arthritis are these seen in?
Osteoarthritis
Heberden nodes in DIP (distal interphalangeal) joints
Bouchard nodes in PIP (proximal interphalangeal) joints
What type of arthritis causes swan neck and boutonniere deformities?
Rheumatoid Arthritis
How should you assess for symmetry and alignment of the knees?
Knees aligned between hips, ankles and feet
What is the significance of a positive Phalen’s sign and Tinel’s sign ?
Carpal Tunnel Syndrome
How do you complete the drop arm test? How is the significance of this assessment?
Determines a patient's ability to sustain humeral joint motion through eccentric contraction as the arm is taken through the full motion of abduction to adduction. It will determine if the patient has an underlying rotator cuff dysfunction
What are the two tests that assess for fluid in the knee joint?
Perform the patellar tap test or fluid displacement test to determine the presence of fluid in the knee joint. When fluid in the knee joint is suspected, palpate the knee joint to determine presence of a small or large amount of fluid.
What test is used to assess the presence of a meniscal tear? Describe the test.
Performed by rotating the knee with the patient in supine position to determine pain, audible clicks, or locking of the knee. Assessment of a meniscal tear is performed when the patient is unable to bear weight on or flex the knee.
How would you assess for hip flexion contractures?
With the patient lying supine with one leg extended, the APRN flexes the other knee to the chest and watches the movement of the extended leg. If the extended leg lifts off the exam table, the patient has a hip flexion contracture.
How would you assess for nerve root compression?
Perform when the patient reports numbness or radiating pain in the buttock or leg. To evaluate for nerve root irritation or lumbar disk herniation, perform straight leg raises. With the patient supine, raise one leg, keeping the knee straight.
How would you document expected findings for the musculoskeletal system?
June 15, 2017 @ 1400: spine is straight with expected curvature: cervical (concave) thoracic (convex), and lumbar (concave), knees, align with hips, ankles and feet, BUE and BLE symmetrical in size (<1 cm), no pain, tenderness, or edema with palpation, Full Active ROM in all joints of BUE and BLE, Strength 5/5 in BUE, BLE, gait is smooth with opposite arm swing, facial muscles are symmetrical, patient denies pain/tenderness------J. Crafton MSN, RN
Have a basic understanding of the following common problems and conditions:
Fracture (open and closed)
Partial or complete break in bone
Closed-skin remains intact
Open- skin is open
Pathologic/spontaneous fracture-results from weakness in bone (osteoporosis or neoplasm)
Children-more prone to forearm
Older adult-hip fractures more common
Clinical Manifestations:
pain, deformity, loss of function
Possible Nursing Diagnosis:
Impaired Physical Mobility r/t limb immobilization AEB
Acute Pain r/t muscle spasms, edema, trauma AEB
Impaired walking r/t limb immobility AEB
Osteoporosis
Loss of bone mineral density (BMD) of 2.5 SD below mean for women
½ all postmenopausal women; due to decline in estrogen, calcium deficit, lack of weight bearing exercise, use of glucocorticoids
Fractures are common
Decreased bone strength
Clinical Manifestations:
(silent disease) loss of height, spontaneous fracture, kyphosis
Potential Nursing Diagnosis:
Impaired physical mobility r/t pain, skeletal changes AEB…
Imbalanced Nutrition (less than body requirements) r/t inadequate intake of calcium and vitamin D AEB…
Acute pain r/t fracture, muscle spasms AEB...
Rheumatoid arthritis
Chronic, autoimmune disease- joint inflammation and degeneration
Eventually the synovial lining of joints becomes inflamed, leading to deterioration of cartilage and erosion of surfaces → bone spurs
Ligaments and tendons around inflamed joints become fibrotic and shortened, causing contractures and subluxation of joints
Clinical Manifestations:
pain, edema and stiffness, low-grade fever and fatigue. Ulnar deviation, swan-neck deformity, and boutonniere deformity may be observed, wakes patient up when lying on affected limb, morning stiffness lasting 1-2 hours, movement helps relieve pain
Osteoarthritis
This form of arthritis is also known as degenerative joint disease
Progressive breakdown and loss of cartilage in one or more joints.
Weight-bearing joints- vertebrae, hips, knees, ankles, and fingers
Pain is relieved by rest and worse with movement
Clinical Manifestations:
edema and aching, diffuse pain with movement, stiffness after awakening in the morning lasting less than 30 minutes and decreases with movement, 3 Joint deformities of fingers develop (Heberden nodes in DIP joints and Bouchard nodes in PIP joints)
Bursitis
Inflammation of a bursa (connective tissue surrounding a joint)
May be precipitated by arthritis, infection, injury or exercise
Clinical Manifestations:
Painful, limited ROM, edema, point tenderness, erythema of affected joint (shoulder, elbow, hand, knee, hip- greater trochanter)
Possible Nursing Diagnosis:
Impaired physical Mobility r/t inflammation in the joint AEB...
Acute Pain r/t inflammation in joint AEB...
Gout
Hereditary disorder involving an increase in uric acid
Increased production or decreased excretion
Inability to metabolize purines for renal excretion- lack of enzyme
High purine foods- poultry, liver, kidney and legumes
Clinical Manifestations:
Erythema, edema of joints (usually great toe), limited ROM, Tophi (round pea-like deposits of uric acid in ear cartilage or large deposits in subcutaneous tissue or other joints), kidney stones, flank pain and costovertebral angle tenderness
Possible Nursing Diagnosis:
Impaired Mobility r/t musculoskeletal impairment AEB...
Chronic Pain r/t inflammation of affected joint AEB...
Readiness for enhanced Knowledge r/t interest in learning AEB…
Herniated nucleus pulposus (aka slipped disk)
When the fibrocartilage surrounding an intervertebral disk ruptures and the nucleus pulposus is displaced and compresses adjacent spinal nerves
The intervertebral disk provides a cushion between two vertebrae and contains a nucleus pulposus encased in fibrocartilage
Clinical Manifestations:
depend on the location of the herniated disk-- when L4 is affected, the patient reports pain along the front of the leg, sensory loss around the knee, and loss of knee-jerk reflex; when L5 is affected, the patient reports pain along the side of the leg, sensory loss in the web of the big toe, and no loss of reflexes. numbness and radiating pain in the affected extremity from a herniated lumbar disk. Straight leg raises cause pain in the involved leg by putting pressure on the spinal nerve. Cervical herniated nucleus pulposus causes arm pain and paresthesia. Deep tendon reflexes may be depressed or absent, depending on the spinal nerve root involved.
Scoliosis
S-shaped deformity of vertebrae
Skeletal deformity of 3 planes
Lateral curvature
Spinal rotation
Rib asymmetry and thoracic kyphosis
Genetic autosomal-dominant trait, congenital malformations, neuromuscular disease, traumatic injury, or unequal leg length
Clinical Manifestations:
Uneven hips, shoulders
Curvatures less than 10% is expected
Curvatures 10-20% is mild
Rotation deformity: rib hump, flank asymmetry on forward flexion
If severe may interfere with lung, spine and pelvic function
Possible Nursing Diagnosis
Impaired Physical Mobility r/t restricted movement, dyspnea, severe curvature of spine AEB…
Acute Pain r/t musculoskeletal restrictions, surgery, re-ambulation with cast or spinal rod AEB…
Impaired skin integrity r/t braces, surgical corrections AEB...
Impaired gas exchange r/t restricted lung expansion AEB…
Disturbed body image r/t use of braces, scares, AEB…
Carpal tunnel syndrome
The medial nerve is compressed between the flexor retinaculum (carpal ligament) and other structures
Caused by repetitive movements of hand/arms, injury to wrist, or systemic disorders-- rheumatoid arthritis, gout, fluid retention that occurs with pregnancy and menopause, or hypothyroidism
Clinical manifestations
Burning, numbness, tingling in hands (often at night), paresthesia during Phalen’s or Tinel’s Sign
Possible Nursing Diagnosis:
Impaired Physical Mobility r/t neuromuscular impairment AEB…
Chronic Pain r/t unrelieved pressure on the median nerve AEB…
Self-Care Deficit (specify- bathing, feeding) r/t pain AEB…
hihi
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