Download NU 325 Health Assessment Exam 4 Flashcards with correct answers graded A and more Exams Nursing in PDF only on Docsity!
graded A
4 phases of Nociception (1) transduction, (2) transmission, (3) perception, and (4) modulation transduction First phase occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery. The periphery includes the skin and the somatic and visceral structures. These injured tissues then release a variety of chemicals. These chemicals are neurotransmitters that transmit a pain message, or action potential, along sensory afferent nerve fibers to the spinal cord. transmission In the second phase, the pain impulse moves from the level of the spinal cord to the brain. Within the spinal cord, at the site of the synaptic cleft, are opioid receptors that can block this pain signaling with our own endogenous opioids or with exogenous opioids if they are administered. However, if not stopped, the pain impulse moves to the brain via various ascending fibers within the spinothalamic tract to the thalamus. perception The third phase signifies the conscious awareness of a painful sensation. Cortical structures such as the limbic system account for the emotional response to pain, and somatosensory areas can characterize the sensation. Only when the noxious stimuli are interpreted in these higher cortical structures can this sensation be identified as "pain." modulation The pain message is inhibited through the 4th phase. Fortunately our bodies have a built-in mechanism that will eventually slow down and stop the processing of a painful stimulus. If not for this phase, the experience of pain would continue from childhood injuries to adulthood. To inhibit and block the pain
graded A
impulse, descending pathways from the brainstem to the spinal cord release a third set of neurotransmitters that produce an analgesic effect. neuropathic pain Is pain that does not adhere to the typical and rather predictable phases in nociceptive pain. It is "pain caused by a lesion or disease of the somatosensory nervous system." It implies an abnormal processing of the pain message from an injury to the nerve fibers. This type of pain is the most difficult to assess and treat. Pain is often perceived long after the site of injury heals, and it evolves into a chronic condition. Nocioceptive pain can change into a _________________ pain pattern over time when pain has been poorly controlled. Conditions that may cause it include diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and chemotherapy. Further examples include CNS lesions such as stroke, multiple sclerosis, and tumor. This type of pain cannot be identified by x-ray image, computerized axial tomography (CAT) scan, or traditional magnetic resonance imaging (MRI). visceral pain Originates from the larger internal organs (i.e., stomach, intestine, gallbladder, pancreas). It often is described as dull, deep, squeezing, or cramping. The pain can stem from direct injury to the organ or stretching of the organ from tumor, ischemia, distention, or severe contraction. Examples include ureteral colic, acute appendicitis, ulcer pain, and cholecystitis. It often presents along with autonomic responses such as vomiting, nausea, pallor, and diaphoresis. deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Pain may result from pressure, trauma, or ischemia. cutaneous pain
graded A
Pain in the aging adult No evidence exists to suggest that they perceive pain to a lesser degree or that sensitivity is diminished. Although pain is a common experience among these individuals, it is not a normal process of __________. Pain indicates pathology or injury. It should never be considered something to tolerate or accept. Unfortunately many clinicians and patients wrongfully assume that pain should be expected, which leads to underreporting of pain and less aggressive treatment. These patients may have additional fears about becoming dependent, undergoing invasive procedures, taking pain medications, and having a financial burden. The most common pain-producing conditions include pathologies such as osteoarthritis, osteoporosis, peripheral vascular disease, cancer, peripheral neuropathies, angina, and chronic constipation. People with dementia do feel pain. Pain in the infant Have the same capacity for pain as adults. In development ascending sensory fibers, neurotransmitters, and connections to the thalamus are developed by 20 weeks' gestation. However, the immaturity of the cortex and lack of conscious awareness may prevent the fetus from experiencing emotional "pain" until 30 weeks' gestation. Conscious or not, pain-producing invasive procedures elicit a stress response, and pain during gestation should be avoided until more is known about it. Inhibitory neurotransmitters are insufficient until birth at full term. Therefore the preterms are rendered more sensitive to painful stimuli. Preverbals are at high risk for undertreatment of pain in part because of persistent myths and beliefs that they do not remember pain. In fact, current evidence suggests that repetitive and poorly controlled pain in skin-breaking procedures (e.g., daily heel sticks, venipunctures) can result in pain hypersensitivity later in life. This suggests use of analgesics during routine painful procedures. Initial Pain Assessment asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors. Further, the clinician adds questions about the manner of expressing pain and the effects of pain that impair one's quality of life
graded A
Brief Pain Inventory asks the patient to rate the pain within the past 24 hours using graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep McGill Pain Questionnaire asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain. Numeric rating scales ask the patient to choose a number that rates the level of pain for each painful site, with 0 being no pain and the highest anchor 10 indicating the worst pain ever experienced. This makes recording of results easy and consistent with those of numerous clinicians. Older adults find this abstract and have difficulty responding, especially with a fluctuating chronic pain experience Verbal Descriptor Scale uses words to describe the patient's feelings and the meaning of the pain for the person. Older adults often respond to scales in which words are selected. Visual Analogue Scale lets the patient make a mark along a 10-cm horizontal line from "no pain" to "worst pain imaginable."
graded A
pain's effect on vital signs Tachycardia Elevated blood pressure Increased cardiac output (increased pulse) Hypoventilation Hypoxia (decreased O2 sats) Decreased cough Atelectasis frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. precentral gyrus of the frontal lobe initiates voluntary movement. parietal lobe's postcentral gyrus is the primary center for sensation occipital lobe is the primary visual receptor center.
graded A
temporal lobe behind ear has the primary auditory reception center, with functions of hearing, taste, and smell. Wernicke's area in temporal lobe is associated with language comprehension. When damaged in the person's dominant hemisphere, receptive aphasia results. The person hears sound, but it has no meaning, like hearing a foreign language. Broca's area in the frontal lobe mediates motor speech. When injured in the dominant hemisphere, expressive aphasia results; the person cannot talk. The person can understand language and knows what he or she wants to say but can produce only a garbled sound. Cranial Nerve I: Olfactory Nerve •Check patency!! •With person's eyes closed, occlude one nostril and present familiar aromatic substance, e.g., coffee, orange, vanilla, soap, or peppermint •Normally, person can identify an odor on each side of nose; normally decreased with aging; any asymmetry in sense of smell is important •Abnormal: anosmia - upper respiratory infection, tobacco or cocaine use, frontal lobe lesion -Sensory Cranial nerve II: Optic Nerve
graded A
Cranial nerve VII: Facial Nerve •Motor function: •Note mobility and facial symmetry as person responds to requests to smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth, puff cheeks •Abnormal in stroke or Bell Palsy •Sensory function: (not tested routinely) •Test only when you suspect nerve injury •Describe, test sense of taste by applying cotton applicator covered with solution of sugar, salt, or lemon juice to tongue and ask person to identify taste •Anterior 2/3 of tongue -Motor and Sensory Cranial nerve VIII: Acoustic Nerve •Test hearing acuity by ability to hear spoken word whisper test -Sensory Cranial nerves IX and X: Glossopharyngeal and Vagus Nerves •Motor function •Clarity of speech, ability to swallow, and note pharyngeal movement as person says "ahhh"; uvula and soft palate should rise in midline •Verbalize - touch posterior pharyngeal wall with tongue blade, and note gag reflex •Verbalize - sense of taste posterior third of tongue
graded A
•Abnormal: Stroke, risk for aspiration -Motor and Sensory Cranial nerve XI: Spinal Accessory Nerve •Symmetry of muscles of neck/shoulders •Check equal strength by asking person to rotate head against resistance applied to side of chin •Ask person to shrug shoulders against resistance •These movements should feel equally strong on both sides •Abnormal - stroke (opposite side of lesion) -Motor Cranial nerve XII: Hypoglossal Nerve •Note forward thrust in midline as person protrudes tongue •Ask person to say "light, tight, dynamite," and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct •Abnormal - tongue deviates to side of lesion/stroke -Motor Mental Status Test •Begin with (ABCT) -Appearance -Behavior -Cognitive abilities •Orientation
graded A
4 = very brisk, hyperactive with clonus, indicative of disease 3 = brisker than average, may indicate disease 2 = Average, normal 1 = diminished, low normal, or occurs with reinforcement 0 = no response -Biceps -Tricep -Brachioradialis -Patellar or Quadriceps -Achilles -Superficial (Cutaneous) *Plantar/Babinski Reflex "positive or negative Babinski" Biceps Reflex You can feel as well as see the normal response, which is contraction of the biceps muscle and flexion of the forearm Triceps Reflex The normal response is extension of the forearm. Brachioradialis Reflex The normal response is flexion and supination of the forearm.
graded A
Patellar or Quadriceps Reflex Extension of the lower leg is the expected response. You also will palpate contraction of the quadriceps. Achilles Reflex Feel the normal response as the foot plantar flexes against your hand. Superficial (Cutaneous) Reflex The normal response is plantar flexion of the toes and inversion and flexion of the forefoot. infant primitive reflexes -Rooting -Sucking -Palmar grasp -Plantar grasp -Babinski -Tonic Neck -Moro -Placing -Stepping
graded A
-Upper motor neuron injury to corticospinal motor tract Paralysis Decreased or loss of motor power caused by problem with motor nerve or muscle fibers. Causes: acute —trauma, spinal cord injury, stroke, poliomyelitis, polyneuritis, Bell palsy; chronic—muscular dystrophy, diabetic neuropathy, multiple sclerosis; episodic—myasthenia gravis. Flaccidity -Decreased muscle tone or hypotonia; muscle feels limp, soft, and flabby; muscle is weak and easily fatigued; limb feels like a rag doll -Lower motor neuron injury anywhere from the anterior horn cell in the spinal cord to the peripheral nerve (peripheral neuritis, poliomyelitis, Guillain-Barré syndrome); early stroke and spinal cord injury are this at first Rest tremor It occurs when muscles are quiet and supported against gravity (hand in lap). Coarse and slow (3 to 6 per second); partly or completely disappears with voluntary movement (e.g., "pill rolling" tremor of parkinsonism, with thumb and opposing fingers). Intention Tremor Rate varies; worse with voluntary movement as in reaching toward a visually guided target. Occurs with cerebellar disease and multiple sclerosis. Essential tremor (familial)—A type of __________ tremor; most common tremor with older people. Benign (no associated disease) but causes emotional stress in business or social situations. Improves with the administration of sedatives, propranolol, or alcohol; but alcohol discouraged because of the risk for addiction.
graded A
Opisthotonos Prolonged arching of back, with head and heels bent backward. This indicates meningeal irritation. Decorticate Rigidity or Posturing Upper extremities—flexion of arm, wrist, and fingers; adduction of arm (i.e., tight against thorax). Lower extremities—extension, internal rotation, plantar flexion. This indicates hemispheric lesion of cerebral cortex. Decerebrate Rigidity or Posturing Upper extremities stiffly extended, adducted; internal rotation, palms pronated. Lower extremities stiffly extended; plantar flexion; teeth clenched; hyperextended back. More ominous; indicates lesion in brainstem at midbrain or upper pons. Central Nervous System -Cerebral Cortex (lobes of brain) -Basal Ganglia (structures inside brain) -Thalamus -Hypothalamus -Cerebellum -Brainstem -Spinal Cord
graded A
-Positive sign is loss of balance that occurs when closing the eyes. You eliminate the advantage of orientation with the eyes, which had compensated for sensory loss. A positive sign occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication), loss of proprioception, and loss of vestibular function. Paraplegia symmetric paralysis of both lower extremities Quadriplegia paralysis in all four extremities Appearance posture, body movements, dress, grooming/hygiene Behavior Level of consciousness, facial expression, speech, mood, affect Flat Affect Lack of emotional response; no expression of feelings; voice monotonous and face immobile Orientation
graded A
The awareness of the objective world in relation to the self. Able to name own person, place, and time. Recent Memory which requires some processing (e.g., medication instructions, 24-hour diet recall, names of new acquaintances), is somewhat decreased with aging Remote Memory is not affected with aging. -Examples: where you were born, what high school did you attend, when were you married Reasoning abstract thinking - parable finger to nose test -Ask the person to close the eyes and stretch out the arms. Ask him or her to touch the tip of his or her nose with each index finger, alternating hands and increasing speed. Normally this is done with accurate and smooth movement. -Misses nose. Worsening of coordination when the eyes are closed occurs with cerebellar disease or alcohol intoxication. abbreviated mental status exam Usually you can assess it through the context of the health history interview. During that time keep in mind the four main headings:
