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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…

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