Nurse understands the pain of an older adult - Pathological condition of something may cause an injury and pain - Not a normal aging process Postoperative pain rating it 0-10 Pain level at 10 assessment finding quality controlled pain - Pain increases blood pressure and pulse rate Nurse assessing pain - Pain is subjective - Assess the patient’s pain and assess them - Administer pain medication and then reassess to see if it was effective or not and where their pain level is now Appropriate question to assess their pain level - Can you rate your pain? - Is the pain local or does it spread? - What does your pain feel like? - How long have you experienced this pain? Question mentioned: A patient with a partial small bowel obstruction describes the pain as "cramping, off-and-on pain that spreads over my stomach.” What type of pain is this patient experiencing? Visceral pain Visceral Pain - Originating from an organ - occurs with obstruction of a hollow organ and causes intermittent cramping pain. Metabolic syndrome Person who is at risk for hypertension, hyperglycemia (diabetes), hyperlipidemia, - Race - Look for “hyper” / elevated levels! - What kind of person would be at risk for this? - 3 - 4 or more diagnosis - increased blood pressure (greater than 130/85 mmHg) - low levels of HDL (“good”) cholesterol in the blood - high triglyceride levels (level above 150 mg/dl) - excess fat around the waist (A waistline of 40 inches or more for men and 35 inches or more for women) - Know which values put person at risk for it Someone complains of tiredness, weakness, or hair loss. Be able to calculate changing weight. Initial vs final weight. Tube feed for several months oral examination swollen gums, bleeding - Deficiency of - Rickets - Vitamin c - ascorbic acid Osteomalacia: softening of the bones, due to lack of vitamin D and C. Inadequate intake of protein and calories ? Bulimia: potentially life threatening eating disorder characterized by a cycle of bingeing large amounts of food and then purging to get rid of the extra calories in an unhealthy way like selfinduced vomiting or use of laxatives. Dietician measuring fat/bone density/lean body mass. What tool is used? - DEXA - dual-energy X-ray absorptiometry Best nutritional intervention for OLDER ADULT planning - GI is not very active (move less and less) need to decrease carbs - they will be bloated - Calorie and protein intake should be lowered - Decrease in peristalsis (GI) causes decrease in absorption? - Pulse rate can be low in older adults Elevated cholesterol and triglycerides part of your teaching - Have to eat well - Reduce fatty foods saturated fats What tools help determine someone's body fat? (BMI) - Weight and Height - Weight Someone having a problem with taste (not a good taste) - Assess - ALWAYS assess first! ADPIE Review organs located in quadrants of the abdomen - Right upper: liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal gland, hepatic flexure of colon, part of ascending and transverse colon - Right lower: cecum, appendix, right ovary and tube, right ureter, and right spermatic cord - Left upper: stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal gland, splenic flexure of colon, part of transverse and descending colon - Left lower: part of descending colon, sigmoid colon, left ovary and tube, left ureter, and left spermatic cord Someone who has a distended bladder - Assess the suprapubic area (pubic symphysis) An enlarged spleen should not be palpated because it can rupture easily. - If you feel an enlarged spleen, refer the person but do not continue to palpate it. An enlarged spleen is friable and can rupture easily with over palpation. Trauma to the abdomen do not palpate the spleen because it can rupture - SPLEEN IN LEFT UPPER QUADRANT - Destroy red blood cells - Produce antibodies - Store red blood cells - Filter microorganisms from blood Which structure is located in the left lower quadrant of the abdomen? - The sigmoid colon is located in the left lower quadrant of the abdomen. When auscultating abdomen in a bigger adult in xiphoid (zygote?)process and umbilicus, should be able hear pulsating of aortic artery - This is a normal finding - Auscultate the abdomen first before palpating so it does not alter the bowel sounds - Should sound like gurgling high pitched When someone complains of pain near the ribs - Coastal vertebral angles - spleen - Kidney inflammation - Liver Ascites: swelling caused by fluid in the abdomen because of distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward - Differentiate ascites from gaseous distention by performing: - Fluid wave test - Shifting dullness test Deep palpation for organs that are extremely large Black tarry stool is an indication of gastrointestinal bleeding Abdominal muscle becomes thin in older adults URINARY Incontinence when laughing or coughing is stress incontinence Male patient with an erection reassure the patient that it is a normal finding and move on Male genitalia - Hypospadias (opening of penis/urethra (meatus) is on the underside rather than the tip) - Hypospadias is a birth defect and it has to be fixed - Anemic patients tend to have longer erections - Epispadias-urethral meatus opens on the dorsal (upper) side of the glans/shaft ("spadelike" penis), rare and less likely than hypospadias Palpating a patient’s scrotum when red, glowing - Fold pillow case, cover scrotum and put it there to release fluids??? What is epididymitis? Acute infection of the epididymis -causes include: prostatitis, trauma of urethra instrumentation, chlamydia, gonorrhea, or other bacterial infection -difficult to differ from testicular torsion -S&S: severe pain, rapid swelling, fever, enlarged scrotum, reddened, tender, WBC and bacteria in urine, enlarged epididymis Colorful like patches on male genitalia indicates: - Chadwick and goodell signs around the cervix Chadwick- bluish-purple discoloration of the cervix, vagina, and labia during early pregnancy resulting from increasing blood flow. Occurs at 8-12 weeks of pregnancy. Goodell- an indication of pregnancy in which the cervix & vagina soften as a result of increased vascularization. Occurs at 4 to 6 weeks of gestation. Indications of someone going through menopause: Deficiency of what hormone? - Estrogen Hormone Replacement Therapy side effects - Increased coagulation and risk of deep vein thrombosis - Bloating. - Breast swelling or tenderness. - Headaches. - Mood changes. - Nausea. - Vaginal bleeding Treated for a UTI (Urinary Tract Infection) with an antibiotic assessment questions to be asked - itchiness , vaginal discharge Costovertebral angle tenderness should be assessed whenever you suspect that the patient may have: pyelonephritis Pyelonephritis (kidney infection) - is characterized by flank pain and costovertebral angle tenderness ***Review neurological & musculoskeletal*** Musculoskeletal System Jarvis Chapter Key Points - - - - - - The musculoskeletal system consists of the body’s bones, joints, and muscles. Its primary function is to provide support and movement. The musculoskeletal system also encases and protects vital inner organs; produces red blood cells, white blood cells and platelets in the bone marrow; and provides for storage of essential minerals. Bone and cartilage are specialized forms of connective tissue. Bone is hard, rigid, and very dense. Its cells are continually turning over and remodeling. The joint (or articulation) is the place of union of two or more bones. Joints are the functional units of the musculoskeletal system, allowing mobility needed for activities of daily living (ADLs). The types of joints are fibrous, cartilaginous, and synovial. In fibrous joints, the bones are united by fibrous tissue and are immovable (sutures in the skull). Cartilaginous joints are separated by fibrocartilaginous discs and are only slightly moveable (the vertebrae). Synovial joints are freely movable because they have bones that are separated from one another and enclosed in a joint cavity, which is filled with the lubricating synovial fluid. Ligaments are fibrous bands that run from one bone to another bone that strengthen the joint and prevent movement in an undesirable direction. There are three types of muscles: skeletal, smooth, and cardiac. - Skeletal muscles, also known as voluntary muscles (those under conscious control), are attached to bone by a tendon- a strong fibrous cord. - Each skeletal muscle is composed of bundles of muscle fibers or fasciculi Skeletal muscles produce following movements: - flexion (bending limb at a joint) - extension (straightening limb at joint) - abduction (moving limb away from midline of body) - adduction (moving limb toward midline of body) - pronation (turning forearm so that palm is down) - supination (turning forearm so that palm is up) - circumduction (moving arm in circle around shoulder) - Inversion (moving sole of foot inward at ankle) - Eversion (moving sole of foot outward at ankle) - Rotation (moving head around central axis) - Protraction (moving body part forward, parallel to ground) - Retraction (moving body part backward, parallel to ground) - Elevation (raising a body part) - Depression (lowering a body part) Humans have 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 or 4 coccygeal vertebrae. Surface landmarks help orient you to the levels of the spine. The musculoskeletal system’s other joints include the temporomandibular joint, the shoulder, elbow, wrist and carpals, hip, knee, ankle, and foot. - Temporomandibular joint - - - - - Articulation of mandible and temporal bone Can feel it in depression anterior to tragus of ear TMJ permits jaw function of speaking and chewing Allows three motions - Hinge action to open and close jaws - Gliding action for protrusion and retraction - Gliding for side-to-side movement of lower jaw The shoulder - Shoulder girdle belt of three large bones - Humerus, scapula, clavicle, joints and muscle - Glenohumeral joint: articulation of humerus with glenoid fossa of scapula - Ball-and-socket action allows mobility of arm on many axes - Rotator cuff - Group of four (SITS) muscles and tendons support and stabilize shoulder - Supraspinatus, infraspinatus, teres minor, and subscapularis - Subacromial bursa - Assist with abduction of the arm - Palpable landmarks to guide your examination - Scapula and clavicle form shoulder girdle - Can feel the bump of the scapula’s acromion process at very top of shoulder The elbow - Elbow joint contains three bony articulations: humerus, radius, and ulna of forearm - Palpable landmarks are medial and lateral epicondyles of humerus and large olecranon process of ulna between them - Radius and ulna articulate with each other at two radioulnar joints, one at elbow and one at wrist The wrist and carpals - Articulation of radius on thumb side and row of carpal bones - Condyloid action permits movement in two planes at right angles: flexion and extension, and side-to-side deviation - Midcarpal joint: articulation allows flexion, extension, and some rotation The hip - Hip: articulation between acetabulum and head of the femur - Ball-and-socket action permits wide range of motion on many axes - More stability for weight-bearing function - Muscles enhance stability and bursae facilitate movement - Palpation of bony landmarks will guide examination - Iliac crest- anterior superior spine to posterior - Ischial tuberosity - Greater trochanter of the femur - - - - The knee - Knee joint: articulation of three bones- femur, tibia, and patella- in common articular cavity - Largest joint in body; hinge joint, permitting flexion and extension of lower leg on single plane - Synovial membrane is largest in body - Twp wedge-shaped cartilages, called medial and lateral menisci, cushion tibia and femur - Knee stabilized by two sets of ligaments - Cruciate give anterior and posterior stability and help control rotation - Collateral ligaments give medial and lateral stability and prevent dislocation - Landmarks of knee joint - Quadriceps muscle, felt on anterior and lateral thigh - Tibial tuberosity-felt as bony prominence in the midline - Note lateral and medial condyles of tibia - Medial and lateral epicondyles of femur are on either side of patella - The ankle and the foot - Ankle or tibiotalar joint: articulation of tibia, fibula, and talus - Hinge joint: limited to flexion (dorsiflexion) and extension (plantar flexion) in one plane - Landmarks are two bony prominences on either side - Joints distal to ankle give additional mobility to foot At different developmental stages, changes in the musculoskeletal system occur. Bone grows rapidly during infancy and steadily during childhood. Rapid growth spurts occur during adolescence. Bone lengthening occurs at the epiphyses, or growth plates. During pregnancy, the most characteristic posture change is progressive lordosis, which adjusts the center of balance as the fetus grows. In the aging adult, bone remodeling occurs, which is the cyclic process of bone resorption and deposition responsible for skeletal maintenance at sites that need repair or replacement. The net effect is a loss of bone density, or osteoporosis. Although some degree of osteoporosis is nearly universal, it is more of a concern among women than men due to decreased levels of estrogen. This section presents critical points about subjective and objective assessments of the musculoskeletal system. To obtain subjective data, the following topics should be discussed: joints, including pain, swelling, stiffness, or limitation of movement; muscle pain, cramps, or weakness; bone pain, deformity, or trauma; the activities of daily living, and patient-centered care. To obtain objective data, assess each joint noting the size and contour of the joint, and inspecting the skin and tissue noting color, swelling and any masses or deformities. - - Palpate each joint for skin temperature, muscle quality, bony articulations, and the condition of the joint capsule. Assess range of motion (ROM) specific to particular joints. Test the strength of the prime mover muscle groups for each joint. Be familiar with developmental milestones in children and keep handy a concise chart of the usual sequence of motor development, so that you can refer to expected findings for children of various ages. During adolescence, kyphosis is common because of chronic poor posture. Additionally, scoliosis screening should be completed. Toward the third trimester of pregnancy, the pregnant woman may experience anterior cervical flexion, kyphosis, and slumped shoulders. The aging adult may experience a decrease in height and slight flexion of the hips and knees. During assessment of the musculoskeletal system, incorporate health promotion. For example, discuss ways to prevent osteoporosis. Emphasize specific measures related to diet, exercise, osteoporosis screening, and fall prevention. Chapter 11: Pain Assessment Differences include the following: - Nociceptive pain: The process is depicted and explained in text under the heading “Nociceptive Pain.” - Neuropathic pain: Does not follow the typical and predictable phases of nociceptive pain; instead, the processing of the pain message is abnormal, and this pain is difficult to assess and treat. - Conditions that may cause neuropathic pain include: diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and chemotherapy - The various sources of pain include the following: - Visceral pain originates from the larger interior organs (such as kidneys, stomach, intestine, gallbladder, pancreas). Pain may result from either direct injury to the organ or from stretching of tissues due to a tumor, ischemia, distention, or severe contraction. - Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Injury may result from pressure, trauma, or ischemia. - Cutaneous pain comes from skin surface and subcutaneous tissues. The injury is superficial, with a sharp, burning sensation. - Referred pain is pain that is felt at a particular site but originates from another location. This type of pain may originate from visceral or somatic structures. Differences between acute and chronic pain include the following: - Acute pain nonverbal behaviors: guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, diaphoresis, or change in vital signs. - Chronic pain nonverbal behaviors: there will be more variability of behaviors with chronic pain because the person adapts, over time, to the pain. Some examples include bracing, rubbing, diminished activity, sighing, and change in appetite. See Table 11.2, Physiologic Changes from Poorly Controlled Pain. 5. The most important and reliable indicator for pain is the patient’s self-report SUBJECTIVE 6. Assessment of pain characteristics includes the following: (1) Where is your pain? (2) When did your pain start? (3) What does your pain feel like? (4) How much pain do you have now? (5) (6) (7) What makes your pain better or worse? How does pain limit your function or activities? How do you usually behave when you are in pain? How would others know that you are in pain? (8) What does this pain mean to you? Why do you think you are having pain? 7. See “Normal Range of Findings” under the “Objective Data” heading in the text. Neurological System Jarvis Key Points - - - - - - The central nervous system is made up of the brain and spinal cord. The cerebral cortex is the outer layer of nerve cell bodies and the center for a human’s highest functions, governing thought, memory, reasoning, sensation, and voluntary movement. Each half of the cerebrum is a hemisphere, and each hemisphere is divided into four lobes. The frontal lobe contains areas that control personality, behavior, emotions, and intellectual function. It also contains Broca’s area, which mediates motor speech. The parietal lobe contains the postcentral gyrus, which is the primary center for sensation. The occipital lobe is the primary visual receptor center. The temporal lobe has the primary auditory reception center, with functions of hearing, taste, and smell. - It also contains Wernicke’s area, which is associated with language comprehension. Other structures of the central nervous system include the basal ganglia, thalamus, hypothalamus, cerebellum, brainstem, and spinal cord. - The basal ganglia are large bands of gray matter that help initiate and coordinate movement and control automatic associated movements of the body. - The thalamus is the main relay station, where sensory pathways form synapses on the way to the cerebral cortex. - The hypothalamus is a major respiratory center with basic vital functions, such as regulating temperature, heart rate, and blood pressure, as well as sleep and appetite. It also coordinates autonomic nervous system activity and the stress response. - The cerebellum is concerned with motor coordination of voluntary movements, equilibrium, and muscle tone. - The brainstem is the central core of the brain, consisting mostly of nerve fibers. It contains the midbrain, pons, and medulla oblongata. - The spinal cord is a long cylindrical structure of nervous tissue that occupies the upper two-thirds of the vertebral canal, from the medulla to lumbar vertebrae L1 to L2. The spinal cord is the main highway for fiber tracts that connect the brain to the spinal nerves. It mediates posture control, urination, and pain response. The central nervous system has sensory and motor pathways that connect the cerebral cortex to other areas of the body. The sensory pathways monitor conscious sensation, internal organ functions, body position, and reflexes. The sensory pathways include the anterolateral tract and the posterior (dorsal) columns. The anterolateral tract transmits sensations of pain, temperature, itch, and crude touch. The posterior columns conduct sensations of position, vibration, and finely localized touch. The motor pathways control movement and include the corticospinal (pyramidal) tract, extrapyramidal tract, and the cerebellar system. The corticospinal tract controls skilled and purposeful movements. The extrapyramidal tract maintains muscle tone and gross automatic movements, such as walking. The - - - - cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The upper motor neurons reside in the central nervous system and convey impulses from motor areas of the cerebral cortex to the lower motor neurons. The lower motor neurons reside in the peripheral nervous system and extend to the muscles where they control movement. The peripheral nervous system includes all the nerve fibers outside the brain and spinal cord. This system carries messages from sensory receptors to the central nervous system and from the central nervous system to muscles and glands. Reflexes are basic defense mechanisms of the nervous system. They are involuntary, operating below the level of conscious control and permitting a quick reaction to potentially painful or damaging situations. Reflexes also help the body maintain balance and appropriate muscle tone. The types of reflexes are deep tendon, superficial, and visceral. Cranial nerves enter and exit the brain rather than the spinal cord. Cranial nerves I and II extend from the cerebrum, and cranial nerves III through XII extend from the lower diencephalon and brainstem. The 12 pairs of cranial nerves supply primarily the head and neck, except for the vagus nerve, which travels to the heart, respiratory muscles, stomach, and gallbladder. Cranial nerves are responsible for the senses of smell, taste, vision, and hearing, as well as other sensory and motor functions. - Cranial nerve 1: Olfactory nerve (not tested routinely) - Smell - Cranial nerve 2: Optic nerve - Vision - Cranial nerve 3: Oculomotor nerve - Motor: most extraocular muscle movement, opening of eyelids - Parasympathetic: pupil constriction, lens shape - Cranial nerve 4: Trochlear nerve - Downward and inward movement of eye - Cranial nerve 5: Trigeminal nerve - Motor function: assess muscles of mastication by palpating temporal and masseter muscles as a person clenches his or her teeth - Sensory function: with a person’s eyes closed, test light touch sensation by touching a cotton wisp to designated areas on a person’s face: forehead, cheeks, and chin - Assess corneal reflex if the person has abnormal facial sensations or abnormalities of facial movement - Tests all three divisions of CN V: ophthalmic, maxillary, and mandibular - Cranial nerve 6: Abducens nerve - Lateral movement of of eye - Cranial nerve 7: Facial nerve - Motor: facial muscles, close eye, labial speech, - Sensory: taste (sweet, salty, sour, bitter) on anterior two thirds of tongue - Parasympathetic: saliva and tear secretion - - - - - - - - Cranial nerve 8: Acoustic nerve (vestibulocochlear) - Hearing and equilibrium - Cranial nerve 9: Glossopharyngeal nerve - Motor: pharynx (phonation and swallowing) - Sensory: taste on posterior one third of tongue, pharynx (gag reflex) - Parasympathetic: parotid gland, carotid reflex - Cranial nerve 10: Vagus nerve - Motor: pharynx and larynx (talking and swallowing) - Sensory: general sensation from carotid body, carotid sinus, pharynx, viscera - Parasympathetic: carotid reflex - Cranial nerve 11: Accessory nerve (Motor) - Movement of trapezius and sternomastoid muscles - Cranial nerve 12: Hypoglossal nerve (Motor) - Movement of tongue The spinal nerves arise from the length of the spinal cord and supply the rest of the body. They are named for the region of the spine from which they exit. The spinal nerves are considered mixed because they contain sensory and motor fibers. The autonomic nervous system is the part of the nervous system that governs the smooth (or involuntary) muscles, cardiac muscle, and glands. Its function is to maintain homeostasis in the body. The neurologic system is not completely developed at birth. Primitive reflexes direct movements, and motor activity is under the control of the spinal cord and medulla. As myelin is acquired, sensory and motor development adjusts and conducts most impulses. This process follows a cephalocaudal and proximodistal order. The aging process causes general atrophy of a steady loss of neuron structure in the brain and spinal cord and a decrease in the velocity of nerve conduction causing a decrease in muscle strength and agility. Age-related memory loss is distinct from early Alzheimer disease. Stroke is an interruption of blood supply to the brain. There is racial/ethnic as well as geographic disparity in the instance of stroke. This section presents critical points about subjective and objective assessments of the neurologic system. To obtain subjective data about the neurologic system, ask questions that investigate headaches or head injuries; dizziness, vertigo, or seizures; tremors, weakness, numbness, tingling, and incoordination; difficulty swallowing or speaking; patientcentered care; and environmental/occupational hazards. To obtain objective data, follow this sequence for a complete neurologic exam: - Mental status - Cranial nerve - Motor system - Sensory system - Reflexes A screening examination should be done on well patients who have no significant subjective findings in their history, a complete examination on those who have neurologic concerns or have shown signs of neurologic dysfunction, and a neurologic recheck on patients with demonstrated neurologic deficits who need periodic assessments. - After assessing mental status, test cranial nerves II through XII. - Test cranial nerve I only in patients who report loss of smell, have head trauma or abnormal mental status, or may have an intracranial lesion. - Next, inspect and palpate the motor system and assess all muscle groups for symmetry of size, strength, and tone. Note any involuntary movements. Assess cerebellar function with coordination and skilled movements, balance, and gait testing. - To continue, assess the sensory system with the patient’s eyes closed. Test sensation and the ability to perceive pain, light touch and temperature, vibration, position, and tactile discrimination. - Finally, assess the reflexes, both the superficial and deep tendon reflexes. - When assessing the neurological system, incorporate health promotion. For example, review the signs, symptoms, and risk factors of stroke and discuss ways to change any modifiable risk factors. One tool particularly useful for public education is the F.A.S.T. acronym (Face drooping, arm weakness, speech difficulty, time to call 911). Also, encourage the patient to seek medical attention for a possible ministroke.
