Health-assessment

Health Assessment ANATOMY: SPECIAL SENSES | SENSE OF HEARING | EARS HEARING Sense of hearing and equilibrium MECHANORECEPTORS - Detect sound waves (touch & hearing)  OUTER EAR PINNA | AURICLE - The only visible part of the ear with its special helical shape EXTERNAL AUDITORY CANAL | EXTERNAL ACOUSTIC MEATUS - A tube running from the outer ear to the middle ear TYMPANIC MEMBRANE - Thin, cone-shaped membrane that separates the external ear from the middle ear  MIDDLE EAR 1|Health assessment TYMPANIC CAVITY - An air chamber It contains a chain of movable bones which transmits the vibrations of the tympanic membrane across the cavity to the middle ear MASTOID ANTRUM | TYMPANIC ANTRUM - An airspace in the petrous portion of the temporal bone AUDITORY TUBE | EUSTACHIAN TUBE - Equalizes the pressure between the outer and inner ear EQUALIZES THE PRESSURE BETWEEEN THE INNER EAR AND THE ATMOSPHERE Methods we use when we feel pressure inside our ear: swallowing yawning, and chewing (happens here) AUDITORY OSSICLES 1. 2. 3. MALLEUS | HAMMES Transmits sound vibrations from the eardrums to the incus INCUS | ANVIL The middle bone; connects to the malleus and to the stapes STAPES | STIRRUP Transmits sound vibrations from the incus to the oval window It connects middle ear to the inner ear  INNER EAR COCHLEA - Receives sounds in the form of vibrations Transforms vibrations of the cochlear liquids and associated structures into a neural signals Organ of hearing VESTIBULE 1. 2. Detect changes in gravity and linear accelerations Responsible in balance Contains utricle and saccule UTRICLE Changes in velocity when traveling (horizontal & vertical) SACCULE Acceleration & Deceleration 2|Health assessment A. OVAL WINDOW | VESTIBULAR WINDOW Transmits the vibrations to the inner ear B. ROUND WINDOW | COCHLOEAR WINDOW SEMICIRCULAR CANALS (ANTERIOR, POSTERIOR, LATERAL) - Helps maintain balance when turning spinning, or tumbling Fluid filled tubes in your inner ear that helps you keep your balance FLUIDS IN THE EAR 1. 2. - Help in transmission of the sound Are separated from each other Chemically different PERILYMPH Fluid outside ENDOLYMPH Fluid inside NOTES: FLUID - The flow of fluid in the ear counter flows the movement of our body to maintain balance CERUMINOUS GLANDS - Produces earwax EARWAX | CERUMEN - Helps keep the skin in the ear canal soft Keeps the bugs out CUPULA - Hair-like structure It helps the movement of the fluid; Endolymph VESTIBULOCOCHLEAR NERVE VII - VESTIBULAR – maintain balance COCHLEAR – auditory sense 3|Health assessment SENSE OF HEARING - Last sense that is last to leave the body when you die First to return when you wake up AUDITORY PATHWAY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. AURICLE EXTERNAL AUDITORY CANAL TYMPANIC MEMBRANE AUDITORY OSSICLE COCHLEAR FLUID is disturbed Ripple disturbs hair cells in the ORGAN OF CONTI/COCHLEA COCHLEAR NERVE BRAIN STEM THALAMUS AUDITORY NERVE OF TEMPORAL LOBE ASSESING THE EAR/HEARING Position - Alignment of pinna with the corner of the eye and within 10 degree angle of vertical position  INFANTS - Inspection: Top of the pinna should match on imaginary line extending from the corner of the eye to the occiput Should be positioned 10 degrees of vertical New born: hasn’t yet developed the cartilage that will give shape and firmness of shape of the external ear Folded/misshape ears are normal for infants - Skin Conditions: Smooth without nodules Colour pink Consistent with the patient’s facial colour Intact on the skin with no lesions - To Assess: To assess gross hearing, ring a bell from behind the infant or; Have the parent call the child’s name to check for a response If there is response to the sound the infant may open eyes wider 3 -4 months of age, the child will turn head toward the sound There are many variations in size and shape of the ear - 4|Health assessment - Palpation: Palpate the external ear; Normal: non tender auricle, tragus Mastoid process for; Normal: no tenderness, warm to touch, mastoid process easily palpated Tenderness, temperature, oedema  Deviations  - Hypoplastic ear Can be genetic  - Ear tag The infant’s external part of the ear are the first areas to develop inside a pregnant mother Associated with loss of hearing in babies It may indicate that the internal ear didn’t form correctly inside 5|Health assessment  - Lop ear Can be treated – treatment: ear moulding  - TINITUS is the perception of noise or ringing in the ears it's a symptom of an underlying condition, such as age-related hearing loss, ear injury or a circulatory system disorder At risk: seniors / older adults military personnel musicians construction workers -  TESTS  Whisper Test - to assess high-frequency hearing have the patient occlude one ear go out of the patient’s sight, at distance of 1-2 ft. , whisper ask the patient to repeat the phrase the patient should be able to repeat the phrases correctly Conductive Hearing Loss - is the result of interrupted transmission of sounds through the external and middle structure of the ear a tear/obstruction in tympanic membrane Sensorineural Hearing Loss - damage to the inner ear, auditory ear, hearing centre in the brain (cochlea) Mixed Hearing Loss - combination of conduction and sensorineural hearing loss 6|Health assessment - external to inner ear  - OTOSCOPY an examination that involves looking into the ear with an instrument called an otoscope (or auriscope) performed in order to examine the 'external auditory canal' – the tunnel that leads from the outer ear (pinna) to the eardrum  - WEBER TEST Ernst Heinrich Weber Using a tuning fork Quick screen test for hearing When holding a vibrating tuning fork, always hold the fork by its base preferable as low as possible Generally performed first and assess for lateralization of sound or whether sound is heard louder in one ear Normal: sound is heard equally in both ears (WEBER NEGATIVE) Deviation: sound is better in impaired ear, including a bone-conductive hearing loss sound is heard better in ear without a problem indicating a sensorineural disturbance (WEBER POSITIVE) If the result is WEBER NEGATIVE no need to perform additional test - 7|Health assessment RINNE TEST In the event of sound lateralization perform Rinne Test Helps to determine in what area have deviation Sound lateralizes to the ear with a conductive hearing loss Masking effect of air conduction has been lost Expected: sound is heard by both air conduction and bone conduction, air conducted sound can mask the bone conducted sound Bone Conductive Deficit: ossicles respond to the direct stimulation of the vibrations and not any sound that is transmitted by air conduction Ear with Conductive Hearing Loss: does not receive any air conduction sound to ask or dilute bone conduction and sound is lateralized to that ear Compare air conduction to bone conduction Normal: air conduction of sound is generally louder and heard twice as long as bone conduction ACBC 2:1 Thus if the patient heard the sound by bone conduction for 8 seconds, sound should be heard by air conduction by 16 seconds Ask whether the patient now hears the sound, sound conducted by air is heard more readily Normal: AC>BC Deviation: BC>AC or BC = AC – indicates a conduction hearing loss GENERALLY:  - 8|Health assessment 9|Health assessment ANATOMY: EYE  SUPERIOR RECTUS MUSCLES OF THE EYE Rolls eyeballs upward INFERIOR RECTUS Rolls eyeballs downward MEDIAL RECTUS Rolls eyeballs medially LATERAL RECTUS Rolls eyeballs laterally SUPERIOR OBLIQUE Rolls eyeballs on axis INFERIOR OBLIQUE Rolls eyeballs on axis 3 LAYERS OF THE EYE 1. SCLERA 2. CHOROID 3. RETINA Hardest part Serves as an attachment Highly pigmented Contains lots of blood vessels | Vascular Avascular / no blood Photoreceptors and very fragile Helps maintain shape Outermost layer Middle layer Innermost layer RODs – acts night-time, detects colour (black, white, and gray), functions in peripheral vision CONEs – acts daytime, detects various/all colours, functions best in bright light 3 types of CONES (BLUE: 16%) (GREEN: 10%) (RED: 74%) 10 | H e a l t h a s s e s s m e n t LACRIMAL GLAND - Produces tears FOVEA CONTRALIS - Small central pit composed of closely packed cones in the eye Located in the center of the macula lutea of the eye MEIBOMIAN GLAND - Produce and oily substance that keeps the eyes moist CONJUNCTIVA - Mucous membrane, lines the inner surface of the eyelids Transparent, coral pink, may visible small vessels CORNEA - Avascular Most exposes and transparent Nothing protects cornea Protective window for which the light passes - Makes the constriction and dilation of pupils Iris muscle CIRCULAR MUSCLE – when contracts it constricts the pupil (parasympathetic) RADIAL MUSCLE – when contracts it dilate the pupil (sympathetic) IRIS PUPIL - Protective reflex Prevents excessively bright light from damaging the delicate photoreceptor 11 | H e a l t h a s s e s s m e n t - - ACCOMODATION PUPILLARY EFFECT – pupil constrict to increase depth of focus of the eye by blocking the light PUPILLARY LIGHT REFLEX – the reflex of the eye to the brightness or dimness of the light CORNEAL LIGHT REFLEX asymmetrical placement of the corneal light reflex indicates that the eye are not in the proper alignment can be due to strabismus generally caused by weakness or paralysis of eye muscle LENS - Avascular like the cornea 65% water 35% protein To focus light rays on the retina by accommodation Distant object – the lens flattens Near object – the lens gets rounder and thicker MACULA LUTEA OR FUVEA - Contains very high concentration of cones CILLARY BODY - Controls the shape of the lens (cilliary muscle) Cillary epithelium – produces aqueous humor Vitreous humor – produced in the non-pigmented portion of the cillary body AQUEOUS HUMOR - Help with the movement of the eye Anterior Nourishing the cornea and the lens by supplying nutrition such as amino acids and glucose, the aqueous humour will: Maintain intraocular pressure. VITREOUS HUMOR - Fillers of the eyeball behind the lens Posterior NORMAL INTRAOCULAR PRESSURE (IOP) - Ranges from - 12 – 21 mm Hg CANAL OF SCHLEMM - Circular canal lying in the substance of the schlerocorneal junction of the eye and; Draining the aqueous humor from the anterior chamber Aqueous humor circulation. 12 | H e a l t h a s s e s s m e n t  VISUAL PATHWAY 1. 2. 3. 4. 5. 6. 7. 8. LIGHT CORNEA PUPIL CLEAR LENS RETINA RODS & CONES OPTIC NERVE BRAIN AQUEOUS HUMOR CIRCULATION 1. 2. 3. 4. CILLIARY BODY POSTERIOR CHAMBER OF THE EYE ANTERIOR CHAMBER OF THE EYE CANAL OF SCHLEMM ASSESSING THE EYES PALPEBRAL FISSURES - Length : Endocanthion to Exocanthion the elliptic space between the medial and lateral canthi of the two open lids In adults, this measures about 10mm vertically and 30mm horizontally. 13 | H e a l t h a s s e s s m e n t EYELIDS -  Overlaps the superior area of / part of the iris and approximate completely with the lower lids when close. INFANTS First week after birth and up to 3 months, baby can focus only on objects and people that are close up, about 10 – 12 inches from her face Four to six months when the baby is able to see colour and perceive depth Baby is able to develop the ability to focus on objects/people – 6 months 8 months – infants can now almost see to the level of an adult with regards to clarity and depth perception, and able to recognize faces Infants do not have tears until – 3 months By 6 months, average infant’s vision is already 20/20 *Binocular fixation pattern  DEVIATIONS  Infantile Esotropia A form of ocular motility disorder where there is an inward turning of one or both eyes, commonly referred to as crossed eyes. It occurs during the first 6 months of life in an otherwise neurologically normal child.  Periorbital area – Periorbital Oedema a term for swelling around the eyes  Purpura discoloration - around the eye  Ptosis Droopy eyelid caused by more serious conditions such as stroke, brain tumour, or cancer of the nerves or muscle Uneven opening of the eyes  Lid Lag static situation in which the upper eyelid is higher than normal with the globe in downgaze most often a sign of thyroid eye disease, but may also occur with cicatricial changes to the eyelid or congenital ptosis  Hordeolum/Sty Most often caused by staphylococcus bacteria Usually lived around the surface of the eyelid without causing any harm When a gland becomes clogged with dead skin cells or old oil, these can become trapped and cause infection Found on the sides of the eye  Chalazion 14 | H e a l t h a s s e s s m e n t - Found at the middle Caused by non-infectious meibomian gland occlusion, whereas a hordeolum usually caused by infection  Conjunctivitis Aka sore eyes  Subconjunctival haemorrhage bleeding underneath the conjunctiva the conjunctiva contains many small, fragile blood vessels that are easily ruptured or broken when this happens, blood leaks into the space between the conjunctiva and sclera  Foreign Object something that enters the eye from outside the body  Pterygium Growth of the conjunctiva that occurs the white part of your eye over the cornea Shape : wedge shape CAUSE: unknown, too much sun/UV exposure  Jaundice Sclera The conjunctiva of the eye are one of the first tissues to change color as bilirubin levels rise in jaundice. This is sometimes referred to as scleral icterus. The sclera themselves are not "icteric" (stained with bile pigment), however, but rather the conjunctival membranes that overlie them. CAUSE: High bilirubin levels  Red Sclera caused by dilation of tiny blood vessels that are located between the sclera and the overlying clear conjunctiva of the eye usually are caused by allergy, eye fatigue, over-wearing contact lenses or common eye infections such as pink eye (conjunctivitis)  - Strabismus one eye looks directly at the object you are viewing, while the other eye is misaligned inward (esotropia, "crossed eyes" or "cross-eyed") outward (exotropia or "wall-eyed") upward (hypertropia) downward (hypotropia)   TESTS SNELLEN’S CHART 15 | H e a l t h a s s e s s m e n t - - Children are tested with snellen letter chart (ages 7 – 8 years old) To assess the quality of the eyesight of the patient Expected visual activity is 20/20 Numerator – indicating distance from the chart, it is constant Denominator – representing the distance a person with normal vision could see and interpret symbol Its score is recorded L 20/40 The patient is 20ft from the eye chart and reads with the left eye at 20ft what the “normal” eye visualizes at 40ft The patient visual acuity is determined by what line the patient can read correctly  FIXATION TEST Used to screen vision in children 6 months to 2½ years and for those children up to 3 years cannot be tested with picture eye * Used : Penlight & colourful object (RED) Cover one eye and hold the light 1 ½ ft. away from the child Move the light/toy from midline, side-to-side Normally the child will track the light or toy with both eyes It fails when he objects  - TESTING VISUAL FIELDS Measure peripheral vision 50 – Upward field 90 – Temporal field 60 – Nasal Field 70 – Downward field Considered a neurological rather than ocular It assesses the integrity of the optic nerve and its appropriate pathways Deviation: homonymous hemianopia - 16 | H e a l t h a s s e s s m e n t  - HIRSCHBERG TEST Muscle strength and position of the eye can also be determined The light reflex should be in the same position bilaterally DEVIATION: Strabismus  - PUPILLARY ASSESSMENT To assess pupillary size in a darkened room, illuminate the face from below. Slowly move the light up to the patient's eye level and check the pupillary response  - ACCOMODATION OF PUPIL The normal pupillary response is constriction of the pupils and convergence of the eyes  PUPILLARY ASSESSMENT Fixed, pinpoint pupils: Indicate PONS involvement or the use of opiates/drugs CN III – Oculomotor – constriction of the eye – Originates from the midbrain - - Tumour, Clotted blood, Oedema, Aneurysm Compression of the nerve may result in dilation on the side of the lesion or the area affected Cataract 17 | H e a l t h a s s e s s m e n t - The lens are affected Number 1 cause is AGING - Arcus Senilis Cause: lipid/cholesterol (those who are fat or obese) deposits in the periphery of the cornea stromal layer  ADDITIONAL/S PERRLA - Normal Pupil size: 3-5 mm Response to light Brisk, sluggish, non-reactive or fixed Normally constrict when exposed directly to light Consensual response Have at least 10 seconds interval between assessment of each eye  - Older adults Visual acuity decreases the eye ages and become more opaque and loses elasticity peripheral vision diminishes eyeball may appear sunken Less absorption of vitamin B12 in the ileum which may result in PALE CONJUNCTIVA ASSESSING THE FACE & SKULL AND NECK FACE 2 Structures of the face that are important in assessing for symmetry 1. Nasolabial Folds 2. Palpebral Fissures HEAD AND NECK 18 | H e a l t h a s s e s s m e n t - Framework of the head is the skull Normal size of the skull (infant) ranges from 32-38 with an average of 34 – 55-57 in adult All of the facial bones are immovable except for mandible The face also consist of many muscles that produce facial movements and expressions NECK - Composed of muscles, ligaments, and the cervical vertebrae Hyoid bone, several blood vessels, larynx, trachea, thyroid gland LYMPH NODES OF THE HEAD AND NECK - Lymph nodes produces lymphocytes and antibodies as defence against invasion by foreign substances Size and shape of lymph nodes vary ; but are buried deep in the connective tissue Normally lymph nodes are either not palpable or they may feel like small beads Order in assessing the lymph nodes 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Pre-auricular Post auricular Occipital Submental Submandibular Jugulodigastric/tonsilar Superficial cervical Deep cervical Posterior cervical Supraclavicular  -  DEVIATIONS Acromegaly Enlargement of the facial features (nose,eyes) and the hands and feet  - Microcephaly Small head  - Anencephaly No brain  - Hydrocephalus Abnormal enlargement of the head  - Cushing’s Syndrome May present with a moon shaped face with reddened cheeks and increased facial hair  - Scleroderma Tightened-face with thinning facial skin Autoimmune disease Unknown cause 19 | H e a l t h a s s e s s m e n t  - Bell’s Palsy Paralysis of the facial nerve (7) Symptoms may include twitching, weakness, paralysis, drooping eyelid and corner of the mouth, drooling  - Hyperthyroidism Enlarged thyroid gland (goiter)  - Exopthalmus Bulging of the eye  - Jugular Vein Distention ccurs when the pressure inside the vena cava increases and appears as a bulge running down the right side of a person's neck  - NVE Pressure in the right side of the heart is high Normal Characteristics of the Thyroid Gland Smooth surface Firm consistency Nontender to gentle pressure - Bruit sound - An indicator of thyroid hyperplasia Best heard with the bell of a stethoscope A soft, pulsatile, whooshing, blowing sound This bruit is not present normally PHYSICAL EXAMINATION Inspection - It is a visual examination This examination must be systematic to assess colour, body shape, wounds, facial expression, motor behaviours and some area to be examined Palpation - Used to validate your inspection It is an examination using the sense of touch. The pads of the fingers are used because the concentration of nerve endings are highly sensitive to tactile discrimination  Light Palpation  Deep Palpation Percussion 20 | H e a l t h a s s e s s m e n t - The examiner places one hand on the patient and then taps a finger on that hand, with the index finger of the other hand It can determine the position, size, and consistency of an internal organ Based on the auditory and tactile perception, the notes heard can be categorized as follows: • Tympanic • Hyperresonant (pneumothorax) • Normal resonance/ Resonant • Impaired resonance (mass, consolidation) • Dull (consolidation) • Stony dull (pleural effusion) Auscultation - Technical term for listening to the internal sounds of the body, usually using a stethoscope; based on the Latin verb auscultare "to listen" To auscultate heart, lungs, abdomen  Palpation -  PRINCIPLES Have short nails Warm your hands prior to placing them on the patient Encourage the patient to breathe normally throughout the palpation If pain is experienced during the palpation, discontinue the palpation immediately Inform the patient what you are going to do and why it is necessary -  TYPES OF PALPATIONS Light Palpation - Light pressure is applied by placing the fingers together and depressing the skin and underlying structures about ½ inch (1cm) Used to check the muscle and tenderness Deep Palpation - It is used/done with caution because pressure can damage internal organs Depresses the skin 2cm or deeper Hooking Technique - To know the size of the liver 21 | H e a l t h a s s e s s m e n t Fingertips - used for localized pulsations Thrills - is felt from light palpation over the chest wall - is a slight movement – a palpable vibration due to strong heart murmur (like a purring cat) Lifts Heaves - is more vigorous movement than the lift, a vibratory sensation felt on the skin overlying an area of turbulence  - Percussion Used to determine the size and shape of internal organs by establishing their border The detect the presence of air, fluid, enlargement of organ BONE – flat sound Lungs / PRESENCE OF AIR – resonance 22 | H e a l t h a s s e s s m e n t ORGANS / WATER – dull ABDOMEN – tympanitic  - Auscultation the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a part of medical diagnosis Diaphragm - breathe sounds bowel sounds normal heart sounds - murmur bruit Bell # Most used position when auscultating are – sitting position and supine 23 | H e a l t h a s s e s s m e n t Instruments used in physical examination BASIC - Stethoscope Opthalmoscope Dermatoscope Otoscope Tape measure Reflex hammer Monofilament Tuning fork STANDARD PRECAUSIONS Nosocomial Infection - Infection acquired during hospitalization Hand Washing / Hand Hygiene - Before and after physical contact with each patient After inadvertent contact (blood, body fluids, secretions, excretions) After handling any equipment w/ body fluids Before and after gloving Gloves - Use when you’re going to be in contact with; Blood and Body Fluids Excretions and Secretions And any contaminated things Gown - Wear in doing any procedure to protect yourself 24 | H e a l t h a s s e s s m e n t Linen / Laundry - Are placed in a private room and linens from patients with infectious disease/s are separated SKIN ASSESSMENT SKIN: FUNCTIONS 1. 2. 3. 4. 5. 6. 7. 8. Regulates body temperature. Prevents loss of essential body fluids, and penetration of toxic substances. Protection of the body from harmful effects of the sun and radiation. Excretes toxic substances with sweat. Mechanical support. Immunological function mediated by Langerhans cells. Sensory organ for touch, heat, cold, socio-sexual and emotional sensations. Vitamin D synthesis from its precursors under the effect of sunlight and introversion of steroids.  Infants and Children Have very smooth skin – lack of exposure to environmental variables Subcutaneous is poorly developed thus predisposing infants to hypothermia Vernix Caseosa - Cheese-like substance (sebum) For the skin not to be easily macerated Creamy substance on newborn’s skin and has anti-microbial and moisturizing qualities that help protect them in their new environment 25 | H e a l t h a s s e s s m e n t Lanugo - The baby’s body (esp. shoulders and back) are covered with fine silky hair (if present) it disappear 10 – 15 days Apocrine Glands - Do not function at this age resulting in odourless perspiration Makes the skin with a less oily texture - Begins to function about 4 weeks Merocrine is a term used to classify exocrine glands and their secretions in the study of histology. A cell is classified as merocrine if the secretions of that cell are excreted via exocytosis from secretory cells into an epithelial-walled duct or ducts and thence onto a bodily surface or into the lumen Merocrine Eccrine Glands - Perspiration – present after 1 hour (after birth) INSPECTION  Skin Colour Erythema – reddening of the skin Cyanosis – bluing Pallor – paling of the skin Jaundice – yellowing of the skin   Skin Uniformity Skin’s generally uniform except in areas exposed to the sun and areas prone to friction (armpit, groins, etc.) Areas with lighter pigmentation (esp. noticeable in dark skinned people) – palms, lips, nail beds Deviations – Abnormal HYPERPIGMENTATION - Abnormal distribution of melanin Freckles, birthmarks, Mongolian blue spots – etc 26 | H e a l t h a s s e s s m e n t Cutis Marmorata - Skin has a pinkish blue mottled or marbled appearance when subjected to cold temperature It loses when exposed to warm temperature / normal temperature again (Rewarming) Senile Lentigines - spots that appears when you get old (hyperpigmentation) Freckles - Indication of sun damage When the skin produces more melanin pigmentation (UV RAYS) Light brown spots (face, neck, and shoulders) More prominent to Caucasians Addison’s Disease 27 | H e a l t h a s s e s s m e n t - Also known as primary adrenal insufficiency, result from the insufficient production of these two hormones, cortisol and aldosterone. Major symptoms include fatigue, gastrointestinal abnormalities, and changes in skin colour (pigmentation). HYPOPIGMENTATION - Pallor Partial or complete absence of melanin Vitiligo - Destruction of melanocytes in the area (most prominent in Africans) Albinism - Complete or partial lack of melanin A congenital disorder (white) skin, hair, and eyes Associated with a number of vision defects; photophobia, nystagmus, amblyopia) They are more prone to sunburn and skin cancer 28 | H e a l t h a s s e s s m e n t Physiological Jaundice - - - RBC / Hemoglobin in the blood is divided to HEME and GLOBIN, HEME is divided into BILIVERDIN and ****** which are then converted to BILURUBIN. BILIRUBIN is collected by the liver, since the new born or infants (physiological jaundice) have undeveloped/not fully developed LIVER, since they don’t have fully developed liver they don’t have the capability to collect the unneeded BILIRUBIN, which then causes the yellowing of the skin of the new born / infant (JAUNDICE) Yellowing of the skin, sclera and mucous membranes Occurs at 3rd – 4th day of life – normal Reaches its maximal intensity (3-6 days) Subside (10 days – 2 weeks) Jaundice occurring in the first 24 hours of life is abnormal – PALPATION  Temperature The skin should be warm (to touch) and the temperature should be equal bilaterally Hypothermia - Generalized or localized coolness May cause immobilized extremity Happens when limb is in cast Hyperthermia - High temperature When you have; fever, infection, trauma -  Skin Turgor Ability of the skin to change shape and return to normal after pinching (turgor) A sign commonly used by health workers to assess fluid loss of dehydration 29 | H e a l t h a s s e s s m e n t Edema - Swelling abnormal accumulation of fluid in certain tissues within the body Edema happens when your small blood vessels leak fluid into nearby tissues INSPECTION | PALPATION Lesions - Uses inspection and palpations to describe skin lesions; Colour, elevation, size, location Pedunculated Lesions -  small wound that have its own blood vessels Shape or Pattern Annular Lesions - The term “annular” stems from the Latin word “annulus,” meaning ringed The lesions appear as circular or ovoid macules or patches with an erythematous periphery and central clearing. 30 | H e a l t h a s s e s s m e n t Confluent Lesions Linear Lesions -  Size Size in centimetres : use ruler to measure -  Location and Distribution Any exudate – note any color Palpate lesions Gently scrape a scale to see if it comes off, or if it bleeds when the scale comes off Do the lesions blanching **Tumbler Test - Used to check if the lesion is pressed a glass and non-blanchable it could be; Erythema, herpes zoster, etc. Herpes Zoster or Shingles – highly infectious 31 | H e a l t h a s s e s s m e n t Macule - Flat, cannot be palpated, skin colour may change (brown, white, tan, purple, red) Note the colour Less than 1cm with circumscribed border - Bigger than macule More than 1cm and may have an irregular border Freckles, flat moles, petechiae, rubella, vitiligo - Small, containing solid mass, elevated Have circumscribed border and are less than 0.5cm - Small flat (small little deviation) Coming together - Small red spots - are tiny, circular, non-raised patches that appear on the skin or in a mucous or serous membrane. They occur as the result of bleeding under the skin - Ex. Meningitis, snake bites Purplish spots Patches Papule Plaque Petechiae Purpura Ecchymosis - Hemorraghic blotching due to pooling of blood under the skin or mucous membrane Comedone - Increased in sebaceous gland activity, creates increase oiliness Common skin problem of adolescence (7-8) Peak (14-16 in girls, 16-19 in boys) - Puss-filled vesicle or bulla Pustule Wheals/Hives - Ex. Allergies, urticarial, insect bites Elevated mass with transient borders that is often irregular Size and color vary - Characterized by elevated lesions caused by local edema Urticarial Acrochordons 32 | H e a l t h a s s e s s m e n t - Skin tags Common in areas where there is skin friction Neck, axilla cheeks and trunk - They feel like large peas under the surface of the skin. - extremely common as people get older Some common benign tumors include: Warts (skin tumor resulting from a virus) Seborrheic keratoses (growths on the skin ranging from light skin color to dark brown) - small, fluid-filled sacs that can appear on your skin The fluid inside these vesicles may be clear, white, yellow, or mixed with blood - fluid-filled sac or lesion that appears when fluid is trapped under a thin layer of your skin It's a type of blister - Cysts are noncancerous, closed pockets of tissue that can be filled with fluid, pus, or other material. can develop as a result of infection, clogging of sebaceous glands (oil glands), or around foreign bodies, such as earrings Nodule Tumour Vesicles Bulla Cyst - Cherry Angioma -  Hair - Red moles They're usually found on people aged 30 and older The collection of small blood vessels inside a cherry angioma give them a reddish appearance Color – texture (fine, straight, curly, kinky) In young, should be shiny Oiliness is natural (not excessive) Note for any scalp lesions; Lice, loss of hair (alopecia)- autoimmune disease 33 | H e a l t h a s s e s s m e n t  Nails - Inspect and palpate the nails Blanching Shape Curvature (Convex, 160 c) ADULT/AGED - drier skin and less perspiration thinning and nuttering epidermis risk for injury greying of hair nail growth slows down the toenails; thicker, hard, brittle and yellowing appearance ASSESSING THE HEART AND NECK VESSELS - When beginning the examination, the ideal location to stand is on the right side INSPECTION -  General Appearance  Skin Colour Skin; warm to touch Homogenous in colouring Without significant moisture 34 | H e a l t h a s s e s s m e n t - - -  Capillary Refill The capillary nail refill test is a quick test done on the nail beds. It is used to monitor dehydration and the amount of blood flow to tissue.  Heaves or Lifts A parasternal heave (or lift) is a precordial impulse that may be felt (palpated) in patients with cardiac or respiratory disease. Precordial impulses are visible or palpable pulsations of the chest wall, which originate on the heart or the great vessels.  Pulsations (apical) – left ventricle on the 5th ICS, left MCL Jugular Venous Pulsation / Distention < is connected to superior vena cava **NVE – Neck Vein Engorgement  Deviations Skin Pallor & Cyanosis - May suggest poor tissue perfusion Skin Diaphoresis - May result from SNS stimulation as a result of diminished cardiac output Cyanosis - Best seen in the lips, earlobes, mucous membranes, or where the skin is thin  Hands and Fingernails -  - Schamroth’s Test Detects fingers clubbing Normal: small diamond-shaped “window” is typically apparent between the nail beds Deviation: increased convexity < loss of normal – 165 degrees between the nail bed and cuticle < may indicate endocarditis or a classic indicator of Cyanotic Congenital Heart Disease (CCHD) << CCHD – cardiac malformations that commonly affect the atrial or ventricular walls, heart valves, or large blood vessels << Endocarditis – inflammation of the heart’s inner lining (endocardium) < TB, Chronic Hypoxia, Liver Cirrhosis, IBD Anterior Chest For visible pulsations or movements Apical impulse / apex beat / Point of Maximal Impulse (PMI) < Location: 5th ICS, left MCL Generally not observed in healthy individuals (unless the patient is thin) 35 | H e a l t h a s s e s s m e n t  - - Internal Jugular Vein & External Jugular Vein IJV_bigger_anteriori EJV_posterior Normal: pressure on the left side of the heart is always higher than the right Deviation: Jugular Vein Distention (JVD) < occurs when the pressure inside the vena cava increases and appears as a bulge down the right side of a person’s neck < sign of increases Central Venous Pressure (CVP) << CVP – measurement of the pressure inside the vena cava Indicates how much blood is flowing back into your heart and how well your heart can move that blood into your lungs and the rest of your body Occurs when CVP increases above a normal/healthy level Can be caused by Right-sided heart failure <often occurs due to left-sided heart failure, when the weakened and/or stiff left ventricle loses power to efficiently pump blood to the rest of the body. As a result, fluid is forced back through the lungs, weakening the heart's right side, causing right-sided heart failure (READ MORE) LINK: https://www.healthline.com/health/jvd - JUGULAR VEIN ASSESSMENT 1. Examine position Head of bed elevated at 45 degree angle Head turned to right - 2. Identify top of venous pulsation in neck (JVP) Jugular Venous Pulsations are inward Contrast with outward Carotid Artery pulsations - 3. Identify the sternal angle (Angle of Louis) Located at superior edge or notch of Sternum - 4. Measure distance between top of pulsation and Sternum Measured in centimetres PRECORDIUM - Book – anterior chest area that overlies the heart and great vessels The region or the thorax immediately in front of the heart Front of the chest wall over the heart 36 | H e a l t h a s s e s s m e n t PALPATION    - Patient should be in supine position Be on his/her right side to gain easy access to the apex of the precordium Pulsation Heaves Thrills Displacement of the apex beat is often associated with ventricular enlargement / cardiomegaly < abnormal enlargement of the heart THRILLS Palpable murmurs – vibratory sensations Felt from light palpation over the chest wall Deviation: loud heart murmur – caused by an incompetent heart valve LIFTS A slight movement HEAVES More vigorous movement Sustained forceful thrusting of the ventricle during systole Palpable lifting sensation under the sternum and anterior chest left sternal border suggest a central precordial heave associated with RVH < Right Ventricular Hypertrophy – affecting right ventricle – right side of the heart is enlarged Caused by either congenital heart conditions or high blood pressure in the lungs / pulmonary hypertension ****MUST TO KNOW**** Left Lateral Decubitus Position (LLDP) - Patient is lying on his/her left side To bring the heart (nearer) to the chest wall to listen/feel for the sounds/vibrations better Tissue Perfusion - Flow of blood **a parasternal heave or lift is a precordial impulse that may be felt (palpated) in patients with cardiac or respiratory disease **Precordial impulse are visible or palpable pulsations of the chest wall, which originate on the heart or the great vessel 2nd Part Palpations - Peripheral Pulses – rate, rhythm, quality Thrills, Heaves, Lifts Apex Beat (PMI) – Point of Maximal Impulse Aortic Pulsation < Deviation: 6th ICS – Posterior Axillary Line < Runs from the heart, down to the centre of the chest, and into the abdomen 37 | H e a l t h a s s e s s m e n t Abdominal Aortic Aneurism (AAA) < occurs in the part of the abdomen < Thoracic Aortic Aneurism – occur in the part of the aorta located in the chest area  - - - Capillary Refill Time (CRT) Refers to the amount of time it takes for capillary circulation to return to the fingertips after capillary circulation is obliterated A common indicator of peripheral tissue perfusion Normal: less than 3 seconds / position above heart level / pinch/blanch finger nails, in older adults – it can be longer than 3 seconds, in neonates – pressure is exerted in the sternum for 5 seconds SIGNIFICANCE Prolonged CRT is suggestive of hypoperfusion and/or dehydration < decreased blood flow through an organ cerebral hypoperfusion (may cause pallor?) In adults prolonged CRT is also suggestive to CHF and/or PVD < CHF Congestive Heart Failure – failure of heart to pump blood with normal efficiency Heart is unable to provide adequate blood flow to other organs, such as the brain, liver, and kidneys < PVD Peripheral Vascular Disease – blood circulation disorder that causes the blood vessles outside the heart to narrow, block, or spasm < Peripheral Artery Disease (PAD) – common cause ATHEROSCLEROSIS << gradual process in which a fatty material builds up inside the arteries Less common cause: blood clots, injury to the limbs PERCUSSION - To estimate heart size AUSCULTATION - Blood Pressure Carotid Bruit Heart Sounds Normal: no sound should be heard Essential that auscultation of heart sounds be done in a quiet environment as possible Avoid a cold stethoscope on an exposed skin - Auscultate the CAROTID ARTERY for the presence of bruit < supplies the brain with blood << RIGHT COMMON CAROTID ARTERY – originates from brachiocephalic trunk the left from the aortic arch in the thorax Presence of bruit indicates atherosclerosis plaque, build up on the interior lumen - 38 | H e a l t h a s s e s s m e n t < means a clogged/plagued/ presence of clotted blood << Thrombus – causes stroke, clogged artery/vein << Embolus – the clotted blood travels through the blood vessels  There would be a presence of a bruit sound when there is/are – fats, blood clot  PENUMBRA - Occlusion of the MCA with irreversibly affected or dead tissue in black and tissue at risk or penumbra in red. CARDIAC OUTPUT - Amount of blood ejected by the heart in 1 minute 5-8 litres per minute 20% of the blood goes to the brain STROKE VOLUME - Amount of blood ejected by the valves/heart per contraction FORMULA: CO = SV x HR/PR SV – constant: 70cc CONDUCTION SYSTEM OF THE HEART Step 1: Pacemaker Impulse Generation The first step of cardiac conduction is impulse generation. The sinoatrial (SA) node (also referred to as the pacemaker of the heart) contracts, generating nerve impulses that travel throughout the heart wall. This causes both atria to contract. The SA node is located in the upper wall of the right atrium. It is composed of nodal tissue that has characteristics of both muscle and nervous tissue. Step 2: AV Node Impulse Conduction The atrioventricular (AV) node lies on the right side of the partition that divides the atria, near the bottom of the right atrium. When the impulses from the SA node reach the AV node, they are delayed for about a tenth of a second. This delay allows atria to contract and empty their contents into the ventricles prior to ventricle contraction. Step 3: AV Bundle Impulse Conduction The impulses are then sent down the atrioventricular bundle. This bundle of fibers branches off into two bundles and the impulses are carried down the center of the heart to the left and right ventricles. Step 4: Purkinje Fibres Impulse Conduction 39 | H e a l t h a s s e s s m e n t At the base of the heart, the atrioventricular bundles start to divide further into Purkinje fibers. When the impulses reach these fibers they trigger the muscle fibers in the ventricles to contract. The right ventricle sends blood to the lungs via the pulmonary artery. The left ventricle pumps blood to the aorta. Cardiac Conduction and the Cardiac Cycle Cardiac conduction is the driving force behind the cardiac cycle. This cycle is the sequence of events that occur when the heart beats. During the diastole phase of the cardiac cycle, the atria and ventricles are relaxed and blood flows into the atria and ventricles. In the systole phase, the ventricles contract sending blood to the rest of the body. Cardiac Conduction System Disorders Disorders of the heart's conduction system can cause problems with the heart's ability to function effectively. These problems are typically the result of a blockage that diminishes the rate of speed at which impulses are conducted. Should this blockage occur in one of the two atrioventricular bundle branches that lead to the ventricles, one ventricle may contract more slowly than the other. Individuals with bundle branch block typically don't experience any symptoms, but this issue can be detected with an electrocardiogram (ECG). A more serious condition, known as heart block, involves the impairment or blockage of electrical signal transmissions between the heart's atria and ventricles. Heart block electrical disorders range from first to third degree and are accompanied by symptoms ranging from light-headedness and dizziness to palpitations and irregular heartbeats.  DIASTOLE s2 During ventricular diastole, the AV valves are open and the ventricles are relaxed. This causes higher pressure in the atria than in the ventricles. Therefore, blood rushes through the atria into the ventricles. This early, rapid, passive filling is called early or protodiastolic filling. This is followed by a period of slow passive filing. Finally, near the end of ventricular diastole, the atria contract and complete emptying blood out of the upper chambers by propelling it into the ventricles. This final active filling phase is called preystole, atrial systole, or sometimes the “atrial kick”. This action raises left ventricular pressure.  SYSTOLE s1 The filling phases during diastole result in large amount of blood in the ventricles, causing the pressure in the ventricles to be higher than in the atria. This causes the AV valves (mitral and tricuspid) to shut. Closure of the AV valves produces the first heart sound (s1), which is the beginning of systole. This valve closure also prevents blood from flowing backward (a process known as regurgitation) in the atria during ventricular contraction. At this point in systole, all four valves are closed and the ventricles contract (isometric contraction). There is now high pressure inside the ventricles, causing the aortic valve to open on the right side of the heart. Blood is ejected rapidly through these valves. With ventricular emptying the ventricular pressure falls and the semilunar valves close. This closure produces the second heart sound (s2), which signals the end of systole. After closure of the semilunar valves, the ventricles relax. Atrial pressure is now higher than the ventricular pressure, causing the AV valves to open and diastolic filling to begin again.  ABNORMAL HEART SOUND s3 Normally diastole is silent DEVIATION: when ventricular filling creates vibration \ 40 | H e a l t h a s s e s s m e n t - Resistant to filling during the early rapid filling phase Occurs immediately after s2 Low pitched, quiet sound – difficult to hear Cause: Myocardium is RIGID When present in adults, s3 is considered pathological indicating decreased ventricular compliance May be produced by either the right or left side of the heart and is often initial of heart failure ANATOMY OF RESPIRATORY SYSTEM  LUNGS Have a lower and upper compartment 3 lobes on the right, 2 lobes in the left  Diaphragm Major muscle for respiration Separates the thoracic from the abdominal region INHALATION – down EXHALATION – up Rests on the lobe of the liver -  UPPER RESPIRATORY o Passageway for respiration o Moistens incoming air o Receptors for smell      Nose Nasopharynx Oropharynx Laryngopharynx Larynx (voice box) 41 | H e a l t h a s s e s s m e n t  NOSTRILS Filters the air we breathe and the debris from the air  NASAL CAVITY -  The nasal cavity is a hollow space within the nose and skull that is lined with hairs and mucus membrane. The function of the nasal cavity is to warm, moisturize, and filter air entering the body before it reaches the lungs. TURBINATE - o o o These structures are responsible for warming, humidifying, and filtering the air we breathe. Normally there are three turbinates including the superior (upper), middle, and inferior (lower) turbinates. Pulmonary Ventilation Internal and External Respiration Cleanse the airs, warms the air, moisture  PHARYNX o Is also called the throat. o Is the passageway for both air and food and forms a resonating chamber for speech sounds o It serves as both a connection between the mouth and the digestive tract and as a connection between the nose and respiratory system. o It is divided into three portions: o Nasopharynx – It has 4 openings in its walls: the 2 internal nares and 2 openings that lead to the auditory or Eustachian tubes. o Oropharynx – It has only 1 opening called Fauces which connects to the mouth; It is a common passageway for both food and air. o Laryngopharynx/Hypopharynx – Connects with the esophagus posteriorly and with the larynx anteriorly.  LARYNX o Is also called the Voice box. o It connects the pharynx to the trachea. o Thyroid Cartilage – It is the largest piece in the larynx. also known as the Adam’s apple which is larger in males than in females. o Epiglottis – Allows food to go down to the oesophagus; It closes the trachea. o Vestibular Folds/ False Vocal Cords. o Vocal Folds/ True Vocal Cords.  EPIGLOTTIS SUPRAEPIGLOTTIS – GLOTTIS (VOCAL CHORDS) – SUBGLOTTIS Closes the trachea for the food and water to enter the oesophagus  TRACHEA It is 42 | H e a l t h a s s e s s m e n t o o o  Is also referred to as the windpipe. It is the passageway for air. Goblet Cells – Produces mucus and the Ciliated Cells provide the same protection against dust particles. ANATOMY OF THE LUNGS o PLEURAL MEMBRANE – It encloses and protects each lung. o PARIETAL PLEURA – It is the outer layer that attaches the lung to the wall of the thoracic cavity. o VISCERAL PLEURA – It is the inner layer which covers the lungs. o PLEURAL CAVITY – Is the space between the parietal and visceral pleura which contains pleural cavity. o PLEURAL CAVITY – It is a pleural fluid that prevents friction between the two membranes and allows them to slide past each other during breathing, as the lungs and thorax change shape. THE BRONCHI AND THE BRONCHIAL TREE BRONCHI 1. o o Passageway of air Has goblet cells that produce mucus Contains mucus that traps foreign bodies The trachea terminates in the chest by dividing into a: Right Primary Bronchus – Goes to the right lung. Left Primary Bronchus – Goes to the left lung. 2. On entering the lungs, the primary bronchi divide to form smaller bronchi called the: o Secondary or Lobar Bronchi – The right lung has 3 lobes and the left lung has 2 lobes. 3. The secondary bronchi continue to branch forming even smaller bronchi called: o Tertiary or Segmental Bronchi 4. And tertiary bronchi divide into smaller branches called: o Bronchioles 43 | H e a l t h a s s e s s m e n t 5. Bronchioles finally branch into smaller tubes called: o Terminal Bronchioles  THE ALVEOLI The actual exchange of respiratory gases between the lungs and the blood occurs by diffusion across the ALVEOLI and the walls of the capillary network that surrounds it.  ALVEOLAR-CAPILLARY MEMBRANE – The membrane through which the respiratory gases move. - The blood–air barrier in the gas exchanging region of the lungs. It exists to prevent air bubbles from forming in the blood, and from blood entering the alveoli.  SURFACTANT o Is a fluid that coats the surface of the membrane inside each alveolus. o It helps reduce surface tension (the force of attraction between water molecules) of the fluid. o Breaks the bond of water molecules o Helps prevent alveoli from collapsing or sticking shut as air moves in and out during breathing. o It is produced by Alveolar Type 2 Cells. o During inspiration, when alveoli expand, the molecules move apart. o During expiration when lungs shortened, molecules move together and become concentrated thus surface tension is reduced.  RESPIRATION PROCESS Carbon Dioxide - Product of metabolism Metabolism – use of carbohydrates, proteins, glucose, etc. of the body RBC carries the OXYGEN and CARBON DIOXIDE and brings it to the lungs Breathing In (Inhalation) a. b. c. d. e. When you breathe in, or inhale, your diaphragm contracts (tightens) and moves downward. This increases the space in your chest cavity, into which your lungs expand. The intercostal muscles between your ribs also help enlarge the chest cavity. They contract to pull your rib cage both upward and outward when you inhale. As your lungs expand, air is sucked in through your nose or mouth. The air travels down your windpipe and into your lungs. After passing through your bronchial tubes, the air finally reaches and enters the alveoli (air sacs). Through the very thin walls of the alveoli, oxygen from the air passes to the surrounding capillaries (blood vessels). A red blood cell protein called hemoglobin (HEE-muh-glow-bin) helps move oxygen from the air sacs to the blood. At the same time, carbon dioxide moves from the capillaries into the air sacs. The gas has traveled in the bloodstream from the right side of the heart through the pulmonary artery. Oxygen-rich blood from the lungs is carried through a network of capillaries to the pulmonary vein. This vein delivers the oxygen-rich blood to the left side of the heart. The left side of the heart pumps the blood to the rest of the body. There, the oxygen in the blood moves from blood vessels into surrounding tissues. 44 | H e a l t h a s s e s s m e n t Breathing Out (Exhalation) A. When you breathe out, or exhale, your diaphragm relaxes and moves upward into the chest cavity. The intercostal muscles between the ribs also relax to reduce the space in the chest cavity. B. As the space in the chest cavity gets smaller, air rich in carbon dioxide is forced out of your lungs and windpipe, and then out of your nose or mouth. ASSESSING THE LUNGS AND THORAX ASSESS SHAPE AND CONFIGURATION - Thorax is oval, its AP Diameter is half its transverse diameter FACIAL EXPRESSION - Should be relaxed LEVEL OF CONSCIOUSNESS - Should be alert and cooperative Brain cells are affected by lack of oxygen SKIN COLOR AND CONDITION - Lips and nail beds are free from pallor and cyanosis QUALITY OF RESPIRATION - Automatic, effortless, regular and even, produces no noise Chest expands symmetrically INSPECT COLOR - Lesions (scars, stretch marks), use of accessory muscle, over prominence of the ribs ( may indicate respiratory problems) - Nares Bulges Asymmetry SYMMETRY AP DIAMETER and TRANSVERSE DIAMETER 45 | H e a l t h a s s e s s m e n t  - Anterioposterior Diameter – side Should be half the size of the transverse diameter The anteroposterior diameter should be less than the transverse diameter. The ratio of anteroposterior to transverse diameter is from 1:2 to 5:7. AP = transverse diameter, or “barrel chest.” Ribs are horizontal, chest appears as if held in continuous inspiration. - AP Diameter is more than half the transverse AGED TAKE THE RESPIRATORY RATE - NORMAL – 12-20 RR ADULT | 30-60 RR INFANT SPINAL ALIGNMENT - Impedes the space of the lung/s Kyphosis - is an abnormally excessive convex curvature of the spine as it occurs in the thoracic and sacral regions – KUBA Lordosis - is defined as an excessive inward curve of the spine, It differs from the spine's normal curves at the cervical, thoracic, and lumbar regions, which are, to a degree, either kyphotic (near the neck) or lordotic (closer to the low back) – LIYAD Scoliosis - is a medical condition in which a person's spine has a sideways curve. The curve is usually "S"- or "C"-shaped PALPATE - Warm your hands before palpating or percussing When palpating and percussing ask the patient to cross arms and bow head, to see the spinal column better No tenderness, masses, bulges, pulsation  LANDMARKS  Anterior Axillary Line  Midclavicular Line  Midsternal Line 46 | H e a l t h a s s e s s m e n t Accessory Muscles - Trapezius Scalene Muscle Respiratory Excursion - Thumbs on the xiphoid process and fingers on the 10th ribs Exhale and inhale – distance between the thumbs should be (5 – 10 cm) If obese – pinch the skin - vibratory tremors that can be felt through the chest by palpation ask the patient to say “99”, “blue moon”, “tres, tres” palpated using the balls of hand or the ulnar side of the hand PLEURAL EFFUSION accumulation of water in the pleural cavity between visceral pleura and parietal pleura Fremitus - Diaphragmatic Excursion - movement of the thoracic diaphragm during breathing 3 – 5 cm distance Checking the diaphragm muscle Measuring the contraction of the muscle Resonance and dullness  DEVIATIONS ATELECTASIS - Collapsed lungs or closure of a lung resulting in reduced or absent gas exchange. It may affect part or all of a lung. 47 | H e a l t h a s s e s s m e n t - It is usually unilateral. It is a condition where the alveoli are deflated down to little or no volume, as distinct from pulmonary consolidation, in which they are filled with liquid. - Swelling (inflammation) of the tissue in one or both lungs. It's usually caused by a bacterial infection. At the end of the breathing tubes in your lungs PNEUMONIA POSTOPERATIVE GUARDING - shallow breathing due to pain - Difficulty and noisy breathing Increased RR Use of accessory muscle Nasal Flaring PECTUS CARINATUM - Pigeon chest breastbone protrudes outward abnormally PECTUS EXCAVATUM - funnel chest sternum and rib cage are shaped abnormally these can be familial most common in boys than girls interferes with the functions of the lungs - is normal with infants deviations in adult MAIN CAUSE: SMOKING Too much accumulation of air COPD Pneumothorax – not with barrel chest EMPHYSEMA – Alveoli is destroyed Barrel Chest Accessory Muscles - Trapezius Scalene Sternocleidomastoid - Note any tenderness, superficial lumps or masses Note skin mobility and turgor, temperature and moisture PERCUSSION 48 | H e a l t h a s s e s s m e n t o o o o o intercostal spaces liver located at the 5th rib to 10th rib intercostal margin Resonance – presence of air Hyperesonance – too Dull – organ (Liver – right, Heart – middle) Tympanitic - stomach Flat – bones Common Characteristics of New Born - Nose breather 30-53 or 40-60 breathes per minute Irregular breathing - THORAX – rounded, diameter from the front is equal, barrel chest AP Diameter is equal to the transverse diameter 30 – 36 cm is the newborn chest, 2 cm smaller that the head circumference Ribs and xiphoid process are prominent Chest wall is thin 85% water 6 years old, AP Diameter has decreased in proportion to the Transverse Diameter 1:2 ratio Tend to breathe normally as with the adult BREATH SOUNDS 49 | H e a l t h a s s e s s m e n t - BRONCHIAL BRONCHOVESICULAR VESICULAR AUSCULTATION Using a stethoscope, the doctor may hear normal breathing sounds, decreased or absent breath sounds, and abnormal breath sounds. Absent or decreased sounds can mean:  Air or fluid in or around the lungs (such as pneumonia, heart failure, and pleural effusion)  Increased thickness of the chest wall  Over-inflation of a part of the lungs (emphysema can cause this)  Reduced airflow to part of the lungs There are several types of abnormal breath sounds. The 4 most common are:  Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales). They are believed to occur when air opens closed air spaces. Rales can be further described as moist, dry, fine, and coarse.  Rhonchi. Sounds that resemble snoring. They occur when air is blocked or air flow becomes rough through the large airways. 50 | H e a l t h a s s e s s m e n t  Stridor. Wheeze-like sound heard when a person breathes. Usually it is due to a blockage of airflow in the windpipe (trachea) or in the back of the throat.  Wheezing. High-pitched sounds produced by narrowed airways. Wheezing and other abnormal sounds can sometimes be heard without a stethoscope. ALVEOLAR HYPOXIA - Less oxygen in lungs - Surround the airways in wheezing - Prone to kyphosis – because of osteoporosis and changes in cartilage Respiratory muscle strength declines after age 50 and continues to decrease into the 70s Small airways, lose their cartilaginous support and elastic recoil; as a result, they tend to close, particularly in basal or dependent portions of the lungs CILIA in the airways decreases in number and are less effective in removing mucus Greater risk for pulmonary infections Smooth Muscles  AGED - ASSESSING THE NOSE AND MOUTH NOSE - Centre of the face The colour should be consistent with the face 51 | H e a l t h a s s e s s m e n t - Has plenty of arteries Nasal Septum – should be in the midline BREATHING - Infants are nose breathers Audible effort to breathe Inability to such is an indicator of obstruction NASAL CAVITY - Moist Dark pink Turbinate - Pulmonary ventilation Cleanse the air, warms the air, moisture Inferior and middle turbinate should be the same colour in the surrounding area Sinuses - Produce mucus to moisturize the inside of the nose Protects from pollutants, microorganisms Allow for voice resonance Adds moisture to any air that is inhaled Mucous - Traps foreign bodies Humidifies the air we breathe  DEVIATIONS Nasal Flaring - indicates difficulty in breathing, commonly seen in children and infants (normal) Epistaxis - nose bleed Dyspnoea - difficulty in breathing 52 | H e a l t h a s s e s s m e n t Dysphagia - difficulty in swallowing MOUTH Tongue - light pink with light coating, smooth and moist rough surface due to presence of papillae moves the food identify the object in the mouth should protrude midline, if not there can be weakness or paralysis NORMAL – light pink with light coating, no cracks, ulcers, or teeth marks surface: rough (presence of papillae), smooth and moist, surrounded by anterior and lateral teeth ABNORMAL – pallor, cyanosis, redness VENTRAL TONGUE – should glisten – and a network of small vessel Frenulum - Is midline, Should allow tongue to reach the roof of the mouth Uvula - Midline, in between the tonsils Cone shaped Large amounts of thin saliva produced by the uvula serves to keep the throat well lubricated Functions in speech as well Should lean towards the area with deviation Soft Palate - Soft palate and uvula Move together to close off the nasopharynx and prevent food from entering the nasal cavity NORMAL - Smooth, mobile Pharynx - Fluid and food passageway Epiglottis 53 | H e a l t h a s s e s s m e n t - A flap in the throat that keeps food from entering the windpipe and the lungs Buccal Mucosa - NORMAL – Pink and moist inside lining of the cheeks and floor of the mouth and is part of the lining mucosa  DEVIATIONS Exudative Tonsillitis - accumulation of pus between the tonsil and its capsule Ankyloglossia - Tongue-tie congenital oral anomaly that may decrease mobility of the tongue tip and is caused by an unusually short, thick lingual frenulum may interfere with breast feeding in infants Oral Leukoplakia - HIV positive patient Fungus Pernicious Anaemia - a condition in which the body can't make enough healthy red blood cells because it doesn't have enough vitamin B12 caused by autoimmune destruction of gastric parietal cells The appearance of the tongue in vitamin B12 deficiency is described as "beefy" or "fiery red and sore" Macrocytic – vitamin B-12 and folate deficiencies can be treated and cured with diet and supplements Microcytic – White Coating - Dehydration or poor hygiene, bad oral care Common with patients in the ICU Yellowing of tongue - Liver or gallbladder problems Digestive system disorder Vagus Paralysis - Failure of the soft palate to rise symmetrically Uvula will deviate towards the affected side PARESIS - Weakness PLEGIA - Paralysis of the nerve or muscle 54 | H e a l t h a s s e s s m e n t ASSESSMENT - Elevation of the soft palate When you say ‘ah’ the movement of the soft palate upwards PALPATION Gums, Teeth, Tongue - Should feel firm, no soft areas, no tenderness LIPS Mentolabial Suculus - Is a permanent crease between the inner lip and the chin, which plays a significant role in movement of the lower lip and in facial NORMAL – vertically and horizontally symmetrical, both are at rest and with movement Vermillion Border - Should be well defined without any evidence of cracking, swelling, and lesions INSPECTION - Lips should be – PINK to RED Vertically and horizontally symmetrical  DEVIATIONS Chapped Lips 55 | H e a l t h a s s e s s m e n t - Bad oral hygiene Dehydration Pale Lips - Anemia Dehydration Dry, Craked Lips - Dehydration Overexposure to cold temperature Cold Sores - STD Herpes simplex Syphilis Cheilosis | Cheilitis - Scaling, painful fissures painful inflammation and cracking of the corners of the mouth sometimes occurs on only one side of the mouth, but usually involves both sides Vitamin B12 deficiency Aphthous Stomatitis - benign and non-contagious mouth ulcers Oral Cancer - which includes cancers of the lips, tongue, cheeks, floor of the mouth, hard and soft palate, sinuses, and pharynx (throat), can be life threatening if not diagnosed and treated early White Patches – Leukoplakia Red/White Patches – Erythroleukoplakia Red Patches – Erthryplakia Addison’s Disease - Hormonal Imbalance Halitosis - Bad breath Xerostomia - dry mouth resulting from reduced or absent saliva flow decrease in saliva production occurs with age, the gums may get thinner and begin to recede TEETH 56 | H e a l t h a s s e s s m e n t - good oral care will increase, production of saliva, contains antibodies, kills the bacteria in the mouth and cleanses the mouth Front teeth – pointed and sharp, for biting and tearing Back Teeth – flat, for crushing and grinding  Children - Infant Deciduous Teeth - begin to erupt by 6 months by 2 years all 20 teeth should be present begins to be lost around 6 years of age by ages 14-15 they are replaced with 32 permanent teeth (same as with the adults) TETRACYCLINE and DOXYCYLINE - should not be administered with children below 8 years old cause tooth discoloration in the infant by affecting enamel development  - AGED Decrease in saliva production occurs with age, causes (XEROSTOMIA) Tooth Enamel - tends to weak away with aging, making the teeth vulnerable to damage and decay  DEVIATIONS Cavities - Poor oral hygiene Bottled water does not have fluoride added so the individual may be missing GUMS - NORMAL – healthy gums are pink in colour, firm, margins of the gums should be tight and well defined NOT NORAML – red, swollen and have tendency to bleed or even have pus most fragile part of the body Gingival Hyperplasia - Swollen gums, oedematous 57 | H e a l t h a s s e s s m e n t - Sodium Dilantin (medication given to patients with seizure) – may cause this deviation – side effect Gingivitis - Red and puffy gums that bleeds easily Common type of periodontal disease Often resolves with oral hygiene Malocclusion - Affect the chewing efficiency as well as the choice of foods This has potential to result in malnutrition and gastric alterations  - OLDER ADULTS Nasal hair becomes coarser, stiffer and more visible Air filtration may not be as effective Reduction in the sense of smell, reduction of olfactory nerve fibres Loss of sense of taste due to loss of papillae Reduction of saliva Gradual loss of teeth, drift causing malocclusion, affects the chewing efficiency and choice of foods - ASSESSING THE PERIPHERAL VASCULAR SYSTEM HEMOGLOBIN in RBC brings oxygen  Ischemia an inadequate blood supply to an organ or part of the body, especially the heart muscles  Albumin Responsible for maintaining the osmotic pressure helps keep fluid in your bloodstream so it doesn't leak into other tissues also carries various substances throughout your body, including hormones, vitamins, and enzymes MADE BY THE LIVER  Diffusion Movement of solute, or particles from a greater to lower concentrated solution  Osmosis Movement of water molecules from lesser to greater concentrated solution  Oedema There is inflammation Increased capillary permeability  Capillary membrane are very thin blood vessels They bring nutrients and oxygen to tissues and remove waste products They have thin walls/single layer – so that exchange of substances will be easy (oxygen, electrolytes, nutrients) 58 | H e a l t h a s s e s s m e n t  5 CARDINALS OF MANIFESTATION 1. REDNESS 2. PAIN 3. WARM TO TOUCH 4. LOSS OF FUNCTION 5. OEDEMA/SWELLING >> If there is a tissue injury caused by an inflammation (cut, fall, trauma, incision, injury) – SNS will be stimulated – it will stimulate adrenal glands in the adrenal medulla to release CATECOLOMINES – EPINEPHRINE (increases Cardiac Rate – more than 100) and NOREPINEPHRINE (increase Blood Pressure 120/80 – arteries constrict) CHEMICAL MEDIATORS will be released due to tissue injury; CHEMICAL MEDIATORS - Will be released if there is tissue injury - Increases capillary permeability Pores in the capillary membrane becomes bigger; Intravascular space decreases, Albumin goes out, there will be swelling/oedema because the water comes out to the interstitial space/third space from the intravascular space.  Histamine – (more) When we come into contact with an allergen, such as pollen or animal dander, histamine is released by the body to the site of contact | vasodilator Brings more blood to the injured site which causes the skin to be warm to touch | causes redness/rubor Injured site such as; surgery, appendectomy, incision  Bradykinin - an inflammatory mediator | a peptide that causes blood vessels to dilate (enlarge), and therefore causes blood pressure to fall Prostaglandin – one of the more potent mediators that cause increased blood flow, chemotaxis (chemical signals that summon white blood cells), and subsequent dysfunction of tissues and organs Serotonin - increases vascular permeability, dilates capillaries, and causes contraction of nonvascular smooth muscle   {VEINS: clotted blood – gives redness in colour – warm to touch} 59 | H e a l t h a s s e s s m e n t {ARTERY: lipids – gives pallor in colour – cold to touch} WALLS OF THE BLOOD VESSELS 1. Tunica Adventitia 2. Tunica Media 3. Tunica Intima ARTERY - Blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries Arterial network is a high-pressure system Blood is propelled under pressure from the left ventricle of the heart There is high pressure, arterial wall must be thick and strong; the arterial walls also contain elastic fibres so that they can stretch COLOUR CHANGE TEST - Arterial occlusion Elevate the leg 12 inches above the client’s <3 NORMAL: it will return to its normal pinkish colour; 15 seconds – veins | 10 seconds or less – artery **IF occlusion has been shown in developing, there will likely be; muscle atrophy skin atrophy loss of hair growth BUERGER TEST - Arterial insufficiency This test can be carried out to further demonstrate poor lower limb perfusion. 1. Ensure the patient is positioned supine 60 | H e a l t h a s s e s s m e n t - 2. Standing at the bottom of the bed, raise both of the patient’s feet to 45º for 2-3 mins: Observe for pallor – emptying of the superficial veins If a limb develops pallor, note at what angle this occurs e.g. 20º (known as Buerger’s angle) A healthy leg’s toes should remain pink, even at 90º A Buerger’s angle of less than 20º indicates severe limb ischaemia 3. Once the time limit has been reached, ask patient to place their legs over the side of the bed: - Observe for a reactive hyperaemia – this is where the leg first returns to its normal pink colour, then becomes red in colour – this is due to arteriolar dilatation (an attempt to remove built up metabolic waste) VEINS - Blood vessels that carry deoxygenated, nutrient-depleted, waste laden blood from the tissues back to the heart The vein contain nearly 70% of the body’s volume Mechanisms 1st - Contains VALVES – permit blood to pass through them on the way to the heart and prevent blood from returning through them in the opposite direction. 2nd – muscular contraction 3rd – creation of a pressure gradient through the act of breathing – inspiration decreases intrathoracic pressure while increasing abdominal pressure, thus producing pressure gradient      Deep Veins Iliac vein Femoral vein Popliteal vein Tibial vein    Superficial Veins Greater Saphenous Vein Lesser Saphenous Vein INSPECTION SKIN COLOUR - There should be no localized colour changes SKIN - Should be mobile and elastic and able to be pinched Extremities should be bilaterally equal in size Veins should not be visible on the surface or through the skin If any veins are visible, elevate the lower extremities; if veins and valves are not compromised ? LESIONS - Petechiae – smaller, tiny red spots | dengue Ecchymosis – medical term for bruises Purpura – bigger, purplish colour | snake bites, venous insufficiency 61 | H e a l t h a s s e s s m e n t HAIR DISTRIBUTION - Should be equally distributed bilaterally  DEVIATIONS DEEP VEIN THROMBOSIS - a blood clot that forms in a vein deep in the body - Most deep vein clots occur in the lower leg or thigh - If the vein swells, the condition is called thrombophlebitis - A deep vein thrombosis can break loose (called EMBOLUS) and cause a serious problem in the lung, called a pulmonary embolism (patient can die after 1 hour)  Valves are not closing completely or incompetent  Veins will be distended  EARLY SIGNS: accumulation of blood – causes-redness  UNILATERAL SWELLING VARICOSITY - Valves incompetent – allowing blood to backflow distending the vein – increasing the pressure – pushing the blood outside the interstitial space/third space – haemoglobin will be released and become haemosiderin – which causes discoloration  TESTS TRENDELENBURG TEST - - To perform this test, elevate the patient’s leg until all of the congested superficial veins collapse (to drain blood | elevate 90 degrees) | Elevate the leg, put tourniquet between femoral and popliteal vein (to temporarily stop blood flow) Apply direct pressure to occlude the superficial veins below the point of suspected reflux from the deep system into the superficial varicosity. With the occlusion still in place, have the patient stand. If the distal varicosity remains empty or fills slowly, quickly remove the occluding hand or tourniquet *** Tourniquet is applied to prevent 1. Backflow of blood, 2. To temporarily stop the blood flow NORMAL: slow filling of blood due to competent valves 62 | H e a l t h a s s e s s m e n t ABNORMAL: incompetent valves allows rapid venous filling causing rubor   Deep Vein – if there is engorgement in the vein before releasing the tourniquet within 5 seconds Superficial Vein – rapid filling of blood after removing the tourniquet within 30 seconds causing rubor CAPILLARY REFILL TEST - 2 seconds is normal – prolonged in PVD ALLEN TEST - Assesses for the; COMPETENCY PATENCY ADEQUATE collateral circulation of blood supply 63 | H e a l t h a s s e s s m e n t  1. 2. 3. PALPATION RATE RYTHYM QUALITY RADIAL & DORSALIS PEDIS ARTERY - Two most distal pulses Palpate using the 1st and 2nd fingers or finger pads  - AMPLITUDE Quality pulse is the measurement of the force of left ventricular contraction that produces the pulse wave Contraction of the heart is slow Integrity of the arterial wall will also have effect on the quality of the pulse wave - The pulse quality is measured on a +3 scale +3 = full/bounding pulse +2 = expected +1 = diminished/barely 0 = absent pulse ASSESSING THE BRAIN AND NERVES INFANTS - - The nervous system begins to form within the first 3 weeks of fetal development At birth, the nervous system is quite immature There is still no BBB (astrocyte) *develops 5-6 years Responses by the newborn are primarily primitive reflexes that are present – should subside while growing up, if not, it indicates an abnormality  Reflexes The disappearance of these reflexes is a measurement of nervous system maturation Persistence of these reflexes – indication of CNS dysfunction Observe the child’s gait – the child just beginning to walk will have a wide-based gait 64 | H e a l t h a s s e s s m e n t - By 4 years of age the child should be able to balance on one foot for about 5 seconds and by age 5 should be able to balance for 8-10 seconds -  Tonic Neck Reflex Appears at birth Disappear – 5-7 mos. Fencing Reflex -  Babinski Reflex Normal up to 2 years -  Rooting Reflex Disappear: 4 mos. -  Landau Reflex Horizontal prone position Appears 6 mos. and hypotonicity (low tone) indicates motor system deficit Appears 3 mos. after birth – last up to 12-24 mos. of age -  Moro Reflex Consists of rapid abduction and extension of arms with the opening of hands The arms then come together as in embrace Any sudden movement of the neck initiates the reflex Elicit by pulling the baby half-way to a sitting position Disappear: 4-6 mos. -  Grasp Reflex | Palmar Grasp Reflex Appear – at birth Disappear – 8-10 mos. -  Sucking Reflex Probably one of the most important reflex – paired with rooting reflex – secretes for a food source INSPECTION 1. LEVEL OF CONSCIOUSNESS (LOC) Awareness is determined by the patient’s orientation to a person, place and time PERSON – who the patient is and recognition of other individuals PLACE – where located at this time TIME – day, month, and year Early manifestation, agitation, drowsy, confusion – probably caused by a lung problem – lack of blood supply (oxygenated) to the brain ASSESSING: Observe the patient’s ability to follow commands Ask the patient to squeeze the examiner’s two fingers 65 | H e a l t h a s s e s s m e n t NORMAL FINDINGS - Awake, alert, and responds appropriately to verbal and environmental stimuli Should be able to follow a simple command and grasp the examiner’s finger - When conducting a neurological exam, cranial nerve assessment is the first component of the exam - Testing CN III (Oculomotor) is the MOST important – because it is an indicator of brain function The remaining 11 CNs are not generally tested unless there is a specific reason to do so GLASGOW COMA SCALE (GCS) - Assesses the LOC CRANIAL NERVES 66 | H e a l t h a s s e s s m e n t - Brainstem – consists of most the cranial nerves The 12 pairs of CNS are part of the peripheral nervous system Can be sensory and/or motor (function)  CLASSIFICATIONS  SENSORY CRANIAL NERVES – contain only afferent (sensory) fibres CN 1 OLFACTORY CN 2 OPTIC CN 8 VESTIBULOCOCHLEAR  MOTOR CRANIAL NERVES – contain only efferent (motor) fibres CN 3 OCULOMOTOR CN 4 TROCHLEAR CN 6 ABDUCENS CN 11 ACCESSORY CN 12 HYPOGLOSSAL  MIXED CRANIAL NERVES – contain both sensory and motor fibres CN 5 TRIGEMINAL CN 7 FACIAL CN 9 GLOSSOPHARYNGEAL CN 10 VAGUS LINK: https://teachmeanatomy.info/head/cranialnerves/summary/?fbclid=IwAR3PzR4ixfyNnJmkvH7STgBpkG8gx0tJpRwjbKpwQTc-HjuQLzmbAguWgp8 LINK: https://www.kenhub.com/en/library/anatomy/the-12-cranial-nerves CRANIAL NERVE 1 OLFACTORY NERVE - SENSORY/AFFERENT - innervates the olfactory mucosa within the nasal cavity ORIGIN: CEREBRUM FUNCTION: Responsible for the sense of smell Smell is an important component of the appreciation of tasks Loss of sense of smell – as a result of TRAUMA INFECTION AGING Do not test routinely Test with: REPORT OF LOSS OF SMELL HEAD TRAUMA SUSPECTED INTRACRANIAL PRESSURE (ICP) First: assess patency by occluding one nostril at a time and asking the person to sniff – with the person’s eyes closed 67 | H e a l t h a s s e s s m e n t - Use familiar smells, conveniently obtainable and non-noxious smells; coffee, toothpaste orange, peppermint. *Alcohol wipes smell are familiar and are easy to find but are irritating Normally, a person can identify an odour on each side of the nose Sense of smell normally decreased bilaterally with aging Any asymmetry is an indication of an abnormality CRANIAL NERVE 2 OPTIC NERVE - SENSORY/AFFERENT - innervates the retina of the eye and brings visual information to the brain ORIGIN: CEREBRUM Test Visual Acuity: Snellen’s Chart for distant vision, newspaper/magazine for near vision Test Visual Fields: Confrontation CRANIAL NERVE 3 OCULOMOTOR - MOTOR/EFFERENT - both a somatic and visceral efferent motor nerve ORIGIN: MIDBRAIN-PONTINE JUNCTION FUNCTION: Helps in moving eyeballs in different direction TEST: Six Cardinal Movements of the Eye TEST: Pupillary Light Reflex Shine a direct light or the pupil – Pupillary constriction **Symptoms of Nerve Damage Double Vision – diplopia, the affected eye turns outward when the unaffected eye looks straight ahead Ptosis – eyelid droop Pupil may be dilated Affected eye can move only to the middle when looking inward and cannot look upward and downward CRANIAL NERVE 4 TROCHLEAR NERVE - MOTOR/EFFERENT ORIGIN: posterior side of the MIDBRAIN It has the longest intracranial length of all the cranial nerves. Superior oblique muscle – eye TEST: Six Cardinal Movements of the Eye CRANIAL NERVE 5 TRIGEMINAL NERVE - SENSORY & MOTOR / AFFERENT & EFFERENT ORIGIN: PONS 3 Branches/Divisions OPTHALMIC (CN V1) - leaves through the superior orbital fissure MAXILLARY (CN V2) - through the foramen rotundum MANDIBULAR (CN V3) - exits via the foramen ovale 68 | H e a l t h a s s e s s m e n t - Temporal and masseter muscles are examined by palpating the muscles and attempts to resist the jaw by applying pressure Testing pain, thermal, and other sensations in the area supplied by the trigeminal nerve TEST: The Corneal Reflex test – wisp of cotton (Normal: smooth, transparent, involuntary blinking) CRANIAL NERVE 6 ABDUCENS - MOTOR/EFFERENT ORIGIN: PONTINE-MEDULLA JUNCTION - originates from the brainstem and exits the skull via the superior orbital fissure FUNCTION: lateral eye movements (lateral rectus muscle) – abducts the eye; thus the name abducens Test for Convergence (far and near object) DEVIATION: Strabismus CRANIAL NERVE 7 FACIAL NERVE - - SENSORY & MOTOR / AFFERENT & EFFERENT ORIGIN: PONTINE-MEDULLA JUNCTION FUNCTION: Once the facial nerve reaches the face it enables many functions, such as facial expression, secretion of glands and taste sensation. Motor – note mobility and facial symmetry as the person responds to these requests; FROWNING SMILING Sensory – test only when you suspect facial nerve injury When indicated, test sense of taste – salt, lemon, TEST: Inspect for NASOLABIAL FOLDS AND PALPEBRAL FISSURES DEVIATION: Inability to close eyelid, Drooping of mouth CRANIAL NERVE 8 VESTIBULOCOCHLEAR - SENSORY/AFFERENT - comprised of two parts: the vestibular nerve and the cochlear nerve. ORIGIN: PONTINE-MEDULLA JUNCTION FUNCTION: The cochlear component enables hearing, while the vestibular part mediates balance and motion. TESTS: Whisper test, Rinne Test, Balance and Hearing CRANIAL NERVE 9 GLOSSOPHARYNGEAL - SENSORY & MOTOR / AFFERENT & EFFERENT MEDULLA OBLONGATA - It originates from the brainstem and leaves the skull through the jugular foramen. FUNCTION: It enables swallowing, salivation, and taste sensation, as well as visceral and general sensation in the oral cavity. TEST: Perform – Gag Reflex Test (observe: soft palate & uvula) DEVIATION: Nerve damage – dysphagia 69 | H e a l t h a s s e s s m e n t CRANIAL NERVE 10 VAGUS - - SENSORY & MOTOR / AFFERENT & EFFERENT ORIGIN: MEDULLA OBLONGATA - It originates from multiple nuclei in the brainstem, and exits the skull through the jugular foramen. It is the longest cranial nerve and the only one to leave the head and neck region. The vagus nerve travels into the thoracic and abdominal cavities, providing parasympathetic supply to visceral organs. FUNCTION: The vagus nerve controls a large number of functions, including gland secretion, peristalsis, phonation, taste, visceral and general sensation of the head, thorax and abdomen. CRANIAL NERVE 11 ACCESSORY - MOTOR/EFFERENT ORIGIN: MEDULLA OBLONGATA - originating from the brainstem and spinal cord FUNCTION: Acting to enable phonation and movements of the head and shoulders. CRANIAL NERVE 12 HYPOGLOSSAL - - MOTOR/EFFERENT ORIGIN: MEDULLA OBLONGATA Anterior to the olive FUNCTION: Its function is to enable tongue movements. extremely important for smooth daily functioning of every person, as it plays a significant role in important mouth functions such as speech and swallowing  PROPRIOCEPTION Unconscious perception of movement and spatial orientation arising from stimuli within the body In humans, these stimuli are detected by nerves within the body itself, as well as the semicircular canals  TESTS CEREBELLAR EXAMINATION - Assess motor activity by the patient’s ability for muscle movement and coordination Should run the test in smooth, rapid, accurate, straight line and coordinated movement  FINGER-TO-NOSE TEST  HANDFLIP TEST  THUMB-TO-FINGER TEST  HEEL-TO-SHIN TEST ALTERED MOTOR RESPONSE - Uncoordinated actions, misses touching the nose/body part several times   DEVIATIONS DYSDIADOCHOKINESIS 70 | H e a l t h a s s e s s m e n t - Inability to perform rapidly alternation movements (may be an indication of multiple sclerosis)  DYSMETRIA Inability to perform point to point movements by over-or-under projection of the fingers Lose of motor strength or proprioception May indicate – Cerebellar lesions SENSORY SUPERFICIAL POINT - With the patient’s eyes closed, touch the patient’s skin lightly with sharp and dull points of a; bent paper clip, pen, broken tongue blade Before testing, it is helpful to touch the patient on both sides LIGHT TOUCH - Use; cotton ball, cotton tip swab Wait 2 seconds between each touch Instruct the patient to indicate where the sensation is felt BALANCE AND EQUILIBRIUM (CN 8 AND CEREBELLUM) ROMBERG TEST - - - Patient should stand with his/her feet together and arms at the side Instruct the patient to close eyes (approx. 30 secs.) Observe the patient’s ability to maintain upright position Patient may demonstrate slight swaying back and forth, without the danger of falling Expected: patient is able to maintain balance and equilibrium within 30 seconds POSITIVE ROMBERG indicates the possibility of; CEREBELLAR ATAXIA Cerebellum becomes inflamed or damaged Cerebellum: responsible for controlling gait and muscle coordination Ataxia: lack of fine motor or voluntary movements VESTIBULAR DYSFUNCTION SENSORY LOSS CEREBELLAR LESIONS In some instances, the patient will lose balance with the eyes closed but be able to regain balance when the eyes are opened (cerebellar lesions) TANDEM GAIT 71 | H e a l t h a s s e s s m e n t - A gait (method of walking or running) where the toes of the back foot touch the heel of the front foot each step Ask the person to walk a straight line in a heel-to-toe fashion This decreases the base of support and will accentuate any problem with coordination NORMALLY the person can walk straight and stay balanced Methods – STATIC BALANCE -  REFLEXES Subconscious actions and reactions that are vital defense mechanisms of the nervous system. - Initiates immediate response to alert and protect the patient - REFLEX ARC - Neural pathway that controls the action reflex A reflex, or reflex action, is an involuntary and nearly instantaneous movement in response to a stimulus. A reflex is made possible by neural pathways called reflex arcs which can act on an impulse before that impulse reaches the brain. DEEP TENDON REFLEXES - Monosynaptic spinal segmental reflexes Easily assessed by tapping the tendon -  BICEP REFLEX Antecubital fossa  TRICEPS REFLEX 72 | H e a l t h a s s e s s m e n t - - - - Identify the triceps tendon, a discrete, broad structure that can be palpated (and often seen) as it extends across the elbow to the body of the muscle, located on the back of the upper arm.  BRACHIORADIALIS REFLEX Identify the triceps tendon, a discrete, broad structure that can be palpated (and often seen) as it extends across the elbow to the body of the muscle, located on the back of the upper arm.  PATELLAR REFLEX LOCATION: Just below the kneecap Striking – will/should cause contraction of the quadriceps muscle – extension of the lower leg  ACHILLES REFLEX LOCATION: Directly behind the ankle Striking Achilles tendon causes contraction of gastrocnemius muscle – resulting in plantar flexion of the foot DEVIATION: lack of reflex – indicates – neuropathy (lower motor neuron) SUPERFICIAL TENDON REFLEXES - - - - Any withdrawal reflex elicited by noxious or tactile stimulation of the skin, cornea, or mucous membrane, including the corneal, pharyngeal, and cremasteric reflexes.  PLANTAR REFLEX plantar flexion of the foot when the ankle is grasped firmly and the lateral border of the sole is stroked or scratched from the heel toward the toes The reflex can take one of two forms. In healthy adults, the plantar reflex causes a downward response of the hallux (flexion). DEVIATION: dorsiflexion of the great toe with or without forming BABINSKI-POSITIVE (this is normal to children under 2y/o)  ABDOMINAL REFLEX A superficial neurological reflex stimulated by stroking of the abdomen around the umbilicus. It can be helpful in determining the level of a CNS lesion.  CREMASTERIC REFLEX A superficial reflex found in human males that is elicited when the inner part of the thigh is stroked. Stroking of the skin causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal. DEVIATION: TESTICULAR TORSION - It happens when the spermatic cord, which provides blood flow to the testicle, rotates and becomes twisted. The twisting cuts off the testicle's blood supply and causes sudden pain and swelling. OLDER ADULTS - Have less blood supply (20% - ages 60^) 73 | H e a l t h a s s e s s m e n t - - Gradual atrophy of the brain occurs due to the loss of neurons in the brain and spinal cord By 80 years of age, brain has lost 15% of its weight Speed of nerve conduction decreases – causing the reaction time of the elderly to decrease Decreased in the speed of learning and processing information There is an increased delay at the synapses, resulting in a slower traveling time for an impulse This may result in a diminished sense of smell and taste as well as decreased sensation of pain and touch These,, therefore are the probable reason why older adults/aged are prone to Alzheimer’s There is an overall loss of muscle bulk that reduces muscle strength GATE CONTROL THEORY - Open Gate -> T-cell -> brings the stimulus to the brain -> the brain (hypothalamus) will interpret it to pain SG – Substantia Gelatinosa - a collection of cells in the gray area (dorsal horns) of the spinal cord found at all levels of the cord it receives direct input from the dorsal (sensory) nerve roots, especially those fibers from pain and thermoreceptors WHAT OPENS THE GATE - Lack of sleep Stressful lifestyle Fear and anxiety about pain Depression Physical activity / tired Mentally focusing on pain Hypoglycemia (Normal: 80/100 mg/dl of blood) Serotonin and Endorphin deficit Consumption of nutrients that increase inflammation (such as fried and oily foods) 74 | H e a l t h a s s e s s m e n t WHAT CLOSES THE GATE - Relaxation Exercise Medications (Pain relievers, Opioids – Morphin, Demerol) Distractions from pain Positive Thoughts Endorphin Avoiding nutrients that increases inflammation (such as fried and oily foods) Acupuncture Serotonin (consumption of food rich in serotonin such as banana) Adequate sleep PAIN Transmission - Impulses from afferent – CNS – Neurons – Spinal Cord – Thalamus – relay station for sensory input – Midbrain – signals cortex to raise awareness of the stimuli PAIN TOLERANCE - Amount and duration of pain a person can stand before seeking relief Can vary between different individuals in the same situations - TOLERANCE A state of adaptation in which exposure to a drug induces charges that result in a decrease in one or more of the drug’s effects over time PAIN THRESHOLD - Point at which each person recognizes pain Tends to be the same among healthy persons INCREASE TOLERANCE - Alcohol Drugs Hypnosis Strong beliefs Distractions Rubbing DECREASE TOLERANCE - Fatigue 75 | H e a l t h a s s e s s m e n t - Anger Boredom Anxiety Stress Depression ** Anxiety and Stress can stimulate or inhibit urination and may provoke urgency and frequency ** Schwann Cells = PNS Oligodendrocytes = CNS = MYELIN SHEATH  Specific Types of Pain  - REFFERED PAIN Discomfort Perceived in a general area of the body but not in the exact site where an organ is anatomically located  - VISCERAL PAIN Arises from internal organs that are diseased or injured Usually accompanied by ANS symptoms Sharp or dull, aching cramping pain  - - SOMATIC PAIN (e. g a hot stove) Pain may originate in the skin tissues SUPERFICIAL PAIN Sharp, pricking, burning DEEP SOMATIC PAIN Muscles or bones, sharp, dull and aching  - NEUROPATHIC PAIN Caused by damage to the CNS or Peripheral nerves Damage: vertebrae – causes pressure to the root nerve causing pain Damage; to myelin sheath – damaged by our own antibody / autoimmune PHANTON PAIN - ENDORPHINS - Endogenous chemicals that act like opioids to inhibit pain impulses in the spinal cord and brain They degrade too quickly  TYPES OF PAIN ACUTE - Tachy – increased bp Associated with SNS CHRONIC - No changes in Vital Signs Assessment of chronic pain should focus on impact of the pain and on patients’ function and daily activities 76 | H e a l t h a s s e s s m e n t **DANGERS OF UNRELIEVED PAIN - Pain causes shallow breathing and cough suppression -> prevention of pulmonary secretions -> pneumonia - may delay the return of normal gastric and bowel function Peristalsis – inhibited Suppress the immune system and heighten susceptibility to illness PAIN CHRONIC PAIN - Lowers the pain threshold as a result of the depletion of SEROTONIN and ENDORPHIN  DRUG THERAPHY Non-Opioid Analgesics - First line therapy for mild to moderate pain Do not produce tolerance or physical or psychological dependence Works primarily at the site of injury rather than the CNS They do not have antipyretic effect Opioid Analgesics - Given when pain is moderate in intensity (PS: 7-10) Also for mild but persistent pain Non-Pharmacologic Methods of Pain Management - - - Massage. A lot of people find relief from gentle massage, and some hospice agencies have volunteers who are trained in massage therapy. Several studies have found that massage is effective in relieving pain and other symptoms for people with serious illness. Relaxation techniques. Guided imagery, hypnosis, biofeedback, breathing techniques, and gentle movement such as tai chi. Relaxation techniques are often very effective, particularly when a patient -- or a caregiver -- is feeling anxious. Acupuncture. Several studies have found that acupuncture can be helpful in relieving pain for people with serious illnesses such as cancer. Physical therapy. If a person has been active before and is now confined to bed, even just moving the hands and feet a little bit can help. Pet therapy. If you have bouts of pain that last 5, 10, or 15 minutes, trying to find something pleasant -- like petting an animal's soft fur -- to distract and relax yourself can be helpful. Gel packs. These are simple packs that can be warmed or chilled and used to ease localized pain. PAIN DICRIMINATION – eyes closed 77 | H e a l t h a s s e s s m e n t

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