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Nursing Assessment.

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Presentation on theme: "Nursing Assessment."— Presentation transcript:

1 Nursing Assessment

2 Physical Assessment Chief complaints and activity level
Health history: medical and surgical Physical signs or symptoms Examination for: Bone integrity Posture Joint function Muscle strength Gait ADL’s

3 Physical Signs and Symptoms
Deformities Crepitus Scoliosis Kyphosis Lordosis Contractures Dislocations

4 Common Structural Disorders
Scoliosis Kyphosis Lordosis Cleft Palate Flatfoot


6 Scoliosis S curve

7 Kyphosis Forward curve

8 Lordosis Forward curve at lumbar spine

9 Cleft Palate Congenital defomity Opening in roof of mouth
Mouth communicates with nasal cavity Infant difficulty nursing (sucks in air) Surgical correction


11 Flatfoot Tendons and ligaments that support arch of foot are weak
Foot flattens Caused by excess weight, poor posture, hereditary failure of arch to form Difficulty or pain walking


13 Assessing Articular Joints
Deformities Nodes Pulses in extremities ROM Edema Fever

14 Range of Motion Ability to change position Muscular strength
Coordination Size of muscles Active Passive

15 Neurovascular Assessment
Following trauma, surgery, casting, splinting, bandaging: Assess the 7 P’s Pulselessness Paresthesias Paralysis or paresthesias Polar temperature Pallor Puffiness (edema) Pain

16 Skeletal Changes in Aging
Loss of calcium salts Loss of protein in bone Decreased collagen in bone, tendons and ligaments Loss of height (0.5 in/20y) Chest diameter decreases about 1 in and less flexible


18 Medications Skeletal muscle relaxants Antigout medications
Antiarthritic medications Osteoporosis prevention and treatment

19 Skeletal Muscle Relaxants
Used to prevent/relieve muscle spasms, treat spasticity associated with spinal cord lesions, painful musculoskeletal disorders Contraindicated in severe liver, renal, heart disease Should not be taken with CNS depressants

20 Skeletal Muscle Relaxants
Act directly on neuromuscular junction Act directly on muscle OR Act indirectly on the CNS Depress neuron activity in the brain or spinal cord

21 Skeletal Muscle Relaxants
Side effects: Dizziness/hypotension Drowsiness Dry mouth GI upset Photosensitivity

22 Skeletal Muscle Relaxants
Baclofen (Lioresal) Causes CNS effects Frequently causes nausea, constipation, retention Can be given by physician through intrathecal pump

23 Skeletal Muscle Relaxants
Dantrolene (Dantrium) Acts directly on skeletal muscles to relieve spasticity Liver damage most serious adverse effect Monitor LFT’s Can cause GI bleeding, impotence, photosensitivity, rash

24 Skeletal Muscle Relaxants
Cyclobenzaprine (Flexeril) Contraindicated in clients who have taken MAOI s within 14 days of initiation (can lead to ↑BP, HTN crisis) Caution in clients with hx urinary retention, glaucoma, or increased intraocular pressure Short term (2-3 weeks) use

25 Skeletal Muscle Relaxants
Methocarbamol (Robaxin) May cause urine to turn brown, black or green Notify MD if blurred vision, nasal congestion, urticaria occur Parenteral form can cause hypotension, bradycardia, anaphylaxis, seizures

26 Skeletal Muscle Relaxants
Chlorzoxazone (Paraflex, Parafon Forte) Monitor for hypersensitivity reactions May cause malaise and urine discoloration Carisoprodol (Soma) Take with food to prevent GI upset Report hypersensitivity to MD

27 Antigout Medications Decrease inflammation
Reduce uric acid production, increase uric acid secretion Use cautiously in clients with GI, renal, cardiac or hepatic disease Allopurinol can increase effect of warfarin and oral hypoglycemic agents

28 Antigout Medications Side effects HA N/V Blood dyscrasias
Flushed skin, rash Uric acid kidney stones Sore gums Metallic taste

29 Nursing Considerations
Monitor serum uric acid levels Monitor I&O Monitor CBC and LFT’s Do not give large doses of Vitamin C with Allopurinol Avoid foods high in purines; ie wine, alcohol, organ meats, sardines, salmon, gravy Concurrent ASA; increased uric acid level, gout attack

30 Antigout Medications Examples: Allopurinal (Zyloprim) Colchicine
Losartan (Cozaar) Probenecid

31 Osteoporosis Prevention
Calcium and Vitamin D supplementation Estrogen replacement therapy after menopause Calcitonin (Calcimar)

32 Antiarthritic Medications
(Source: ATI Testing Tutorial) Types of Drugs NSAIDS Tx. Pain and inflammation Glucocorticoids Disease-Modifying Antirheumatic Drugs Target: Musculoskeletal system

33 Antiarthritic Medications
Disease-Modifying Antirheumatic Drugs “DMARD” ↓ joint inflammation ↓ joint damage Initially given with NSAIDS  slow onset of therapeutic effects. NSAIDS may be discontinued when DMARDs begin exerting therapeutic effect

34 Antiarthritic Medications
DMARD I Category: Major Non-biologic Antimetabolite Drug: interferes with normal metabolic process Protogype Drug: Methotrexate (Rheumatrex Other: Leflunomide (Arava) NOTE: DMARDs suppress the immune system (a primary effect)

35 Antiarthritic Medications
DMARD I (cont.) Can slow or stop progression of RA Can tx. Cancer in larger doses Adverse effect/side effects: Liver damage Bone marrow suppression (↓platelets, RBCs, WBCs) ↑ risk for infection GI ulceration Pulmonary Fibrosis

36 Antiarthritic Medications
DMARD I (cont.) Methotrexate = Cat. D Pregn. (can damage developing fetus & can pass through breast mild) Leflunomide = Cat. X pregn.

37 Antiarthritic Medications
DMARD I (cont.) Nursing considerations: Monitor for: ↓ platelets, wbc’s, rbc’s S/sx. Infection LFT, Observe for jaundice GI bleed (Methotrexate) Respiratory distress, ↓ oxygenation

38 Antiarthritic Medications
DMARD I (cont.) Nursing considerations (cont.) Dosing and Administration: Methotrexate – 1x / week (po, sq, im) Weekly folic acid supplement (↓ risk toxicity) Drink oz. Glasses water/day Report: jaundice skin/eyes; s/sx infection; ulcerations of mouth, tongue; abdominal bldg, bruising, petechaeie; blood in vomit or stool; dyspnea, SOB

39 Antiarthritic Medications
DMARD I (cont.) Nursing considerations (cont.) Avoid: 1. giving DMARD I drugs during pregnancy and for 6 months after completion of treatment 2. ingestion of alcohol Precautions: (while on DMARD I tx.) ↑ risk for active bacterial or viral infection Peptic Ulcer Disease Ulcerative Collitis Contraindications: (to DMARD tx.) Liver Insufficiency Hepatitis Renal Insufficiency Women who are pregnant

40 Osteoarthritis Prevention and Treatment
Biphosphonates Inhibit osteoclast mediated bone resorption, increases total bone mass Examples Etidronate (Didronel) Alendronate (Fosamax) Pamidronate (Aredia) Risedronate (Actonel)

41 Osteoporosis Prevention
Biphosphonates Fosamax-taken after rising in AM with full glass water No eating/drinking for 30 min after taking med, do not lie down for 30 min after taking med

42 Osteoporosis Prevention
Estrogen receptor modulators (Evista) Mimic effect of estrogen in bone by reducing bone resorption Teriparitide (Forteo) Stimulates new bone formation Used to treat osteoporosis in men and post menopausal women at high risk for fractures

43 Laboratory and Diagnostic Examinations

44 Radiographic Studies Most common X-ray Diagnostic imaging

45 Laboratory and Diagnostic Examinations
Radiographic studies Myelogram Electromyography Bone scan Bone mineral density X-ray Endoscopic examination Arthroscopy

46 Radiographic Studies Reveals presence of fluid in joint, irregularity of joint, spur formation, and changes in size or contour of the joint Visualizes fractures, length, tumors, and cavities of bone Pregnant women should not have an x-ray, unless it is absolutely necessary, to prevent potential damage to the fetus

47 Laminography/planography or body section roentgenography
Radiographic Studies Laminography/planography or body section roentgenography Locates small cavities, foreign bodies and lesions that are overshadowed by opaque structures

48 Scanography Radiographic Studies
Uses a series of parallel beams that eliminate size distortion when producing a radiograph of internal body organs Allows accurate measurement of the length of the bone

49 Used to determine the presence of herniated discs or tumors
Myelogram Used to determine the presence of herniated discs or tumors

50 Myelogram An x-ray study in which dye is injected into the spinal fluid. (The spinal cord is not visible on a normal x-ray.) Injection of this dye outlines the spinal cord, and makes it visible on the x-ray.

51 Myelogram The injection of dye may be done in the cervical or lumbar area Before the dye is injected, a sample of spinal fluid is collected from the patient and is submitted to the laboratory for analysis.


53 Myelogram Water based dye is used most often because the body will reabsorb it and will be excreted in the urine Oil-based dye will be removed because it may cause irritation within the subarachnoid space

54 Myelogram Headache is most common after a myelogram but seizure, infection, numbness, or paralysis may occur

55 Myelogram Prior to procedure: Post-procedure Informed consent
Provide hydration 12h before test Assess for allergies Premedicate as ordered Post-procedure VS/neuro checks as ordered If water based dye used, HOB up degrees for 8 h If oil based dye used, flat for 6-8 h If air used, head lower than trunk Force fluids, monitor I&O

56 Electromyography (EMG)
Measures electrical potential associated with skeletal muscle contractions Needles inserted into muscle; electrical activity traced on recording paper Informed consent Needle insertion uncomfortable No stimulants/sedatvies 24h prior to procedure Slight bruising at insertion sites

57 Electromyography Your doctor has ordered this test to help determine the cause of your pain. This test is specifically performed to identify if abnormal nerve function is present. The small electric pulses cause a mild tingling feeling.

58 EMG are using a transcutaneous electrical nerve stimulator (TENS) unit
Inform your physician if you: are using a transcutaneous electrical nerve stimulator (TENS) unit are taking blood thinners have hemophilia have a cardiac pacemaker Do not apply lotion to the arms or legs on the day of the test.

59 Nuclear Scanning Uses scanners or camera detectors that record images on radiographic film Doses of radioactive isotopes are low; no need for precautionary measures as required for radium therapy

60 Nursing Interventions
Obtain written consent Informing patient that radioactive isotopes will not affect family/visitors Follow instructions as outlined by the nuclear medicine department as to special preparation for the specific scans

61 Magnetic Resonance Imaging
Used to detect pathological conditions: Cerebrum Spinal Cord Currently used to detect herniated nucleus pulposes (herniated disc)

62 MRI Involves use of Magnetism and Radio Waves to make images of cross sections of the body Very detailed pictures of fluid-filled soft tissue and blood vessels

63 Nursing Considerations
Patient preparation Remove any metal No jewelry, clothing with metal fasteners, glasses, and hair clips

64 Nursing Considerations
CANNOT HAVE MRI if patient has a metal prostheses: Heart valves Orthopedic screws Cardiac pacemakers or defibrillators

65 Nursing Consideration
Patient must be able to lie still for 45 to 60 minutes Enters the tunnel head first anxiety and/or claustrophobia May need sedative Relaxation therapy can help However: No use of relaxation techniques that require flexing and relaxing of muscles – Pt. HAS TO LIE MOTIONLESS! After test: Routine vital signs Pretest activities can be resumed

66 Computed Axial Tomography CT Scan
Views body sections from different angles CT scanner produces a narrow x-ray beam Produces a three-dimensional picture of structures 100 times more sensitive than x-ray Should not be used unnecessarily because of radiation exposure Iodine contrast is sometimes used Used for the head and body

67 CT or CAT Scan Useful in locating
Injuries to ligaments or tendons Tumors of soft tissue Identifying fractures in difficult areas Performed with or without contrast (iodine) dye

68 Patient Preparation Consent form
Check Allergies to iodine and seafood (shellfish) NPO 3 to 4 hours before test if dye is used (dye can cause nausea/vomiting) Baseline vital signs Void Remove jewelry and hairpins Lie still; may feel warm and slightly nauseated for a few minutes when dye is injected

69 Nursing Consideration
After the test: Observe for delayed allergic reaction Encourage fluids Pretest diet and activity can usually be resumed

70 Bone Scan A bone scan is a nuclear scanning test that identifies new areas of bone growth or breakdown. It can be done to evaluate damage to the bones, detect cancer that has spread (metastasized) to the bones, and monitor conditions that can affect the bones (including infection and trauma). A bone scan can often detect a problem days to months earlier than a regular X-ray test.


72 Bone Scan For a bone scan, a radioactive tracer substance is injected into a vein in the arm. The tracer then travels through the bloodstream and into the bones. A bone scan may be done on the entire body or just a part of it.

73 Bone Scan Areas that absorb little or no amount of tracer appear as dark or "cold" spots, which may indicate a lack of blood supply to the bone (bone infarction) or the presence of certain types of cancer. Areas of rapid bone growth or repair absorb increased amounts of the tracer and show up as bright or "hot" spots in the pictures. Hot spots may indicate the presence of a tumor, a fracture, or an infection.

74 Bone Scan Isotope excreted within 48h Hold fluids for 4 hrs. prior to
Informed consent

75 Bone Mineral Density Lose some bone mass as we age
Bones become thinner (osteopenia) Existing bone broken down faster than new bone is made bones lose Ca⁺ and other minerals  become lighter, less dense, more porous  weaker bones; ↑ risk for fx.

76 BMD With further bone loss, osteopenia leads to osteoporosis . So the thicker your bones are, the longer it takes to get osteoporosis. Although osteoporosis can occur in men, it is most common in women older than age 65.

77 BMD Measures bone mass of spine, other bones and total body
Minimal radiation exposure Used to diagnose metabolic bone disease, monitor changes in bone density with treatment

78 Arthroscopy Provides endoscopic examination of various joints
Cartilage abnormalities assessed, loose bodies removed, cartilage trimmed Biopsy may be performed


80 Arthroscopy Interventions:
Instruct pt. to fast 8-12h prior to procedure Informed consent Pain med as prescribed post procedure Elastic wrap 2-4 days post procedure Walking without weight bearing permitted after sensation returns, limit activity for 1-4 days Elevate extremity, ice to minimize swelling

81 Arthrocentesis Synovial fluid aspiration, removal of pus, blood or medication instillation Informed consent Compression bandage post procedure Rest joint 8-24 h afterwards Notify physician if fever/swelling occurs

82 Laboratory Tests: Serum
Calcium Erythrocyte sedimentation rate (ESR) Lupus erythematosus (LE) preparation Rheumatoid factor (RF) Uric acid (blood)

83 Laboratory Tests: Serum
ANA, antinuclear antibodies Detects SLE, a collagen disease Arthritis can result from SLE Normal = negative Client prep For non-fasting blood draw Radioactive scan in last week may increase ANA level

84 Laboratory Tests: Serum
CRP, C-reactive protein inflammation and auto-immune disorders show abnormal protein Normal = female 1-20, male 1-13mm/h Can get false negative Client Prep, usually non-fasting blood draw Meds that increase: contraceptives & IUD Meds that decrease: NSAIDS, steroids, salicylates

85 Laboratory Tests: Serum
Uric Acid-Blood Elevated with Gout and arthritis Normal = male , female mg/dl Client prep: usually non-fasting blood draw Cause: increase: stress, ETOH, ascorbic acid, ASA, caffeine, cisplatin, diuretics, epinephrine, levdopa Cause: decrease: x-ray contrast agents

86 Laboratory Tests: Urine
Uric Acid-Urine (24 hour collection) Normal = ml/24hr Client prep: no special diet, void and discard- note start time on specimen container, collect the rest of voids in container until same time next day, keep on ice or refrigerate,

87 Laboratory Tests: Serum
ESR, Erythrocyte Sedimentation Rate Increases with inflammation, infection, necrosis, or cancer Normal = male up to 15, female up to 20 mm/hr Client prep: non-fasting blood draw; hold some meds Cause increase: pregnancy, menstruation, PCN, oral contraceptives, aldomet, theophylline, vitamin A Cause decrease: if not processed within 3 hours, ASA, quinine, cortisone

88 Laboratory Tests: Serum
RF, Rheumatoid Factor (IgM) Elevated with autoimmune disease such as Rheumatoid arthritis and SLE Normal = < 60 U/ml Client prep: non-fasting blood draw Elderly may show false positive

89 Laboratory Tests: Serum
Serum Calcium (detects calcium metabolism) Normal = 9.0 – 10.5 mg/dl < 6mg/dl may lead to tetany (cramps, convulsions, twitching) > 14mg/dl may lead to coma Client prep: non-fasting blood draw Increase may indicate: metastatic bone tumor, Paget’s disease, acromegaly Decrease may indicate: rickets, osteomalacia, vitamin D deficiency

90 Laboratory Tests Serum Calcium
Cause increase: vitamin D intoxication, excessive milk, calcium salts, lithium, diuretics, hyperparathyroidism Cause decrease: anticonvulsants, ASA, calcitonin, cisplatin, corticosteroids, heparin, oral contraceptives

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