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Final

NURS 203 Study Guide - Final Guide: Varicose Veins, Venous Stasis, Nipple Discharge


Department
Nursing
Course Code
NURS 203
Professor
Cheryl Besse
Study Guide
Final

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Nursing 203: Abnormal Findings
1. Unit 2: Neurological System
2. Unit 3: Eyes and Ears
3. Unit 4: Heart and Neck Vessels
4. Unit 5: Peripheral Vascular System and Lymphatic System
5. Unit 6: Breasts and Regional Lymphatics
6. Unit 7: Thorax and Lungs
7. Unit 8: The Abdomen
8. Unit 9: Anus, Rectum and Prostate / Male and Female Genitourinary System
Unit 2: The Neurological System
Abnormalities in the Cranial Nerves
I: Olfactory Anosmia (lack of sense of smell)
II: Optic -Defect in or absence of central vision
-Defect in peripheral vision
-Absence of light reflex
III: Oculomotor -Dilated pupil, ptosis, eye turns out and slightly down
-Failure to move eye up, in, down
-Absence of light reflex
IV: Trochlear -Failure to turn eye down or out
V: Trigeminal -Absence of sense of touch and pain
-No blink
-Weakness of masseter or temporalis muscles
VI: Abducens -Failure to move laterally, diploplia on lateral gaze
VII: Facial -Absence of or asymmetrical facial movement
-Loss of taste
VIII: Acoustic -Decrease or loss of hearing inflammation, occlusion, otosclerosis, etc.
IX:
Glossopharyngeal
-See cranial nerve X
X: Vagus -Deviation of uvula to side
-No gag reflex
-Hoarse or brassy voice
-Nasal twang
-Dysphagia, etc.
XI: Spinal accessory -Absence of movement of sternomastoid or trapezius muscles
XII: Hypoglossal -Deviation of tongue to side
-Slowed rate of movement
Abnormalities in Muscle Tone
Flaccidity Decreased muscle tone lower motor neuron injury
Spasticity Increased tone upper motor neuron injury to corticospinal motor tract, CVA
Rigidity Constant state of resistance injury to EPT
Abnormalities in Muscle Movement
Paralysis -Trauma, spinal cord injury, CVA, MS, diabetic neuropathy, etc.
Fascicultation Rapid, continuous twitching of resting muscle or part of muscle w/o movement of
limb, that can be seen or palpated not significant
Tic Involuntary tremor that is repeating
Myoclonus Rapid, sudden jerk or a short series of jerks at fairly regular intervals normal when
falling asleep or with grand mal seizures
Tremor Involuntary contraction of opposing muscle group.
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Rest tremor,
intention tremor,
chorea, athetosis
Etc.
Abnormal gaits Spastic hemiparesis, cerebellar ataxia, parkinsonian, scissors, steppage or footdrop,
waddling, short leg (p. 707)
Upper Motor neuron
lesion
-In muscles that correspond to distribution of damage in pyramidal tract lesion;
usually in hand grip, arm extensors, leg flexors
-E.g., CVA
-Hyperrlexia
-Increased tone and spascity
Lower motor neuron
lesion
-In specific muscles served by damaged spinal segment, ventral root, or peripheral
nerve
E.g., Poliomyelitis, herniated disc
-Decreased tone and flaccidity
-Hyporeflexia
Patterns of Motor
System Dysfunction
Parkinsonism -Defect of extrapyramidal tracts; loss of dopamine
-Tremor, rigidity, akinesia, etc.
Multiple Sclerosis -Chronic, progressive, immune-mediated disease in which axons undergo
inflammation, demyelination, degeneration, and sclerosis.
Involves: optic nerve, oculomotor nerve, corticospinal tract, posterior column tract,
and cerebellum.
Pathological Reflexes
Babinski -Stoke lateral aspect and across ball of foot extension of great toe, fanning of toes
corticospinal tract disease (e.g., stroke and trauma)
Speech Disorders
Dysphonia Voice difficulty or discomfort in talking, with abnormal pitch or volume, caused
by laryngeal disease.
Dysarthria Articulation distorted speech sounds; speech may sound unintelligible; basic
language is intact
Aphasia Language comprehension and production
Broca’s area expressive aphasia lesion in anterior language area
Wernicke’s area receptive aphasia lesion in posterior language area
Unit 2: Eyes and Ears
Extraoculuar Muscle Dysfunction
Symmetrical Corneal
Light reflex
-pseudostrabismus normal for a young child
Asymmetrical
Corneal Light Reflex
-strabismus true disparity of the eye axes.
-Estropia inward turn of the eye
-Extropia outward turning of the eyes.
Cover-uncover test -Uncovered eye: if it jumps to fixate on designated point, it was out of alignment
before (i.e., when you cover the stronger eye, the weaker eye now tried to fixate.
Covered eye: If this is the weaker eye, once macular image is suppressed, the eye
drifts to relaxed position.
-As eye is uncovered: if it jumps to re-establish fixation, weakness exists.
Diagnostic Positions
test
-Paralysis is apparent during movement through six cardinal positions of gaze.
-Test of ocular muscles (6):
2
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-IO, IR, LR, MR, SO, SR
Abnormalities in the Eyelids
Exophthalamos Protruding eyes
Enophthalmos Sunken eyes
Ptosis Drooping upper eyelid caused by neuromuscular weakness, oculomotor cranial
nerve III damage, or sympathetic nerve damage (e.g., Horner’s Syndrome)
Abnormalities in the Pupil
Unequal pupil size -Anisocoria CNS disease
Monocular Blindness -When light is directed to the blind eye, no response occurs in either eye.
-When light is directed to normal eye direct and consensual response to light as
long as the oculomotor nerve is intact.
Miosis Constricted and Fixed Pupils
Mydriasis Dilated and fixed pupils drugs
Horner’s Syndrome -Lesion of the sympathetic nerve, causes unilateral, small, regular pupil that does
react to light and accommodation.
-Ptosis and absence of sweat on the same side of the face are also present
Visual Field Loss
Retinal damage -Macula: central blind area (e.g., in diabetes
-Increasing intraocular pressure: decrease in peripheral vision (e.g., glaucoma)
-Retinal detachment; patient has shadow or diminished vision in one quadrant or
one half of visual field.
Lesion in globe or
optic nerve
-Causes blindness in one eye, or unilateral blindness
Vascular Disorders of the External Eye
Conjunctivitis -Infection of the conjunctiva (“pink eye”) causes vessels at periphery to appear red
and beefy, but usually the area around the iris is clearer.
-Bacterial or viral infection, allergy, or chemical irritation.
Acute Glaucoma -Occurs with sudden increase in intraocular pressure caused by blockage of outflow
from anterior chamber.
-Cloudy vision and sudden eye pain and sees halos around lights.
Unit 3: Ears see pp. 360-367 + Objective Data Notes
Unit 4: Heart and Neck Vessels
Clinical Portrait of Heart Failure
Dilated pupils -sympathetic NS response
Skin pale, gray or
cyanotic
Dyspnea SOB is an early symptom from pulmonary congestion
Orthopnea Cannot breathe unless sitting up
Crackles, wheeze Adventitious breath sounds
Cough Frothy pink or white sputum
Decreased BP Stimulates sympathetic NS, which acts on heart to increase rate and increase force of
contraction
Nausea and vomiting As peristalsis slows and bile and fluids back up into the stomach
Ascites Fluid in the peritoneal cavity
Dependent, pitting
edema
In sacrum and legs
Anxiety Gasping from pulmonary congestion
3
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