240 integration Flashcards
Assess the floor of mouth for tongue symmetry, movement, color, surface characteristics, frenulum, and Wharton’s ducts. Document your findings.
- pink and even
- dorsal surface roughened by papillae, a thin white coating may/may not be present
- ventral surface smooth, glistening and shows veins, saliva present (but not excessive)
- frenulum intact & connects the ventral surface of the tongue to the floor of mouth,
- Wharton’s ducts on either side of frenulum in floor of mouth
Possible history questions for mouth
Have you been experiencing abnormally dry mouth?
Do you smoke or did you used to smoke?
Have you experienced any change in taste?
Do you drink alcohol? How often?
Assess the hard and soft palates for color, mobility, and assess uvula. Document your findings.
- Hard; white with irregular transverse rugae
- Soft; pinker, smooth, upwardly movable
- Uvula; fleshy pendant, midline, rises when pt says ahhh (CN X)
possible history questions for palates/uvula
- Experience of dysphagia?
- History of sores/lesions on roof of mouth?
- History of smoking?
Assess the oropharynx for color, drainage, and assess tonsils. Document your findings.
TO ASSES:
-inspect oropharynx and tonsillar pillars (same color as surrounding tissue)
-observe posterior wall of pharynx
NORMAL:
-tonsils same pink as mucosa, surface peppered w/ crypts
-gag reflex when touching posterior wall (CN IX,X)
-stick out tongue CN XII
history questions for oropharynx
- drink alcohol? how often?
- how often do you brush your teeth?
- experiencing sore throat?
- history of mono?
- experience any hoarseness or voice change?
Palpate lips, cheeks, buccal surfaces, tongue, and teeth. Document your findings.
Lips:
-deeper pink than facial skin, moist, no cracking or lesions
Clench teeth and smile:
-teeth should line up with no over/underbite
-normal occlusion upper teeth resting directly on lower teeth with front upper incisors slightly overriding lower incisors
Buccal mucosa:
-hold cheek open with wooden tongue blade
–should be pink, smooth, moised
Gums:
-pink with dotted surface, tight, well defined
-no bleeding/swelling/discoloration
Count teeth:
-32
questions for lips/cheeks/buccal surfaces/tongue/teeth
- history of braces?
- cavities?
- smoke history?
- bleeding gums?
- toothaches or tooth extractions?
Assess the ear for position, size, patency of external canal. Palpate external ear and mastoid process for skin texture, tenderness, nodules, or swelling. Document your findings.
normal:
- equal size bilaterally
- no swelling
- skin color consistent with face
- no tenderness at mastoid process/pinna/tragus
- no discharge
questions for ear
- any discharge from ears?
- any tenderness in your external ears/behind ears?
- notice discoloration in the skin on ears?
- any sticky or yellow discharge when cleaning your ears?
Inspect the external canal and tympanic membrane and relate findings concerning color of canal tissue, color of TM , tissue intactness, discharge, deformities, masses, lesions, presence of and characteristics of cerumen. Identify landmarks such as the umbo, malleus, light reflex, pars tensa, pars flaccida, and annulus. Document your findings.
normal: -shiny translucent and pearly grey -drum slightly concave -cone of light 7 in left -cone of light 5 in right -umbo, manubrium and short process visible -mild cerumen (wet=yellow grey) (dry= light brown/black)
ear otoscopic history questions
- frequent earaches/pain in the ears?
- frequent ear infections as a child?
- notice any hearing loss?
- discharge?
- any ringing in your ears?
- tubes placed in ears as a child?
Assess patient for nystagmus and document your findings.
procedure:
- have pt follow penlight with their eyes WITHOUT moving head
- if eye twitch/delay, pt has nystagmus
Perform correct hand hygiene. When may you use hand sanitizer and when is washing with soap and water required?
- Wash → if hands are visibly soiled or you came in contact w/bodily fluids or mucous membranes
- Hand sanitizer → all other occasions (before and after Pts, not visibly soiled, etc.)
Assess patient’s range of motion and/or lead patient through ROM exercises.
(watch video!) normal: -motions smooth and controlled -no pain/limitations with movement head: -chin to chest, turn left and right, touch ear to shoulder, tilt head backwards
ROM questions
- FH of arthritis?
- notice any tenseness/limitations during everyday activities?
- any injuries that would limit ROM?
making unoccupied bed
video
making occupied bed
video
identify potential safety hazards in the room
- call light
- break on bed
- railing
- temp
****assess patient’s lymph nodes
check
tilt pt head and palpate relaxed side
- pre auricular
- posterior auricular (mastoid)
- occipital
- submental
- submandibular
- jugulodigastric
- superficial cervical
- deep cervical
- posterior cervical
- supraclavicular
should be moveable without any tenderness/swelling/pain
assess for possible skin melanoma using ABCDE
Asymmetry
–1/2 unlike the other
Borders
–irregular scalloped or poorly defined border
Color
–varied from one area to another, shades of tan/brown/black
Diameter
–melanomas usually > 6mm (pencil eraser)
Evolving
–mole/skin lesion that looks different from rest or changing in size/shape/color
identify several skin lesions and document your findings
https://quizlet.com/129421703/jarvis-skin-assessment-flash-cards/
perform weber test
- tests for lateralization of hearing
- place of midline of parietal bone
- ask if heard equally through both ears
rinne test
- tests air conduction and bone conduction
- place fork on mastoid process
- -when do u stop hearing it?
- place fork outside of ear canal
- -when do u stop hearing it?
whisper test
- stand 1-2 ft behind patient
- occlude tragus on opposite ear that isn’t being tested
- whisper letters/numbers/words and have them repeat back
assess vestibular function using romberg test
- stand with feet shoulder-width apart, arms at sides and close eyes
- note swaying/imbalanced
- have arms out in case patient falls
patients memory
- recent
- remote
- rote
- recall
- recent: what you ate last night
- remote: first job, birthday/anniversary dates, historical events relevant to pt
- rote: count 1-30
- recall: tell me the 6 words i asked you to remember
assess patient’s nose (structure, patency, septum, turbinates, drainage)
external:
-symmetric, midline, proportionate to other facial features
patency:
- close one nostril and have them breathe
normal cavity:
-red, smooth, moist, middle and inferior turbinates visible
history questions for nose
- history of excessive drainage?
- experienced obstruction in one/both nostrils?
- any allergies?
- frequent nosebleeds?
- noticed any change in your sense of smell?
- trauma to your nose?
assess patient’s mouth and document your findings
check buccal mucosa, gums, teeth, tongue, everything mentioned before, ducts
assess patient’s ADLs and document your findings
-measure pt’s ability to bathe, dress, use bathroom, eat, walk, cook, social relationships, self-concept and coping,
questions for ADLs
-pertaining to above
OLD CARTS
Onset Location Duration Characteristics Associated factors Relieving factors Timing Severity
PQRST
Provoking Quality Radiation Severity Timing
assess orientation to person, place, and time
tell me your:
- name
- DOB
- where we are rn
- city/state
- date
- season
- day of the week
- year
