Exam 1 Flashcards
What does SOAP stand for?
S- Subjective data, O- Objective Data, A- Assessment, and P- Plan
What is legal blindness?
20/200
How is vision on the Snellen chart recorded?
Record the smallest written line that the patient can read in full; record as fraction: numerator is the distance of the patient from the chart and denominator is the distance at which the average eye can read the line
How to test for peripheral vision
Confrontation test- have the patient cover one eye and have the patient tell you when your fingers come into sight from each side
What is Xanthelasma?
flat to slightly raised oval, irregular shaped, yellow-tinted lesions on the periorbital tissues that represent depositions of lipids and a sign of abnormal lipid metabolism
Describe ptosis and its cause
When an open eyelid covers the iris to the pupil; typically a congenital acquired weakness of the levator muscle or a paresis of a branch of the 3rd cranial nerve
What is ectropion?
When the bottom lid turns away from the eye and can cause excessive tearing
What is entropion?
When the eyelid is turned inward towards the globe, eyelashes would cause corneal and conjunctival irritation and increase risk of infection
What is blepharitis?
a bacterial infection that causes crusting along the eyelashes
Changes to the eyes in older adults
Decreased tear production, lacrimal ducts involute, glaucoma, cataracts, macular degeneration, Drusen bodies
What is the purpose of the lacrimal gland of the eye?
It produces tears that moisten the eye
Where is the lacrimal gland located?
the temporal region of the superior eyelid
Which cranial nerves innervate the six eye muscles?
CN III (oculomoter), IV (trochlear), and VI (abducens)
What is the sclera of the eye?
dense, avascular structure that is the white of the eye
What is the conjunctiva of the eye?
a clear, thin mucous membrane; palpebral conjunctiva coats the inside of the eyelids and the bulbar conjunctiva covers the outer surface of the eye
What is the cornea of the eye?
The anterior sixth of the globe; continuous with the sclera. It is a major part of the refractive power of the eye
What is the major physiologic eye change in the aging population?
progressive weakening of accommodation (focusing power) known as presbyopia
Signs of hyperthyroidism seen in the eyes
Fasciculations or tremors of the closed eyelids
Lagophthalmos
When the eyelids do not close completely- can cause dry cornea and increased risk for infection
What can pain on palpation of the eye indicate?
scleritis, orbital cellulitis, and cavernous sinus thrombosis
What can an eye that feels firm upon palpation indicate?
severe glaucoma or retrobulbar tumor
What is a pterygium?
An abnormal growth of conjunctiva that extends over the cornea from the limbus; common in people exposed to ultraviolet light
How do you test corneal sensitivity?
Touch a wisp of cotton to the cornea- patient should blink
What diseases are associated with decreased corneal sensation?
diabetes, herpes, trigeminal neuralgia or ocular surgery
What factors can cause miosis (pupillary constriction)
iridocyclitis, miotic eye drops, and opioid abuse
What factors can cause mydriasis (pupillary dilation)?
mydriatic eye drops, midbrain lesions or hypoxia, oculomotor (CNIII) damage, acute-angle glaucoma, stimulant abuse
What is a corneal arcus (arcus senilis)?
lipids deposited in the periphery of the cornea
What is an Argyll Robertson pupil?
bilateral, miotic, irregularly shaped pupils that fail to constrict with light; caused by neurosyphillis or lesions in midbrain
Signs of oculomotor (CNIII) nerve damage
pupil dilated and fixed, eye is deviated laterally and downward, ptosis
What is adle pupil (tonic pupil)?
Affected pupil is dilated and reacts slowly or not at all to light; caused by impairment of postganglionic parasympathetic innervation to sphincter pupillae muscle or ciliary malfunction
How to use ophthalmoscope for eye exam
start with the lens on the 0 setting, and place free hand on the patient’s shoulder or head; have patient look at distant fixation point; visualize red reflex first
What is the red reflex of the eye?
Caused by the light illuminating the retina during exam
What could absence of the red reflex during exam indicate?
improperly positioned ophthalmoscope or total opacity of the pupil by a cataract or hemorrhage
What is the optic disc?
where the retina converges to the optic nerve; a blind spot; yellow to creamy pink and 1.5 mm in diameter
Correct order of ophthalmoscope assessment
Red reflex, retina, blood vessels, vascular supply to the retina, the optic disk, then the macula
Describe a myelinated retinal nerve fiber
white area with soft, ill-defined peripheral margins continuous with the optic disc
Describe papilledema
Loss of definition of the optic disc margin; caused by increased intracranial pressure
Describe the cotton wool spot
ill-defined, yellow areas caused by infarction of nerve layer of the retina; caused by vascular disease secondary to hypertension or diabetes
What is ophthalmia neonatorum?
conjunctival inflammation and drainage in the newborn
Describe coloboma
Congenital abnormality in the newborn: keyhole pupil, tissue around the pupil not fully formed
Symptoms of coloboma
microphthalmia, blindness, cataracts, increased eye pressure
What are brushfield spots?
White or grayish raised spots arranged in a circular pattern around the iris
What population is most likely to have brushfield spots?
Children with downsyndrome but can occur in normal children too
Describe hyphema
an accumulation of blood in the front chamber of the eye; usually caused by eye trauma
Describe a subconjunctival hemorrhage
bright red blood in a sharply defined area surrounded by healthy appearing conjunctiva
Is the cornea a vascular tissue?
No it is avascular, blood vessels should not be present
How do you test CN V?
Touch a whisp of cotton to the cornea
Describe cornea arcus
spots composed of lipids that are deposited in the periphery of the cornea; most often seen in those older than 60
What is the difference between the accommodation and pupillary reflexes?
The pupillary light reflex compensates for changes in illumination level, whereas the accommodation responses compensate for changes in eye-to-object-viewed distance.
What is anisocoria?
unequal size in pupils, congenital or caused by local eye medications
Signs and symptoms of Oculomotor (CNIII) damage
pupil dilated and fixed, eye deviated laterally and downward, ptosis
Why would the sclera appear green or yellow?
Liver or hemolytic disease
What is a senile hyaline plaque?
a dark, slate gray pigment anterior to the insertion of the rectus muscle; benign
What is epscleritis?
Inflammation of the superficial layers of the sclera anterior to the insertion of the rectus muscles; S&S: acute onset mild to moderate discomfort or photophobia, watery discharge without crusting
What is band keratopathy?
deposits of calcium in the superficial cornea; S&S: decrease in vision as deposition progresses, foreign body sensation, horizontal grayish bands interspersed with dark areas that look like holes
What is a corneal ulcer?
A disruption of the corneal epithelium and stroma; S&S: pain, photophobia, blurry vision, wears contacts, visual acuity changes, inflammation of the lids and conjunctiva, purulent exudate, ulcer often round or oval
What is strabismus?
When both eyes do not focus on an object simultaneously but can focus with either eye; may be a sign of increased IOP; S&S: poor vision, sudden onset of double vision, eye deviation
Describe horner syndrome
interruption of sympathetic nerve innervation to the eye; Triad symptoms: ipsilateral miosis, mild ptosis, and loss of hemifacial sweating; PAM (Ptosis, Anhidrosis, miosis) Horner
Name the most common causes of cataracts
Denaturation of lens protein caused by aging, hypoparathyroidism, steroids, and congenital cataracts
Describe diabetic retinopathy
Dot hemorrhages or microaneurysms and the presence of hard and soft exudates; S&S: blood vessels with ballon-like sacs, blots of hemorrhages on the retina, tiny yellow patches of hard exudates, cotton wool spots
What is lipemia retinalis?
Creamy white appearance of retinal vessels that occurs with excessively high serum triglyceride levels
Objective findings for lipemia retinalis
elevated serum triglycerides, Grade 1- early white and creamy aspect of peripheral retina vessels, grade 2- creamy color extends toward the optic disk, grade 3- retina appears salmon color and all vessels have a milky appearance
What is retinitis pigmentosa?
An autosomal recessive disorder in which the genetic defects cause cell death, predominantly in the rod photoreceptors
S&S of retinitis pigmentosa
Earliest symptom- night blindness, tunnel vision, painless loss of vision; late stages- optic atrophy with a waxy pallor, narrowing of the arterioles, and peripheral bone spicule pigmentation
What is glaucoma?
Disease of the optic nerve where the nerve cells die, usually due to excessively high intraocular pressure
What causes acute angle glaucoma?
Dramatic elevated IOP if the iris blocks the exit of an aqueous humor from the anterior chamber
What causes open-angle glaucoma?
decreasing aqueous humor absorption leads to increased resistance and painless buildup of pressure in the eye
S&S of acute angle glaucoma
intense ocular pain, blurred vision, halos around lights and a red eye with dilated pupil
Objective findings for glaucoma
Loss of peripheral vision
What are drusen bodies?
Small yellowish discrete dots that accumulate under the retina; increased risk for macular degeneration; S&S: glistening yellow deposits seen on fundoscopic exam
What is macular degeneration?
central portion of the retina, known as the macula, wears down over time causing severe and permanent vision loss
What is chorioretinitis?
an inflammatory process involving both the choroid and the retina; most common cause is laser therapy; can also be caused by cleaning cat litter box; S&S: floaters, reduced vision, sharply defined whitish-yellow lesion
When does development of the inner ear occur?
during the first trimester or pregnancy
What are some differences to the anatomy of the ear in children?
External auditory canal is shorter than the adults and has an upward curve; eustachian tube is wider, shorter, and more horizontal/soft; allows easier reflux of secretions
What disease of the ears are children more likely to develop and why?
a middle ear effusion: growth of lymphatic tissue may occlude the eustachian tube and interfere with aeration of the middle ear
What causes hearing loss in older adults?
degeneration of hair cells in the organ of Corti, loss of cortical and organ of Corti auditory neurons, degeneration of the cochlear conductive membrane, and decreased vascularity in the cochlea
Name the different types of hearing loss
conductive and sensorineural
What causes conductive hearing loss?
cerumen impaction and tympanosclerosis or otosclerosis caused by calcification of tissues in the middle ear
Describe sensorineural hearing loss
reduced transmission of sound in the inner ear; caused by damage to CN VIII, congenital infection, trauma, ototoxic meds
Why are older adults’ ears often larger than other adults?
Cartilage formation continues as we age, making the auricle larger
What condition would cause a blue color to the skin of the ear?
Cyanosis
What can palllor or redness of the external ear indicate?
frostbite
What can a cauliflower ear indicate?
blunt trauma and necrosis of cartilage of the ear
Describe tophi
white uric acid crystals that deposit on the ear
Correct patient positioning for an otoscope exam
tilt patient’s head toward the opposite shoulder; pull auricle upward and back to straighten auditory canal; insert speculum 1-1.5 cm
For the Rinne test what is the normal result?
Air conduction should be twice as long as bone conduction
What is otitis externa also known as?
Swimmer’s ear: itching in ear canal, usually after swimming
S&S of otitis externa
itching ear canal, intense pain with movement of the pinna and chewing; watery (early), purulent and foul smelling drainage (late), conductive hearing loss, red, edematous, canal with obscured tympanic membrane
S&S of otitis media with effusion
sticking or cracking sound on yawning or swallowing; feeling of fullness in the ear; conductive hearing loss; tympanic membrane retracted or bulging, impaired mobility, and yellowish; no discharge
S&S of acute otitis media
S: abrupt onset, fever, feeling of blockage in ear, anorexia, deep earache that interferes with sleep; discharge present only if tympanic membrane ruptures; conductive hearing loss
O: tympanic membrane- erythema, thickened or clouding, bulging, bubbles
What is cholesteatoma?
abnormal squamous epithelial tissue behind the tympanic membrane; could cause tympanic membrane perforation, erosion of the ossicles and temporal bone, and invade the inner ear structures
S&S of cholesteatoma
S: hx or recurrent otitis media, unilateral hearing loss, ear fullness or pain, tinnitus, mild vertigo, discharge from ear canal
O: spherical white cyst or pouch behind tympanic membrane, conductive hearing loss, possible tympanic membrane bulge, facial nerve paralysis (rare)
S&S of conductive hearing loss
S: turns TV on louder, speaks softly
O: bone conduction > air conducting with Rinne, lateralization to affected ear with Weber, loss of low-frequency sounds
S&S of sensorineural hearing loss
S: Hearing loss begins with higher frequency sounds, complaints that people mumble, speaks loudly, unable to hear in a crouded room
O: Weber test lateralizes to unaffected ear, loss of high frequency sound, air conduction > bone conduction with Rinne
What is vertigo most often related to?
a disorder of the inner ear
Describe Meniere’s disease
an inner ear disorder characterized by episodes of hearing loss, vertigo, tinnitus, and ear fullness; likely caused by genetic and environmental factors, excess secretion of endolymph or failure of reabsorption in the subarachnoid space
S&S of Meniere’s
S: sudden onset vertigo from moving head, hearing loss, whistling or roaring sounds in ear, ear fullness or pressure
O: hearing loss to low tones initially with fluctuating progression to profound sensorineural hearing loss, imbalance, nystagmus
Describe acute vestibular neuronitis
inflammation of the vestibular nerve after an acute viral upper respiratory infection
S&S of acute vestibular neuronitis
S: spontaneous episodes of vertigo that is severe initially and lessens over a few days, difficulty walking , N/V, benign paroxysmal positional vertigo
O: spontaneous horizontal nystagmus with or without rotary nystagmus, staggering gait
Development of sinuses in children
sphenoid sinuses by age 5, frontal sinuses begin at 7-8 years and complete development during adolescence
Changes to nares/sinuses in older adults
deterioration of the sense of smell from loss of olfactory sensory neurons- 60 years of age, cartilage formation continues around the nose- nose becomes larger, odor sensitivity declines
How do you evaluate patency of a patient’s nares?
by occluding one naris and have them breath in and out of non-occluded nares; should be noiseless
What color should the nasal mucosa be?
glistening and deep pink
What cranial nerve is responsible for smell?
CN I (olfactory)
Where and how to palpate frontal and maxillary sinuses
using thumb: under the boney brow on each side of the nose; under the zygomatic processes lateral to the nose using either thumb or index & middle fingers to palpate the maxillary sinuses
Expected findings for normal sinus exam
no tenderness or swelling over the soft tissue
Describe sinusitis
bacterial infection of one or more of the paranasal sinuses, inflammation, allergies, or structural defects of the nose may block the sinus meatus and prevent the sinus cavity from draining
S&S of sinusitis
S: upper respiratory infection that worsens or persists after 7-10 days, frontal headache, facial pain or pressure, purulent nasal discharge, persistent cough, worse at night
O: purulent nasal discharge, tenderness over frontal or maxillary sinuses, sinus does not transilluminate
Differences to mouth in infants
salivation increases by the time the infant is 3 months old, infant drools until swallowing is learned, teeth erupt between 6-24 months, permanent teeth around 6 years and complete by 15 years
Why would tooth eruption timing be delayed in children?
poor nutrition and chronic conditions
Changes to mouth in older adults
gingival tissue may recede: more easy teeth erosion, lost teeth- diet changes and difficulty chewing, the tongue may become more fissured, altered motor function of tongue, problems with swallowing, saliva production may decrease, taste declines
Where would the nurse visualize the parotid (Steensen) duct?
It would be aligned with the second upper molar, it is a whitish yellow or whitish pink protrusion
Expected findings on visual assessment of oral cavity
mucous membranes are pinkish-red, smooth, and moist; gums are more pigmented in darker-skinned races, gums should have no inflammation, swelling, or bleeding
What would deep fissures in the lips indicate?
infection, irritation, nutritional deficiencies, or overclosure of mouth
What finding on the lip would indicate peutz-jeghers syndrome?
round oval irregular bluish gray macules
How would you assess CN VII?
have the patient clench their teeth and smile
Characteristics of the anterior portion of the tongue
papillae and small fissures
Characteristics of the posterior portion of the tongue
rugae or a smooth, slightly uneven surface with a thinner mucosa
What characteristic can be found on either side of the frenulum
Wharton ducts- thin tubes that carry saliva
Name some expected findings of the hard palate
dome shape with transverse rugae
How to assess movement of the soft palate
have patient say “ah”
Normal findings for the pharynx
should be smooth, glistening, pink with some small irregular spots of lymphatic tissue and small blood vessels
How do you test cranial nerves IX & X?
touch the posterior wall of the pharynx to illicit the gag response
What is acute bacterial pharyngitis?
infection of tonsils or posterior pharynx by Group A beta-hemolytic streptococci
S&S of acute bacterial pharyngitis
S: sore throat, ear pain, fever, malaise, fetid breath without nasal drainage or cough
O: red and swollen tonsils, crypts filled with purulent exudate, palatal petechiae, enlarged anterior cervical lymph nodes
Tonsil grade 1
tonsils occupy less than 25% of the lateral dimension of the oropharynx
Tonsil grade 2
tonsils occupy 26-50% of the lateral dimension of the oropharynx
Tonsil Grade 3
Tonsils occupy 51-75% of the lateral dimension of the oropharynx
Tonsil Grade 4
the tonsils and the uvula are Kissing: can occlude airway
What is a peritonsillar abscess?
A deep infection in the space between the palatine tonsil capsule and pharyngeal muscles; complication of adenotonsillitis or blockage of weber glands
S&S of peritonsillar abscess
S: dysphagia, odynophagia, drooling, sore throat with pain radiating to the ear, malaise, fever
O: unilateral red, swollen tonsil and adjacent soft palate, tonsil may be pushed forward or backward, trismus, muffled voice
What is a retropharyngeal abscess?
A life-threatening deep neck space infection that has the potential to occlude the airway, occurs in the potential space extending from the base of the skull to the posterior mediastinum; could occur from spread of infection or direct inoculation from trauma
S&S of retropharyngeal abscess
S: recurrent URI, acutely ill, fever, drooling, anorexia, irritable, neck pain, limited neck movement
O: fever, lateral neck movement increases pain, torticollis, lateral pharyngeal wall distorted medially, respiratory distress
What is oral cancer often associated with?
Squamous cell carcinoma- HPV
S&S of oral cancer
S: painless sore in mouth that does not heal, pain with later stage lesions
O: ulcerative lesion appearing as piled-up edges around a core on the lateral border of mouth floor; red or white patch on tissues, tooth mobility when no peridontal disease present
What is peridontal disease?
chronic infection of the gums, bones, and other tissues that surround and support the teeth
S&S of periodontal disease
S: red and swollen gums that bleed easily, tender gums, loose teeth
O: plaque and tartar buildup on teeth, deep pockets between the teeth and gingiva, loose or missing teeth
What are oropharyngeal clefts?
craniofacial congenital malformation, result of the lip or palate failing to fuse during embryonic development before the 12th week of gestation; combination of genetic & environmental factors
S&S of oropharyngeal cleft
S: can be diagnosed in prenatal ultrasound, difficulty sucking, failure to thrive
O: apparent at birth, cleft may be unilateral or bilateral and involve all palates and lips
Correct order for a health history
Chief concern HPI PMI Family history Personal and social history ROS
The 5 Ps of sexual history
partners, practices, protection, past history of STI, prevention of pregnancy
What is a hordeolum?
also known as a stye: red and tender bump on the edge of the eyelid
