Exam 2: Physical assessment, *HEENT, Cranial Nerves, Vision & Hearing Flashcards
1st step of nursing process is
assessment
Assessment
collection of data pertinent to the patients health/situation
Clincal reasoning is based on
good assessment
The nurse collects health data from the client to
Compare to the ideal state of health
When collecting health data, take into account
Age Gender Culture Ethnicity Physical & Psychological status
What do nurses do after collecting health data
Incorporates it all to develop a plan of care that will help client maximize his or her health
Develop a care plan that
Always stays patient-centered
Always involve the patient
Components of health assessment
- Health history & interview (subjective)
- Performing a physical examination & review of systems: (Collecting objective data)
- Documenting finds
Health history would be an example of
Subjective data when interviewing
Patient-sources information about :
Current state of health medications previous illnesses & surgeries Family history Patient concerns, symptoms, problem, compliant
A symptom is
A report of what the client experiences associated with a problem
A symptom is considered
Subjective data
Physical examination involves the
Objective data collected by the nurse
Objective data are referred to as
Signs
During physical examination, the nurse obtains objective data using techniques of
Inspection
Palpation
Percussion
Auscultation
Nurse also measures the
Clients height weight blood pressure temperature respiratory rate pain
Official chart documents are also
Objective data
Why do we document assessment findings
allow other health care providers to use for information
What improves the effectiveness of the entire health care team
Complete, accurate, and descriptive documentation
Documentation provides
Evidence for care, services, referrals
Patient chart is
Legal document
Protected by HIPPA
can be reviewed by patient at their request
Purpose of a physical examination
- baseline data
- supplement, confirm, or refute subjective data
- identify and confirm nursing diagnosis
- make clinical decisions about a patients changing health status and management
- evaluate the outcomes of care
Preparation for examination
-Infection control
-Environment
-Equipment
-physical preparation of patient
-psychological preparation of patient
-assessment of age groups
-cultural sensitivity
-
As soon as you meet the client, what does you initial inspection tell you
Hygiene?
Movement?
Emotions/expressions?
Behaviors?
Organization of the examination
Head to toe approach
- compare sides for symmetry
- assess body systems most at risk for being abnormal
- offer rest periods
- perform painful procedures at the end
- be specific when recording assessments
- records quick notes during examination and then longer
OLD CART
Onset (1st time it started)
Location (& radiation)
Duration (how long it lasts)
Characteristics (descriptors: sharp, dull, achy)
Aggravating factors (what makes it worse)
Relieving factors (what makes it better?)
Treatment (what has been tried & effectiveness)
Inspection
- Adequate lighting to see
- inspect each area for size, shape, color, symmetry, position, and abnormality
- position and expose body parts as needed
- SYMMETRY
- validate findings with patient
Palpation
- Uses touch to gather information
- use different parts of hands to detect for different areas
- hands should be warm, short fingernails
Start with ____ palpitations then end with ____ palpitations
light, deep
Percussions
- Tap skin with fingertips to vibrate underlying tissues and organs
The denser the tissue…
the quieter is the sound
Auscultation requires
- good stethoscope
- good hearing or an amplified stethoscope
- knowledge
- concentration and practice
Sound characteristics for auscultation
Frequency
soundness
quality
duration
General survey include
- General appearance and behavior
- vital signs
- height and weight
Examples deep palpitation
Abdomen, feeling a mass or a baby?
Examples of general appearance and behavior
gender, race, age, signs of distress, body type, posture, gait, movements, hygiene, dress, mood, speech, signs of abuse, substance abuse
Subjective data for head
headaches, injury, dizziness, neck pain, ROM
Objective data for head
Inspect & Palpate
hygiene of skin/hair
skull symmetry, size, shape, scalp, masses
Facial feature symmetry
Skin, Lymph nodes
Hiar distribution, color, texture, lesions, lice
TMJ dysfunction indicated by
Limited movement, pain with movement, and/or clicking sound
Subjective data for nose
Patient reported symptoms
-discharge, congestion, sinus pain, trauma, epistaxis (nosebleed). allergies, altered smell
Objective data for nose
- inspect and palpate external
- size & shape
- symmetry/midline
- patency /obstruction
- skin
- smell
If is it not PATENT, you
Can not assess the cranial nerve
Olfactory nerves =
Smell
What triggers olfactory testing?
Olfactory is not often tested, but an altered taste often triggers assessment
Evaluate olfactory cranial nerve
- Close eyes and mouth
- occlude one nostril while testing the other
- identify familiar substances (coffee, toothpaste, etc.)
Smell normally decreases with
aging
One cannot test smell when
Air passages are occluded with upper respiratory infection or with sinusitis
Abnormal findings for nose
Epistaxis rhinitis rhinorrhea sinusitis deviated septum nasal polyp anosmia
Epistaxis
Nose bleeds
Rhinitis
nasal inflammation, congestion
Rhinorrhea
Nasal discharge
Sinusitis
inflammation of sinuses pain on cheeks, teeth, and gums
deviated septum
ingrowth of lower nasal septum
Nasal polyp
Non painful overgrowth of nasal mucosa
Anosmia
Decrease or loss of smell occurs bilaterally with tobacco smoking, allergic rhinitis, cocaine use
What does it mean with a nose is patent?
ability to move air (smelling!)
Subjective date for eyes
Visions changes, floaters, photophobia, pain, redness, swelling, discharge, diplopia, strabismus, glaucoma, glasses/contacts, excessive lacrimation or other discharge
Objective for eyes
General appearance, position and alignment, any subjective complaints that are observable would be objective
Eye lids
No ptosis, entropia, extropia
Sclera
White; grey-blue tinged normal variation; yellow? Jaundice?
Iris
Round, regular shape
Corneal light reflex
Point of light reflection should be the same in each eye, same quadrant
numerator of vision test
distance person is from the chart
denominator for vision test
Distance at which normal eye can read
The larger the denominator, the
Poorer the vision
Normal vision acuity
20/20
Test optic nerve for visual acuity using
SLOAN letters (In the past, snellen)
Oculomotor nerve controls
- Pupillary constriction and dilation
- controls extra-ocular movements
What nerves are tested together because they all control different muscles of the eye for movement
Oculomotor (III)
Trochlear (IV)
Abducens (VI)
Why do we test the oculomotor, trochlear, and abducens together?
they all control different muscles that provide eye movement
P.E.R.R.L.A
Pupils are Equal Round Reactive to Light Accommodation
Pupillary light reflex is
Normal constriction of the pupils when bright light shines on the retina
Normal responses of pupillary light reflex
When one eye is exposed to bright light, a direct light reflex occurs
A direct light reflex
Constriction of the pupil when light is directly on an eye
Consensual light reflex
simultaneous constriction of the other pupil
test for accommodation (reflex) by asking
Person to focus on a small distant object and far objects
distance during accommodation test should
dilate
Close objects during accommodation =
Constrict
A normal response during the accommodation test includes
Pupillary constriction
Convergence of the axes of the eyes
During and extra ocular eye movement lead the eyes through
6 cardinal positions of gaze will elicit muscle weakness during movement
a normal response in EOMs test is
Smooth tracking
Nystagmus (abnormal EOMs findings)
Jerky or oscillating movement
Another abnormality found in EOMs
Inability to move in a particular direction
Nystagmus
Extraocular movements from which cranial nerves
Oculomotor (III)
Trochlear (IV)
Abducens (VI)
Abnormal findings of (III) cranial nerve
- Diminished to absent pupillary constriction, lack of consensual light reflex, lack of accommodation
- Increased intracranial pressure or trauma to the midbrain may exert pressure on CN III
- pupil size can be changed by drug effects (heroin, cocaine)
Each abducens nerve is a motor nerve that
Extends to the lateral rectus muscles of the eyes
The lateral rectus muscle
Abducts the eyes
Abnormal findings of CN III, IV, VI
- eye movement not parallel
- Failure to follow in a certain direction indicates weakness of an extra ocular muscle or dysfunction of cranial nerve
- Report ptosis or the eye, note any nystagmus
ptosis
Eyelid droop
expected finding of cover-uncover test
No movement
if uncovered eye during cover-uncover test moves to focus, ___ is present
Strabismus is present
Strabismus or crossed eye
Both eyes do not look at the same place at the same time
Strabismus is caused by
Poor eye muscle control and evident by age 3
Early diagnosis or strabismus is essential in preventing vision loss that occurs as a result
Amblyopia
Amblyopia
Occurs when vision does not develop normally because eyes are not aligned
Treatment of strabismus
Eyeglasses, patching or eye muscle surgery
—-EYEPATCH ON STRONG EYE
exophthalmos
Protruding eyes (Associated with hyperthyroidism)
Myopia
nearsightedness
Hyperopia
farsightedness
Astigmatism
Refraction of light causes blurred or double vision
Conjuctivitis (pink eye)
Inflammation od conjunctiva, usually bacteria
Hordeolum (Stye)
Localized staphylococcal infection of hair follicles
Subconjunctival hemorrhage
Caused by increased intraoccqular pressure, coughing, vomiting, weight, lifting, labor, straining at stool, trauma
CN V
Trigeminal nerve
Trigeminal nerves split
into 3 branches
sensory neurons in all 3 branches of CN V
Sensation from the skin and mucosa of the head & from the teeth
Motor fibers on CN V run
to the muscles of mastication
How to test CN V motor function
Have client clench teeth, then palpate temporal & master muscles for mass & Strength
How to test CN V sensation of light touch
Have client close eyes then wipe a cotton ball slightly over the three areas then repeat bilaterally
When to do corneal reflex for CN V
Only do it if individual does not respond to CN V sensation of light touch
Corneal reflex tests
Sensory afferent in cranial nerve V & motor efferent in cranial nerve VII
If individual has contacts, should they keep them in during corneal reflex test?
No, remove any contact lenses
Corneal reflex test
person looking forward, bring wisp of cotton in from the side (to minimize defensive blinking) & lightly touch the cornea (not the conjunctiva)
How to know if corneal reflex may be abnormal
Absence in blink is abnormal, but the corneal reflex may be decreased or absent in those who have worn contact lenses !!
Abnormal findings in CN V
- Inequality in muscle contractions, pain, twitching, or asymmetry is abnormal
- Decreased or unequal sensation is abnormal
- —– Record extent of the involved areas
- —– Trigeminal neuralgia
Trigeminal neuralgia
characterized by stab-like pain radiating along the trigeminal nerve
What is trigeminal neuralgia cause by
Cause by the degeneration of or pressure on the nerve
CN VII motor fibers of facial nerve extend
by way of several branches to the superficial muscles of the face and scalp, controls facial expression
CN VII facial nerve sensory fibers detect
Salt and sweet taste
CN VII facial nerve inspects
face at rest and during conversation
When testing CN VII facial nerve, have the client
raise both eyebrows, smile, frown, close the eyes tightly, show the teeth, puff both cheeks
Abnormal findings of CN VII facial nerve
Asymmetry, facial weakness, dropping of one side of the face or mouth, or inability to maintain position until instructed to relax
Signs of damage to CN VII facial nerve
- Eye does not close
- Eyeball rolls up
- flat nasolabial fold
- forehead not wrinkled
- eyebrow not raised
- paralysis of lower face
Subjective data for ears
Earaches Infections Discharge Hearing Loss Tinnitus (ringing) Vertigo Self care behavior
Objective data for ears
Inspection
Test cranial nerves
CN VIII: Vestibulocochlear nerve has two distinct divisions:
- Vestibular nerve
- Cochlear nerve
vestibular nerve & Cochlear nerve are both
Sensory nerves!
Vestibular nerve transmits impulses that
result in sensations of equilibrium
Conductions by the cochlear nerve results in
Sensations of hearing
Evaluate CN VIII hearing test
Test hearing acuity by the ability to hear normal conversations;
Notice how they hear during the history-taking phase of the assessment
CN VIII: Assessment of sensorineural or conductive hearing loss
- Whispered voice test
- Weber & Rinne tuning fork tests
- Audiometer testing
Presbycusis
Age-related hearing loss
Sensorineural
Impaired cranial nerve transmission or inner ear dysfunction
Conductive
Impaired sound transmission to inner ear
Mixed hearing loss
combination of sensorineural and conductive
Conductive hearing loss
Sounds cannot get through the outer and middle ear, may be hard to hear soft sounds.
Louder sounds may be muffled
Hearing loss conductive fix
Medicine or surgery can often fix this type of hearing loss!
Can conductive hearing loss be corrected?
Yes! It can be corrected
causes of conductive hearing loss
Fluid in middle ear from colds or allergies
Ear infection
Poor Eustachian tube function
A hole in your eardrum
Benign tumors
earwax/cerumen in your ear canal
an object stuck in your outer ear. a child puts a pebble/toy in ear
Problem with how the outer or middle ear is formed before birth or traumatized after birth
Sensorineural hearing loss happens
- After inner ear damage
- Problems with the nerve pathways from your inner ear to your brain can also cause SNHL
Most common type of permanent hearing loss
Sensorineural Hearing loss
Can medicine or surgery fix SNHL?
No! SNHL cannot be fixed, but hearing aids can help you hear
Causes of sensorineural
Illnesses Drugs that are toxic to hearing Genetic hearing disorders Aging A blow to the head A problem in the way the inner ear is formed Listening to loud noises or explosions
How to test cranial nerve VIII: Vestibulocochlear nerve
Whisper test!
How to do whisper test
Have patient cover one ear and stand on the other side and whisper 3 words
Abnormal findings in whisper test
unable to hear some/all of whispered word
Normal findings of whisper test
repeat each word correctly
Whisper is a
High frequency sound & is sued to detect high frequency hearing loss, common in geriatric patients
What is the weber test
It is used to test CN VIII when hearing is better with one ear than other
What is the weber test
place a vibrating tuning fork in the midline of the person’s skull and ask whether the tone sounds the same in both ears or better in one ear
Abnormal findings of weber test
Lateralization of sound to the “bad side”/affected side
What is another way to demonstrate the weber test
Plug one ear and humm, the sound will be louder on the bad ear
Rombergs test: test for equlibrium and balance
Have person stand feet together, close eyes and hold position
abnormal romberg test
sways, falls, widens base to avoid falling
A positive rombergs sign is
loss of balance that occur when closing the eye, may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function
Subjective data for mouth and pharynx
Sore/lesions, bleeding gums, tooth aches, dysphasia, altered taste, smoking, alcohol consumption, self-care behaviors
Objective data for mouth and pharynx
Lips: Moisture and color Buccal mucosa gums/teeth tongue floor of mouth/roof/palate pharynx/tonsils/uvula breath odor hoarseness symmetry of head position
When doing neck assessment, inspect for
Deviations of muscles, swelling, bumps, trachea position, swallow, pulsations, jugular distention
When doing a neck assessment, palpate
Nodes trachea position swallow carotids: ONE SIDE AT A TIME swallow if needed
When assessing the neck, auscultate
Carotids
What cranial nerve supplies the fibers in the tongue and pharynx
Cranial nerve IX: Glosspharyngeal nerve
How to test CN IX & X
Have patient open mouth and say “ahhhh”
- note uvula staying in midline
- soft palate rises in the midline
Abnormal findings of CN IX & X
absence or asymmetry of soft palate movement
Uvula deviates to side
Asymmetry of posterior pharynx
Cranial nerve X: Vagus nerve
Mixed cranial nerve with many widely distributed branches
What CN supplies sensory fibers to the pharynx, larynx, and trachea as well as internal organs
CN X: VAGUS NERVE
Most motor fibers of the vagus nerve are
Autonomic (parasympathetic) Fibers
CN X assess
Swallowing, speech, and other sounds, and gag reflex
—– We do not attempt to elicit the gag reflex unless warranted
Cranial nerve XI : (spinal) accessory nerve is a
Accessory nerve that is a motor nerve; can be considered as an accessory to the vagus nerve
CN XI extends to
the trapezius and sternocleidomastoid muscles
Assessing CN XI
- assess trapezius and sternocleidomastoid
- rotate head against resistance
- shug shoulders against resistance
Abnormal findings of CN XI
Muscle atrophy, weakness or paralysis
Assessing Cranial nerve XII: Hypoglossal nerve
Move tongue up and down, side to side, and inspect the top of tongue and under the tongue
Abnormal findings of CN XII
- Asymmetric movement or weakness of the tongue may indicate impairment
- Tumors of the tongue may develop from alcohol, tobacco, or chronic irritation
Good verbal articulation depends on
CN V, VII, X, XII
Poor articulation
Dysarthria
