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Nursing 314: Assessing and Promoting Wellness > Exam 2: Physical assessment, *HEENT, Cranial Nerves, Vision & Hearing > Flashcards

Exam 2: Physical assessment, *HEENT, Cranial Nerves, Vision & Hearing Flashcards

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1
Q

1st step of nursing process is

A

assessment

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2
Q

Assessment

A

collection of data pertinent to the patients health/situation

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3
Q

Clincal reasoning is based on

A

good assessment

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4
Q

The nurse collects health data from the client to

A

Compare to the ideal state of health

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5
Q

When collecting health data, take into account

A 
Age 
Gender 
Culture 
Ethnicity 
Physical & Psychological status
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6
Q

What do nurses do after collecting health data

A

Incorporates it all to develop a plan of care that will help client maximize his or her health

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7
Q

Develop a care plan that

A

Always stays patient-centered

Always involve the patient

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8
Q

Components of health assessment

A
  • Health history & interview (subjective)
  • Performing a physical examination & review of systems: (Collecting objective data)
  • Documenting finds
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9
Q

Health history would be an example of

A

Subjective data when interviewing

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10
Q

Patient-sources information about :

A 
Current state of health 
medications 
previous illnesses & surgeries 
Family history 
Patient concerns, symptoms, problem, compliant
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11
Q

A symptom is

A

A report of what the client experiences associated with a problem

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12
Q

A symptom is considered

A

Subjective data

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13
Q

Physical examination involves the

A

Objective data collected by the nurse

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14
Q

Objective data are referred to as

A

Signs

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15
Q

During physical examination, the nurse obtains objective data using techniques of

A

Inspection
Palpation
Percussion
Auscultation

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16
Q

Nurse also measures the

A 
Clients height 
weight 
blood pressure 
temperature 
respiratory rate 
pain
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17
Q

Official chart documents are also

A

Objective data

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18
Q

Why do we document assessment findings

A

allow other health care providers to use for information

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19
Q

What improves the effectiveness of the entire health care team

A

Complete, accurate, and descriptive documentation

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20
Q

Documentation provides

A

Evidence for care, services, referrals

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21
Q

Patient chart is

A

Legal document
Protected by HIPPA
can be reviewed by patient at their request

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22
Q

Purpose of a physical examination

A
  • 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
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23
Q

Preparation for examination

A

-Infection control
-Environment
-Equipment
-physical preparation of patient
-psychological preparation of patient
-assessment of age groups
-cultural sensitivity
-

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24
Q

As soon as you meet the client, what does you initial inspection tell you

A

Hygiene?
Movement?
Emotions/expressions?
Behaviors?

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25
Q

Organization of the examination

A

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
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26
Q

OLD CART

A

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)

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27
Q

Inspection

A
  • 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
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28
Q

Palpation

A
  • Uses touch to gather information
  • use different parts of hands to detect for different areas
  • hands should be warm, short fingernails
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29
Q

Start with ____ palpitations then end with ____ palpitations

A

light, deep

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30
Q

Percussions

A
  • Tap skin with fingertips to vibrate underlying tissues and organs
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31
Q

The denser the tissue…

A

the quieter is the sound

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32
Q

Auscultation requires

A
  • good stethoscope
  • good hearing or an amplified stethoscope
  • knowledge
  • concentration and practice
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33
Q

Sound characteristics for auscultation

A

Frequency
soundness
quality
duration

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34
Q

General survey include

A
  • General appearance and behavior
  • vital signs
  • height and weight
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35
Q

Examples deep palpitation

A

Abdomen, feeling a mass or a baby?

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36
Q

Examples of general appearance and behavior

A

gender, race, age, signs of distress, body type, posture, gait, movements, hygiene, dress, mood, speech, signs of abuse, substance abuse

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37
Q

Subjective data for head

A

headaches, injury, dizziness, neck pain, ROM

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38
Q

Objective data for head

A

Inspect & Palpate
hygiene of skin/hair
skull symmetry, size, shape, scalp, masses
Facial feature symmetry
Skin, Lymph nodes
Hiar distribution, color, texture, lesions, lice

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39
Q

TMJ dysfunction indicated by

A

Limited movement, pain with movement, and/or clicking sound

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40
Q

Subjective data for nose

A

Patient reported symptoms

-discharge, congestion, sinus pain, trauma, epistaxis (nosebleed). allergies, altered smell

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41
Q

Objective data for nose

A
  • inspect and palpate external
  • size & shape
  • symmetry/midline
  • patency /obstruction
  • skin
  • smell
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42
Q

If is it not PATENT, you

A

Can not assess the cranial nerve

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43
Q

Olfactory nerves =

A

Smell

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44
Q

What triggers olfactory testing?

A

Olfactory is not often tested, but an altered taste often triggers assessment

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45
Q

Evaluate olfactory cranial nerve

A
  • Close eyes and mouth
  • occlude one nostril while testing the other
  • identify familiar substances (coffee, toothpaste, etc.)
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46
Q

Smell normally decreases with

A

aging

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47
Q

One cannot test smell when

A

Air passages are occluded with upper respiratory infection or with sinusitis

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48
Q

Abnormal findings for nose

A 
Epistaxis 
rhinitis 
rhinorrhea 
sinusitis 
deviated septum 
nasal polyp 
anosmia
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49
Q

Epistaxis

A

Nose bleeds

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50
Q

Rhinitis

A

nasal inflammation, congestion

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51
Q

Rhinorrhea

A

Nasal discharge

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52
Q

Sinusitis

A

inflammation of sinuses pain on cheeks, teeth, and gums

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53
Q

deviated septum

A

ingrowth of lower nasal septum

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54
Q

Nasal polyp

A

Non painful overgrowth of nasal mucosa

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55
Q

Anosmia

A

Decrease or loss of smell occurs bilaterally with tobacco smoking, allergic rhinitis, cocaine use

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56
Q

What does it mean with a nose is patent?

A

ability to move air (smelling!)

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57
Q

Subjective date for eyes

A

Visions changes, floaters, photophobia, pain, redness, swelling, discharge, diplopia, strabismus, glaucoma, glasses/contacts, excessive lacrimation or other discharge

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58
Q

Objective for eyes

A

General appearance, position and alignment, any subjective complaints that are observable would be objective

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59
Q

Eye lids

A

No ptosis, entropia, extropia

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60
Q

Sclera

A

White; grey-blue tinged normal variation; yellow? Jaundice?

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61
Q

Iris

A

Round, regular shape

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62
Q

Corneal light reflex

A

Point of light reflection should be the same in each eye, same quadrant

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63
Q

numerator of vision test

A

distance person is from the chart

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64
Q

denominator for vision test

A

Distance at which normal eye can read

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65
Q

The larger the denominator, the

A

Poorer the vision

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66
Q

Normal vision acuity

A

20/20

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67
Q

Test optic nerve for visual acuity using

A

SLOAN letters (In the past, snellen)

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68
Q

Oculomotor nerve controls

A
  • Pupillary constriction and dilation

- controls extra-ocular movements

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69
Q

What nerves are tested together because they all control different muscles of the eye for movement

A

Oculomotor (III)
Trochlear (IV)
Abducens (VI)

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70
Q

Why do we test the oculomotor, trochlear, and abducens together?

A

they all control different muscles that provide eye movement

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71
Q

P.E.R.R.L.A

A 
Pupils are 
Equal 
Round 
Reactive to 
Light 
Accommodation
72
Q

Pupillary light reflex is

A

Normal constriction of the pupils when bright light shines on the retina

73
Q

Normal responses of pupillary light reflex

A

When one eye is exposed to bright light, a direct light reflex occurs

74
Q

A direct light reflex

A

Constriction of the pupil when light is directly on an eye

75
Q

Consensual light reflex

A

simultaneous constriction of the other pupil

76
Q

test for accommodation (reflex) by asking

A

Person to focus on a small distant object and far objects

77
Q

distance during accommodation test should

A

dilate

78
Q

Close objects during accommodation =

A

Constrict

79
Q

A normal response during the accommodation test includes

A

Pupillary constriction

Convergence of the axes of the eyes

80
Q

During and extra ocular eye movement lead the eyes through

A

6 cardinal positions of gaze will elicit muscle weakness during movement

81
Q

a normal response in EOMs test is

A

Smooth tracking

82
Q

Nystagmus (abnormal EOMs findings)

A

Jerky or oscillating movement

83
Q

Another abnormality found in EOMs

A

Inability to move in a particular direction

Nystagmus

84
Q

Extraocular movements from which cranial nerves

A

Oculomotor (III)
Trochlear (IV)
Abducens (VI)

85
Q

Abnormal findings of (III) cranial nerve

A
  • 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)
86
Q

Each abducens nerve is a motor nerve that

A

Extends to the lateral rectus muscles of the eyes

87
Q

The lateral rectus muscle

A

Abducts the eyes

88
Q

Abnormal findings of CN III, IV, VI

A
  • 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
89
Q

ptosis

A

Eyelid droop

90
Q

expected finding of cover-uncover test

A

No movement

91
Q

if uncovered eye during cover-uncover test moves to focus, ___ is present

A

Strabismus is present

92
Q

Strabismus or crossed eye

A

Both eyes do not look at the same place at the same time

93
Q

Strabismus is caused by

A

Poor eye muscle control and evident by age 3

94
Q

Early diagnosis or strabismus is essential in preventing vision loss that occurs as a result

A

Amblyopia

95
Q

Amblyopia

A

Occurs when vision does not develop normally because eyes are not aligned

96
Q

Treatment of strabismus

A

Eyeglasses, patching or eye muscle surgery

—-EYEPATCH ON STRONG EYE

97
Q

exophthalmos

A

Protruding eyes (Associated with hyperthyroidism)

98
Q

Myopia

A

nearsightedness

99
Q

Hyperopia

A

farsightedness

100
Q

Astigmatism

A

Refraction of light causes blurred or double vision

101
Q

Conjuctivitis (pink eye)

A

Inflammation od conjunctiva, usually bacteria

102
Q

Hordeolum (Stye)

A

Localized staphylococcal infection of hair follicles

103
Q

Subconjunctival hemorrhage

A

Caused by increased intraoccqular pressure, coughing, vomiting, weight, lifting, labor, straining at stool, trauma

104
Q

CN V

A

Trigeminal nerve

105
Q

Trigeminal nerves split

A

into 3 branches

106
Q

sensory neurons in all 3 branches of CN V

A

Sensation from the skin and mucosa of the head & from the teeth

107
Q

Motor fibers on CN V run

A

to the muscles of mastication

108
Q

How to test CN V motor function

A

Have client clench teeth, then palpate temporal & master muscles for mass & Strength

109
Q

How to test CN V sensation of light touch

A

Have client close eyes then wipe a cotton ball slightly over the three areas then repeat bilaterally

110
Q

When to do corneal reflex for CN V

A

Only do it if individual does not respond to CN V sensation of light touch

111
Q

Corneal reflex tests

A

Sensory afferent in cranial nerve V & motor efferent in cranial nerve VII

112
Q

If individual has contacts, should they keep them in during corneal reflex test?

A

No, remove any contact lenses

113
Q

Corneal reflex test

A

person looking forward, bring wisp of cotton in from the side (to minimize defensive blinking) & lightly touch the cornea (not the conjunctiva)

114
Q

How to know if corneal reflex may be abnormal

A

Absence in blink is abnormal, but the corneal reflex may be decreased or absent in those who have worn contact lenses !!

115
Q

Abnormal findings in CN V

A
  • Inequality in muscle contractions, pain, twitching, or asymmetry is abnormal
  • Decreased or unequal sensation is abnormal
    • —– Record extent of the involved areas
    • —– Trigeminal neuralgia
116
Q

Trigeminal neuralgia

A

characterized by stab-like pain radiating along the trigeminal nerve

117
Q

What is trigeminal neuralgia cause by

A

Cause by the degeneration of or pressure on the nerve

118
Q

CN VII motor fibers of facial nerve extend

A

by way of several branches to the superficial muscles of the face and scalp, controls facial expression

119
Q

CN VII facial nerve sensory fibers detect

A

Salt and sweet taste

120
Q

CN VII facial nerve inspects

A

face at rest and during conversation

121
Q

When testing CN VII facial nerve, have the client

A

raise both eyebrows, smile, frown, close the eyes tightly, show the teeth, puff both cheeks

122
Q

Abnormal findings of CN VII facial nerve

A

Asymmetry, facial weakness, dropping of one side of the face or mouth, or inability to maintain position until instructed to relax

123
Q

Signs of damage to CN VII facial nerve

A
  • Eye does not close
  • Eyeball rolls up
  • flat nasolabial fold
  • forehead not wrinkled
  • eyebrow not raised
  • paralysis of lower face
124
Q

Subjective data for ears

A 
Earaches 
Infections 
Discharge 
Hearing Loss 
Tinnitus (ringing) 
Vertigo 
Self care behavior
125
Q

Objective data for ears

A

Inspection

Test cranial nerves

126
Q

CN VIII: Vestibulocochlear nerve has two distinct divisions:

A
  • Vestibular nerve

- Cochlear nerve

127
Q

vestibular nerve & Cochlear nerve are both

A

Sensory nerves!

128
Q

Vestibular nerve transmits impulses that

A

result in sensations of equilibrium

129
Q

Conductions by the cochlear nerve results in

A

Sensations of hearing

130
Q

Evaluate CN VIII hearing test

A

Test hearing acuity by the ability to hear normal conversations;

Notice how they hear during the history-taking phase of the assessment

131
Q

CN VIII: Assessment of sensorineural or conductive hearing loss

A
  • Whispered voice test
  • Weber & Rinne tuning fork tests
  • Audiometer testing
132
Q

Presbycusis

A

Age-related hearing loss

133
Q

Sensorineural

A

Impaired cranial nerve transmission or inner ear dysfunction

134
Q

Conductive

A

Impaired sound transmission to inner ear

135
Q

Mixed hearing loss

A

combination of sensorineural and conductive

136
Q

Conductive hearing loss

A

Sounds cannot get through the outer and middle ear, may be hard to hear soft sounds.

Louder sounds may be muffled

137
Q

Hearing loss conductive fix

A

Medicine or surgery can often fix this type of hearing loss!

138
Q

Can conductive hearing loss be corrected?

A

Yes! It can be corrected

139
Q

causes of conductive hearing loss

A

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

140
Q

Sensorineural hearing loss happens

A
  • After inner ear damage

- Problems with the nerve pathways from your inner ear to your brain can also cause SNHL

141
Q

Most common type of permanent hearing loss

A

Sensorineural Hearing loss

142
Q

Can medicine or surgery fix SNHL?

A

No! SNHL cannot be fixed, but hearing aids can help you hear

143
Q

Causes of sensorineural

A 
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
144
Q

How to test cranial nerve VIII: Vestibulocochlear nerve

A

Whisper test!

145
Q

How to do whisper test

A

Have patient cover one ear and stand on the other side and whisper 3 words

146
Q

Abnormal findings in whisper test

A

unable to hear some/all of whispered word

147
Q

Normal findings of whisper test

A

repeat each word correctly

148
Q

Whisper is a

A

High frequency sound & is sued to detect high frequency hearing loss, common in geriatric patients

149
Q

What is the weber test

A

It is used to test CN VIII when hearing is better with one ear than other

150
Q

What is the weber test

A

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

151
Q

Abnormal findings of weber test

A

Lateralization of sound to the “bad side”/affected side

152
Q

What is another way to demonstrate the weber test

A

Plug one ear and humm, the sound will be louder on the bad ear

153
Q

Rombergs test: test for equlibrium and balance

A

Have person stand feet together, close eyes and hold position

154
Q

abnormal romberg test

A

sways, falls, widens base to avoid falling

155
Q

A positive rombergs sign is

A

loss of balance that occur when closing the eye, may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function

156
Q

Subjective data for mouth and pharynx

A

Sore/lesions, bleeding gums, tooth aches, dysphasia, altered taste, smoking, alcohol consumption, self-care behaviors

157
Q

Objective data for mouth and pharynx

A 
Lips: Moisture and color 
Buccal mucosa 
gums/teeth 
tongue 
floor of mouth/roof/palate 
pharynx/tonsils/uvula
breath odor 
hoarseness 
symmetry of head position
158
Q

When doing neck assessment, inspect for

A

Deviations of muscles, swelling, bumps, trachea position, swallow, pulsations, jugular distention

159
Q

When doing a neck assessment, palpate

A 
Nodes 
trachea position 
swallow 
carotids: ONE SIDE AT A TIME 
swallow if needed
160
Q

When assessing the neck, auscultate

A

Carotids

161
Q

What cranial nerve supplies the fibers in the tongue and pharynx

A

Cranial nerve IX: Glosspharyngeal nerve

162
Q

How to test CN IX & X

A

Have patient open mouth and say “ahhhh”

    • note uvula staying in midline
    • soft palate rises in the midline
163
Q

Abnormal findings of CN IX & X

A

absence or asymmetry of soft palate movement
Uvula deviates to side
Asymmetry of posterior pharynx

164
Q

Cranial nerve X: Vagus nerve

A

Mixed cranial nerve with many widely distributed branches

165
Q

What CN supplies sensory fibers to the pharynx, larynx, and trachea as well as internal organs

A

CN X: VAGUS NERVE

166
Q

Most motor fibers of the vagus nerve are

A

Autonomic (parasympathetic) Fibers

167
Q

CN X assess

A

Swallowing, speech, and other sounds, and gag reflex

—– We do not attempt to elicit the gag reflex unless warranted

168
Q

Cranial nerve XI : (spinal) accessory nerve is a

A

Accessory nerve that is a motor nerve; can be considered as an accessory to the vagus nerve

169
Q

CN XI extends to

A

the trapezius and sternocleidomastoid muscles

170
Q

Assessing CN XI

A
  • assess trapezius and sternocleidomastoid
  • rotate head against resistance
  • shug shoulders against resistance
171
Q

Abnormal findings of CN XI

A

Muscle atrophy, weakness or paralysis

172
Q

Assessing Cranial nerve XII: Hypoglossal nerve

A

Move tongue up and down, side to side, and inspect the top of tongue and under the tongue

173
Q

Abnormal findings of CN XII

A
  • Asymmetric movement or weakness of the tongue may indicate impairment
  • Tumors of the tongue may develop from alcohol, tobacco, or chronic irritation
174
Q

Good verbal articulation depends on

A

CN V, VII, X, XII

175
Q

Poor articulation

A

Dysarthria

Nursing 314: Assessing and Promoting Wellness (26 decks)

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