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