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314 > HEENT > Flashcards

HEENT Flashcards

1
Q

What is the first step of the nursing process?

A

assessment

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2
Q

assessment

A

collection of data pertinent to the patient’s health/situation

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3
Q

health assessment

A
  • systematic method of collecting data
  • nurses collects health data from the client
  • compares this to the ideal state of health
  • takes into account patient’s age, gender, culture, ethnicity, physical/psychological status
  • incorporates it all to develop a plan of care that will help the client maximize his or her health potential
  • ALWAYS patient-centered and involve the patient
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4
Q

What are the three components of a health assessment?

A
  1. health history and interview (subjective)
  2. performing a physical examination and review of systems (objective data)
  3. documenting the findings
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5
Q

symptom

A

report of what the client experiences associated with a problem and is considered subjective data

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6
Q

health history

A

subjective data!
- patient sourced information about current state of health, meds, previous illnesses/surgeries, family history, patient concerns/symptoms

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7
Q

physical examination

A

objective data!
- signs
- inspection
- palpation
- percussion
- auscultation
- vital signs

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8
Q

What are the purposes of a physical examination?

A
  • gather baseline data about a patient’s health status
  • supplement, confirm, or refute subjective data obtained
  • identify and confirm nursing diagnoses
  • make clinical decisions about a patient’s changing health status and management
  • evaluate the outcomes of care
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9
Q

How to prepare for an examination

A
  • infection control
  • environment
  • equipment
  • physical preparation of patient
  • psychological preparation of patient
  • assessment of age groups
  • cultural sensitivity
  • begin as soon as meeting the client (hygiene, movement, emotions/expressions, behaviors)
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10
Q

organization of an examination

A
  • assessment of each body system
  • systematic and organized
  • head to toe approach (compare sides for symmetry, assess body systems most at risk for being abnormal, offer rest periods as needed, perform painful procedures at the end, be specific when recording assessments, record quick notes during exam/larger notes at the end)
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11
Q

What is the order of a physical assessment?

A
  1. inspection
  2. palpation
  3. percussion
  4. auscultation
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12
Q

inspection

A
  • use adequate lighting
  • inspect each area for size, shape, color, symmetry, position, and abnormality
  • position and expose body parts as needed for viewing, but respect privacy
  • remember symmetry
  • validate findings with the patient
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13
Q

palpation

A
  • uses touch to gather information
  • use different parts of hands to detect different characteristics
  • hands should be warm, fingernails short
  • start with light palpation, end with deep palpation
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14
Q

percussion

A
  • tap skin with fingertips to vibrate underlying tissues and organs
  • sound determines location, size, and density of structures
  • denser the tissue, the quieter the sound
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15
Q

auscultation

A
  • requires a good stethoscope, good hearing, knowledge, concentration and practice
  • sound characteristics (frequency, loudness, quality, duration)
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16
Q

general survey

A
  • general appearance and behavior (gender, race, age, signs of distress, body type, posture, gait, movements, hygiene, dress, mood, speech, signs of abuse, substance abuse)
  • vital signs
  • height/weight
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17
Q

head assessment

A
  • subjective data: headaches, injury, dizziness, neck pain, ROM
  • objective data: inspect and palpate general hygiene of skin/hair, skull symmetry, size, shape, scalp masses, facial feature symmetry, skin/lymph nodes, temporomandibular joint dysfunction, hair distribution
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18
Q

nose assessment

A
  • subjective data: patient reported symptoms: discharge, congestion, sinus, pain, trauma, epistaxis (nosebleeds), allergies, altered smell
  • objective data: inspect internal/external, palpate external, size/shape, symmetry/midline, patency/obstruction, skin, smell
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19
Q

CN I

A
  • olfactory
  • altered taste often triggers assessment
  • evaluating: close eyes and mouth, occlude one nostril while testing the other, identify familiar substances
  • normally a person can identify an odor on each side of the nose
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20
Q

abnormal findings of CN I

A
  • client reports absence of smell or lack of taste of food/drink
  • one cannot test smell when air passages are occluded with upper respiratory infection or with sinusitis
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21
Q

epistaxis

A

nose bleeds

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22
Q

rhinitis

A

nasal inflammation, congestion

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23
Q

rhinorrhea

A

nasal discharge

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24
Q

sinusitis

A

inflammation of sinuses, pain on cheeks, teeth, and gums

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25
Q

deviated septum

A

ingrowth of lower nasal septum

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26
Q

nasal polyp

A

non-painful overgrowth of nasal mucosa

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27
Q

anosmia

A

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

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28
Q

eye assessment subjective data

A
  • vision changes
  • floaters
  • photophobia
  • pain
  • redness
  • swelling
    -discharge
  • diplopia
  • strabismus
  • glaucoma
  • glasses/contacts
  • excessive lacrimation or other discharge
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29
Q

eye assessment objective data

A
  • general appearance, position and alignment, any subjective complaints can be objective as well
  • eye lids: no ptosis, entropia, extropia
  • sclera: white; grey-blue tinged normal variation; yellow = jaundice
  • iris: round, regular shape
  • cornea and lens: no opacities/ulcerations, point of light reflection should be the same in each eye
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30
Q

CN II

A
  • optic nerve
  • test the optic nerve using SLOAN letters
  • numerator = distance person is from the chart (20)
  • denominator = distance at which normal eye can read the line
  • larger the denominator, the poorer the vision
  • normal acuity = 20/20
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31
Q

abnormal findings of CN II

A

loss of visual acuity

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32
Q

CN III

A
  • oculomotor nerve
  • controls pupillary constriction and dilation
  • helps with extra-ocular movements
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33
Q

What are the three nerves tested together?

A

CN III (oculomotor), CN IV (trochlear), and CN VI (abducens) because they all control different muscles that provide movement

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34
Q

PERRLA

A

pupils should appear equal in size, be round, be reactive to light, and demonstrate accommodation

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35
Q

pupillary light reflex

A
  • the normal constriction of the pupils when bright light shines on the retina
  • normal response: when one eye is exposed to bright light, a direct light reflex occurs (constriction of that pupil) as well as a consensual light reflex (simultaneous constriction of the other pupil)
36
Q

testing CN III

A
  • test for accommodation (reflex) by asking the person to focus on a generally small distant object (this will dilate the pupil; distance = dilate)
  • have person shift their gaze to a near object (close = constrict)
  • normal response includes: pupillary constriction and convergence of the axes of the eyes
37
Q

testing CN III, IV,and VI

A
  • assess extraocular eye movements
  • leading the eyes through 6 cardinal positions of gaze will elicit muscle weakness during movement (nystagmus)
  • ask patient to hold head steady and follow the movement of a finger, pen, etc. only moving their eyes
  • hold target 12 inches away
  • normal response is smooth tracking
  • abnormal: jerky or oscillating movement (nystagmus) or inability to move in a particular direction
38
Q

abnormal findings in the CN III

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
39
Q

CN IV

A
  • trochlear
  • assess EOM: downward, inward movement of eye
40
Q

CN VI

A
  • abducens
  • each abducens nerve is a motor nerve that extends to the lateral rectus muscles of the eyes
  • lateral rectus muscle abducts the eye
41
Q

abnormal findings for CN III, IV, and VI

A
  • eye movement is not parallel
  • failure to follow in a certain direction indicates weakness of an extraocular muscle or dysfunction of cranial nerve innervating it
  • report ptosis (eyelid droop) of the eye, note any nystagmus
42
Q

steps to cover-uncover test

A
  1. ask patient to stare straight ahead at your nose
  2. cover one of the patient’s eyes and pause for a brief moment
  3. observe uncovered eye as you remove your covering
    - expected finding: no movement
    - if uncovered eye moves to focus, strabismus is present
43
Q

strabismus

A
  • crossed eyes
  • both eyes do not look at the same place at the same time
  • occurs when an eye turns in, out, up, or down
  • usually caused by poor muscle control
  • may be evident all the time or with fatigue
  • usually evident by age 3
  • early diagnosis is essential in preventing vision loss
  • treatment may include eyeglasses, patching, or eye muscle surgery
44
Q

amblyopia

A

occurs when vision does not develop normally because the eyes are not aligned

45
Q

exophthalmos

A

protruding eyes (associated with hyperthyroidism)

46
Q

myopia

A

nearsightedness (longer eye)

47
Q

hyperopia

A

farsightedness (shorter eye)

48
Q

astigmatism

A

refraction of light causes blurred or double vision

49
Q

conjunctivitis (pink eye)

A

inflammation of conjunctiva, usually bacteria

50
Q

hordeolum (stye)

A

localized staphylococcal infection of hair follicles

51
Q

subconjunctival hemorrhage

A

caused by increased IOP, coughing, vomiting, weight lifting, childbirth, straining at stool, trauma

52
Q

CV V

A
  • trigeminal nerve
  • 5th pair of CN because they split into 3 large branches
  • sensory neurons in all three branches: sensation from the skin and mucosa of the head and teeth
  • motor fibers run to the muscles of mastication
53
Q

testing CV V

A
  • testing motor function: have client clench teeth, then palpate temporal and masseter muscles for mass and strength
  • to test sensation of light touch: have the client close his or her eyes, then wipe cotton lightly over the three areas touched; repeat bilaterally
54
Q

corneal reflex

A
  • tests the sensory afferent in CN V and the motor efferent in CN VII
  • generally omitted when the client is alert and blinking naturally
  • remove any contact lenses
  • with the person looking forward, bring a wisp of cotton in form the side and lightly touch the cornea
  • normally: person blinks bilaterally
  • absence of a blink is normal, but the corneal reflex may be decreased or absent in those who have worn contact lenses
55
Q

abnormal findings in CV V

A
  • inequality in muscle contractions, pain, twitching, or asymmetry
  • decreased or unequal sensation (record the extent of the involved areas)
56
Q

trigeminal neuralgia

A

stab-like pain radiating along the trigeminal nerve, caused by degeneration of or pressure on the nerve

57
Q

CN VII

A
  • facial nerve
  • motor fibers of the facial nerve extend by way of several branches to the superficial muscles of the face and scalp; controls facial expression
  • sensory fibers: salt/sweet taste
58
Q

inspecting CN VII

A
  • inspect face at rest and during conversation
  • have client raise both eyebrows, smile, frown, close eyes tightly, show the teeth, and puff both cheeks
  • he or she should be able to correctly perform each request
59
Q

abnormal findings of CN VII

A

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

60
Q

signs of damage to CN VII

A
  • eyes do not close; eye ball rolls up
  • flat nasolabial fold
  • forehead not wrinkled, eyebrows not raise
  • paralysis of lower face
61
Q

subjective data for ears

A

earaches, infections, discharge, hearing loss, tinnitus, vertigo, self-care behaviors

62
Q

objective data for ears

A

inspection and test cranial nerves

63
Q

CN VIII

A
  • vestibulocochlear nerve (acoustic)
  • hearing and balance
64
Q

What are the two divisions of the vestibulocochlear nerve?

A

the vestibular and cochlear nerve (both sensory)

65
Q

vestibular nerve

A

transmits impulses that result in sensations of equilibrium

66
Q

cochlear nerve

A

conduction by cochlear nerve results in sensations of hearing

67
Q

evaluating CN VIII

A
  • evaluate for hearing
  • test hearing acuity by the ability to hear a normal conversation
  • notice how he/she hears during the history-taking phase of the assessment
68
Q

assessment of sensorineural or conductive hearing loss

A
  • whispered voice test
  • Weber and Rinne tuning fork tests
  • audiometer testing
69
Q

presbycusis

A

age-related hearing loss

70
Q

sensorineural hearing loss

A
  • impaired cranial nerve transmission or inner ear dysfunction
  • happens after inner ear damage
  • problems with nerve pathways from your inner ear to your brain can also cause SNHL
  • most common type of permanent hearing loss
  • CAN’T FIX
  • hearing aids may help
71
Q

conductive hearing loss

A
  • impaired sound transmission to inner ear
  • sounds cannot get through the outer and middle ear
  • harder to hear soft sounds
  • loud sounds muffled
  • CAN be corrected
72
Q

causes of conductive hearing loss

A
  • fluid in your middle ear from colds or allergies
  • ear infection
  • Poor Eustachian tube function
  • a hole in your eardrum
  • benign tumors
  • earwax/cerumen in ear canal
  • an object stuck in outer ear
  • problem with how the outer or middle ear is formed before birth or traumatized after birth
73
Q

causes of sensorineural hearing loss

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
74
Q

Whispered Voice Test

A
  • test one ear at a time: plug other ear
  • shield mouth so lip reading isn’t possible
  • at 1-2ft distance from the person’s ear, exhale and whisper slowly some two-syllable words, such as Tuesday, armchair, baseball, fourteen
  • normal: they repeat each word correctly
  • abnormal: unable to hear some/all whispered words
75
Q

whisper

A

high frequency sound and is used to detect high frequency hearing loss, common in geriatric patients

76
Q

Weber Test

A
  • used when hearing is better with one ear than the other
  • 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
  • person should hear the tone conducted equally to both ears
  • abnormal findings: lateralization of sound to the “bad” side/affected side
77
Q

Romberg Test

A
  • test for equilibrium and balance
  • DEFER if not safe
  • ask person to stand feet together and arms at the sides
  • once stable, ask to close eyes and to hold the position
  • wait about 20 seconds
  • normal: maintain posture and balance even with eyes closed, although slight swaying may occur
  • abnormal: sways, falls, widens vase of feet to avoid falling; Positive Romberg sign is loss of balance that occurs when closing the eyes (may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function)
78
Q

mouth and pharynx subjective data

A

sores, lesions, bleeding gums, toothache, dysphasia, altered taste, smoking, alcohol consumption, self-care behaviors

79
Q

mouth and pharynx objective data

A
  • lips: moisture/color
  • buccal mucosa
  • gums/teeth
  • tongue
  • floor of mouth/roof/palate
  • pharynx/tonsils/uvula
  • breath odor
  • hoarseness
80
Q

neck assessment

A
  • inspect for obvious deviations (muscles, swelling, bumps, trachea position, swallow, pulsations, jugular distention
  • palpate nodes, trachea position, swallow, carotids unilaterally
  • auscultate carotids
81
Q

CN IX

A
  • glossopharyngeal nerve
  • supplies fibers to tongue and pharynx
  • tested with CN X (vagus)’
  • As person says “Ahh” note uvula stays midline and soft palate rises in the midline
  • abnormal findings: absence or asymmetry of soft palate movement, uvula deviates to side, asymmetry of posterior pharynx
82
Q

CN X

A
  • vagus nerve
  • mixed cranial nerve with many widely distributed branches
  • sensory fibers supply the pharynx, larynx, and trachea as well as many internal organs
  • most motor fibers of the vagus nerve are autonomic (parasympathetic fibers)
  • assess swallowing, speech, other sounds, and gag reflex
83
Q

CN XI

A
  • spinal/accessory nerve
  • motor nerve
  • accessory to the vagus nerve
  • extends to the trapezius and sternocleidomastoid muscles
84
Q

assessing CN XI

A
  • assess trapezius and sternocleidomastoid
  • check equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the chin
  • ask person to shrug the shoulders against resistance
  • movements should feel equally strong on both sides
  • abnormal findings: muscle atrophy, weakness, or paralysis
85
Q

CN XII

A
  • hypoglossal nerve
  • under the tongue
  • ask patient to protrude tongue, note symmetry
  • ask patient to move tongue towards the nose, the chin, and side to side
86
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
87
Q

assessing CN XII

A
  • listen to the way patients articulates words
  • good verbal articulation depends on CN V, VII, X, and XII
  • poor articulation = dysarthria

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