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N321: Nursing Assessment of Clients > Module 10 > Flashcards

Module 10 Flashcards

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1
Q

Subjective Factors for the Head,Face,Neck Health history

A

Headaches
Jaw Pain
Neck Pain
Dental Pain
Mouth Lesions
Sore Throat
Hoarseness
Epistaxis

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2
Q

Past Medical History Considerations for Face, head, and Neck exams?

A

History of headaches, head injury, or seizures

allergies

tonsillitis

surgeries

medications

cancer: BCC, squamous cell, melanomas

Chronic illnesses

STDS: HSV and HIV

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3
Q

Family Health History Considerations for Head, Face, and Neck Exams

A

Malignancy

Blood Disorders

Recent Infections

History of HA (Migraines)

Musculoskeletal issues

thyroid problems

rhinitis in family

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4
Q

Social History/Habits/Lifestyle Considerations for Head, Face, Neck Exams

A

Alcohol Use

Smoking

drug use

their job (ex: Welders getting metal flecks in eyes)

environmental exposures

coping strategies

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5
Q

HEENOT

A

Head Ears Eyes Nose Oral Throat

Oral includes gums, teeth, mucosa, palette, etc

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6
Q

Epistaxis

A

significant nose bleeding

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7
Q

BCC

A

basal cell carcinoma

v common on face due to sun exposure

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8
Q

What is a very important thing to ask about for HEENOT?

A

Any traumatic brain injuries that occurred (loss of cons, injury to face/neck, change in behavior, cognitive issues, risk factors)

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9
Q

Important characteristics of headaches to ask about?

A

Onset

Duration

Location

Character

Severity

Visual Prodromal Events (distortion of size, shape, location)

Pattern of Headaches

Associated Symptoms

Precipitating Factors

Efforts to treat

*COLDSPA essentially

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10
Q

Sinus headache

A

pain in sinus regions

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11
Q

Cluster Headache

A

pain clusters in one region

ex: in right eye

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12
Q

Tension Headache

A

pain in the frontal area of the head

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13
Q

Migraine

A

headache pain and sensitivity to light in one half of the head (or whole)

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14
Q

Treatments for headaches

A
  1. Medication:
    (ex: Anticonvulsants
    Anti arrhythmic
    beta blockers
    calcium channel blockers
    oral contraceptives
    serotonin antagonists or agonists
    uptake inhibitors
    antidepressants
    nonsteroidal anti inflammatory drugs
    narcotics
    caffeine containing drugs
    nonprescription drugs)
  2. Alternative or Complementary Therapy (relaxation, acupuncture, magnesium (v helpful Mg))
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15
Q

Techniques for HEENOT Physical Exam

A

Inspection –> Palpation

Examine Exterior then Interior

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16
Q

Important Landmarks of the Head to Know

A

Frontal
Parietal
temporal
Occipital
Zygomatic
Lacrimal
Sphenoid
Maxilla/Mandible

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17
Q

Head Exam in Infants

A

measured at each well child visit up to age 3

importantly checking for size (cephalic): micro, macro, normo

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18
Q

Palpation of the Scalp involves looking at…

A

Texture and Distribution of Hair (distribution, alopecia, facial [hirsutism], color, infestation,)

Tenderness

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19
Q

Alopecia

A

hair loss

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20
Q

Hirsutism

A

excessive hair growth that is male like in women

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21
Q

Physical examination of the face involves…

A

inspection general survey:

asymmetry v symmetry: dropping and drooling

facial expressions

palpation of temporal artery for tenderness and make sure to auscultate it

edema

color, condition, cyanosis, jaundice of skin

lesions

TMJ - open and close jaw (mandibular joint dysfunction)

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22
Q

When we auscultate the temporal artery we should use what side of the stethoscope?

A

the bell

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23
Q

Sinuses

A

Frontal (Forehead), maxillary (cheekbone), Sphenoid (behind eye), Ethmoid (near nose)

Tran illuminate –> Palpate –> Percuss

Pain elicited on palpation or percussion may mean infection or congestion

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24
Q

important nose considerations in HEENOT

A

size (widens with age ion men)

shape

symmetry

drainage

internal mucosae

color differences

intactness

perforations of septum

nasal polyps (can occlude airway)

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25
Q

A unilateral drainage from the nose may indicate…

A

CSF leak

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26
Q

What sounds do we want to hear from the nose?

A

Smoothness, not rumbling or congestion

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27
Q

Epistaxis

A

Hemorrhage from the nose

may be a serious problem leading to airway compromise or significant blood loss

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28
Q

Most common site of epistaxis? Most dangerous site of epistaxis?

A

Anterior; Posterior (as seen in the back of the throat, and harder to treat)

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29
Q

Treatments for Epistaxis

A

Topical Vasoconstrictors

Packing of Nasal Cavity or Balloon Catheter

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30
Q

Nursing Care for Patients w/ Epistaxis

A

Assess Bleeding

Monitor Airway and Breathing

Get Vital Signs

Reduce their anxiety

Teach patient on avoiding nasal trauma, nose picking, nose blowing, air humidification

Put pressure on nose to stop bleeding, and if it does not stop in 15 minutes then seek medical attn

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31
Q

Important emphasis in HEENOT is on the mouth, what things are important to look at here?

A

Color (lesions and odor)

Lips (ulcers, color, moisture)

Teeth (28 to 32 present, color, condition, number, dentures should be removed for viewing by going to the side and breaking suction)

gums (bleeding, hyperplasia with Dilantin and calcium channel blockers)

tongue (color, texture, moisture, mobility)

Palate (intact, color)

Buccal mucosa

Tonsils (color, size, exudate, cobble stoning)

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32
Q

Poor Dentition and Pain in the mouth may impact …

A

nutritional health and vice versa!!

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33
Q

Tonsil Scale

A

0, +1, +2, +3, +4

+4 = kissing tonsils

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34
Q

When doing oral examination, make sure to do what with the tongue?

A

move it side to side to check for lesions

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35
Q

Leukoplakia

A

condition in which one or more white patches or spots (lesions) form inside the mouth

can eventually become oral cancer

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36
Q

Anatomy Parts of the Neck

A

Sternocleidomastoid

Trapezius

Trachea

Thyroid Gland

Salivary Gland (parotid, submandibular, sublingual)

Cervical Lymph Nodes (check all of them)

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37
Q

What to inspect during neck exam?

A

Evaluate ROM

Evaluate Sternocleidomastoid, scalene, trapezius (accessory resp muscles)

Check movement

Check lymph nodes for size, shape, consistency, definition, mobility, and tenderness

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38
Q

Torticollis

A

problem involving muscles of the neck that cause the head to tilt down or in another condition

congenital often in infants

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39
Q

Where are the parotid, sublingual, and submandibular glands?

A

Back of throat region, under the tongue, lower and inner jaw

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40
Q

Important Lymph Node Locations to Know

A

Preauricular
Posterior Auricular
Occipital
Submandibular
Submental
tonsillar
Superficial Cervical/Deep Cervical
Posterior Cervical Chain
Supraclavicular

(look at HEENOT side 37)

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41
Q

Techniques for Thyroid Examination

A

Inspect –> palpate –> auscultate

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42
Q

important considerations during thyroid exam

A

Masses

Scars

Lesions

Trauma

Atrophy/Hypertrophy

Exophthalmos

Goiters

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43
Q

Exophthalmos

A

Bulging Eyes

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44
Q

What occurs / is inspected with hypothyroidism

A

SKIN AND HAIR CHANGES:

thinning hair

myxedema

fingernails are thick

skin is dry

constipation

menorrhagia

warmth

weight gain

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45
Q

What occurs / is inspected with hyperthyroidism

A

SKIN AND HAIR CHANGES:

Fine Hairs

Thin breakable fingernails

bulging eyes

goiter and neck pain

increased bowel activity

amenorrhea

increasing weakness/neuro

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46
Q

Anterior Palpation Approach of The Thyroid Exam

A

Pads of fingers on one hand finds gland –> find cartilage and cricoid cartilage then move inferiorly to isthmus –> work laterally into gutter between trachea and sternocleido to feel one thyroid lobe for masses –> have patient swallow and see if thyroid moves superiorly –> feel for masses during swallowing and repeat on other side

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47
Q

Posterior Palpation Approach of the Thyroid Exam

A

Similar except done from behind on patient

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48
Q

Auscultation of the neck Exam / Thyroid Exam

A

Use Diaphragm thyroid

Use bell on carotids

Look for bruits, especially if the gland is enlarged

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49
Q

Bruits

A

blockages in arteries that disrupt the smooth swirling noise of blood

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50
Q

Risk Factors for oropharyngeal cancer

A

tobacco and heavy alcohol use

smoking and drinking together

HPV

exposure to sunlight (lip cancer only)

being male (2x as common)

> 55 y/o

fair skin

poor oral hygiene

poor diet and nutrition (low fruit/vegi)

chewing betel quid or gutka (S and SE Asia)

weak immune system

graft v host disease

genetic syndromes

lichen planus

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51
Q

Betel Quid and Gutka

A

Betel nuts and lime wrapped in betel leaves - Betel Quid

mixture of betel quid and tobacco - Gutka

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52
Q

Categories of Larynx Cancer

A

Supraglottic
Glottic
Subglottic

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53
Q

Supraglottic cancer

A

false vocal cords above vocal cords larynx cancer

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54
Q

Glottic Cancer

A

true vocal cord cancer / larynx cancer

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55
Q

Subglottic Cancer

A

Below vocal cords cancer (larynx cancer type)

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56
Q

Symptoms of Larynx Cancer

A

Hoarseness

Persistent Cough

Sore Throat or Pain, Burning in Throat

Lump in Neck

Later Symptoms: Dysphagia, Dyspnea, Unilateral nasal Obstruction, Persistent Hoarsness, Persistent Ulceration, foul Breath

Generalize Symptoms: Weight loss, debilitation, lymphadenopathy, radiation of pain to ear

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57
Q

The nursing process is …

A

systematic

patient centered

cyclic

interrelated

outcome oriented

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58
Q

Nursing Long Term Goal End terminology

A

ONGOING

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59
Q

Nursing Intervention End terminology

A

done, not done, partially done

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60
Q

Nursing Short Term Goal End terminology

A

met, not met, partially met

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61
Q

Hydrocephalus

A

extra fluid around the head, but not the brain

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62
Q

PERRLA

A

pupils, equal, round, reactive to light, accommodation

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63
Q

Eye Orbit

A

cushion of fat surrounding the eyeballs

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64
Q

eyelids do what?

A

prevent foreign objects from getting in

squinting for limiting light

lubrication

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65
Q

Conjunctiva

A

thin transparent membrane on lower eyelid

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66
Q

Lacrimal Gland

A

lubricating ducts of the eyes

can get blocked and cause dryness or excess drainage

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67
Q

Canthus

A

divot of the eye near the nose containing the caruncle

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68
Q

Suspensory Ligaments

A

support lens position posterior to iris

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69
Q

Iris

A

circular disk of muscle determinin color and pupil size

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70
Q

Optic Disc

A

on retina

cream color

on retina near medial nasal side of eye where the optic nerve enters

usually round and oval in shape

71
Q

Eye Chamber

A

Anterior - between cornea and iris

Posterior - between iris and lens

Vitreous - behind lens to the retina

fluid (aqueous or vitreous fill these chambers to provide cleanliness and nourishment and maintain ocular pressure)

72
Q

What can a yellow sclera indicate?

A

relationship to the digestive system - liver issue

73
Q

Edema or Dehydration of the body may be apparent in what eye area?

A

periorbital area around the eye

74
Q

Above the neck is indicative of …

A

the whole body interacting with one another

75
Q

Subjective Data to collect during eye exam?

A

Vision difficulties

Acuity changes

blurriness
floaters

blind spots

halos

pain

acute primary angle (closed) - glaucoma

headaches

redness and swelling

discharge from allergies

PMH of surgery, cataracts, diabetes, or retinal issues

Glaucoma (last testing and FMH)

Macular Degeneration (last test and FMH)

cataract present in FMH

use of glasses/contacts (last eye exam, effectiveness, problems, use with make up)

Occupation (work environment, school, nutrition, exercise)

Medications (eye gtts/ointments, systemic or topical digoxin)

76
Q

Floaters

A

visual abnormality common in people 40+ that is not necessarily concerning

77
Q

Night Blindness is associated with

A

vitamin a deficiency

78
Q

Diplopia

A

double vision from trauma, injury, or pressure

79
Q

It may be a medical emergency if found to have ___ ___ ___ ___ ___

A

Acute Primary Angle (Closed) Glaucoma

80
Q

Headaches DO relate to ___

A

vision

81
Q

Glaucoma

A

high pressure in the eye taht affects the optic nerve

acute angle glauc can cause nausea, blurriness, lights, headaches, erythema of the eye

should be screened for as you get older

risks: age, FMH, thin cornea history, sus optic nerve, cupping size appearance, nearsightedness, eye surgeries, high BP, diabetes, corticosteroid use, cream use

*look up angle closure glaucoma for more info

82
Q

Macular Degeneration

A

starting to lose central vision with macular process tending to be blurred and distorted

start screening at 65+ and sooner if at risk (age, smoking, female, FMH, race (caucasian), prolonged sun exposure, high fat/chol, HTN, already in one eye)

83
Q

Cataracts

A

often preventable

cloudiness of clear lense

opacity and vision decrease

screening should be done with risks: age 30+, newborns, alcohol use, diabetes, lots of UV exposure, previous eye trauma, corticosteroid use, smoking

84
Q

The leading cause of blindness is due to …

A

cataracts

85
Q

If it is not considered a medical need, what will not be covered by insurance?

A

Eye Exams

86
Q

Eye Exam Tools

A

Snellen chart

Jaegar Card

Occluder

Penlight

Opthalmoscope

87
Q

Important Cranial Nerves for the Eye

A

2 3 4 6

88
Q

Objective Data from eye Exam

A

General Appearance of Eye and Structures

thin or seborrhea eyebrows

eyelids and lashes - entropion v ectropion

conjunctiva and sclera - should be white not jaundice yellow

89
Q

Entropion

A

where the inner eyelids turn toward the eye

90
Q

Ectropion

A

where the inner eyelids turn outward from the eye

not necessarily needs treatment unlike entropion

91
Q

Lacrimal Apparatus and the Eye Exam

A

inspect it for redness, swelling and tenderness

structures for tear production and excretion

above eye laterally and medially along the nose

92
Q

Cornea and the Eye Exam

A

anterior outer layer that covers the pupil and iris

shine a light from the side and check for smoothness clarity and breaking

93
Q

Iris and Pupil & the Eye Exam

A

iris should be flat, round, and even in color

Pupil should be checked for size shape and equality

reaction to light can glean info on the neurological

94
Q

Brushfield Spots

A

white specks found in the iris that is a sign of down syndrome

95
Q

PERRLA

A

Pupils Equal Round Reactive Light Accommodation

96
Q

A in PERRLA

A

Accommodation

look at the pupil and notice constriction and dilation

this means the eye accommodates for distance and near vision (by bringing the finger close) and seeing if the pupils constrict and then dilate as you move your finger to a thing in the distance

97
Q

Conjuntivitis

A

Pink eye / eye inflammation / conjunctiva inflammation

98
Q

Pupillary Light Reflex / Response

A

Darken the room and have the patient look straight ahead –> bring a light to the side –> look for direct and consensual response which is normally 3-5 mm

99
Q

Direct Constriction Response

A

pupil response to light entering the same eye

100
Q

Consensual constriction Response

A

pupil response to light entering the opposite eye

101
Q

How to check accommodation and convergence

A

Have the patient look at a distant object, and you should see pupils dilate with distance (D - DISTANCE)

Have patient look at object 3 inches from eyes, and pupils should constrict with closeness (C - CLOSENESS)

102
Q

Snellen Chart

A

stand 20 ft away

leave correcting lenses or contacts on

cover one eye

read smallest line of print

103
Q

Normal Snellen

A

20/20

num - distance from chart

denom - distance normal eye could read chart

104
Q

Jaegar Card

A

Near vision check

hold card 14 in away

test eyes individually with glasses

can check for myopia and hyperopia

normal value is 14/14 in each eye

could use magazine if no card

over 40 should have this checked for presbyopia

105
Q

Confrontation test

A

measure of peripheral vision

practitioner visual field must be normal too!!!

advance from periphery with finger slight behind the patient

should see from normal angle values

document normal as “visual fields intact”

106
Q

Normal Values from Confrontation Test

A

50 degree periphery upward

90 degree periphery temporal

70 degree periphery downward

60 degree periphery nasal

107
Q

Extraocular Muscle Function: Testing Cranial Nerves

A

Tests Cranial Nerves 3 4 and 6 for ability to move eye

108
Q

Corneal Light Reflection

A

an extraocular muscle function test

assesses alignment of eyes by having patient look straight ahead and viewing reflections of light on the corneas

a normal reflection should be symmetric in both eyes but abnormal indicates doing a cover/uncover test

109
Q

Cover / Uncover Test

A

Extraocular Muscle Function Test

patient looks straight ahead at a distant object and one eye is covered –> when uncovering the covered eye should not move and should also be looking in the same direction as the other eye –> repeat on other side

110
Q

Cardinal Position of Gaze

A

Extraocular Muscle function te4st

patient keeps head still and follows finger or penlight with their eyes ONLY in 6 positions (done in a “H” Shape

Normal results should have tracking with both eyes symmetrically but lateral gaze or nystagmus is abnormal findings

111
Q

Nystagmus

A

shaking movement of the eyes during cardinal position of gaze

could be due to MS, inner ear issues, or opioid/narcotic use

112
Q

Cardinal position of gaze positions

A

1 2
3 H 4
5 6

  1. Inferior Oblique
  2. Superior Rectus
  3. Medial Rectus
  4. Lateral Rectus
  5. Superior Oblique
  6. Inferior Rectus
113
Q

Tool used to look at eye internal and external structures?

A

Opthalmoscope

114
Q

Red Reflex

A

hold ophthalmoscope 10-15 in from eye while using your same corresponding eye

we want to see a reddish/orange glow from the light being reflected back off the retina to the device

115
Q

Black Red Reflex

A

cataract

blood

scarring

etc

116
Q

White Red Reflex

A

leukocoria

117
Q

Yellow / Orange Red Reflex

A

normal red reflex

118
Q

Leukocoria

A

a retinal blastoma which is a malignant tumor in childhood

found with white red reflex

119
Q

Macula

A

should be round red spot with the fovea centralis darker in the middle seen during ophthalmoscopy exam

120
Q

Physiologic Cup / Optic Disc in Ophthalmoscope Exam

A

yellow halo of light with arteries and veins leading in and out from it

121
Q

Special Considerations for Eye Exams in Infants and Children

A

Malformation

Term infants have 20/200 acuity while school age kids should have 20/20

Peripheral vision develops at birth and central vision develops later

red reflex important to check here, especially for leukocoria

122
Q

Special Considerations for Eye Exams in Older Adults

A

70 years of age should expect Presbyopia (farsightedness from loss of lens elasticity)

visual disturbances begin when driving, night vision, and ambulating

older adults have smaller pupils

know their last eye exam for cataracts and vision loss

eye discomfort like dryness or burning

arcus senilis

123
Q

Arcus Senilis

A

arching white around the iris

does not mean much but does begin to occur with age

124
Q

Important Principles to keep in mind with eye exams?

A

Use Adequate Light (those over 60 need 2x as much light to do eye tasks as the average 20 y/o)

Use color (avoid monochrome colors because older people have trouble discriminating borders)

125
Q

Population other than Elderly and Children to keep in mind during eye exams?

A

Pregnant women

126
Q

How to care for patient eyes

A

Clean from inner to outer canthus with a wet warm cloth/cotton ball/ compress

use artificial tear solution or normal saline every 4 hours if blink reflex is absent - if ordered by physician

care for their eyeglasses, contacts, or artificial eyes as they are expensive

127
Q

How to instill eye drops

A

1 wash hands

2 glove up

3 offer tissues

4 clean eye, eyelids, and eyelashes

  1. tilt their head back
  2. hold the dropper close but DONT touch the eye
  3. let the drop(s) fall in as prescribed in the conjunctival sac
  4. press LIGHTLY on inner canthus to decrease systemic effect
128
Q

How to apply eye ointmentys

A
  1. Perform 11 rights for med administration
  2. wash hands
  3. wear gloves
  4. clean eye, eye lids, eye lashes
  5. tilt head back
  6. apply pressure downward to expose lower eye
  7. apply prescribed amount along the conjunctival sac
  8. close eyes gently
129
Q

You must wait how long between instilling 2 different types of eye drops?

A

at least 5 minutes

130
Q

Main function of the ears is …

A

hearing and equilibrium

131
Q

Cranial Nerve that is stimulated by sound waves moving through the ext, mid, and inner ear?

A

CN VIII (which then passes the info to the temporal lobe for interpretation)

132
Q

Equilibrium is maintained through the ___ of the inner ear

A

vestibule (sensory receptors here, and semicircular canals maintain static and dynamic equilibrium inside it) of the bony labyrinth

133
Q

External Ear Structures

A

Auricle
Helix
External Ear Canal (Meatus)
modified sweat glands producing cerumen

134
Q

Middle Ear Structures

A

Tympanic Membrane
Tympanic Cavity (air filled)
Eustachian tube
Auditory Ossicles (malleus, incus, stapes)

135
Q

Inner Ear Structures

A

bony labyrinth
cochlea
spiral organ of corti
semicircular canals
vestibule

136
Q

Conductive Hearing

A

conduction of sound through the external and middle ear

137
Q

Sensorineural Hearing

A

transmission of sound from the inner ear

138
Q

Which part of the inner ear is the sensory organ for hearing?

A

Spiral Organ of Corti in the inner cochlear duct

139
Q

Subjective Information to Gather on Ear Assessments

A

Hearing difficulties

any balance issues

otalgia

otorrhea

head trauma

recent health problems

noise pollution, work, home

tinnitus

medications

PMH (immunizations, chronic illness, surgeries, childhood illness, allergies)

FMH (genetic disorders, cultural differences)

Ear Care (q tip use, wax amount)

140
Q

Otorrhea

A

ear drainage

141
Q

Otalgia

A

earachews

142
Q

Tinnitus

A

ringing in the ears

143
Q

Prebycusis

A

age related change in being able to hear different tones

144
Q

Gird and MI may have ..

A

ear referred pain

145
Q

Signs of Hearing Loss

A

Repeating statements

Straining

leaning forward

tilting their head

shouting ion conversation

raising volume

avoiding large groups

social isolation

146
Q

Important Considerations for the Ear Examination in Children and Infants

A

Ear Placement

Hearing Tests done prior to Discharge

Infections

147
Q

Important Considerations for the Ear Examination in Young and Middle Adutls

A

excessive or chronic noise exposure

148
Q

Important Considerations for the Ear Examination in Older Adults

A

common issues like presbycusis

stiffening of cilia (and getting wiry) causing cerumen to accumulate

149
Q

Important Objective Data of Ear Examination

A

Patient should be in a sitting position:

Inspection –> Palpation of External ear

Inspect: Size, shape, position, condition of skin, color, drainage, impacted cerumen

Palpate: tenderness, ear structures (tragus, mastoid process, helix)

150
Q

Unilateral Bloody and Watery Ear Drainage is ..

A

Cerebrospinalfluid !!!

151
Q

Purulent Ear Drainage may indicate …

A

otitis media (middle ear infection)

152
Q

Use of the Otoscope Principles

A

use shortest and largest speculum you can

tilt the head to the opp shoulder

hold patients head

hold the otoscope with the handle up

view the external ear canal and assess the Tympanic membrane

use a cerumen scoop to clear the canal

assess mobility of TM by using the bulb to release air, and a normal TM should flutter and then return to rest (non-movement means an issue like infection or fluid)

153
Q

NEVER irrigate the ear canal unless ..

A

the TM is intact

154
Q

Grey, Pearly, Translucent, Slight concave, Cone Shaped Reflection TM?

A

Normal TM

155
Q

Red or Bulging TM

A

potentially otitis media

156
Q

Yellow TM

A

could be cerumen behind the TM

157
Q

Blue or Darkish TM

A

potentially from some trauma, like perforation or scarring, so check landmarks like the cone of light that should appear

158
Q

Pulling on the Auricle of the Ear in Adults v Children

A

The positions of the canals are different so for adults pull UP AND BACK but children grip[ DOWN AND BACK

159
Q

Important things to view in otoscopic exam?

A

External ear canal: color, drainage, lesions

TM: color, position of landmarks, intactness, grey color, slightly concave, cone of light, position of bony landmarks, mobility (flat, bulging, retracted)

160
Q

Cone of light and positioning

A

reflection of the TM by the otoscope

Right ear should have it at 5 o clock, left ear should have it at 7 o clock

161
Q

Conductive Loss

A

occurs when there is a PHYSICAL OBSTRUCTION to the transmission of sound waves like cerumen, tumors, or ossicles scar tissue buildup

162
Q

Sensorineural Loss

A

due to a DEFECT IN THE ORGAN OF CORTI, CN VIII, or the brain due to infections, surgery, DM (from vascular loss), meds, trauma, or CN VIII damage

163
Q

Most profound hearing loss comes from

A

Mixed Conductive and Sensorineural Hearing Loss

164
Q

Whisper Test (Voice Test)

A

Stand 1-2 feet behind and whisper having them cover one ear, and they should repeat

do again on other side saying something different

165
Q

Watch test

A

hold ticking watch within 5 inches

cover other ear

often noted in elders

166
Q

Weber Test

A

place tuning fork on top of patients head

normal = tone heard midline without lateralization (heard equally and bilaterally)

167
Q

Issue with weber Test

A

cannot distinguish conductive or sensorineural hearing loss, but they will report lateralization to the poor ear in conductive loss, and lateralization to good ear in sensorineural loss

Lateralization (best hearing) to the poor ear in conductive loss is due to bone conduction with no air conduction making the perception as louder in the affected ear

Lateralization (best hearing) in the intact ear is because air condition is impaired in the worst ear (sensorineural hearing loss) meaning that there is a softer/quieter perception

168
Q

Rinne Test

A

place vibrating tuning fork on mastoid process (BC) and count

have patient signal when the sound stops and then move to the front of the ear (AC)

length of time should be Air Conduction > Bone Conduction (2:1 ratio)

169
Q

With conductive hearing loss, what happens to the Rinne test ratio…

A

the bone conduction is heard longer or equal to air conduction

170
Q

How does Air v Bone Conduction work in Rinne Test

A

Conduction through bone but lack of ability to hear when the fork is conducting only air means that some issue or trauma has occurred to the vibrating parts of the outer/middle ear

Conduction heard through the air but not the bone means that the middle and outer ear are still working, so it must be a sensorineural issue

171
Q

Romberg’s Test

A

Balance Test relating to the ears

have patient stand with feet together with eyes closed, and stand nearby and note their ability to maintain balance

a positive Romberg is if they move their feet apart to prevent falling which may indicate vestibular disorder

172
Q

Administering Ear Drops

A
  1. Perform 11 rights for med administration
  2. wash hands
  3. glove up
  4. position patient with the affected ear toward you and unaffected ear down
  5. clean any drainage
  6. again check 11 rights
  7. stabilize dropper hand to avoid ear canal damage
  8. straighten ear canal and instill drops (angle INTO the ear canal, not directly onto TM)
  9. have patient remain for 5-10 minutes to allow meds to go into the ear canal
173
Q

Caring for Patient Ears

A

Wash external ear with washcloth covered finger

DONT use Q tips

Perform hearing aid teaching and care if indicated

174
Q

*WATCH HEENOT VIDEOS AGAIN FOR REVIEW BEFORE THE NEXT EXAM

A

REMINDER

N321: Nursing Assessment of Clients (18 decks)

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