Week #2 Concept Review Flashcards
Eyes, ENMT, HNL
What is the sequence of the eye exam assessment , and what additional assessment tool is used?
1) Inspection
2) Palpation
*Tool: use of ophthalmoscope
What are expected findings for pupil size in bright light and in the dark?
Normally pupils are equal in size.
In bright light; 2-4 mm
In dark light; 4-8 mm
What is miosis and what can causes it, include 8 examples?
-Constricted pupils maybe unilateral or bilateral
-May be caused by something neurological or medications
-Things to consider includes: narcotics, opiates, heroin, fentanyl, Percocet, codeine, poisoning, or hemorrhage
What is mydriasis and what can cause it?
-Prolonged dilated pupils without change in light, observed in a client with Glaucoma (Pupils 7 MM)
-Street drugs, antihistamines, Botox, anesthesia
What is the part of the eye that is most sensitive to pain?
Cornea
What is a blink reflex?
A normal response of a client when the nurse gently touches the eye with a sterile cotton swab
What is the Snellen Test?
An eye test for distant vision, normal results are 20/20. The numerator is the distance away from the Snellen. The denominator is the grade reading of the client.
How is Snellen Test Graded?
-When a client can read most of the letters in a line, that is the grade reading of the client. If the client can only read less than half of the letter in a given line the grade reading of the client is the line above the Snellen chart.
What does it mean if the client has a 20/200 Snellen reading?
The client is considered legally blind
How is the Snellen test 20/70 interpreted?
The client being tested can see at 20 feet what a client with normal vision can see at 70.
What is the Rosenbaum Test?
Eye test for close vision by holding the chart 12-14 inches from the eyes. A normal Rosenbaum Test results in a score of 14/14
What is myopia?
Near sighted. Client has difficulty with far vision.
What is hyperopia?
Far sighted. Client has difficulty with near vision.
What is presbyopia.
Far sighted in a client 45 years old or older. The lens of the eye loses elasticity, resulting in the eye to change in shape to accommodate for near vision.
What is confrontation?
A test for peripheral vision.
What is consensual response-normal findings?
When pupil subjected to direct light or illumination, the eye constricts faster than non-direct illuminated light. Non direct illuminated eye, however, still constricts sluggishly during test.
What is ptosis?
Eye lid drooping, CN III (oculomotor nerve) defect.
What is a cataract?
A yellow thickened dense lens due to over exposure to the sun and dust. The client will have blurred vision, this is also apart of the aging process.
What is Arcus Siniles?
Light grey or whitening surrounding the iris due to deposition of lipids. It does not affect vision. Occurs in elderly.
What is pterygium?
Opacity of the bulbar conjunctiva that can grow over the cornea and block vision. Common in elderly.
When an elderly complains of a burning sensation, redness of the eyes, feeling grainy, what would be the appropriate action of the nurse?
Advise the client that these are signs and symptoms due to dry eyes, common in elderly. Advise the client to use artificial tears OTC and follow the direction of the bottle.
What is macular degeneration.
The loss of central vision but intact peripheral vision.
In Ophthalmology Clinic which client requires immediate attention?
A client with acute glaucoma, because client can lose vision in 1-2 hours and once nerve in eye is damage, it will not regenerate. Signs and symptoms of Acute Glaucoma include; severe headache, eye pain, N/V, blurred vision, halos around the light, eye redness.
What is the Test for Accommodation?
Ask the client to stare at an object as you move the object close to the eyes. Normal findings, constriction of the pupils and convergence of the eyes.
Describe Cover/ Undcover?
A preferred test for strabismus for pediatric clients.
What does the H-Method test for, and what is the Wheel Wagon used to test for?
These test for CN III (Oculomotor, CN IV (Trochlear), CN VI (Abducens).
H-Method test for EOM (extra ocular movements).
The Wheel Wagon test for the 6 Cardinal fields of gaze.
What is the normal finding for 6 cardinal field of gaze?
No nystagmus or no jerky eye movements.
What does Nystagmus mean?
Jerky movements of the eyes on 6 cardinal field of gaze which is an abnormal finding
What is Corneal Light Reflex?
Normal findings; reflection of light is symmetric on both eyes. No symmetry of reflection of light suggest weakness in the extra ocular muscles (EOM).
When the pupil look white on ophthalmoscopic exam in an infant, what does this indicate?
Exam in infants is an indication of Retinoblastoma. An eye cancer in children leading to blindness, usually starts before age 5.
Ectropion
Lower lid everted, exposing the lower conjunctiva, causing dryness in the eye.
Entropian
Upper eyelid is inverted into the eyes causing irritation of the eye.
Diabetic Retinopathy
Leading cause of blindness in USA
History of Allergies
The most important question to ask a person with Rhinitis
Why is it important to ask a client with hearing loss, if any members of the family has hearing loss?
Hearing loss is a familial tendency.
Presbycusis
High frequency hearing loss, associated with aging.
What is the reason a nurse should not advise a client to use Q-tips when cleaning the ears?
The client can accidentally perforate the tympanic membrane.
How does a normal tympanic membrane appear on otoscopic exam?
Shiny pearly grey, translucent and opaque
What does white patches on the tympanic membrane indicate?
Previous ear infections
Otitis Externa
Infection of the ear that effects the ear canal and the outer ear but the the tympanic membrane is still shiny pearly grey
Otitis Media
Infection of the ear that involves the outer and the middle ear (malleus, incus, stirrup)
Otitis Interna or Labyrinthitis
Infection of the ear that goes deeper and extends to the semi-circular canal, cochlea, and vestibule. The client has severe vertigo. N/V and spinning world feeling.
How to conduct a Rinne test?
After activating the tines, place the base of the tunning fork at the mastoid process then the client cannot hear the vibration anymore move the tines 1 inch from the auricle.
Place the base Rinne test
Hearing test using tuning fork by comparing air conduction with bone conduction. Normal findings, air conduction is 2X greater than bone conduction (AC 30 seconds, BC 15 seconds).
Weber Test
Hearing test using tuning fork by activating the tines of the tuning fork and placing the base of the tuning fork at the top of the midline of the skull. Normal findings- equal lateralization of the vibration equally to both the right/ left ears. Abnormal findings- lateralization goes to the defective ear with impacted cerumen.
What should a nurse do when unable to visualize the tympanic membrane using otoscope?
The nurse must remove the otoscope, reposition the auricle then reinsert the otoscope.
What is a cause for concern when assessing the ear?
Tenderness on the mastoid process because infection can easily go to the brain.
How to perform a Romberg Test?
Advise the client to stand erect with both feet together, hands on the sides, and close both eyes while nurse is placing her arms in front and back of client for possible support for falling for 20 seconds and observe for swaying. Swaying over 2 inches positive for Romberg Test. Client has balance problems and at risk for fall.
What should be done if a client has a positive Romberg Test to meet elimination needs and to prevent fall.
Obtain a bedside commode
Direct percussion of the sinuses is the technique used to assess client for?
Sinus pressure headache
Red Glow?
Normal finding’s on transillumination of the sinus
Absence of Red Glow?
Abnormal Findings on transillumination of the sinuses. Sinuses congested and filled with fluids.
Leukoplakia
Whitish thickening of the mucus membrane of mouth and tongue that cannot be scrapped off. It can be precancerous. Causes; smoking and drinking.
Oral Candidiasis or Thrush or Yeast Vaginal Infections
Curd like white, overgrowth of normal flora fungi in the mouth or vagina. Causes; Fungi called Candida Albicans. Can be scraped off but bleeding occur. Common in Autoimmune clients (diabetes or HIV), use of antibiotics.
What is the most common S/S of a mouth infection?
Petechiae and edema
What are the Grading of Tonsils?
Grade 0-Absent- Removed
Grade 1-Normal-Tonsils hidden behind the tonsilla pillars. Less than 25% lateral dimension
Grade 2- Tonsils extend to edges of the tonsillar pillar. 26- 50% of lateral dimension
Grade 3- Tonsils extend to edges of tonsillar pillar, not midline 51-75% of lateral dimension
Grade 4- Tonsils extend to midline more than 75% of the lateral dimension
What are the 4 types of headaches?
1) Classic Migraine
2) Cluster HA
3)Tension HA
4) Sinus HA
Classic Migraine
HA may or may not by preceded by aura, client see spots or flares of lights, tingling sensation of the extremities going to the face, weakness of one side of the body, vertigo, N/V, and tremors. May last 4 hours (Dark Quit Place)
Cluster HA
Onset is sudden. Numerous HA over a period of days or months that last for only few minutes few hours. No aura. Begins suddenly, with and excruciating pain on one side of the face spreading upward behind one eye.
Tension HA
Onset gradual. Also known as a muscle contraction HA. Pain is steady, maybe unilateral of bilateral. Typically ranges from cervical region to the top of the head. Maybe associates with stress over work, dental problems and other problems
Sinus HA
HA due to sinus infections
Hydrocephalus
Enlargement of a baby’s head due to inadequate drainage of the cerebrospinal fluid resulted in abnormal growth of skull.
Craniosynostosis
Premature closure of the sagittal and coronal sutures of the head of the baby resulting in altered head, face, and orbits.
Fetal Alcohol Syndrome
Exposure of the baby to high level of alcohol resulting in epicanthal folds, narrow palpebral fissures, deformed upper lip and intellectual disability.
10 lymph nodes of the head and neck with abnormal findings.
Normal findings in adults- not palpable. In children can be palpable but can still be normal- refer to the physician.
1) Preauricular
2) Postauricular
3) Occipital
4) Submental
5) Submandibular
6) Retropharyngeal
7) Deep Cervical Chain
8) Anterior Cervical Chain
10) Supraclavicular
S/S of gingivitus
Red, Bleeding & Receding Gums
Bacterial Conjunctivitis
Erythema, thick whitish or yellowish eye discharge/ Tx: Antibacterial
Viral Conjunctivitis
Pink eye with watery discharge. Accompanied by cold, cough, sneezing, respiratory infection, or other cold-related symptoms. No TX is required. Tx: Antihistamine if due to allergy
Sequence of Head and Neck Assessments
1) Inspection
2) Palpation
3) Auscultation
Sequence of Ears, Nose, & Mouth Assessments
1) Inspection
2)Palpation
3)Percussion
4) Additional Assessment- Transillumination
