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Assessment
Test 2
| Question | Answer |
|---|---|
| Lacrimal Apparatus | -Glands and ducts to lubricate the eye -Lacrimal gland = Produces tears and drain into the nasal meatus |
| Accommodation | -Functional reflex allowing eye to focus on near objects -Accomplished through movement of cilliary muscles causing an increase curve of the lens |
| Cataracts | Risk Factors: -Increasing age -Exposure to ultraviolect B light (near equator) -Diabetes Mellitus -Cigarette smoking -Alcohol use -Diet low in antioxidant vitamins (esp. E & B) -High BP -Eye injuries/surgery -Steroid use -Female gender |
| Vision Tests | -Distant Visual Acuity -Near Visual Acuity -Visual Field for gross peripheral vision |
| Distant Visual Acuity | -Snellen Chart - 20ft away -Read each line until can't decipher letters -Normal = 20/20 |
| Near Visual Acuity | -Only needed for middle-aged clients or clients with difficulty reading -Hand-held snellen chart (14 in) -Cover 1 eye; Normal = 14/14 |
| Visual fields for gross peripheral vision | -Sit @ eye level -Client cover L eye, you cover R eye -Slowly move one finger upward from below until client sees your finger -Test 3 vields -superior, temporal and nasal -Normal - client should see the examiner's finger at same time examiner sees i |
| Testing Extraocular Muscle Function | -Corneal Light reflex -Cover Test -Positions test |
| Corneal Light Reflex | - Reflection should be in same spot on each eye = parallel alignment |
| Cover Test | -Detects deviation in alignment or strength in eye movement -Both eyes remain fixed straight ahead |
| Positions Test | -Eye muscle strength and cranial nerve function -Eye movement should be smooth and symmetrical |
| Consensual pupillary constriction | -Indirect -Exposure to light in one eye results in constriction of the pupil in the opposite eye |
| PERRLA | Pupils are equal, round, react to light and accommodation |
| External Ear | -AKA pinna -Auricle, tragus, lobule, auditory canal -Tympanic membrane - handle and short process of the malleus, umbo, cone of light, pars flaccida, pars tensa |
| Middle Ear | -Tympanic cavity -Round and oval windows -Three auditory ossicles: malleus, incus, stapes -Eustachian tube |
| Inner Ear | -Labyrinth - bony and inner membranous labyrinth -Bony labyrinth - cochlea, vestibule, and semicircular canals -Spiral organ of Corti -Vestibular nerve and cochlear nerve = 8th cranial nerve |
| Conductive Hearing loss | -Bone conduction hear longer or equally as long as air -Rinne - don't hear vibrations with fork in front of ear |
| Sensorineural Hearing loss | -Perceptive hearing loss -Air conduction heard longer |
| Presbycusis | -50+ years -Don't hear high pitched frequencies |
| Drainage from ear | -Otorrhea -Usually indicates infection -Purulent, bloody = inner ear; associated w/ pain and popping sensation; characteristic of otitis media |
| Rinne Test | -Tuning fork to mastoid process then external ear |
| Weber Test | -Tuning fork on top of hear -Louder in one ear than the other? |
| Romberg Test | -Close eyes for 20 seconds -Do they sway? |
| Risk Factors: Hearing loss | -Genetic Predispostion -Congenital anomalies -Otitis media -Fluid -Poor nutrients -Ototoxic Meds -Trauma to ear drum -Otosclerosis -Viral infections -Meniere's disease, impacted cerumen -Acoustic neuroma -Brain diseases -Child w/ rubel |
| Transillumination of sinuses | -Strong narrow light source -See if filled w/ fluid or pus -Red glow is normal |
| Grading of tonsils | 1+ Tonsils are visible 2+ Tonsils are midway between tonsillar pillars and uvula 3+ Tonsils touch the uvula 4+ Tonsils touch each other |
| Coughing and Medications | -Beta Blockers, ACE inhibitors, -Associated w/ persistent coughing as side effect -Can be contraindicated by asthma |
| Measuring Chest Expansion | -Place hands on T9/T10 and press together small skin fold -Ask client to take deep breath and observe movement of thumbs -Should move 5-10cm apart symmetrically |
| Auscultation of the chest | -Auscultate for anterior breath sounds, adventitious sounds and voice sounds |
| Sputum Colors | -White = colds,viral infections, bronchitis -Yellow/Green = bacterial infections -Blood = serious resp. conditions -Rust = tuberculosis, pneumonia -Pink, Frothy = pulmonary edema |
| Abnormal spine curvature | -Barrel Chest -Scoliosis - S shaped spine -Kyphosis - Hump |
| Pleurisy & breathing | -Parietal - Lines the chest cavity -Visceral - Covers the external surfaces of the lungs -Pleural space - lies between the two pleural layers |
| Right Upper Quadrant | -Ascending and transverse colon -Duodenum -Gallbladder -Hepatic flexure of colon -Liver -Pancreatic head -Pylorus -Right adrenal gland -Right Kidney -Right ureter |
| Right Lower Quadrant | -Appendix -Ascending colon -Cecum -Right Kidney -Right ovary and tube -Right ureter -Right spermatic cord |
| Left Upper Quadrant | -Left adrenal gland -Left kidney -Left ureter -Pancreas -Spleen -Stomach -Transverse descending colon |
| Left Lower Quadrant | -Left Kidney -Left ovary and tube -Left ureter -Left spermatic cord -Descending and sigmoid colon -Left spermatic cor |
| Scratch test | -If can't accurately percuss the liver borders -Scratch lightly over the abdomen, progressing upward towards liver -Sound gets more intense over liver |
| Involuntary Reflex Guarding | -Serious,reflects peritoneal irritation -Can involve all or part of abdomen but is usually seen on the side because of nerve tract patterns -Right side could = cholecystitis |
Created by:
prettyinpink7
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