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Head and neck assess
| Question | Answer |
|---|---|
| if the head is tilted to one side thats an indicator of | unilateral hearing or visual loss |
| horizontal jerking or bobbing is.. | a tremor |
| what is hydrocephalus | buildup of cerebrospinal fluid in the ventricles.. infants larger head |
| what is acromegaly | adults with enlarged jaws and facial bones caused by excessive secretion of growth hormone |
| Examination of the eyes include | visual acuity, visual fields,extraocular movements,external and internal eyes movements. |
| assessing near vision | ask client to read printed material |
| if assessing distant vision use | snellen chart. |
| checkin light perception | shine penlight in eye. shutoff light |
| to test extraocular movements | put the fingers up and down side to side |
| what is cataracts | increased opacity of the lens. blocks the rays from entering the eye. develop slowly and progressivly after age 35 or sudden trauma |
| what is glaucoma | intraocular structural damage resulting from elevate intraocular pressure. obstruction of the outflow of aqueous humor causes it |
| what is macular degeneration | blurred central vision. progressive degeneration of the center of the retina. most common over age 50. most common blindness in adults |
| what is strabismus | crossed eyes impairment of the extraocular muscles or nerves |
| what is retinopathy | leading cause of blindness. noninflammatory eye disorder resulting in changes in retinal blood vessels. |
| what is hyperopia | far sightedness.. a refractive error in which ray of light enters the eye and focus behind the retina. cant see close |
| what is myopia | near sightedness.. a refractive error in which rays of light enter the eye and focus in front of the retina. cant see distance |
| what is nystagmus | involuntary rhythimal oscillation of the eyes by periodicaly stopping the movement of the finger |
| Bulging eyes are | exophthalmos |
| an abnormal drooping of the lid over the pupil is called | ptosis caused by edema or impairment of third cranial nerve |
| ectropin | older adults lid margins are turned out |
| entropion | older adults lid margins are turned in |
| sty | acute suppurative inflammation |
| the lacrimal gland is responsible for | tear production |
| The presense of redness indicates...in the sclera | conjuctivities or allergies |
| bright red blood in a localized area surrounded by normal appearing conjunctiva indicates | subconjunctival hemorrhage |
| a thin white ring along the margin of the iris | arcus senilis.. common in aging uncommon under age 40 |
| pupis are normally | 3-7 cmm |
| dilated pupils result from | glaucoma/trauma/neurological disorders/eye meds or withdrawl from opioids |
| inflammation of iris or use of drugs | constricted pupils |
| directly illuiminated pupil constricts | vise verzsa |
| if pupil is normal all tests | PERLLA |
| DEEPER INTO THE EYE FROM AN ADVANCED NURSE | ophthalmoscope |
| inspect and palpate the external ear | inspect middle ear with otoscope |
| test inner ear by | hearing acuity |
| external ear structure consists of | auricle.outer ear canal. tympanic membrane |
| the middle ear | air filled cavity containing bony ossicles. malleus. incus. stapes |
| eustachian tube | connected the middle ear to the nasopharynx. pressure between atmosphere and middle ear is stabilized through this tube |
| inner ear | cochlea. vestibule.semicircular canals. |
| otoscope | observing deep into external and middle ear |
| cerumen | yellow wax in ear |
| reddened canal | infection or inflammation |
| what is conduction hearing loss | interrupts sound waves as they travel from the outer ear to the cochlea of the inner ear because the sound waves arent transmitted through the outer and middle ear structures |
| sensorineural loss | involves inner ear, auditoy nerve, or hearing center of the brain |
| mixed loss | combintation of sensorineural loss and conduction loss |
| what is ototoxicity | injury to auditory nerve resulting from high maintenance doses of antiobitocs |
| what is a tuning fork used for | 256-512 hertz most commonly used allows for hearing by bone conduction with that of air conduction |
| what is webers test | hold at base and tap against heel of palm place above head see if the client hears in both ears |
| What is the rinne test | place stem of tuning fork against client mastoid process. vibrate it go next to ear and ask if she hears it vibrating still |
| when assessing integrity of nose and sinuses what do u do | inspect and palpatation! |
| penlight allows for gross examination of each naris | when inspecting external nose.. observe shape. color. skin. size. |
| close one naris and breath and vise versa! | when illuimanting the naris check for mucosa. color. lesions. discharge. sweling and evidence of bleeding. |
| sinus infection | yellowish green discharge |
| allergies | clear discharge |
| what is excoriation | local skin breakdown characterized by redness and skin sloughing in the nose.. maybe b y a nasogastric tube |
| deviated septum | obstructs breathing and interferes with passage of nasogastric tube |
| What is a polyp | tumor like growth or purulent drainage |
| Examination of sinus's | Involves palpation |
| frontal and maxillary facial areas | palpating the sinuses, thumb up and under clients eyebrow |
| assess the oral cavity use a | penlight and tongue depressor |
| inspect the lips for... | color texture hydration contour and lesions |
| pallor lips = | anemia with cyanosis caused by respitory or cardio problems |
| cherry coated lips= | carbon monoxide poisoning |
| any lesions such as nodules or ulcerations= | infection.irratation or skin cancer |
| symmetrical smile= | normal facial nerve function |
| note color of teeth.alignment. | presence of caries |
| chalky white on the teeth= | cavities |
| brown or black discoloration= | formation of caries |
| yellow stain | tobacco use |
| brown stain | coffee tea cola |
| inspect mucosa for | color. hydration. texture. lesions.ulcers.abrasions.cycsts. |
| thick white patches in buccal mucosa | leukoplakia, precancerious lesions. alcks and smokers |
| spongy gums that bleed= | periodontal disease and vitamin c deficiency |
| gingivitis | swollen gums. mobile teeth. pockets of debris at tooth margin |
| varicosities | swollen tortuous veins common in older adults. rarely caused issues |
| exostosis | bony growth between 2 palates |
| examination of pharyngeal | infection.inflammation or lesions |
Created by:
ziogas
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