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Exam 4
Health Assessment
| Question | Answer |
|---|---|
| Assessment techniques of the mouth | start w/ the anterior structures and move posteriorly using tongue blade hold tongue w/ gauze and swing out to each side |
| Abnormal tongue assessment findings | lesions, white patches, cracks, ankyloglossia, atrophic glossitis, fissured tongue |
| Ankyloglossia | short lingual frenulum fixing tip of tongue to floor of mouth; "tongue tie" |
| Atrophic glossitis | smooth, glossy tongue |
| fissured tongue | several folds and cracks on tongue area |
| External nasal assessment | inspect and palpate; symmetry, deformities, inflammation, lesions, patency, sense of smell |
| Nasal cavity assessment | inspect with otoscope w/ head tilted back; assess for edema, discharge, or foreign body |
| Nasal septum assessment | inspect for deviations, drainage, or perforations. Tender, so avoid touching w/ otoscope |
| Nasal turbinate assessment | inspect for polyps, growths, color, or edema. Don't advance otoscope far because of vasculature. Normal = same color as nasal mucosa |
| Seasonal allergies nasal mucosal findings | moist, itchy, swollen, watery discharge |
| Viral infection nasal mucosal findings | redder, thicker mucus, yellow/green mucus, facial pressure |
| Normal changes of oral mucosa during pregnancy | gums may become softened and hyperemic. May have bleeding gums |
| Normal variations of oral structures for African Americans | Bluish lips, dark line of gingival margin, patchy hyperpigmentation in buccal mucosa |
| Leukoedema | benign, milky, bluish-white, opaque area in buccal mucosa. When mild, patch disappears as you stretch cheeks. Usually in Black and East Indian persons |
| Normal variations for Native Americans, Inuits, and Asains | Nodular bony ridge down middle of hard palate |
| Palpation of sinuses | -using thumbs, press the frontal sinuses by pressing firmly up and under the eyebrows -press maxillary sinuses below the cheekbones |
| Normal findings when palpating sinuses | person should feel firm pressure but no pain |
| Abnormal findings when palpating sinuses | sinus area tender |
| Normal tympanic membrane color | pearly-gray |
| A 6 month-old who can hear will can be expected to...? | turn his or her head toward the source of sound |
| Who would be expected to find difficulty in hearing the highest frequency? | Older adults |
| For best results, an otoscopic and oral exam on a child should be performed when? | At the end of the exam |
| Symptoms of middle ear effusion | ear pain, bulging red ear drum |
| symptoms of otitis externa | pain at movement of ear; sticky, yellow discharge; redness and swelling; purulent otorrhea; itching; fever |
| How to perform child otoscopic exam | save for last; let them hold your "flashlight"; have parent help hold child in lap; pull pinna down |
| How to perform adult otoscopic exam | have pt sit up straight and pull pinna up/back; avoid touching "bony" section of canal wall; perform before you test hearing |
| Developmental considerations that predispose younger children to ear infections | eustachian tubes shorter, wider, and more horizontal; lumen is easily occluded; external ear canals are shorter and have slope opposite of adults |
| Subjective vertigo | feeling the you're spinning |
| Objective vertigo | objects around you are spinning |
| Cultural considerations with ear | traditions like ear piercings; perception of hearing |
| function of middle ear | -conducts sound vibrations from outer ear to central hearing apparatus in inner ear -protect inner ear by reducing amplitude of loud sounds -eustachian tube allows equalization of air pressure on each side of tympanic membrane so it doesn't rupture |
| Client prep for abdominal assessment | empty bladder, disrobe and gown, supine, head of pillow, knees bent, arms at side/across chest, pt ID area of pain |
| Nurse prep for abdominal assessment | warm hands and stethoscope, warm environment, good lighting, approach slowly, monitor pt fact, tender areas last |
| Order of abdominal assessment | inspect, auscultate, percuss, palpate |
| Dysphagia | difficulty swallowing |
| Dysphasia | language disorder |
| Charting abdominal inspection: Contour | flat, rounded, protuberant |
| Charting abdominal inspection: symmetry | tumor, pregnancy, hernia |
| Charting abdominal inspection: umbilicus | inverted and midline, cullens (bluish) |
| Charting abdominal inspection: skin | striae, texture, color, lesions |
| Charting abdominal inspection: surface motion | pulsations, peristalsis |
| Other things to chart during abdominal inspection | respiratory movement, hair distribution, demeanor |
| Normal auscultation findings | high pitched, gurgling, cascading, growling (borborygmus), rushing |
| Abnormal auscultation findings | bruit, venous hum, peritoneal friction rub *alert dr. if bowel sounds absent |
| Costovertebral angle tenderness | causes tissue to vibrate; pain with kidney inflammation |
| Murphy's sign | gallbladder test; inspiratory arrest (sudden stop in inspiration with RUQ palpation); hold fingers under liver border and ask pt to take a deep breath, typically should take a deep breath w/o pain |
| Complications of splenomegally | tissue death; may become overactive, causing decreased WBC and platelets; could rupture (life-threatening); palpable = 3x normal size |
| Viscera organs | liver, spleen, uterus |
| hollow viscera organs | colon, stomach, small intestines |
| Abdominal changes during pregnancy | enlarging uterus displaces intestines up and back; decreased bowel sounds; constipation; heartburn; displaced appendix; skin changes |
| Melena | black stool/tarry; due to upper GI bleeding or nontarry from Fe meds |
| Abdominal percussion findings | assess for relative density; tympany, dullness, hyperresonance; CVA tenderness |
| Abdominal dullness findings | distended bladder, adipose, fluid, mass |
| Abdominal hyperresonance findings | gaseous distention |
| Ascites | free fluid in peritoneal cavity |
| Why is ascites assessed? | due to a distended abdomen, bulging flanks, and protruding umbilicus |
| What causes Ascites? | CHF, hypertension, cirrhosis, cancer |
| Ptosis | drooping or falling of upper eyelid |
| Entropion | eyelid turns inward |
| Ectropion | eyelid turns outward |
| Blepharitis | lid inflammation |
| Chalazion | infection of meibomian gland |
| Hordeolum | stye |
| Pterygium | opacity that grows over the cornea |
| Pinguecula | yellowish elevated nodule secondary to thickened conjuctiva |
| Who might you see subconjuctival hemorrhage in? | Those coughing, vomiting, weight lifting, childbirth, or trauma |
| Which CN carries sensory response to cornea? | CN II -- Optic nerve |
| Which CN carries motor response to cornea? | CN III -- Oculomotor nerve |
| What type of vision does the Snellen chart test? | central vision |
| What does 20/50 mean? | a person can see clearly at 20 ft that a normal vision can see at 50 ft |
| Which CN affects pupillary response? | CN II and III |
| Miosis | Constriction <2 mm; caused by organophosphates, pilocarpine, opiates |
| Mydriasis | dialation >6 mm; caused by amphetamines, cocaine, atropine, brain damage, alcohol, diabetes |
| Anisocoria | unequal pupil size |
| What CNs affect EOM? | CN III, IV, VI |
| Strabismus | cross-eyed |
| What assessment techniques screen for strabismus? | cover-uncover test |
| Amblyopia | lazy-eye |
| What is the red light reflex? | when light from ophthamaloscope reflects of retina |
Created by:
julie.russell