Exam II NU 325

bone conduction

a pathway of hearing,alternate route of hearing,bones of the skull vibrate,vibrations transmitted directly to inner ear and to cnviii

air conduction

a pathway of hearing,normal pathway of hearing,twice as long as bone conduction

middle ear

air filled cavity inside temporal bone

ototoxic drugs

antibiotics: gentamicin,vancomycin,diuretics:lasix

hearing loss

anything that obstructs the transmission of sound that impairs hearing

palpebral fissure

area of eye between upper and lower lid

abnormal lesion

asymmetry,border irregularity,color variation,diameter greater than 6mm,elevation and enlargement these are examples of

lens

biconvex disk located just behind the pupil,its transparent

cyanosis

blue

limbus

border between the cornea and sclera

melanin

brown pigment

lanugo

by midgestation most of skin is covered with fine downy hair of the newborn infant

mixed loss

conductive and sensorineural loss in the same ear

stiae gravidarum

connective tissue develops increased fagility,may develop in the skin of the abdomen,breast or thighs of pregnant women

horny cell layer

consists of dead keratinized cells that are interwoven and closely paked.the cells are constantly being shed or desquamated,and are replaced with new cells from below.the epidermis is completely replaced every 4 weeks.each person sheds about 1lb. of skin each year

middle ear

contains tiny bones-auditory ossicles,malleus,incus,stapes

pupil

controlled by the parasympathetic and sympathetic nervous system

cornea

covers the lens of the eye,very sensitive,bends to allow incoming rays

xerosis

dry

sclera

during the assessment of an african americans skin color, the nurse identifies jaundice,to validate this finding,the nurse should assess the

it determines eye alignment and coordination

during the examination of a clients eyes,the nurse assesses the six ocular movements,why is this important

infants and children

eustacian tube is shorter,wider,more horizontal than adults,easier for pathogens to migrate to the middle ear from nasopharynx,increased incidence of ear infections

otitis media

eustacian tube obstruction or passage of secretions into middle ear,increased incidence in children,american indians,hispanics,premature infants,down syndrome,bottle fed babies,persistant middle ear effusion with this,impairs hearing,delayed speech and cognitive develpment

anterior approach

face patient,head slightly forward and to the right and left,hold sip of water,use two fingers of one hand

vellus hair

fine and faint,covers most of the body

dry cerumen

flaky and gray,most common in asians, american indians

assess for lesions

freckles,moles,birthmarks

iris

functions as the diaphragm,controls the amount of light that we let in

nails

hard plates of keratin on the dorsal edges of the fingers and toes

inner ear

holds the sensory organs for equilibrium and hearing

14

how many facial bones are there

nursing diagnosis

impaired swallowing,risk for ineffective airway clearance,fluid volume deficit, disturbed body image,sleep pattern disturbance,acute or chronic pain these are examples of

melasma

in blacks,mask of pregnancy,patchy tan or dark brown discoloration of the face

pseudofolliculitis

in blacks,razor bumps or ingrown hairs caused by shaving too closely with a razor

keloids

in blacks,scars that form at the site of a wound and grow beyond the normal boundaries of the wound

linea nigra

in pregnant women,change in hormone levels results in increased pigment in the areolae,nipples,vulva,and sometimes in the midline of the abdomen

senile purpura

in the aging adult,vascularity of skin diminishes while the vascular fragility increases,minor trauma may produce dark red discolored areas called

hyperpigmenetation

increase in color

inner canthus

inner corner of the eye

basal cell layer

inner layer forms new skin cells,their major ingredient is the tough,fibrous protein keratin,the melanocytes interspersed along this layer produce the pigment melanin,which givess brown tones to the skin and hair

dermis

inner supportive layer consisting mostly of connective tissue,or collagen.

size,symmetry,intactness,tenderness

inspect and palpate the bony structures of the face and jaw,noting?

subcutaneous layer

is adipose tissue,which is made up of lobules of fat cells,this tissue stores fat for energy,provides insulation for temperature control,and aids in protection by its soft cushioning effect.this loose layer gives skin its increased mobility over structures underneath

middle ear functions

it has 3 functions-conducts sound waves from external ear to inner ear,protects inner ear by reducing amplitude of loud sounds,eustachian tube equalizes pressure to prevent membrane rupture

palpebral

lines upper and lower lids

hypopigmentation

loss of color

cyanosis

low oxygen levels in the blood cause the tips,fingers,and toes to look blue

lacrimal system

lubricates conjunctiva and cornea,secretes tears,drains into the puncta and nasolacrimal duct

conductive

mechanical dysfunction of the external,middle ear,cerumen,foreign bodies,perforated tympanic membrane,blood,pus,or fluid in middle ear,otosclerosis

wet cerumen

moist,honey brown to dark brown,most common in african americans and caucasians,not related to poor hygiene

nevus

moles

otosclerosis

most common in adults,common cause of conductive hearing loss,gradual hardening causing the stapes in the middle ear to become fixed in the oval window,impedes transmission of sound,causing progressive deafness

presbycusis

most common in aging adults,increased incidence in early,sensorineural hearing loss caused by nerve degeneration,onset in 50's,progresses with age,words sound garbled,inability to localize sound

presbycusis

nerve degeneration occurs with aging

fluid loss

newborns skin is thin smooth and elastic and is relatively more permeable than that of the adult so the infant is at greater risk for

seborrhea

oily

cochlea

organ of corti-sensory organ of hearing,change vibrations to electrical impulses,travel from cnviii to brainstem

outer canthus

outer corner of the eye

posterior approach

palpation of the thyroid,stand behind patient, have patient hold a sip of water in mouth until told to swallow,use both hands locate the cricoid process

lunula

part of nail,white,opaque,semilunar area at the proximal end of the nail

subjective data

past history of skin disease,change in pigmentation,change in mole,excessive dryness or moisture,pruritis,excessive bruising,rash or lesion,medications,hair loss,change in nails,environmental or occupational hazards,self care behaviors these are

sensorineural

pathology of inner ear,cnviii,or auditory areas of cerebral cortex,presbycusis,ototoxic drugs

vernix caseosa

present at birth,thick cheesy substance made up of sebum and shed epithelial cells

sebaceous glands

produce protective lipid substance,which is secreted through the hair follicles

functions of the skin

protection,prevents penetration,perception,temperature regulation,identification,communication,wound repair,absorption and excretion,produces vitamin d these are functions of

sebum

protective lipid substance,oils and lubricates the skin and hair and forms an emulsion with water that retards water loss from the skin,most abundant in the scalp,forehead,face and chin

bulbar

protects the entire eye

lacrimal apparatus

provides constant irrigation keeps eye lubricated

perrlac

pupils are equally round reactive to light both direct and consensual they accomodate and converge

erythema

red

vascular bed

red-purple tones that are underlying

external auditory canal

secretes cerumen,protects and lubricates the ear,outer 1/3 of canal-curves up and toward the back of the hand,inner 2/3 of canal-slight s shaped curve in adults,angles down and forward toward the nose

tympanic membrane

separates the external and middle ear,translucent,pearly gray,oval and slightly concave,short process of malleus,cone of light-located at 5 oclock in right,located at 7 oclock in left,anterior reflection of otoscope light

external ear

serves to funnel sound waves into the opening of the ear,consists of the helix,antihelix,tragus,antitragus,lobule,external auditory meatus

marasmus

severe malnutrition

telangiecstasia

spider veins

eccrine gland

sweat gland,coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat,widely distributed through the body and are mature in the 2 month old infant

apocrine gland

sweat gland,produce a thick,milky secretion and open into the hair follicles,located mainly on the axillae,anogenital area,nipples and navel and are vestigial in humans,they become active during puberty,and secretion occurs with emotional and sexual stimulation

up and back

the correct positioning of the ear for the otoscope examination for an adult is

terminal hair

the darker thicker hair that grows on the scalp and eyebrows,and after puberty on the axillae,pubic area,face, chest

collagen

the tough fibrous protein that enables the skin to resist tearing

inspection and palpation

these are the techniques used to assess skin,hair and nails

epidermis

thin but tough,its cells are bound tightly together into sheets that form a rugged protective barrier.it is stratified into several zones

hair follicles

this develops in the fetus at 3 months gestation

chloasma

this happens in the face its the same as linea nigra

Assessment of the Skin

this includes-color,temperature,moisture,texture,thickness,edema,mobility and turgor,vascularity or bruising,lesions

sclera

tough protective white covering that protects the iris and pupil

conjunctiva

transparent protective covering over the exposed area of the eye

ecchymosis

vascularity or bruising

diaphoresis

very wet

bony labyrinth

vestibular apparatus,cochlea these two things are part of

vestibular apparatus

vestibule,semicircular canals

retina

visual receptive layer of the eye,in which the light waves are fed into the eye

1-2 seconds

what is normal capillary refill

frontal,parietal,occipital,temporal

what the 4 cranial bones

craniosynostosis

when the skull closes late or early

cnviii

which cranial nerve transmits electrical impulses from the inner ear to the brain

pallor

white

jaundice

yellow

carotene

yellow orange tones