Assessment Module 8

Hyperesthesia

(increased sensitivity to touch)

Assess CN V (trigeminal)

---> Test motor function: --> Normal: temporal & masseter muscles contract bilaterally -->ABNORMAL: 1. Decreased contraction in one of both sides. 2.Asymmetric strength in moving the jaw may be seen with lesion or injury of the 5th cranial nerve. 3.Pain w clenching of the teeth. 4.Bilateral muscle weakness is seen with peripheral or central nervous system dysfunction. 5.Unilateral muscle weakness may indicate a lesion of cranial nerve V (trigeminal). ---> TEST SENSORY FUNCTION: 1.using a paperclip: touch client on face forehead, cheeks, chin 2. close eyes, tell what you feel (sharp or dull) 3. repeat w cotton tip --->NORMAL: Client idnetifies type of touch --->ABNORMAL: Inability to feel & correctly identify stimiuli, note: lesions of the trigeminal nerve or lesions in the spinothalamic tract or posterior columns ---> Test corneal reflex ask client to look away and lightly touch cornea w fine wisp of cotton NORMAL: eyelids blink bilaterally. ABNORMAL: lesions of the trigeminal nerve or lesions of the motor part of cranial nerve VII (facial). NOTE: Reflec may be absent or reduced w contacts

<--->ASSESS: CNIII (oculmotor) CN IV(Trochlear) CN VI (Abducens)

--->Normal: -Eyelid covers about 2mm of iris --->ABNORMAL: Ptosis: dropping of the eyelid) is seen with weak eye muscles such as myasthenia gravis <--->ASSESS EXTRAOCULAR MOVEMENTS NYSTAGMUS: --->Normal: eye moves in a smooth coordinated motion in all directions. --->ABNORMAL: 1.Nystagmus-rhythmic oscillation of the eyes): cerebellar disorders 2.Limited eye movement through the six cardinal fields of gaze: increased intracranial pressure. 3.Paralytic Stabismus: Paralysis of the oculomotor, trochelar, or abducens nerves. <--->Assess pupillary response to light (direct & indirect) & accommodation in both eyes. -->Normal: -Bilateral illuminated pupils constrict simultaneously. -Pupil opposite the one illuminated constricts simultaneously. -->Abnormal: 1. Dilated pupil (6-7 mm): oculomotor nerve paralysis. 2.Argyll Robertson pupils: CNS syphilis, meningitis, brain tumor, alcoholism. 3.Constricted, fixed pupils: narcotics abuse or damage to the pons. 4.Unilaterally dilated pupil unresponsive to light or accommodation: damage to cranial nerve III (oculomotor). 5.Constricted pupil unresponsive to light or accommodation: lesions of the sympathetic nervous system.

2. Discuss the risk factors for hearing loss across cultures and ways to reduce one's risks.

-Aging, especially due to many years of exposure to sounds that can damage inner ear cells -Heredity, with genetics that are related to susceptibility to ear damage -Occupational loud noises as regular part of the working environment (e.g., farming, construction, factory work) -Recreational noises and exposure to explosive noises (firearms and fireworks; snowmobiling, motorcycling, listening to loud music or MP3s, especially if volume is high) -Ototoxic medications (e.g., gentamicin, some chemotherapy medications; or high-dose aspirin, some other pain relievers, antimalarial drugs, or loop diuretics can lead to tinnitus or hearing loss) -Illnesses, especially with high fever (e.g., meningitis) -Age (between 6 months and 2 years especially, due to size and shape of eustachian tubes) -Group childcare -Babies fed from a bottle, especially lying down -Seasons of fall and winter, due to exposure to colds, flu, and increased allergens -Poor air quality, especially irritants in the air (e.g., cigarette smoke) -Family history -Cleft palate -Down syndrome -Ethnicity (Alaskan Indians and Inuits have higher incidence) -Enlarged adenoids REDUCE RISK!!!! -Avoid loud noise exposure. -avoid recreational risks -avoid loud music for long periods -wear hearing protection -hearing checked esp. after 50 -immunize children, measeles, meningitis, rubella & mumps. -rubella before becoming pregnant -pregnant? screen for sphypllis & stis, prenatal care, treatment for baby w jaundice. -avoid ototoxic drugs, manage proper dose -newborn do not feed why lying on back -newborn screening for hearing -treat ear infections ASAP -tonsil & adenoid infections & inflammation -keep child home from school to prevent spread of ear infection -teach child to avoid foreign bodies in ear -avoid q tips, other things into ear canal

Spinal Cord

-Anterior & posterior horns -Ascending pathways - spinothalamic tract, posterior columns -Descending pathways - pyramidal and extrapyramidal tracts

Test for meningeal irritation

-Assess neck mobility -Brudzinski sign - flex neck, watch hips & knees for flexion -Kernig sign - flex leg at both hip & knee, then straighten knee, watch for pain and increased resistance

External Ear

-Auricle (pinna) - conducts sound waves to the auditory canal -External auditory canal - S shaped in adults -Cerumen - WAX -bacteriostatic -protection from foreign bodies

1. Describe the structures and function of the central nervous system.

-Cerebrum - variety of functions -Diencephalon - thalamus & hypothalamus - relay station, hypothalamus regulates temperature, appetite, thirst, sleep cycles, pain perception & other functions ***water balance, appetite, vital signs (temperature, blood pressure, pulse, and respiratory rate), sleep cycles, pain perception, and emotional status. -Cerebellum - coordination, balance, muscle tone -Brainstem - breathing & heartrate, BP, relay cranial nerve functions -Spinal cord - ascending (afferent) and descending (eferent) tracts tracts transmit sensory and motor impulses, spinal reflexes

motor and cerebellar systems

-Condition & movement of muscles -Strength & tone of muscles -Unusual involuntary movements -Gait & balance -Tandem walking, heel walking, toe walking CEREBELLAR CONT... -Romberg -Finger touch to nose -Rapid alternating movements -Heel to shin test -Decorticate & decerebrate posturing

Describe structures and function of peripheral nervous system

-Cranial nerves- 12, transit motor or sensory messages. FIND MNEMONIC -Spinal nerves- -Autonomic nervous system --Sympathetic - T1 to L2 --Parasympathetic - S1 to S4, CN III, VI, IX, X

Abnormalities EXTERNAL EAR STRUCTURES

-Ears: smaller than 4 cm or larger than 10 cm. -Malaligned or low-set ears: may be seen with genitourinary disorders or chromosomal defects. -Microtia: (see Abnormal Findings 17-1) is a congenital deformity in which the external ear and sometimes the ear canal are not fully developed. -Macrotia: is a congenital excessive enlargement of the external ear. -Ear malformations are often related to other congenital anomalies such as face, jaw, dental, and kidney disorders -Enlarged preauricular and post auricular lymph nodes- Infection -Tophi (non-tender, hard, cream color nodules on the helix or antihelix, containing uric acid crystals)- GOUT -Blocked sebaceous glands- postauticular cysts -SKIN CANCER: ulcerated, crusted nodules that bleed. (often seen on the helix due to skin exposure) -Redness, swelling, scaling, or itching -Otitis externa -Pale blue ear color= frostbite -PAINFUL auricle or tragus ass. otitis externa or posaurculiar cyst. -Tenderness mastoid process suggest mastioiditis (An infection that affects the mastoid bone, located behind the ear.) -Tenderness behind the ear may occur with otitis media ( ear infection)

Lifestyle and Health Practices: EAR

-Exposure to loud noise: -Machinery, Music, explosives **hearing loss unless the ears are protected with ear guards FARMERS -Ear protection: informed of their options for using hearing protective devices -Exposure to water: Otitis externa: Swimmers Ear -water stays in the ear canal for long periods of time, providing the perfect environment for germs to grow and infect the skin. GERMS in water. SX: Itchiness inside the ear, redness and swelling of the ear, pain in the ear when pressure is applied or the ear is pulled on (pain may be severe), drainage of pus. DRY: external auditory canal should be dried using a hair dryer on the lowest heat setting. NO EAR PLUGS USE Tight-fitting bathing cap= better protection -Affect of hearing loss on self care, work: drive, talk on the telephone, or operate machinery safely because of decreased hearing acuity. i.e receptionist or tele operator -Affect of hearing loss on social activity:withdraw, isolate themselves, or become depressed because of the stress of verbal communication -Last hearing exam:Annually(if exposed to loud noises for long periods), know the date to determine recent changes. -Use of hearing aides: -may not be visible -not functioning well and need to be adjusted. -may not be aware of this until someone indicates that they are not hearing well. -Ear care and cleaning practices: warm, moist washcloth should be used to clean the outside of the ears, but nothing should be inserted into the ear canal. -few drops: mineral oil, baby oil, glycerin, or commercial drops. help moisten earwax -ENT Doc: discharge, fullness, ear pain, reduced hearing, or other persistent ear symptoms Remove excess earwax: irrigation (syringing), wax-dissolving eardrops, and manual cleaning with a microscope and specialized instruments.

1. Describe the functions and the structures of the ear.

-External ear -Middle Ear (tympanic cavity) -Inner Ear

cerebral hemispheres

-Frontal - mental function, voluntary movement, communication, emotion, reasoning, judgement -Temporal - hearing center, Wernicke's area -Parietal - tactile sensation -Occipital - visual center, reading & understanding ability

Grading Scale Reflex w Hammer

-Grade 4+ Hyperactive, very brisk, rhythmic oscillations (clonus); abnormal and indicative of disorder -Grade 3+ More brisk or active than normal, but not indicative of a disorder -Grade 2+ Normal, usual response -Grade 1+ Decreased, less active than normal -Grade 0 No response

2. Discuss the risk factors for stroke (also known as cerebral vascular accident [CVA]) across cultures and ways to reduce one's risks.

-HTN -DM -CHD, cardiomyopathy, CHF, AF (atrial fibrillation) -Smoking, ETOH(ethyl alcohol, or ethano), illegal drugs -Age, gender, race -Personal or family hx CVA or TIA (Transient ischemic attack/ mini stroke) -Brain aneurisms of AVM (Arteriovenous malformation)-abnormal connection between arteries and veins, usually in the brain or spine. -Sickle cell disease, vasculitis, bleeding disorders -Sedentary lifestyle -Obesity -Stress, depression -Diet, high cholesterol Prolonged use of NSAIDs REDUCE RISKS: -Do not smoke, if you do quit -Control cholestrol, thru diet exercise, medicines. -control hbp -control diabetes -exercise at least 30min a day -healthy foods, eating less, weight loss program -diet in rich fruits, veggies, whole grains -lean protein, chicken, fish, beans, legumes -low fat dairy, 1% milk -reduce cheese, cream, eggs -avoid salt, fats, fried foods, processed & baked foods -STAY AWAY from saturated fat, contain partically hydrogenated fats -limit alchohol -ask about birthcontrol risk -aspirin or clopidogrel (Plavix) to help reduce blood clots. ask dr first before taking aspirin

sensoineural hearing (Perceptive):

-Movement of fluid in labyrinth (inner ear)stimulates receptors of Organ of Corti -Nerve impulses travel to brain via CN VIII

Middle Ear (Tympanic cavity)

-Separated from outer ear by tympanic membrane (eardrum) -Separated from inner ear by bony partition with two openings (round & oval windows) -Auditory ossicles: tiny bones are responsible for transmitting sound waves from the eardrum to the inner ear through the oval window. 1. malleus: the nearest auditory ossicle that can be seen through the translucent membrane 2. Incus:small anvil-shaped bone in the middle ear, transmitting vibrations between the malleus and stapes. 3. stapes:

EVALUATE GAIT

-assess gait and balance, ask the client to walk naturally across the room. Note posture, freedom of movement, symmetry, rhythm, and balance. Normal: steady, arms swing opposite. ABNORMAL: affected by disorders of the motor, sensory, vestibular, and cerebellar systems. -walk is uncoordinated or unsteady. appearent w tandem walking or walking on heels & toes. OLDER ADULT: slow uncertain gait. - wider & shorter base, hips & knees may be flexed for a bent-forward appearance. TANDEM WALKING: (Heel to toe) client maintain balance.

Tympanic membrane (EAR DRUM)

-translucent, gray appearance -serves as a partition stretched across the inner end of the auditory canal, separating it from the middle ear. -Handle and short process of malleus:the nearest auditory ossicle that can be seen through the translucent membrane -Umbo (base of malleus, center landmark) -Cone of light: reflection of otoscope light seen as a cone due to concave nature of the membrane. -Pars flaccida: (top portion, less taut) Pars tensa: (bottom portion, taut)

Sensory System: Assess light touch, pain, and temperature sensations.

1. close both eyes, tell you what they feel and where they felt. 2. Scatter stimuli, oer distal & proximal parts of extermities & trunk. (DERMATOMES) NOTE: no need to cover entire body unless abnormal SX= pain, numbness, or tingling. NORMAL: client identifies light touch. ABNORMAL: Diseases alter ability to to perceive sensation correctly. peripheral neuropathies (due to diabetes mellitus, folic acid deficiencies, and alcoholism) lesions of the ascending spinal cord, brain stem, cranial nerves, and cerebral cortex.

5. Perform a physical assessment of the nervous system using the correct techniques of inspection auscultation palpation and percussion.

< --->TestCN1 (olfactory): correctly identifies scent presented to each nostril. -->ABNORMALITIES: TestCN1 (olfactory): Inability to smell (neurogenic anosmia)- 1. olfactory tract lesion or tumor or lesion of the frontal lobe. 2.congenital or due to other causes such as nasal or sinus problems 3.injury of nerve tissue at the top of the nose or the higher smell pathways in the brain due to viral upper respiratory infection 4.smoking and use of cocaine may also impair one's sense of smell.

General Observation of hearing and equilibrium Test

>65 30% some type of hearing loss - between 45 & 64- 14% hearing loss 8mil between 18 & 44- hearing loss ADULTS: screened 10 years through age 50 & at 3-year int.

serous otitis media (SOM)

A collection of clear fluid in the middle ear that may follow acute otitis media or be due to an obstruction of the eustachian tube. Note the yellowish, bulging membrane with bubbles behind it.

CN XI- ANY

ASSESSORY- spinal accessory - shrug shoulders -movement of the shoulders and head rotation

CN VI- ACTS

Abducens- test extraocular movements, pupil reaction

Otitis Externa (Swimmer's Ear)

An infection of the outer ear, with severe painful movement of the pinna and tragus, redness and swelling of pinna and canal, scanty purulent discharge

Cone of light should be visible where?

Anterior inferior quadrant

Test sensitivity to position.

Ask the client to close both eyes. Then hold the client's toe or a finger on the lateral sides and move it up or down (Fig. 25-26). Ask the client to tell you the direction it is moved. Repeat on the other side. normal:Client correctly identifies directions of movements. ABNORMAL: Inability to identify the directions of the movements may be seen in posterior column disease or peripheral neuropathy (e.g., as seen with diabetes or chronic alcohol abuse). OLDER ADULT: sense of position of great toe may be reduced. Clinical tip: Position sense is intact distally , then it is intact proximally.

Assess/ Test CN XI(spinal accessory)

Ask the client to shrug the shoulders against resistance to assess the trapezius muscles NORMAL: there is symmetric, strong contraction of the trapezius muscles. Abnormal: Asymmetric muscle contraction or drooping of the shoulder may be seen with paralysis or muscle weakness due to neck injury or torticollis. (A rare condition in which the neck muscles contract, causing the head to twist to one side.) ---> turn the head against resistance, first to the right then to the left, to assess the sternocleidomastoid muscles NORMAL: strong contraction of sternocleidomastoid muscle on the side opposite the turned face. ABNORMAL: ATROPHY: ( body tissue or an organ) waste away, typically due to the degeneration of cells, or become vestigial during evolution) Fasciculations may be seen with peripheral nerve disease.

Reflexes

Biceps - C5 & 6 Brachioradialis - C5 & 6 Triceps - C6, 7 & 8 Patellar - L2, 3 & 4 Achilles - S1 & 2 Plantar - L4 - S2 Abdominal - T10, 11 & 12 Cremasteric - T12, L1 & 2

inner ear (labyrinth)

Bony labyrinth: -Cochlea: spiral organ of Corti, which is the sensory organ for hearing -Vestibule: Sensory Receptors -Semicircular canals: sense position, head movements help maintain static & dynamic equilibrium Inner membraneous labyrinth: -Organ of Corti -Vestibular nerve connects w/ cochlear nerve (combine to form CN VIII-8th) (acoustic or vestibulocochlear nerve)

3. Describe the teaching opportunities to reduce a client's risk of stroke and to promote health.

CVA/STROKE/BRAIN ATTACK Blood flow to a portion of the brain is interrupted or stops, depriving the brain cells from oxygen. -blood flow is blocked, brain cells begin to die, PERMANENT damage may result. KINDS OF STROKE: 1. hemorrhagic: brain aneurysm bursts or a weakened blood vessel in the brain leaks. Less common, 15% strokes & 40% stroke deaths. 2. ischemic:blood vessel carrying blood to the brain is blocked by a clot. 3. TIA (or transcient ischemic attack- mini-stroke that causes no damage but indicates stroke risk. SX last for a short time but may last up to 24hrs before sX disappear. SIGNS & SYMPTOMS: 1. Sudden numbness or weakness of face, arm, or leg, especially on one side of the body 2. Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes 3.Sudden trouble walking, dizziness, loss of balance, or coordination 4. Sudden severe headache with no known cause FAST: FACE:Ask person to smile. Droop? ARMS:Raise both. One Drift? SPEECH: Repeat simple phrase TIME:ANY SX call 911 RISK: -Hypertension:at or above 140/90 -DM - Heart Disease -Smoking -Age/Gender -Race/ethnicity -HX:Personal or fam -Brain aneutrsms or arteriocenous malformations AVM CONTROLLED RISK: -Alcohol and illegal drug use -Certain medical conditions such as sickle cell disease, vasculitis, or bleeding disorders -Lack of physical activity -Overweight and obesity -Stress and depression -Unhealthy cholesterol levels -Unhealthy diet -Use (especially prolonged use) of NSAID medications, such as ibuprofen and naproxen, but not aspirin

Chapter 17 Assessing Ears

Chapter 17 Assessing Ears

Chapter 25: ASSESSING NEUROLOGIC SYSTEM

Chapter 25: ASSESSING NEUROLOGIC SYSTEM

CN VIII (acoustic/vestibulocochlear) Test hearing ability.

Client hears whispered words from 1 to 2 ft. Weber test: Vibration heard equally well in both ears. Rinne test: AC > BC (air conduction is twice as long as bone conduction). ABNORMAL: -Vibratory sound lateralizes to good ear in sensorineural loss. - Air conduction is longer than bone conduction, but not twice as long, in a sensorineural loss NOTE: vestibular component, responsible for equilibrium, is not routinely tested. In comatose clients, the test is used to determine integrity of the vestibular system.

Types of hearing loss

Conductive:when hearing loss is due to problems with the ear canal, ear drum, or middle ear and its little bones (the malleus, incus, and stapes). Sensorineural:when hearing loss is due to problems of the inner ear (cochlea), also known as nerve-related hearing loss. MOST COMMON TYPE OF PERMANENT hearing loss. Mixed:combination of conductive and sensorineural hearing loss. This means that there may be damage in the outer or middle ear and in the inner ear (cochlea) or auditory nerve. Congenital - maternal rubella, syphilis, hypoxia during birth, maternal use of certain medications: minoglycosides, cytotoxic drugs, antimalarial drugs, and diuretics. Severe Jaundice: can cause damage hearing nerve in newborn Acquired - meningitis, measles, mumps, ear infection, collection of fluid in ear (otits media) ototoxic medications:antibiotic and antimalarial, head or ear injury, exposure to noise Bilateral or unilateral: Temporary or permanent: -allergies -blocked eustachian tubes -wax buildup in the ear canal -ear infections -foreign bodies in the ear canal injuries -scarred or perforated eardrum -reactions to certain ototoxic medications (e.g., aminoglycosides, chloroquine, quinidine Presbycusis: gradual sensorineural hearing loss, is common after the age of 50 years. Difficult hearing consonsants w whispered words. difficulty increases over time.

Microtia

Congenital abnormality where the external ear does not fully develop.

8. Analyze the data from the interview and physical assessment of the nervous system to formulate valid nursing diagnoses collaborative problems and/or referrals.

DIAGNOSES: -Risk for injury r/t disturbed sensory patterns -Risk for aspiration r/t impaired gag reflex -Impaired verbal communication r/t aphasia aeb lack of word finding ability -Impaired swallowing r/t absent gag reflex aeb failed swallow test COLLABORATIVE PROBLEM & REFERRALS: -R/C Increased intercranial pressure -R/C Seizures -R/C Stroke

sensorineural hearing loss (inner ear/ nerves)

Dysfunction of inner ear: examples:hearing loss, tinnitus-(ringing in ear), vertigo (dizziness) and imbalance Problem with Organ of Corti: basilar membrane vibrates, Corti to move against the tectoral membrane, stimulating generation of nerve impulses to the brain. Damage to CN VIII: Labyrinthitis refers to inflammation of the membranous labyrinth (inner ear), resulting in damage to the vestibular and cochlear branches of the vestibulocochlear nerve. Hearing loss

Abnormalities INTERNAL EAR STRUCTURES

EXTERNAL AUDITORY CANAL: -foul-smell, sticky, yellow DC otitis externa (swimmers ear) or impated foreign body. SKULL TRAUMA-Bloody, purulent DC (cerebrospinal fluid) refer to hcp Immediately Conductive hearing loss: imapted cerumen (wax) blocking view of external canal Foreign bodies: bugs, plants, food to hcp for removal due to possible swelling and infection Button Battery: EMERGENCY leaking chemicals can burn & damage ear canal within 1 hr COLOR. CONSISTENCY, CHARACTER OF NODULES: -Otitis extra: redden, swollen canals -Exostoses- (nonmalignant nodular swellings) -Polyps may block view of eardrum INSPECTION TYMPANIC MEMBRANE: -pearly gray, shiny, translucent, WO bulging or retraction. slightly concave, smooth & intact. -Cone-shaped relection w light, seen at 5oclock in right ear 7oclock in the left ear. -Clear & visible: short process: malleus & umbo -Acute Otitis Media- Red, bulging eardrum and distorted, diminished, or absent light reflex -Serous Otitis Media: Yellowish, bulging membrane with bubbles behind -SKULL TRAUMA: Bluish or dark red color—blood behind the eardrum -SCARING INFECTION: Whit spots -TRAUMA FRM INFECTION: Perforations -Obstructed eustachian tube: Prominent landmarks—eardrum retraction from negative ear pressure -CHRONIC OTITIS MEDIA: Obscured or absent landmarks—eardrum thickening OLDER ADULT: Appear cloudy Landmarks: may be more prominent bc atrophy of tympanic membrane normal with aging.

Assess Coordination

FINGER TO NOSE TEST: accuracy of movements 1. extend & hold arms out to the side with eyes open 2.Touch the tip of your nose first with your right index finger, then with your left index finger" x3 3.REPEAT W EYES CLOSED normal: Client touches finger to nose with smooth, accurate movements, with little hesitation. ABNORMAL: Uncoordinated, jerky movements and inability to touch the nose may be seen with cerebellar disease COORDINATION OF MOVEMENTS: -dominant side may be more coordinated than the non-dominant side.

CN IX- GOOD

Glossopharyngeal (taste) Promotes swallowing

4. Obtain an accurate nursing history of a client's neurologic system.

HISTORY OF PRESENT CONCERN: pg. 573 Headaches: Seizures: Dizziness/PARESTHESIA: Numbness: Sensory ability Tinnitus Visual changes Difficulty speaking of swallowing Change in bladder or bowel control Muscle weakness Loss of movement Repetitive involuntary trembling Memory loss PERSONAL HX: Head injury Meningitis, encephalitis Injury to spinal cord Stroke -Family history of HTN, stroke, Alzheimer's, dementia, brain CA, Huntington's chorea LIFESTYLE & HEALTH PRACTICES: -Medications, drugs such as cocaine, barbiturates, tranquilizers, marihuana -Alcohol & tobacco -Seatbelt & protective headgear use -24 hour diet recall -Exposure to lead, insecticides, pollutants, other chemicals -Heavy lifting -Ability to perform IADL's -Change in self concept -Stress

3. Interview a client for an accurate nursing history of the ears and hearing.

HX OF PRESENT CONCERN: Recent changes in hearing: -otitis media: middle ear infection - cerumen impaction: Ear eax buildup & Blockage Presbycusis: a gradual sensorineural hearing loss, is common after the age of 50 years. -Often begins w loss of high-frequency sounds -Woman's voice -Followed later by the loss of low-frequency sounds Concern about possible hearing loss: self-assessment "Ten Ways to Recognize Hearing Loss BOX 17-1 All sounds affected or just some sounds: OTHER SYMPTOMS: Ear drainage: -(Otorrhea)=Infection -Purulent, bloody drainage suggests an infection of the external ear (external otitis) -Purulent drainage: W/ PAIN & popping sensation= otitis media: (middle ear infection). W perforation of tympanic membrane. Ear pain: COLDSPA OTALGIA: defined as EAR PAIN. Earache occur w/ ar infections, cerumen blockage, sinus infections, or teeth and gum problems. Swimmers ear: manipulating, or wiggling, the pinna may suggest otitis externa: (swimmer's ear) Tinnitus:Ringing in ears. excessive earwax buildup, high blood pressure, or certain ototoxic medications (such as streptomycin, gentamicin, kanamycin, neomycin, ethacrynic acid, furosemide, indomethacin, or aspirin), loud noises, or other causes. Dizziness: Subjective Vertigo (true spinning motion): -inner ear problem Objective vertigo: (room is spinning ) Subjective vertigo - client feels like she is spinning Objective vertigo - client feels like the rest of the world is spinning BENIGN PAROXYSMAL Positional vertigo (BPPV): -any age - >50 -common in women -unknown cause -head injury or damage to balance organs can underlie BPPV Crystals (otolith organs- related to gravity) become dislodged and create dizziness along with vertigo (sense of spinning), nausea, and vomiting. -unexplained dizziness more than a week visit HCP -EMERGENCY:Associated with new, different, or severe headache; double vision or loss of vision; hearing loss; falling or difficulty walking; or other signs of stroke HEALTH HISTORY: Personal: Previous infections, trauma, earaches: -repeated infections affect tympanic membrane & hearing Treatments for ear problems: -dissatisfied with past treatments for ear or hearing problems. OLDER ADULT: -hearing aids and may refuse to wear one. negative self-image with a hearing aid. Family- Hearing loss in family: Age-related hearing loss tend to run in families. -M

Tophi:

Hard external ear nodules associated with deposits of uric acid crystals in advanced gout.

Assess rapid alternating movements

Have the client sit down. First, ask the client to touch each finger to the thumb and to increase the speed as the client progresses. Repeat with the other side. NORMAL: Client touches each finger to the thumb rapidly. ABNORMAL: Inability to perform rapid alternating movements may be seen with cerebellar disease, upper motor neuron weakness, or extrapyramidal disease. --->NEXT ask the client to put the palms of both hands down on both legs, then turn the palms up, then turn the palms down again (Fig. 25-21). Ask the client to increase the speed. NORMAL: Client rapidly turns palms up and down. ABNORMAL: Uncoordinated movements or tremors are abnormal findings. They are seen with cerebellar disease (dysdiadochokinesia) NORMAL: Client is able to run each heel smoothly down each shin. ABNORMAL: Deviation of heel to one side or the other may be seen in cerebellar disease. COMATOSE OR UNCONSCIOUS NOTE POSTURE: Primitive posturing-unconscious states due to loss of motor control. (A) Decorticate posturing occurs when cortical loss is present. (B) Decerebrate posturing occurs when the midbrain is involved

Cranial Nerves

I - olfactory - occlude each nostril and offer a scent on cotton SMELL II - optic - near & far vision, visual fields, view retina & optic disc VISION III, IV, & VI - oculomotor, trochlear, abduscens - test extraocular movements, pupil reaction V - trigeminal - clench teeth, sharp or dull sensation to face, corneal reflex VII - facial - smile, raise eyebrows, show teeth - taste VIII - acoustic/vestibulocochlear - whisper test, Romberg IX, X - glossopharyngeal, vagus - uvula, gag reflex, swallow test XI - spinal accessory - shrug shoulders XII - hypoglossal - tongue movement

Conductive hearing loss (outter ear)

Impacted cerumen:Earwax blockage Otitis media: Middle ear infection Foreign body: Perforation of tympanic membrane: Ruptured Ear Drum Drainage in middle ear: (swelling) infection, cold allergies Otosclerosis: inherited disorder that causes hearing loss due to the ear's inability to amplify sound. Aging auditory ossicles develop spongy consistency results in hearing loss.

Perform a physical assessment of the ears and hearing ability using the correct techniques. INSPECTION INTERNAL EAR

Inspect the external auditory canal: -small amounts of cerumen (earwax) the only DISCHARGE normally present. -Cerumen color (WAX): yellow orange red brown grey black -Consistency may be soft, moist, dry, flaky or even hard. CULTURAL CONSIDER: Earwax glands one form of aporcrine gland Apocrine sg & mammary glands=aporcrine glands Lower apocrine function produce drier ear wax, less body odor, lower rate of breast cancer. Dry earwax, 10-20% western european descent, not African descent. OLDER ADULT: Drier cerumen build as cilla in the ear canal ridgid. Coarse, thick, wire-like hair at external canal. ONLY abnormal if it impairs hearing INSPECT color, consistency, character of nodules: -pink, smooth WO nodules MOBILITY of TYMPANIC MEM: -Pnumatic ostoscopy: bulb insufflator attached or otoscope w bulb insufflators. OBSERVE: position of tympanic mem when bulb inflated & again when the air is released. Normal: mem flutters when bulb is inflated & returns to resting position once air is released. Abnormal: otitis media, membrane does not move or flutter upon inflation of bulb.

Bone Conduction

Less efficient, but provides an alternate path Bones of skull involved Used in Weber and Rinne tests

Sensory System

Light touch, pain, temperature Vibratory sensation Sensitivity to position Point localization Graphesthesia Two point discrimination Extinction

MOTOR & CEREBELLAR SYSTEMS: Condition & movement of muscles. Assess size & symmerty of all muscle groups

Muscles are fully developed and symmetrical ABNORMAL: 1.Muscle atrophy: disease of lower motor neurons or muscle disorders. 2. Injury to spinal cord associated w extremity weakness. 3. Loss of Motor function: pain & temp. seem in ANTERIOR CORD SYNDROME 4. Loss of proprioception seen in posterior cord syndrome. - A loss of strength, proprioception, pain and temperature is seen in Brown-Séquard syndrome. OLDER ADULT: reduced muslce mass from degeneration of muscle fibers.

Assess the strength and tone of all muscle groups

NORMAL: 1. Relaxed muscle contract involuntarily show mild, smooth resistance to passive movement. 2.muscle groups are equally strong against resistance, without flaccidity, spasticity, or rigidity. ABNORMAL: Soft, limp, flaccid muscles are seen with lower motor neuron involvement. 2.Spastic muscle tone is noted with involvement of the corticospinal motor tract. 3.Rigid muscles that resist passive movement are seen with abnormalities of the extrapyramidal tract.

To perform the Romberg's test, the nurse asks the patient to stand erect with arms & feet together: Note: Unsteadiness o swaying -Body postion, close eyes for 20 sec. -Note any imbalance or swaying

NORMAL: Client stands erect with minimal swaying, with eyes both open and closed. ABNORMAL: POSTIVE ROMBERG TEST: Swaying and moving feet apart to prevent fall is seen with disease of the posterior columns, vestibular dysfunction, or cerebellar disorders. SAFTEY: Stand near client to prevent fall should client lose balance. ---> 1.Stand on one foot & bend knee of leg the client is standing on. 2. Client Hop on that foot 3. repeat on other foot. NORMAL: Bends knee while standing on one foot; hops on each foot without losing balance. ABNORMAL: Inability to stand or hop on one foot is seen with muscle weakness or disease of the cerebellum. OLDER ADULT: Test is impossible to perform bc of decreased flexibility & strength. -puts client at risk for fall

UNUSUAL INVOLUNTARY MOVEMENTS. such as fasciculations, tics, or tremors.

Normal: No fasciculations, tics, or tremors are noted. ABNORMAL: 1. Fasciculation (rapid twitching of resting muscle in lower motor neuron disease or fatigue. 2.Tic (twitch of the face, head, or shoulder) from stress or neurologic disorder. - Unusual, bizarre face, tongue, jaw, or lip movements from chronic psychosis or long-term use of psychotropic drugs. 3. Tremors (rhythmic, oscillating movements) from Parkinson disease, cerebellar disease, multiple sclerosis (with movement), hyperthyroidism, or anxiety. 4. Slow, twisting movements in the extremities and face from cerebral palsy. 5. Brief, rapid, irregular, jerky movements (at rest) from Huntington chorea. 6. Slower twisting movements associated with spasticity (athetosis) seen with cerebral palsy.

8. Analyze the data from the interview and physical assessment of the ears and hearing to formulate valid nursing diagnoses, collaborative problems, and/or referrals.

Nursing DX: Readiness for enhanced verbal communication r/t ... Risk for injury r/t hearing impairment Risk for loneliness r/t hearing impairment Acute pain r/t ... aeb ... Impaired social interaction r/t hearing loss aeb ... Impaired verbal communication r/t hearing loss aeb Collaborative Problems & Referrals: R/C otitis media R/C perforated tympanic membrane R/C otitis externa

Perform a physical assessment of the ears and hearing ability using the correct techniques. Equipment

Objective Data: Prepare client: -seated comfy -explain -answer ?s -watch Qs of not hearing Obtain equipment: Otoscope: Pg. 346 (17-1) flashlight-type viewer used to visualize the eardrum and external ear canal Watch with second hand Tuning fork (512 or 1024 Hz):

CN I- ON

Olfactory (smell)

CN mnemonic

On Occasion Our Trusty Truck Acts Funny Very Good Vehicle Any How O: Olfactory -CNI O: Optic -CNII O: Oculomotor -CNIII T: Trochlear -CNIV T: Trigeminal -CNV A: Abducens -CNVI F: Facial -CNVII V: Vestibulocochlear -CNVIII G: Glossopharyngeal -CN IX V: Vagus -CN V A: Accessory -CN XI H: Hypoglossal -CN XII

CN II- OCCASION

Optic - vision

4. Perform a physical assessment of the ears and hearing ability using the correct techniques. INSPECTION EXTERNAL EAR STRUCTURES Objective data

Physical Exam: INSPECT the auricle, tragus, and lobule: -Size:Normally 4-10cm -shape:equal bilaterally -position:10 degree angel vertical postion -Earlobes may be free, attached, or soldered: tightly attached no apparent lobe. PALPATE auricle and mastoid process: Tenderness: may indicate otitis externa: otitis media: mastoditis: Otoscopic exam: -External auditory canal -Tympanic membrane (color, shape, and consistency of landmarks) Cultural: African Americans and Caucasians: free lobes -Asians have attached or soldered lobes Older Adult: elongated earlobes with linear wrinkles.

REFLEXES SEE TEXT PG 581

REFLEXES SEE TEXT PG 581

Assess tactile discrimination (fine touch)

Remember that the client should have eyes closed. To test stereognosis, place a familiar object such as a quarter, paper clip, or key in the client's hand and ask the client to identify it (Fig. 25-27). Repeat with another object in the other hand. NORMAL: Client correctly identifies object. ABNORMAL: Inability to correctly identify objects (astereognosis), area touched, number written in hand; to discriminate between two points; or identify areas simultaneously touched may be seen in lesions of the sensory cortex.

Romberg Weber Rinne Whisper

Romberg: equilibrium Weber/Rinne:: distinguish between sensorineural and conductive hearing loss Whisper:assess hearing loss

Test vibratory sensation

Strike a low-pitched tuning fork on the heel of your hand and hold the base on the distal radius (Fig. 25-25A), forefinger tip (Fig. 25-25B), medial malleolus (Fig. 25-25C), and, last, the tip of the great toe Ask the client to indicate what he or she feels. Repeat on the other side. NORMAL:Client correctly identifies sensation. ABNORMAL: Inability to sense vibrations may be seen in posterior column disease or peripheral neuropathy (e.g., as seen with diabetes or chronic alcohol abuse). OLDER ADULT: Vibratory sensation at the ankles may decrease after age 70 -vibration sense is more likely to be absent at the great toe and preserved at the ankle bones TIP: IF vibratory sensation is intact distally, then it is intact proximally.

Assess/ TEST CN VII (Facial)

TEST MOTOR FUNCTION: -smile -frown -show teeth -puff out cheeks -purse lips -raise eyebrows -close eyes tightly against resistance NORMAL: Movements & symmetric ABNORMAL: 1. Bell palsy (a peripheral injury to cranial nerve VII [facial])---inability to close eyes, wrinkle forehead, or raise forehead along with paralysis of the lower part of the face on the affected side is seen with 2. Paralysis of the lower part of the face on the opposite side affected may be seen with a central lesion that affects the upper motor neurons, such as from STOKE ---> SENSORY of CN VII: RARELY TESTED: 1. touch the anterior two thirds of the tongue with a moistened applicator dipped in salt, sugar, or lemon juice. 2.Pt to identify NORMAL: Client ids flavor ABNORMAL: Inability to id correctly indicate impairment of CNVII OLDER ADULT: sense of taste decreased.

Test CN IX (glossopharyngeal) and X (vagus).

Test motor function: 1. Client open mouth wide "say ah". W tounge depressor on clients tounge. Normal: -Uvula & soft palate rise bilaterally & symmetrically on phonation. ABNORMAL: Soft palate does not rise with bilateral lesions of cranial nerve X (vagus). Unilateral rising of the soft palate and deviation of the uvula to the normal side are seen with a unilateral lesion of cranial nerve X (vagus). ---> TEST GAG REFLEX: touching posterior pharynx with tounge depressor NORMAL: Gag reflex intact. Some normal clients may have a reduced or absent gag reflex. ABNORMAL: absent gag reflex may be seen with lesions of cranial nerve IX(glossopharyngeal) or X (vagus). ---> Check clients ability to swallow: Client to drink water. note: quality of voice Normal: Client swallows without difficulty. No hoarseness noted. ABNORMAL: Dysphagia or hoarseness may indicate a lesion of cranial nerve IX (glossopharyngeal) or X (vagus) or other neurologic disorder.

Romberg Test

Tests equilibrium 1. Client should maintain position 20 seconds standing, arms at side, once with eyes open and then eyes closed. Stay near client for safety. Normal: clients maintains postion for 20 seconds WO swaying or w minimal swaying. -Client moves feet apart to prevent falls or starts to fall from loss of balance. may indicate VESTIBULAR DISORDER: imbalance.

CN IV-TRUSTY

Trochlear- Contracts one eye muscle to control inferomedial eye movement.

TEST CNII(Optic): (Assessment)

USE SNELLEN CHART Client Has 20/20 VISON OD (right side) & OS (leftside) --->ABNORMAL: 1.difficulty reading Snellen chart, missing letters, and squinting. --->Read magazine or newspaper: Client reads at 14 in wo difficulty --->Abnormal: by holding closer than 14 in or holds print farther away as in presbyopia, which occurs with aging. <--->Full visual fields by confrontation --->ABNORMAL: Retinal damage or detachment, with lesions of the optic nerve, or with lesions of the parietal cortex <--->Opthalmoscope(view retina & optic disc): 1. Round red reflex is present, optic disc is 1.5 mm, round or slightly oval, well-defined margins, creamy pink with paler physiologic cup. Retina is pink --->ABNORMAL: 1. Papilledema (swelling of the optic nerve)blurred optic disc margins and dilated, pulsating veins. Papilledema: intracranial pressure from intracranial hemorrhage or a brain tumor. 2. Optic atrophy occurs with brain tumors

CN X- VEHICLE

VAGUS- uvula, gag reflex, swallow test, talking

Hearing Tests

Whisper test: 1. Start with better ear 2. Cover ear not being tested 3. Two syllable word 4. Two feet behind client 5.3/6 words passing! IF unable to repeat word X2 tries, indicates hearing loss. Refer to Audiologist. WEBER TEST: Client reports loss of hearing in one ear. 1. Tuning fork to middle of head 2. In conductive loss (sound waves transmitted by the external and middle ear), -vibration will be heard louder in affected ear 3. In sensorineural loss (sound waves transmitted by the inner ear) -vibration heard louder in good ear RINNE TEST: 1.Place tuning fork on mastoid process, when client stops hearing move to front of ear 2. Normal 2:1 ratio of air to bone conduction 3. Decreased air conduction indicates conductive hearing loss

Atrophy and fasciculations OF TOUNGE

a patient with amyotrophic lateral sclerosis.

exostosis of external ear

a projection arising from a bone that develops from cartilage

Analgesia

absence of pain sensation

ASSESS/TEST XII (hypoglossal)

assess strength and mobility of the tongue, protrude tongue, move it to each side against the resistance of a tongue depressor, and then put it back in the mouth. NORMAL: tounge movement is symmetric & smooth, bilateral strength ABNORMAL: Fasciculations and atrophy of the tongue may be seen with peripheral nerve disease. -Deviation to the affected side is seen with a unilateral lesion.

To test graphesthesia

blunt instrument to write a number, such as 2, 3, or 5, on the palm of the client's hand (Fig. 25-28). Ask the client to identify the number. Repeat with another number on the other hand. NORMAL: Id number written ABNORMAL: Inability to correctly identify objects (astereognosis), area touched, number written in hand; to discriminate between two points; or identify areas simultaneously touched may be seen in lesions of the sensory cortex.

To test point localization,

briefly touch the client and ask the client to identify the points touched. NORMAL: Correctly id. ABNORMAL: Inability to correctly identify objects (astereognosis), area touched, number written in hand; to discriminate between two points; or identify areas simultaneously touched may be seen in lesions of the sensory cortex.

Hypalgesia

decreased sensitivity to pain

scarred tympanic membrane

eardrum has white patches of scar tissue due to repeated ear infections.

CN VII- FUNNY

facial - smile, raise eyebrows, show teeth - taste

CN XII- HOW

hypoglossal - tongue movement, movement of food & talking

Hyperalgesia

increased sensitivity to pain)

blue/dark red tympanic membrane

indicates blood behind eardrum due to trauma

Acute Otitis Media (AOM)

middle ear infection

To test light touch sensation, use a wisp of cotton to touch the client (Fig. 25-23). To test pain sensation, use the blunt (Fig. 25-24A) and sharp ends (Fig. 25-24B) of a safety pin or paper clip. To test temperature sensation, use test tubes filled with hot and cold water.

normal: Client correctly differentiates between dull and sharp sensations and hot and cold temperatures over various body parts. ABNORMAL: Client reports: 1. Anesthesia (absence of touch sensation) 2. Hypesthesia (decreased sensitivity to touch) 1. Hyperesthesia (increased sensitivity to touch) 2.Analgesia (absence of pain sensation) 3.Hypalgesia (decreased sensitivity to pain) 4.Hyperalgesia (increased sensitivity to pain)

Two point discrimination

normal: Client identifies two points on: -Fingertips at 2-5 mm apart -Forearm at 40 mm apart -Dorsal hands at 20-30 mm apart - Back at 40 mm apart Thighs at 70 mm apart ABNORMAL: Inability to correctly identify objects (astereognosis), area touched, number written in hand; to discriminate between two points; or identify areas simultaneously touched may be seen in lesions of the sensory cortex.

CN III- OUR

oculomotor- eye movement Contracts eye muscles to control eye movements (interior lateral, medial, and superior), constricts pupils, and elevates eyelids.

retracted tympanic membrane

prominent landmarks are caused by negative ear pressure due to obstructed eustachian tube or chronic otitis media

Perforated Tympanic Membrane

rupture caused by increased pressure, usually from untreated infection or trauma.

Test extinction

simultaneously touch the client in the same area on both sides of the body at the same point. Ask the client to identify the area touched. NORMAL: Normal reflex scores range from 1+ (present but decreased) to 2+ (normal) to 3+ (increased or brisk, but not pathologic). ABNORMAL: Absent or markedly decreased (hyporeflexia) deep tendon reflexes (rated 0) occur when a component of the lower motor neurons or reflex arc is impaired; this may be seen with spinal cord injuries. Markedly hyperactive (hyperreflexia) deep tendon reflexes (rated 4+) may be seen with lesions of the upper motor neurons and when the higher cortical levels are impaired.

frontal lobe of cerebrum

the top, front regions of each of the cerebral hemispheres. They are used for reasoning, emotions, judgment, and voluntary movement.

Conductive hearing

transmission of sound waves through the external and middle ear -sound Vibrations transmitted through air -Collected and funneled by external ear -Tympanic membrane vibrates -Vibration transmitted through auditory ossicles -Stapes vibrates in oval window -stimulate hair cells, sprial organ of corti, nerve impulses travel to the brain by way of acoustic nerves.

CN V- TRUCK

trigeminal - clench teeth, sharp or dull sensation to face, corneal reflex pain, touch, and temperature from the face to the brain. Influences clenching and lateral jaw movements (biting, chewing).

CN VIII- VERY

vestibulocochlear /acoustic- whisper test, Romberg HEARING & BALANCE