Health Assessment Exam 3

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CN12

Hypoglossal nerve STICK OUT TONGUE, TONGUE STRENGTH, AND SPEAKING

CN12

Hypoglossal nerve STICK OUT TONGUE, TONGUE STRENGTH, AND SPEAKING.

Temperature is controlled by which part of the brain?

Hypothalamus

Babinski reflex

In response to the sole of the foot being stroked, a baby's big toe moves upward or toward the top surface of the foot and the other toes fan out

Conjunctivitis

Inflammation of the conjunctiva

If a headache presents with a rash and fever, we should think...

Meningitis

Deep tendon reflexes (DTR)

Muscle contraction in response to a stretch caused by striking the muscle tendon with a reflex hammer. test used to determine if muscles are responding properly

Nasolabial folds

Nasolabial folds are the indentation lines on either side of the mouth that extend from the edge of the nose to the mouth's outer corners

If there is fluid behind the tympanic membrane, but it is still transparent, is it infected?

The name of cranial nerve II is what?

Optic nerve

Confrontation Tests what?

Peripheral vision

Confrontation tests for what and uses which cranial nerve?

Peripheral vision, optic nerve

If we see a slow, clumsy, or decrease in coordination, we should think...

Possible cerebral/vestibular disease or drunk

You walk into a patient's room and see the patient is ashen and is not breathing. Your heart starts racing and you start to sweat. This response is part of the____.

Sympathetic nervous system

When we palpate the frontal and maxillary sinuses, what are we looking for?

Tenderness

When we see Rigid muscle tone, we should think...

Tetanus

Where is the eustachian tube located?

The middle ear

Which parts of the ear does the tympanic membrane separate?

The outer and middle ear

Tragus

The small, rounded, fleshy bulge that lies immediately anterior to the ear canal.

Issues with which organ often cause exophthalmoses?

Thyroid problems

A spinning sensation accompanied by nystagmus and ataxia is _____

Vertigo

Iris

a ring of muscle tissue that forms the colored portion of the eye around the pupil and controls the size of the pupil opening. Also a great song by the Goo Goo dolls.

Epistaxis

bleeding from the nose

LLQ

descending and sigmoid colon

Nits

lice eggs

What is the occipital lobe responsible for?

visual processing

Ototoxic drugs

-aspirin, aminoglycosides, vancomycin, erythromycin, loop diuretics (like furosemide), the anti-malarial medications, sildenafil (tadalafil, vardenafil) and cisplatin

Headache red flags

•Recent onset •>50 yrs age •Acute onset like "thunderclap" •Markedly elevated blood pressure •Presence of rash or signs of infection •Presence of cancer, HIV, or pregnancy •Vomiting (esp projectile) •Recent head trauma

CN6

Abducens nerve EOM

Sensory nerves are called ___

Afferent

Posterior pillar

Arch of tissue extending from the soft palate to the pharynx

Ear tubes

Equilize pressure so that air can circulate Will stay in for 1-2 years Used when the Eustachian tube does not work

In adults sutures are ____

Fused

When checking LOC in a patient, which answer to your questions is the most concerning?

I do not know who I am

Sympathetic Nervous System

"Fight or flight" Stress response -Heart rate, blood pressure, pupil size -Think about realizing that you are about to be in a bad situation—as you realize this, your body goes into fight or flight. Thinking quick on feet. -Increased HR, BP, RR-because more oxygen is needed to figure out a strategic move and nutrients to muscles to help with the fight -Pupil size will dilate to let in as much information as possible.

Malleus

"Hammer", a small bone in the middle ear that transmits vibrations of the eardrum to the incus.

Parasympathetic nervous system

"REST AND DIGEST", CONSERVES BODY RESOURCES TO MAINTAIN NORMAL BODILY FUNCTIONS. -INCREASE GASTRIC SECRETIONS, SLOWS HEART RATE.

Stapes

"stirrup"; inner of the 3 ossicles of the middle ear

Graphesthesia

"write" a number in palm and ask them to identify If they are unable to do this, they have a sensory cortex lesion

5 components needed for DTR response:

(Important to know... hint hint) -Intact sensory nerve (afferent) -Need to feel -A functional synapse in the cord -For message to be sent -An intact motor nerve fiber (efferent) -Send response message -A functional joint -Need to move -A competent muscle -Need muscle to move

Testing the Central and Peripheral Nervous system

*MENTAL STATUS/ LOC - CEREBRAL CORTEXT (CEREBERUM) TESTING ORIENTATION TO THEIR SURROUNDINGS *CRANIAL NERVES: -BRAINSTEM *COORDINATION AND MOTOR SYSTEM -CEREBELLUM, CEREBRAL CORTEX, CORTICOSPINAL, AND EXTRAPYRAMIDAL TRACTS. *SENSORY SYSTEM: CEREBAL CORTEX, SPINAL CORD, AND POSTERIOR COLUMNS -light tough or painful stimuli—ability to carry messages all the way through -REFLEXES

EOMs

- 6 cardinal fields of gaze (2 upper, 2 laterals, 2 lowers) doing the H method will test all fields -Look for Nystagmus (bouncing of the eyes at end ROM) -Nystagmus normal at extremes of gaze -In labyrinth disorder- nystagmus will be present in certain positions

Expressive dysphasia

- CAN UNDERSTAND WHAT OTHERS ARE SAYING - WORDS ARE SLOW AND LABORIOUS, BUT MEANINGFUL - OFTEN GET FRUSTRATED - EX: BROCA'S APHASIA - Barbara Broca is a very grumpy and frustrated lady because she knows what you are saying but she cannot get the words out. (Expressive)

Eye- EOM Test

-Position and alignment -Corneal light reflex- when we shine the light at the bridge of the nose and should see a light reflecting back from the pt cornea in the same location on both eyes -EOMs (6 cardinal fields of gaze) (2 upper, 2 laterals, 2 lowers) doing the H method will test all fields -Look for Nystagmus (bouncing of the eyes at end ROM) -Nystagmus normal at extremes of gaze -Cover/Uncover test- Assess for strabismus; the weaker eye will deviate away during this test (you will notice because it breaks to where you are looking when you uncover the eye)

Documenting DTRs

-Possible cervical cord compression -Documenting DTR: (kind of similar to pulse) -Know scar tissue may affect DTR. -Clonus doesn't stop engaging in spastic response - 4+ very brisk (clonus present) - 3+ Brisker than average - 2+ average - 1+ somewhat diminished - 0 no response ***Mismatch on each side is not a run moment; collect more data!

Headaches

-Primary v. Secondary •Secondary: Arises from other conditions •Rule out other conditions first -Need to rule out life-threatening causes »Aneurysm »CVA »Meningitis »Subdural or intracranial hemorrhage »Tumor

PERRLA

-Pupils -Equal (are the pupils the same size and shape) -Round (are they round or not) -Reactive to Light (talking about direct, when you shine the light into each eye) (consensual, when you shine the light in only one eye and the other constricts as well) -Accommodation (looking far= dilated, looking close= constrict)

Cogwheel rigidity

In cogwheel rigidity, your muscle will be stiff, like in other forms of rigidity. But you might also have tremors in the same muscle when it's at rest. Cogwheel rigidity can affect any limb, but it's most common in the arms. ... Therefore, cogwheel rigidity can help doctors diagnose Parkinson's disease

What is the highest priority nursing diagnosis for this patient (the picture shows the airway is almost completely blocked off due to enflamed tonsils)

Ineffective airway clearance

STAR Causes of Sensorineural heaing loss

Inner ear: -Meniere's disease -Noise exposure -Presbycusis -Ototoxicity

A student tells the nurse "my eye is doing something funny. It has been twitching since early this morning. What is causing this?" The nurse should respond:

It is called fasciculation and it is likely because you are tired.

Relating MSK to Neuro

-STRENGTH against gravity and full resistance (note as 0-5, recorded as "5/5" = normal) -Muscle size and symmetry (atrophy, hypertrophy) -Full range of motion of joints -Muscle tone: slight resistance with passive motion **THINKING NEURO** -Diabetic Neuropathies -Atrophy from polio, MS -Paralysis -Involuntary movements -Tics(normally when awake, muscle spasm, involuntary movement), tremors(can happen when resting or sleeping, involuntary movement) -Seizures are involuntary -Fasciculations: Ex: eye twitches because the muscle is tired -Pain in ROM, resistance -Muscle tone -FLACCID: POLIO, GUILLIAN-BARRE -SPASTIC(muscle itself, muscle tone): CEREBRAL PALSY, SPINAL CORD INJURY -Constant muscle constriction -RIGID (board like so hard to push-feels like pushing on concrete): TETANUS -COGWHEEL RIGIDITY (very jerky motion): PARKINSONS

How should you hold an otoscope?

Make sure your knuckles holding the otoscope are touching the patient's mastoid process. That way if they move you wont jam the otoscope too deep in their ear.

Relating MSK to neuro

Secondary Headaches

-Secondary headaches are more likely to occur after age 50 years with a sudden severe onset and should be ruled out before making the diagnosis of a primary headache.

Nose - Subjective Data

-Sinus pain, facial pain, teeth pain -Hx sinusitis, sinus surgeries -Hx COVID-19 (with loss of smell and taste) -Nasal stuffiness, discharge, bleeding -Postnasal drip (dripping down the back of the throat) -History of previous nose issues/surgery/injuries -Seasonal Allergies -Snoring (excessive that needs to be evaluated) -Changes in ability to smell -Lifestyle habits, air quality, pets, alcohol, tobacco, recreational drugs

Nose- Subjective Data

Facial Expression

-Smile -Puff cheeks -Show teeth -Wrinkle brow -Squeeze eyes shut against resistance

Oral Cancer

-Sores, bumps, lumps, unusual spots -Red or white sores/lesions on gums of inside cheek -Pain/numbness (cheeks, tongues, gums, throat) -Difficulty talking, chewing, drinking, breathing -Chronic sore throat/knots in neck or cheeks -Feeling like something is stuck in mouth/throat -Severe bleeding/Sudden loss of teeth -Obvious signs of infection that persist like thrush and you cannot get rid of it -Seen in smokers, Black men, and dippers

Corneal light reflex

-Tests position and alignment -Also known as the Hirschberg test, assesses parallel alignment; have pt look straight ahead, shine light from 12" and look for reflection on corneas in exactly the same position in both eyes; asymmetry indicates deviation in alignment from eye muscle weakness or paralysis Basically, when we shine the light at the bridge of the nose and should see a light reflecting back from the pt cornea in the same location on both eyes

Diagnostic Tests-Mouth and Throat

-Visual Acuity Tests (Snellen, color blindness, other visual abnormalities) -Nasal swab (Flu, Covid, respiratory panel, etc) -Throat Culture, Rapid Strep Test (completed just like a throat culture, this test is about 90% accurate) -Barium Swallow (looking at patient as they swallow and seeing how well they swallow) -Biopsy -Laryngoscopy (looking at larynx) -Nasal Endoscopy (looking for structural abnormalities) -Hearing Tests -Ultrasound (thyroid, mouth, glands) -CT/MRI

Diagnostic tests for HEENT

Inspection and palpation of mouth

-Want to check lips, buccal mucosa, gums, teeth, palate, salivary ducts. -Have patient stick tongue out, grab with gauze, move side to side, test strength. -Check the dorsum, sides, and ventral surface of tongue for erosions, discoloration, lumps or bumps -Note any slurred speech, drooling, etc.

Mouth and Throat inspect ad palpate

-Want to check lips, buccal mucosa, gums, teeth, palate, salivary ducts. Have patient stick tongue out, grab with gauze, move side to side, test strength. Check the dorsum, sides, and ventral surface of tongue for erosions, discoloration, lumps or bumps -Note any slurred speech, drooling, etc.

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds once you close your eyes, now you are testing the cerebellum on its own and you can't fake this. You take away any other assistance

Vasovagal response

-can be a response to any stressor or low blood sugar -autonomic nervous system reacts causes bradycardia and allows vasodilation in the lower extremity vessels- decrease blood - decrease O2 to brain - on floor. -taller people can have a higher chance of passing out

Sensorineural hearing loss

-cochlear, auditory nerve damage or auditory area of cerebral cortex damaged -Presbycusis •loss of high frequency sound due to aging -Inner ear disease, ototoxic drugs

Conductive hearing loss

-mechanical dysfunction in external or middle ear -foreign object in canal, perforated TM, otosclerosis

Alterations in sensory function

-weakness (and think about one-sided), paralysis, spasms -vision, hearing, taste, smell -pain - Paresthesia: Numbness, tingling, burning, crawling sensation -peds may say "I feel like there are bugs in my fingers" -Think about nerves -difficulty swallowing (DYSPHAGIA) -difficulty speaking, forming words, or language comprehension(DYSPHASIA) -Think about strokes if there are sudden changes in speech

Blood pressure is controlled by which part of the brain?

Medulla

Respiratory rate is controlled by which part of the brain?

Medulla and pons

When we think photophobia, we should be thinking...

Meningitis

Ear Structure and Function

Middle Ear -Conducts sound, equalizes air pressure and reduces loudness -Auditory ossicles (little bones that transmit vibrations from Tympanic membrane to the inner ear Malleus, Incus, Stapes) transmits vibration from TM to inner ear -Eustachian tube- Equalizes air pressure from middle ear to nasopharynx, More horizontal in child; more angled in adult Inner ear -Labyrinth made up of Semicircular Canals, Vestibule, and Cochlea and these are Responsible for balance and transmission of sound -Cochlea- Converts vibrations and sends through cochlear nerve to brain

Otitis media is a condition affecting which portion of the ear?

Middle ear

Where are the auditory ossicles located?

Middle ear

The nurse's assessment of an older adult client's ears and hearing suggest the possible presence of conducting hearing loss. What is the most likely etiology of this abnormal finding?

Middle ear infection

The nurse's assessment of an older client's ears and hearing suggests the possible presence of conductive hearing loss. What is the most likely etiology of this abnormal finding?

Middle ear infection

Glasgow coma scale

Most sensitive indicator for decreased neuro function and earliest change in acute ICP changes -Eye opening (1-4) -Verbal response (1-5) -Motor response (1-6)

Where is the thyroid gland located?

Mostly behind the trachea -Think butterfly gland

Cerebellum

Motor coordination, equilibrium, and balance DEALS WITH MOTOR CORDINATION LIKE WALKING, RUNNING WITHOUT FALLING OVER. - MOST COMMON BRAIN INJURIES WE WILL SEE ARE DUE TO CAR ACCIDENTS: COUP AND CONTRA-COUP INJURIES

The nurse is testing the function of cranial nerve XI. Which of the following best describes the response the nurse would expect if the nerve is intact?

Moves the head and shoulders against resistance with equal strength

Tests for cerebral function

What is a normal number of bowel sounds?

5-34 per minute

Convergence

A binocular cue for perceiving depth; the extent to which the eyes converge inward when looking at an object

Polio

A highly contagious infectious disease of the spinal cord caused by a filterable virus.

Temporal artery

A major artery of the head, under the skin of the forehead

Abdominal reflex

Normal response is the ipsilateral contraction of the abdominal muscles with an observed deviation of the umbilicus towards the stroke.

If there is fluid visible behind the tympanic membrane, is it infected?

Not necessarily. If the tympanic membrane is still clear then it is not infected, despite the presence of fluid and bubbles. -Look for purulence or white color instead of transparency for indication of infection

The patient is complaining of diplopia(double vision) after his head injury. The nurse recalls that what cerebral lobe is responsible for this?

Occipital lobe

CN3

Oculomotor nerve -Responsible for movement of the eye in all directions except in and toward the nose. -Constricts and dilates pupil PERRLA and EOM

CN1

Olfactory nerve -Smell test

CN2

Optic nerve SNELLEN TEST, CONFRONTATION

Neurological Physical Exam

Orientation: FIRST AWARENESS OF WHETHER BRAIN IS INTACT -Person (severe impairment; last to go; identity of self)-MOST concerning; Ex: My name is Susie, but it's actually John -Place -Time -4 th - familiar person or situation VITAL SIGNS -CLUE TO STATUS OF AUTONOMIC NERVOUS SYSTEM AND BRAINSTEM. - HR--> Vagus - Respiratory --> Medulla and pons - BP --> Medulla - Temperature --> Hypothalamus (the thermostat of the body) -impossible to regulate until the hypothalamus is fixed

Which term refers to drainage from the ear?

Otorrhea

Sensory system function test

PATIENT WILL HAVE EYES CLOSED, TEST SENSATION: First sensation you will lose is in the peripheral spots. -light touch(going down the body) -sharp/ dull -Monofilament(extremely specific places) -first sensation lost with peripheral neuropathies -> feet *examine in detail if: -Reduced sensation -Numbness or pain -Motor or reflex abnormal **REMEMBER THAT WHEN PERFORMING A SENSORY FUNCTION TEST, THE EYES HAVE TO BE CLOSED**

PERRLA

PERRLA: -Pupils -Equal (are the pupils the same size and shape) -Round (are they round or not) -Reactive to Light (talking about direct, when you shine the light into each eye) (consensual, when you shine the light in only one eye and the other constricts as well) -Accommodation (looking far= dilated, looking close= constrict)

Cognitive interpretation tests

PT should have eyes closed for these tes - Stereognosis: paperclip or familiar item in hand, patient will try to ID it. -Unable to ID it indicates a sensory cortex lesion. -**it has to be a familiar item, they have to be able to know the object - Graphesthesia: "write" a number in palm and ID it. -unable to ID it = sensory cortex lesion -Move to their side to write in relation to the PT -Use different number on different hand

When we see cogwheel rigidity, we should think...

Parkinson's

This disease is characterized by flat, expressionless, or mask-like face, a staring gaze, oily skin, and elevated eyebrows

Parkinson's disease

Conjunctivitis

Pattern of Redness- Conjunctival injection: diffuse dilation of conjunctival vessels with redness that tends to be maximal peripherally Pain- mild discomfort rather than pain Vision- Not affected except for temporary mild blurring due to discharge Pupil is not affected Corneas are clear Significance- Bacterial, viral, and other infections; allergy; irritation

What color should the tympanic membrane be when healthy?

Pearly grey with a cone of light reflecting from the otoscope

A 35-year-old man in a MVA is brought to the ED. He is not responding to questions and unable to follow simple commands. Which is the best assessment skill to perform next?

Perform sternal rub

Stereognosis

Place a familiar object in the patient's hands with their eyes closed and ask them to identify If they are unable to ID, then they have a sensory cortex lesion

Which neuro diseases often lead to muscle atrophy?

Polio and MS

When we see flaccid muscle tone, we should be thinking...

Polio or Guillian-Barre

Ampulla

Portion of the vestibular system which receives endolymph from semicircular canals. The movement is detected by stereocilia which release neurotransmitters that signal the brain about the direction of movement

When we see projectile vomiting, we should think...

Possible head trauma

Presyncope

Presyncope—a near faint from "feeling faint or lightheaded"; causes include orthostatic hypotension, especially from medication, arrhythmias, and vasovagal attacks (∼5%)

Headache from meningitis

Process- Viral or bacterial infection of the meninges surrounding the brain and spinal cord Location- generalized Quality/severity- Steady or throbbing, very severe Onset- Fairly rapid, usually <24 hours; may be sudden onset Duration- Variable, usually days Course- Viral: usually <1 week; bacterial: persistent until treatment Associated symptoms- Fever, stiff neck, photophobia, change in mental status Factors tat aggrivate Factors that relieve- Immediate antibiotics until diagnosis of if bacterial or viral

Headaches from Sinusitis

Process: Mucosal inflammation of the paranasal sinuses Location: Usually, frontal sinuses above the eyes or over the maxillary sinus Quality/severeity: Aching or throbbing, severity variable; consider possible migraine Variable onset Duration: Often daily several hours at a time, persisting until treatment Course: Often daily in a repetitive pattern Associated Symptoms: Local tenderness, nasal congestion, discharge, and fever Aggravating factors: May be aggravated by coughing, sneezing, or jarring the head Relieving factors: Nasal decongestants, antibiotics

Temporal lobe

A region of the cerebral cortex responsible for hearing and language. Senses, taste, hearing, smell - damage to this area from side to side, strokes or infarcts to those area (Ex: it smells like fire)

Frontal Lobe

A region of the cerebral cortex that has specialized areas for movement, abstract thinking, planning, memory, and judgement WHERE WE GET OUR PERSONALITY AND EMOTIONS, MAINLY DRAW OUR INTELLECT AND BEHAVIORS.

Autonomic nervous system

The part of the peripheral nervous system that controls the glands and the muscles of the internal organs (such as the heart). Its sympathetic division arouses; its parasympathetic division calms. SMOOTH MUSCLES (INVOLUNTARY MOVEMENT) -MEDIATES UNCONSCIOUS ACTIVITIES (HOMEOSTASIS, HEART, GLANDS) -THINK ABOUT THE AUTOMATIC THINGS YOUR BODY DOES TO KEEP YOU ALIVE. -Smooth muscles and involuntary movement

When testing DTR's, your patient has a +2 patellar response on the left and a +1 patellar response on the right. How does the nurse interpret this finding?

The right patellar DTR is diminished

Near syncope

The sensation that one might lose consciousness.

Proprioception

The sense through which we perceive the position and movement of our body, including our sense of equilibrium and balance -Keeps us upright when we close our eyes

Occipital Lobe

A region of the cerebral cortex that processes visual information RESPONSIBLE FOR VISUAL RECEPTORS -These are the most common injuries you will see because neck flexes forward while the brain smashes up against the skull. Will hit the frontal lobe area—backwards effect in the occipital lobe—Coup and contra-coup injury! -This is why you may see someone who is fighting treatment and it is because their frontal lobe has been damaged. Double vision and can't see from occipital lobe.

Parietal Lobe

A region of the cerebral cortex whose functions include processing information about touch. DEALS WITH SENSATION "OH THAT'S HOT"

lid retraction and exophthalmos

A wide-eyed stare suggests retracted eyelids. Note the rim of sclera between the upper lid and the iris. Retracted lids and a lid lag (p. 254) are often due to hyperthyroidism. In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism. Edema of the eyelids and conjunctival injection may be associated. Unilateral exophthalmos is seen in Graves disease or a tumor or inflammation in the orbit. "Dizziness" is a nonspecific term used by patients encompassing several disorders that clinicians must carefully sort out. A detailed history usually identifies the primary etiology. It is important to learn the specific meanings of the following terms or conditions:

Eyelid retraction and Exophthalmos

Order of neuro deterioration

A&O alters: time and/or place, last is self 1. Lose ability obey simple commands Then... 2. responses deteriorate from purposeful to purposeless responses to pain Then... 3. absence of response to pain Then... 4. loss of corneal and gag reflexes (full loss of brain function)

Why did Dr. Walsh say that ears are like vaginas?

They are "self-cleaning ovens" and do not need to be cleaned. ...I thought that was an odd comparison too

Meninges

Three protective membranes that surround the brain and spinal cord

T&A

Tonsillectomy and adenoidectomy

The nurse places an index (2 nd ) finger on one clavicle head and the ring (4 th ) finger on the other clavicle head. What is the nurse preparing to assess?

Tracheal deviation

Tic vs tremor

Tremor: Rhythmic oscillations caused by intermittent muscle contractions. Tics: Paroxysmal, stereotyped muscle contractions, commonly suppressible, might be simple (single muscle group) or complex

CN5

Trigeminal nerve -Only cranial nerve where we worry about sensory and motor function (MASTICATION) CLENCH TEETH, SENSORY-COTTON TO CHEEKS WITH EYES CLOSED

CN5

Trigeminal nerve -Only cranial nerve where we worry about sensory and motor function (MASTICATION) CLENCH TEETH, SENSORY-COTTON TO CHEEKS WITH EYES CLOSED.

What is the name of CN5 and what is its job?

Trigeminal, controls muscles of mastication

CN4

Trochlear nerve -Responsible for when the eyes are looking down and in toward the nose PERRLA and EOM

T/F During accommodation, the nurse expects the pupils to constrict when looking at a near object.

True

T/F Tonsils can be large (3+) without being infected, especially in children

True

Tinnitus is commonly heard as musical ringing in the ear

True

Iron tablets effect on stool

Turns it a dark green

If a patient has ascites and is lying on their side, where will you hear tympany and dullness?

Tympany on upper side, dullness on lower side (due to fluid shift)

If a patient has ascites and is laying supine, where will you hear tympany and dullness upon percussion?

Tympany over midline and dullness over flanks

Anisocoria

Unequal pupils without shining light into them

Test Achilles reflex

Use FLAT END of hammer on back of heel -Foot will plantar flex

Test patellar reflex

Use FLAT END of hammer on tendon just below knee

Test brachioradialis reflex

Use FLAT END of hammer, aim for first 1/3 of forearm

Test Bicep reflex

Use POINTY END of hammer and strike your own thumb placed over the elbow crease

Test tricep reflex

Use POINTY END of hammer on elbow, when you are supporting patient's arm underneath

Otitis Externa

AKA "swimmers ear" -Pain, redness, and discharge -Starts in ear canal and can spread

If tympanic membrane bursts due to otitis media, what do we need to do?

Usually nothing, as it will heal on its own unless the perforation is really large

Heart rate is controlled by which cranial nerve?

Vagus nerve

Visual fields by confrontation

AKA peripheral vision -Position yourself with 12 inches between you and patient, face to face -Instruct patient to look at your eyes; do not move eyes -Wiggle two fingers in each outer quadrant at edge of visual field -Begin OUTSIDE the range of vision behind patient then... -Bring two fingers INTO the range of vision -Test all 6 fields

CN10

Vagus nerve SAY "AHH", GAG REFLEX, TASTE, SWALLOWING, VAGUS "VEGAS" "BIG DADDY"

Visual fields by confrontation

AKA peripheral vision -Position yourself with 12 inches between you and patient, face to face -Instruct patient to look at your eyes; do not move eyes -Wiggle two fingers in each outer quadrant at edge of visual field (make sure to do all 6 fields) -Begin OUTSIDE the range of vision behind patient then bring two fingers INTO the range of vision

Meniere's disease

Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears).

Strabismus

Abnormal deviation of the eye

Pathologic reflexes

Abnormal reflexes, such as Babinski reflex in an adult

Dyscoria

Abnormally shaped pupil

Guillian-Barre Syndrome (GBS)

Acute inflammatory condition involving the spinal nerve roots, peripheral nerves and possibly cranial nerve.

Tips and tricks for DTRs

Aim right for the tendon. - Position limb so muscle is slightly stretched. - Muscle MUST be relaxed (cannot already be engaged). - Reflex hammer should strike tendon briskly to stretch tendon -ONLY hit the tendon - Compare side by side (Bilaterally)

What often causes fluid behind tympanic membrane when an infection is not present?

Allergies

Efferent nerves

Also called motor nerves; nerves that carry information out of the brain and spinal cord to other areas of the body.

Afferent Nerves

Also called sensory nerves; nerves that carry information about the external environment to the brain and spinal cord via sensory receptors.

What does the Romberg test assess?

Altered proprioception -A positive Romberg means that you lost your balance while standing with eyes closed.

When testing patient's sense of smell, we want to make sure we ask about what?

Ask about allergies!!!!!!

Cover/Uncover test

Assess for strabismus; the weaker eye will deviate away during this test (you will notice because it breaks to where you are looking when you uncover the eye)

Objective data of auditory acuity

Conductive loss (external ear issue) -mechanical dysfunction in external or middle ear -foreign object in canal, perforated TM, otosclerosis (hardening and bones do not move well) Sensorineural loss (inner ear issue) -cochlear, auditory nerve damage or auditory area of cerebral cortex damaged -Presbycusis -loss of high frequency sound due to aging -Inner ear disease, ototoxic drugs (vancomycin and gentamycin) Mixed loss- a little of both

Miosis

Constriction of the pupil

What is the parietal lobe responsible for?

Contains the primary somatic sensory area, which integrates somesthetic information (pressures, pain, temperature, touch). Also contains supra marginal gyrus and the angular gyrus

Broca's area

Controls language expression - an area of the frontal lobe, usually in the left hemisphere, that directs the muscle movements involved in speech.

Which is the best test to perform when checking for strabismus?

Cover/Uncover

What is the best test to perform when checking for strabismus?

Cover/uncover test

Contra coup injury

Damage to the brain on the side opposite the side that received the initial impact or blow

Presbyopia

Decreased accommodation due to aging -Will need to move an object farther away to see it. -Think of old people moving a book further away to read.

Parkinson's disease

Decreased facial mobility blunts expression. A mask-like face may result, with decreased blinking and a characteristic stare. Since the neck and upper trunk tend to flex forward, the patient seems to peer upward toward the observer. Facial skin becomes oily, and drooling may occur.

Deviated Septum

Defect in the wall between the nostrils that can cause partial or complete obstruction

Mydriasis

Dilation of the pupil

While collecting the history of the nose and sinuses, a patient complains of having rhinorrhea. What question would the nurse ask to determine associated manifestations of the symptom?

Do you have a cough, sore throat, or sinus pressure (this is associated manifestations)

Vertigo

In addition to conducting sound, what else does the middle ear do?

Equalizes air pressure and reduces loudness of sound

The labyrinth of the inner ear is responsible for maintaining the body's ______

Equilibrium

Ears- Inspection using the otoscope

Exam -Pull ear up and back in adults to straighten canal -Pull ear down and back in children -Auditory canal -color, edema, discharge, cerumen (ear wax) -Tympanic membrane (should be pearly grey) (should not be bulging out and can see purulent material= ear infection) (if there is a hole in the tympanic membrane= a perforation) -Color, +/- perforation, bulge (OM) -Ears are self-cleaning, but q-tips are not for the ears, they can cause scrapes in the ear canal and possibly disrupt the tympanic membrane by going to deep -The more you use q-tips the more cerumen you make (cerumen is the protective layer for the ear canal

STAR Causes of conductive hearing loss

External ear: -Impacted cerumen -Foreign bodies -External otitis Middle Ear: -Otitis Media -Serous Otitis -Otosclerosis

Orientation

FIRST AWARENESS OF WHETHER BRAIN IS INTACT -Person (severe impairment; last to go; identity of self)-MOST concerning; Ex: My name is Susie, but it's actually John -Place -Time -4 th - familiar person or situation

CN7

Facial nerve SMILE, FROWN, PUFF CHEEKS OUT, KEEP EYES CLOSED AGAINST RESISTANCE

CN7

Facial nerve SMILE, FROWN, PUFF CHEEKS OUT, KEEP EYES CLOSED AGAINST RESISTANCE.

T/F Microcephaly is an anomaly characterized by a larger head in proportion to the body?

False

T/F When a person shifts gaze from a far object to a near one, the pupils dilate

False

Difference between tremor and fasiculation

Fasiculation will go away if you rest the muscle a tremor will not

6 Fs of protuberant abdomen

Fat, Fluid, Farts, Fetus, Feces, Fatal Growth

Anterior pillar

Fold of tissue extending down in front of the tonsil.

What is the MOST SENSITVE indicator for decreased neuro function and earliest change in acute ICP changes

Glasgow Coma Scale

What is the name of cranial nerve IX

Glossopharyngeal nerve

CN9

Glossopharyngeal nerve SAY "AHH", GAG REFLEX, TASTE, SWALLOWING, VAGUS "VEGAS" "BIG DADDY"

What is the temporal lobe responsible for?

Hearing, taste, and smell

Vertigo

Vertigo—a spinning sensation accompanied by nystagmus and ataxia; usually from peripheral vestibular dysfunction (∼40% of "dizzy" patients) but may be from a central brainstem lesion (∼10%; causes include atherosclerosis, multiple sclerosis, vertebrobasilar migraine, or transient ischemic attack [TIA]) Presyncope—a near faint from "feeling faint or lightheaded"; causes include orthostatic hypotension, especially from medication, arrhythmias, and vasovagal attacks (∼5%)

If we see an inability to walk straight, when should think...

Vestibular or cerebral disease (MS) or drunk

CN8

Vestibulocochlear nerve WHISPER TEST, RINNE, WEBER

If someone says they have an allergy, what is the first question you should ask them?

What happens when you (take med or eat that specific food)?

Ala

Winglike tip of the outer side of each nostril

How do we palpate the frontal sinuses?

With frontal sinus you go up and under the eye brow

How do we palpate the maxillary sinuses?

With maxillary sinus you go under the cheek bone

Is it normal to see nystagmus in the extremes of gaze?

Yes

fasiculation

a brief, spontaneous contraction affecting a small number of muscle fibers, often causing a flicker of movement under the skin. It can be a symptom of disease of the motor neurons.

Cochlea

a coiled, bony, fluid-filled tube in the inner ear through which sound waves trigger nerve impulses

Primary Headache

a headache for which no specific organic cause can be found

Vestibular labyrinth

a part of the inner ear specialized for the detection of head motion; consists of the otolith organs and semicircular canals -Each semicircular canal is angled in a way to detect head motion in a specific plane.. They are filled with a fluid called endolymph that will move through the canal into the ampulla

Submandibular gland

a salivary gland inside the lower jaw on either side that produces most of the nocturnal saliva

Incus

a small anvil-shaped bone in the middle ear, transmitting vibrations between the malleus and stapes.

Nasal polyp

abnormal protruding growth from the nasal mucosa

exophthalmoses

abnormal protrusion of the eyeball

Presbycusis

age related hearing loss

Pharyngeal tonsil

also called adenoids; located in posterior wall of nasopharynx

Scleroderma

an autoimmune disorder in which the connective tissues become thickened and hardened, causing the skin to become hard and swollen

Coup injury

an injury to the brain occurring on the same side as the site of impact.

When we think about an intense headache with a sudden onset like a thunderclap, we should think....

aneurism

Fovea centralis

area consisting of a small depression in the retina containing cones and where vision is most acute

Sternomastoid muscle

arises from the sternum and the clavicle and extends diagonally across the neck to the mastoid process behind the ear; accomplishes head rotation and head flexion; divides each side of the neck into two triangles

RLQ

ascending colon, appendix, cecum, 2/3 of ileum, ileocecal valve, iliac artery

Halitosis

bad breath

Pepto bismol turns your tongue what color

black

Hard palate

bony anterior (front) portion of the palate -Roof of the mouth

Hematochezia

bright red blood in stool

When we see spastic muscle tone, we should think...

cerebral palsy or spinal cord injury

Emotional lability

characteristic of a right hemisphere infarct where there is an inability to control emotions and outbursts of laughing or crying that are inconsistent with the situation

Mixed hearing loss

combination of sensorineural and conductive hearing loss

Wernicke's area

controls language reception - a brain area involved in language comprehension and expression; usually in the left temporal lobe

Superficial reflexes

corneal reflex and abdominal reflex

Strabismus

crossed eyes

Dysphasia

difficulty speaking

Dysphagia

difficulty swallowing

Diplopia

double vision, the perception of two images of a single object

Goiter

enlargement of the thyroid gland

Syncope

fainting or sudden loss of consciousness caused by lack of blood supply to the cerebrum

Hyperopia

farsightedness

Presbyopia

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age. -Caused by decreased accommodation

Secondary headache

headache identified as a symptom of another organic disorder (e.g., brain tumor, hypertension)

Rinne test

hearing test using a tuning fork; checks for differences in bone conduction and air conduction -Tuning fork placed on mastoid process in front of the ear -Compares AC to BC (Air conduction and bone conduction) -AC>BC is normal (can be abnormal in patients with severe sensorineural hearing loss because their good ear is picking up the sound). -BC>AC is abnormal and a sign of conductive hearing loss

Ataxia

inability to perform coordinated movements -Inability to walk and stand up

Glaucoma

increased intraocular pressure results in damage to the retina and optic nerve with loss of vision

Otitis Media

infection of the middle ear -Will see scattered cone of light -Purulent material visible behind ear drum -Dilated blood vessels visible -Pearly grey color will be gone and it will look more white due to pus build-up -Bones no longer visible through tympanic membrane -If too much pressure builds up, the tympanic membrane can burst

Otis externa

infection of the outer ear

Nystagmus

involuntary, jerking movements of the eyes

LOC

level of consciousness

RUQ

liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal, hepatic flexure of colon, part of ascending and transverse colon

Lingual tonsil

located at the base of the tongue

Palatine tonsils

located on the left and right sides of the throat in the area that is visible through the mouth

Tonsils are part of the _____ system

lymphatic

Conjunctiva

mucous membrane lining the eyelids and covering the anterior portion of the sclera

Myopia

nearsightedness

Pupillary light reflex

normal constriction of pupils when bright light shines on retina -Measured in mm -Can be direct or consensual

Epistaxis

nosebleed

Nares

nostrils

In children, sutures are ___

open

What is the frontal lobe responsible for?

personality, behavior, emotion, intellectual functions

Soft palate

posterior portion, not supported by bone

Decerebrate posturing

posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe. VERY OMINOUS

Clonus

rapidly alternating involuntary contraction and relaxation of a muscle in response to sudden stretch

Red reflex

red glow that appears to fill the person's pupil when first visualized through the ophthalmoscope

JVD upon inspection of neck is indicative of what?

right sided heart failure

Mastoid process

round projection on the temporal bone behind the ear

Sublingual gland

salivary gland under the tongue

Parotid gland

salivary gland within the cheek, just anterior to the ear

Photophobia

sensitivity to light -Often seen in meningitis

Nevi

small, dark skin growths that develop from melanocytes in the skin; also known as moles

Uvula

soft tissue hanging from the middle of the soft palate

LUQ

spleen, stomach, aorta, pancreas, transverse colon

Nuchal rigidity

stiffness in cervical neck area -Not able to flex neck

Cremasteric reflex

superficial reflex of the muscle that pulls up the scrotum If you run a nail on one thigh, the testicle on the same side will pull up (BUT ONLY THAT SIDE)

How to test nasal patency

test the patency of the nostrils by pushing each nasal wing shut with your finger while asking the person to sniff inward through the other naris; will reveal any obstruction

Pupil

the adjustable opening in the center of the eye through which light enters

Utricle

the larger of two sacs within the membranous labyrinth of the vestibule in the inner ear -Detects horizontal movement

Otolith organs

the mechanical structures in the vestibular system that sense both linear acceleration (forward ad backward movement) and gravity -Utricle (horizontal movements) -Saccule (Vertical movements)

Where does the lacrimal sac drain to?

the nasal cavity (inferior nasal meatus) via the nasolacrimal duct -Will see lots of tearing in the eyes if there is a blockage (seen frequently in babies)

Accommodation

the process by which the eye's lens changes shape to focus near or far objects on the retina -Pupils constrict when looking a a nearby object -Pupils dilate when looking at a far away object

PNS

the sensory and motor neurons that connect the CNS to the rest of the body

Saccule

the smaller of two sacs within the membranous labyrinth of the vestibule in the inner ear -Detects vertical movements

Muscle tone

the state of balanced muscle tension that makes normal posture, coordination, and movement possible

patency

the state of being open or unobstructed

Precentral gyrus

the strip of frontal cortex, just in front of the central sulcus, that is crucial for motor control Primary motor area

Postcentral gyrus

the strip of parietal cortex, just behind the central sulcus, that receives somatosensory information from the entire body Primary sensory area

Lacrimal apparatus

the structures that produce, store, and remove tears

Myoclonus

the sudden, involuntary jerking of a muscle or group of muscles

Cornea

the transparent layer forming the front of the eye.

Lens

the transparent structure behind the pupil that changes shape to help focus images on the retina

Pinna

the visible part of the ear

Auditory Ossicles

three small bones linked together that connect the eardrum to the inner ear Malleus, Incus, Stapes -Transmit vibration to inner ear

Ear tubes

tiny ventilating tubes placed through the eardrum to provide ongoing drainage for fluids and to relieve pressure that can build up -Tympanostomy tubes

TIA

transient ischemic attack (mini stroke) -Warning sign of a stroke coming within the next 3 months

What is anisocoria?

unequal pupil size

Anisocoria

unequal pupil size without shining light into pupils

Diopter

unit of strength of the lens settings on the ophthalmoscope that changes focus on the eye structures

Sclera

white of the eye

Cerumen

yellow waxy material that lubricates and protects the ear canal

Macula

yellowish region on the retina lateral to and slightly below the optic disc

Head and Face - Subjective Data

•Common or concerning symptoms -Headaches -Head injury -Head or neck surgery -Traumatic brain injury •Dizziness- syncope v. near syncope v. vertigo •Lumps or masses •Surgery -Trauma: head, face •Scalp/Hair Issues •New or old issues with face (lumps, skin, etc) •Allergies •Medications and/or treatments used •Immunizations •Family history

Eye- Inspection using the opthalmoscope

•Diopter or instrument's lens -Used to focus on internal structures •Use aperture dial in front for the largest spot of light (start at 0 - without any lines in it) •Be sure room is darkened •Client focuses on distant spot on wall •Need to remove client's glasses •Hold instrument against your eyebrow when looking at eye •Shine light into pupil, start at outer side of patient and move around to front of patient about 15 inches from client's face -Same eye to same eye method (otherwise you'll be kissing the patient), you see pinkish red pupil looking back at you

Eustachian tube

•Equalizes air pressure from middle ear to nasopharynx •More horizontal in child; more angled in adult -Located in middle ear

Face-objective data

•Facial structures -eyebrows, palpebral fissures, nasolabial folds, symmetry •Facial expression - formed by facial muscles and facial nerve VII •symmetry •Temporomandibular Joint (TMJ) -Clench teeth •palpate muscles above and below joint -Palpate joint •anterior to tragus during opening and closing of mouth

Head and scalp - objective data

•Hair- quality, quantity, distribution, texture •Scalp-lumps, nevi, scaling, dandruff, nits •Skull -Size- normocephalic, microcephalic, macrocephalic -Contour- deformities, lumps, depressions, suture lines, tenderness, protrusions

Neck-subjective history

•Stiffness, pain •Injury •Medications •Neck masses •Swollen glands •Swollen thyroid (goiter) •Surgery

Neck - Objective history

•Symmetry -Palpate trachea •Assess for deviation -Obvious masses •Musculature (MSK system) -Palpate shoulders, turn head (against resistance) -Bend neck forward and back, side to side, rotation (range of motion) •Blood supply (CV/PV system) -Carotid pulses -Jugular distention •Glands -Salivary -Palpate thyroid (lower 1/3 of neck) •Lymph nodes when looking at the neck we will inspect and palpate, trachea with the pointer and ring finger to check for tracheal deviation (pneumothorax or collapsed lung)

As people age they are less able to hear _____pitch sounds

High pitch

Dysarthria

(formulating the word, lack of muscle) signifies dysfunction of the muscles needed to produce speech like lips, tongue, vocal cords, diaphragm, etc.

Altered LOC

-Not waking up, not following simple commands -Sternal rub to elicit a painful response -Use acute care exam: -LOC (Glasgow Coma Scale)

4+ tonsils are also called what?

"Kissing tonsils"

Rhinorrhea

Clear nasal discharge, "runny nose"

A DTR of 4+ means what?

Clonus

What is the function of the external ear?

Collect sounds and support inner ear structure

Vertigo

Condition of dizziness, "room spinning"

Mrs. Jones is 3-day post-acute CVA (cerebral vascular accident or stroke). You enter her room and say, "good morning! How did you sleep?" She answers "Man green go lines" with a smile on her face. This is an example of:

Dysphasia

Motor nerves are called _____

Efferent nerves

Cushing's disease

Elevated cortisol, leads to buffalo hump, moon face, big belly

How do we grade tonsil size?

1+ is just to posterior pillar 2+ is about halfway to uvula 3+ is to the uvula 4+ pushes against and may displace uvula

Acute care neuro assessment

1. LOC 2. Motor function 3. Pupillary response 4. Vital signs 1&2 are assessed using the Glascow Coma Scale (GCS)

What is the highest possible GCS score?

15, A score of 3-8 means coma

What is the "normal" frequency of bowel elimination?

2-3x per day to 3x per week

How far away is the Snellen chart from the patient?

20 feet

How far away does the patient need to stand for the Snellen Visual Acuity test?

20 ft

What Snellen chart score is considered legally blind (with correction)?

20/200

A GCS score of what indicates coma?

3-8

CN11

Spinal accessory TURN HEAD AND SHRUG SHOULDERS AGAINST RESISTANCE

Palpation of the thyroid

Standing behind patient, place hands lateral to cricoid cartilage, and feel for nodules or swelling. Ask patient to swallow and feel movement. Right hand palpates while left hand displaces Feel for nodules, enlargement, and tenderness

Pressure in the brainstem from herniation will cause what?

Sudden Pupil dilation and nonreactive pupil -Cranial nerve III

Weber test

Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard. -Differentiates between conductive and sensorioneural hearing loss. -Normal result is equal bilaterally - In case of sensorineural loss, vibrations will be louder in the ear WITHOUT hearing loss -In case of conductive hearing loss, vibrations will be louder in ear WITH hearing loss (since there is no extra noise from outside, the sound will be heard louder)

What des it mean to have 20/100 vision?

That you can see at 20 feet what normal people see at 100 feet

Why do children tend to get middle ear infections more frequently than adults?

The Eustachian tube is more horizontal in children, becoming more angled as they get older

Vestibule

The area just inside the nostril (nose opening) that leads into the nasal cavity. The nasal vestibule is supported by the cartilage of the nose and lined with tissue that contains small, course hairs. These hairs help filter dust, sand, and other particles to keep them from entering the lungs

The SNS and PNS are components of what?

The autonomic nervous system

If a patient has exophthalmoses, what will you be able to see?

The bottom whites of their eyes since their eyeballs are protruding forward. Normally you can only see the top whites

The client's vision is tested using the Snellen chart. The results of the tests are documented as 20/60. The nurse interprets this as what?

The client can read at a distance of 20 ft what a client with normal vision can see at 60 ft

Which part of the ear converts sound to nerve impulses?

The cochlea in the inner ear

Columella

The columella is the bridge of tissue that separates the nostrils at the bottom of your nose. Ideally, the columella is positioned so that at most 4 millimetres of nostril is seen on profile view. A nose is said to have increased "columella show" when more than 4 millimetres of the nostril is visible

Somatic nervous system

The division of the peripheral nervous system that controls the body's skeletal muscles

Tympanic membrane

The eardrum. A structure that separates the outer ear from the middle ear and vibrates in response to sound waves.

Acromegaly

The increased growth hormone of acromegaly produces enlargement of both bone and soft tissues. The head is elongated, with bony prominence of the forehead, nose, and lower jaw. Soft tissues of the nose, lips, and ears also enlarge. The facial features appear generally coarsened.

Palpebral fissure

The palpebral fissure is the elliptic space between the medial and lateral canthi of the two open eyelids. In simple terms, it is the opening between the eyelids. In adult humans, this measures about 10 mm vertically and 30 mm horizontally.

How do we palpate the thyroid?

-Palpate while swallowing: isthmus, right and left lobes -Feel for nodules, enlargement and tenderness -How we palpate- put pointer on cricoid cartilage that sticks out and go to the side and feel from there. -The thyroid is a butterfly gland that wraps around the trachea, most is behind the trachea, want to feel for lumps, bumps and have pt swallow and want to have smooth feeling, no lumps or bumps

Visceral reflexes

Pupillary response to light

Neurological System History

- Headache, Fever - Neck pain (Nucal rigidity), photophobia (sensitivity to light or pain to bright light) (Meningitis could be the disease process if they can't flex their neck) -Canals in the posterior that carry CSF that cushions the brain—increase in ICP. - Fainting (syncope full loss of conscious), near syncope (almost passed out) -VASOVAGAL RESPONSE: -can be a response to any stressor or low blood sugar -autonomic nervous system reacts causes bradycardia and allows vasodilation in the lower extremity vessels- decrease blood - decrease O2 to brain - on floor. -taller people can have a higher chance of passing out -Ask if anyone witnessed what happened-PT not a good historian if the passed out *IMPORTANT TO KEEP IN MIND WHEN SOMEONE PASSES OUT AND GETTING A HEAD INJURY* -Head injury: vomiting, headache, irritability (ask if they are usually this irritable), LOC IS MOST IMPORTANT -Seizures, tremors -Coordination changes: Talk to loved ones for elderly patients -altered balance -altered gait or coordination *Medication: HTN, CV, antidepressants, antianxiety, alternative medications, alcohol, street drugs, tobacco (increased risk of stroke), hormone therapy because there is a link with CVAs). *Past medical history: strokes (more likely to reoccur), seizure dx, DM, hypertension, diabetes; hx trauma (head, neck, back), syphilis, varicella, psych dx, surgical -Chronic brain injuries cause increased risk for Alzheimer's and Parkinson's. *Family history: neoplasms, strokes (genetic), Alzheimer's (genetic), psychiatric disorders, HTN, epilepsy, muscular dystrophies, Parkinson's *Once a patient has a stroke, they are at higher risk of having another stroke* *Varicella is good to ask because having it in the past, higher risk of shingle.

Receptive Aphasia

- LITTLE OR NO COMPREHENSION OF WORDS - SPOKEN WORDS ARE FLUENT AND NONSENSICAL - NO IDEA THE WORDS AND THE LANGUAGE IS WRONG. - EX: WERNICKE'S APHASIA - Whitney Wernicke, she can't understand what other people are saying to her, but she is answering and not making sense. (Receptive)

Decorticate posturing

-"flexor posturing" or "mummy baby" (think Egyptian mummy preservation) -adduction of arms (arms fold to chest); flexion of elbows and wrists

Awake patient LOC

-ALERT -INATTENTION (inability to hold attention) -CONFUSION (will not test on this) -Delirium (will not test on this)

Eye- objective data of visual acuity

-Chart is 20 feet away from the patient. We are going to test by cover one eye during testing, then switch to the other eye, then both eyes -The larger the denominator= the poorer the vision -20/200= legally blind -Myopia: nearsighted Can't see things far away -Hyperopia: farsighted Can't see things that are close -Presbyopia: decreased accommodation with aging and needs to move object farther away to see it Ex: I have 20/100 vision means at 20 feet I can see what normal people can see at 100 feet

Mouth and Throat- Subjective Data: general history, lifestyle, and self-care

-Condition of gums and teeth: do you go to the dentist at all or on a regular basis??? -Correlation between oral health and physical health (cardiovascular issues) -Painful teeth or gums (gingiva can become red and enflamed very easily and with the bacteria that lives in the mouth a patient can become susceptible to illness) (easy trip to brain, heart, lungs, etc.) -Bleeding, bad breath, sore tongue, lip, mouth, hoarseness, drooling (never normal with adults, indicates trouble swallowing), difficulty swallowing/speaking, sore throat -Lifestyle: use of tobacco, vaping -PMHx: infections, chronic issues

Mouth and Throat- subjective data

Middle Ear

-Conducts sound, equalizes air pressure and reduces loudness -Auditory ossicles (Malleus, Incus, Stapes) •transmits vibration from TM to inner ear -Eustachian tube •Equalizes air pressure from middle ear to nasopharynx •More horizontal in child; more angled in adult

Eye- Inspection using the opthalmoscope

-Diopter or instrument's lens is used to focus on internal structures -Use aperture dial in front for the largest spot of light (start at 0 - without any lines in it) -Be sure room is darkened and have client focuses on distant spot-on wall -Need to remove client's glasses and hold instrument against your eyebrow when looking at eye -Shine light into pupil, start at outer side of patient and move around to front of patient about 15 inches from client's face Same eye to same eye method (otherwise you'll be kissing the patient), you see pinkish red pupil looking back at you

Eyes- objective data: inspection

-Eyelids, eyebrows, eyelashes (what do we see, are they symmetrical, are they thinning or thickening on one side) -Conjunctiva (pull down to look at and good indication of health (oxygenation, infection, etc.)) -Sclera (is it clear) -Cornea (how does it look) -Lens, Iris and Pupil (look at both when shine light, and does it constrict directly and consensually (when you shine a light into one eye and the other constricts as well)) -Pupillary light reflex (in mm): direct, consensual -Accommodation: pupillary constriction when focusing on a near object after looking far away -Convergence: eyes inward -Lacrimal apparatus PERRLA: -Pupils -Equal (are the pupils the same size and shape) -Round (are they round or not) -Reactive to Light (talking about direct, when you shine the light into each eye) (consensual, when you shine the light in only one eye and the other constricts as well) -Accommodation (looking far= dilated, looking close= constrict)

Primary Headaches

-Headaches are classified as primary, without underlying pathology, or secondary, with a serious underlying cause often warranting urgent attention. -About 90% of headaches are primary headaches and fall into four categories: tension, migraine, cluster, and chronic daily headache. -Risk factors include obesity; more than one headache a week; caffeine ingestion; use of headache medications >10 days a month, such as analgesics, ergots, and triptans; and sleep and mood disorders.

Eyes- Subjective data

-History: cataracts, glaucoma; family history -Surgery: acuity correction, glaucoma, cataract repair -Trauma -Environmental irritants, occupational hazards -Any vision screening? --Last exam: date, results, do you wear Glasses or contacts -Visual changes: blurring, dark spots, diplopia (double vision), photophobia (light sensitivity) -Do you have any pain, redness, discharge (what does it look like) -Excessive tearing (having too much water in the eyes and it drips down the face) -Do we work at places that put strain on eyes like welding?

Eyes: Subjective data

Nose and sinuses- objective data: inspect/palpate

-Inspection of nose (internal and external) -Use the otoscope with largest speculum piece appropriate for the patient (use for light source only) -Palpation of sinuses (frontal, maxillary) -With frontal sinus you go up and under the eye brow -With maxillary sinus you go under the cheek bone -Nasal patency (sniff) -Sense of smell (ask about allergies!) -Use odiferous scent like spices, coffee, cinnamon, etc. -If combining patency with sense of smell: Pt closes eyes, covers one nare then test one side; repeat for other side with different smell.

Nose/Sinuses- objective data: inspect and palpate

-Inspection of nose (internal and external) -Use the otoscope with largest speculum piece appropriate for the patient (use for light source only) -Palpation of sinuses (frontal, maxillary) frontal sinus maxillary sinus -With frontal sinus you go up and under the eye brow -With maxillary sinus you go under the cheek bone -Nasal patency (sniff) -Sense of smell (ask about allergies!) -Use odiferous scent like spices, coffee, cinnamon, etc. -If combining patency with sense of smell: Pt closes eyes, covers one nare then test one side; repeat for other side with different smell.

Ears- Objective Data: Inspection/Palpation

-Job is to collects sound and supports inner structures -Inspect pinna -Palpate pinna - move/pull and assess for canal tenderness -External auditory canal- S-shaped (pull up and back in adults) (pull down and back in children) -2.5 cm long (adults) -Palpate mastoid process and tragus (the triangle on the outside of the ear) -Inspect tympanic membrane (TM) (use otoscope to inspect)

Inner Ear

-Labyrinth •Semicircular Canals, Vestibule, and Cochlea -Responsible for balance and transmission of sound •Cochlea -Converts vibrations and sends through cochlear nerve to brain

WHAT DOES A FULL NEURO EXAM CONSIST OF?

-Mental status -Cranial nerves -Sensory system -Reflex -Motor system -cerebellar -muscular

Cutaneous reflexes

-Normal in infants but abnormal in adults (suggest diffuse brain disease) -Babinski: make a backwards 7; toes flex forward in a normal response; fanning out of toes is an abnormal response in adults -Grasp -Sucking

Hospitalized assessment for HEENT

-PERRL (always do this!) (do not always need to do accommodation, because it is difficult to do in the hospital bed) -Evaluate facial movement and external eyes when conducting this test -Assess airway (mouth, nose, throat, if they have external airway look at trach) -Assess speech -Inspect oral cavity (hydration status, lips, dentures, oral care, gums/buccal membranes for color, and ability to swallow) -Assess O2 delivery system and tubing (nasal membrane, behind ears, facemask pressure points) -Assess hearing/hearing aids if used -Assess vision: glasses at bedside, squinting, tracking while moving -Ensure gag reflex is intact before giving anything orally so they don't asphyxiate

Hospitalizedpatient HEENT assessment

Ears- Subjective data

-Pain -Hearing loss (use of assistive devices) -Discharge (otorrhea) -Tinnitus (ringing in ears) -Vertigo (intense spinning) -Trauma, noise overexposure -Medications (certain meds can cause tinnitus and hearing loss, did not state which) -URI/allergy symptoms -nasal congestion, fever, sore throat, jaw/tooth pain -History of infections (OM Otitis medias= internal ear infection, OE otitis externus= swimmers' ear), surgery (tubes) -Family history -Presbycusis (Loss of hearing with age) (typically higher pitched note loss)

Tests for cerebral function

1) Coordination of hands and legs -Rapid rhythmic and alternating movements - back of the hands and palms to thighs -fingers to nose with eyes closed -point to point movement -finger to nose examiner's finger -finger to nose with eyes closed. **note rapid, smooth, and accurate motion, slow, clumsy, decreased coordination = possible cerebral / vestibular disease or drunk** 2) Gait and posture -casual -heel to toe in straight line (tandem) -walking on the toes and heels **note width of gait - widens for balance? **inability to walk straight = vestibular or cerebral disease (MS) or drunk **advanced stages of Parkinson's will have shuffling gait 3) Balance -Romberg Test- stand upright, feet together, close eyes -Positive Romberg test = loss of balance (cerebral/vestibular disorder, drunk), altered proprioception Pronator drift- "Pizza box" at chest level, supinated palms, close eyes and hold. After 20 seconds tap downwards on alternating arms -If abnormal arm will drift downward, palm pronates, or unable to find original point. Indicative if motor neuron disease or metabolic disease

Peripheral Nerve

BUNDLE OF FIBERS OUTSIDE THE CENTRAL NERVOUS SYSTEM (CNS); AND THERE ARE TWO TYPES OF FIBERS: AFFERENT: SENSORY MESSAGES TO THE CNS FROM SENSORY RECEPTORS (DANG THAT IS HOT) EFFERENT: MOTOR MESSAGES FROM THE CNS OUT TO THE MUSCLES, ORGANS, AND GLANDS. (THE MOTION OF MOVING YOUR HAND WHEN ITS HOT). --Effect of that feeling -AUTONOMIC NERVOUS SYSTEM

How do you inspect and palpate conunctiva and sclera?

Basically pull their bottom eyelids down and look at their eyes

Which tendon to we test by striking our own thumb placed over top of the tendon?

Biceps

Which group of people is more likely to develop oral cancer?

Black men

Melena

Black tarry stool

In planning care for a client with exophthalmoses, the nurse includes which nursing diagnosis?

Body image disturbance

During a vasovagal response, what happens to the cardiovascular system?

Bradycardia and vasodilation -->less O2 to brain --> syncope

CNS

Brain and spinal cord

"Red flags" of headaches do NOT include what? A) Sudden "thunder-cap" headache B) Vomiting associated with a headache C) Dull, throbbing headache D) Elevated BP with headache

C) Dull, throbbing headache

Which cranial nerve is responsible for pupil dilation/constriction?

CN3 - Oculomotor

Which cranial nerve is the ONLY one where we will worry about both sensory and motor?

CN5, trigeminal

A perforated tympanic membrane will cause what kind of hearing loss?

Conductive hearing loss

Otosclerosis causes what type of hearing loss?

Conductive hearing loss

Migraine headaches

Process: Neuronal dysfunction, possibly of brainstem origin, involving low serotonin level, spreading cortical depression and trigeminovascular activation; types: with aura, without aura, variants Lifetime Prevalence: 10% of headaches; prevalence 18% of U.S. adults; affects ∼15% of women, 6% of men Location: Unilateral in ∼70%; bifrontal or global in ∼30% Quality and severity: Throbbing or aching, pain, moderate to severe in intensity; preceded by an aura in up to 30% Onset: Fairly rapid, reaching a peak in 1-2 hours Duration: 4-72 hours Course: Recurrent—usually monthly, but weekly in ∼10%; peak incidence early to mid-adolescence Associated symptoms: Prodrome: nausea, vomiting, photophobia, phonophobia; aura in 30%; either visual (flickering, zig- zagging lines), or motor (paresthesias of hand, arm, or face, or language dysfunction) Triggers/Factors That Aggravate or Provoke: Alcohol, certain foods, or stress may provoke; also menses, high altitude; aggravated by noise and bright light Factors That Relieve: Quiet, dark room; sleep; sometimes transient relief from pressure on the involved artery

Tension headache

Process: Process unclear—possibly heightened CNS pain sensitivity. Involves peri cranial muscle tenderness; etiology also unclear Lifetime prevalence: Most common headache (40%); prevalence about 50% Location: Usually bilateral; may be generalized or localized to the back of the head and upper neck or to the frontotemporal area Quality and severity: Steady; pressing or tightening; no throbbing pain; mild to moderate intensity Described in onset, duration, course Gradual onset Duration- 30 minutes to 7 days Sometimes photophobia, phonophobia; scalp tenderness; nausea absent Triggers/Factors That Aggravate or Provoke: Sustained muscle tension, as in driving or typing; stress; sleep disturbances Factors That Relieve: Possibly massage, relaxation

Ptosis

Ptosis is a drooping of the upper lid. Causes include myasthenia gravis, damage to the oculomotor nerve, and damage to the sympathetic nerve supply (Horner syndrome). A weakened muscle, relaxed tissues, and the weight of herniated fat may cause senile ptosis. Ptosis may also be congenital.

The nurse is testing the function of cranial nerve VII. Which of the following best describes the response the nurse would expect if the nerve is intact?

Puff's cheeks out; air is withheld against resistance.

How do you inspect the ear canal in children?

Pull ear down and back to straighten ear canal

To inspect an adult's ear canal, what do we do?

Pull ear up and back to straighten the canal -Look for color, edema, discharge, and cerumen -Look at tympanic membrane color, perforation, and bulge

Neurological structure/function - reflexes

Reflexes (automatic = autonomic) - DTR (STRIKING THE KNEE WITH THE HAMMER) - Superficial (corneal reflex, abdominal reflex) -DON'T NORMALLY DO THIS TO PEOPLE AWAKE - Visceral (pupillary response to light, COUGH REFLEX, gag) - Pathologic- (abnormal: present Babinski in adult) -brain is decompensating to the form of an infant -Variant of normal—happening because of disease process REFLEXES ARE: - INVOLUNTARY - HELPS MAINTAIN MUSCLE TONE - PROTECTS- PERMITS QUICK RESPOSE TO BAD STIMULI

External auditory canal

S-shaped -2.5 cm long (in adults)

What is the labyrinth composed of?

Semicircular canals, vestibule, and cochlea -Responsible for balance and transmission of sound

Cochlear damage will cause what kind of hearing loss?

Sensorineural

Ototoxic drugs lead to what kind to hearing loss?

Sensorineural

FAST

Signs of a stroke Facial drooping Arm weakness Speech differences Time to call 911

Eyes- objective data of visual acuity

Snellen vision acuity chart -Chart is 20 feet away from the patient. We are going to test by cover one eye during testing, then switch to the other eye, then both eyes -The larger the denominator= the poorer the vision -20/200= legally blind -Myopia: nearsighted Can't see things far away -Hyperopia: farsighted Can't see things that are close -Presbyopia: decreased accommodation with aging and needs to move object farther away to see it Ex: I have 20/100 vision means at 20 feet I can see what normal people can see at 100 feet

Health Assessment Exam 3

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