NUR 352 Exam 2

Nose: Subjective

Discharge Frequent colds, upper respiratory infections Sinus pain Trauma Epistaxis, nosebleeds Allergies Altered smell

Patient Rights

A patient has the right: To be informed about a medication To refuse a medication To have a medication history To be properly advised about experimental nature of medication To receive labeled medications safely To receive appropriate supportive therapy To not receive unnecessary medications To be informed if medications are part of a research study

Developmental considerations

Adolescent Acne Open and closed comedones Pregnancy Striae Linea nigra Chloasma Vascular spiders Aging Senile lentigines Keratoses Xerosis Skin tags or acrohordons Thin parchment Decreased hair growth Decreased nail growth and brittle nails

Health History Questions

Adolescents Skin problems such as pimples, blackheads? Aging adults What changes have you noticed in your skin in past few years? Any delay in wound healing? Any change in feet: toenails, bunions, wearing shoes? Falling: bruises, trauma? History of diabetes or peripheral vascular disease?

Planning

Always organize your care activities to ensure the safe administration of medications. Goals and outcomes Setting goals and related outcomes contributes to patient safety and allows for wise use of time during medication administration. Setting priorities Provide the most important information about the medications first. Teamwork and collaboration

Performance

An individual's performance of ADL is basic to functional assessment

Vision difficulty questions

Any difficulty seeing or any blurring? Blind spots? Come on suddenly or slowly? One eye or both? Constant, or does it come and go? Do objects appear out of focus or clouding of objects? Do spots move in front of your eyes? One or many? In one or both eyes? Any halos, rainbows, rings around objects? Any blind spot? Does it move as you shift your gaze? Any loss of peripheral vision? Any night blindness?

Ears: Subjective Questions

Any earache or other pain in ears? Location: Does it feel close to surface or deep in head? Does it hurt when you push on ear? Character: Is it dull, aching or sharp, stabbing? Is it constant or does it come and go? Is it affected by changing position of head? Any accompanying cold symptoms or sore throat? Any problems with sinuses or teeth? Ever been hit on ear or on side of head or had any sport injury? Ever had any trauma from a foreign body? What have you tried to relieve pain? Infections Any ear infections? As an adult or in childhood? How frequent were they? How were they treated? Discharge Any discharge from your ears? Does it look like pus, or is it bloody? Any odor to the discharge? Any relationship between discharge and ear pain? Tinnitus Ever felt ringing, crackling, or buzzing in your ears? When did this occur? Does it seem louder at night? Are you taking any medications? Vertigo Ever felt vertigo, that the room is spinning around or feel that you are spinning? Ever felt dizzy, like you are not quite steady, or falling or losing your balance? Giddy, lightheaded?

Subjective data- Self-care

Are there any occupational hazards that could affect muscles and joints? Do they involve heavy lifting? Are there any repetitive motions or chronic stress to joints? Have you made any efforts to alleviate these? Tell me about your exercise program: describe type of exercise, frequency, warm-up program Do you have any pain during exercise? How do you treat it? Have you had any recent weight gain? Please describe your usual daily diet. Are you taking any medications such as aspirin, antiinflammatories, muscle relaxants, or pain relievers? If person has chronic disability or crippling illness: How has your illness affected: Interaction with your family? Interaction with your friends? The way you view yourself?

Rapid Alternating Movements

Ask person to pat knees with both hands, lift up, turn hands over, and pat knees with backs of hands; then ask person to do this faster Normally done with equal turning and quick rhythmic pace Alternatively, ask person to touch thumb to each finger on same hand, starting with the index finger, then reverse direction

Romberg Test

Ask person to stand up with feet together and arms at sides; when in stable position, ask person to close eyes and to hold position for about 20 seconds Normally person can maintain posture and balance even with visual orienting information blocked Ask person to perform shallow knee bend or hop in place, first on one leg, then other Demonstrates normal position sense, muscle strength, and cerebellar function Some individuals cannot hop because of aging or obesity

Corneal Light Reflex/ Hirschberg test

Assess parallel alignment of eye axes by shining a light toward person's eyes Direct person to stare straight ahead as you hold the light about 30 cm (12 inches) away Note reflection of light on corneas; should be in exactly same spot on each eye

ADL's/ Mobility

Barthel Index- activities of daily living

Function of musculoskeletal

Central nervous system (CNS), which includes brain and spinal cord Peripheral nervous system (PNS), which includes all nerve fibers outside brain and spinal cord Includes 12 pairs of cranial nerves, 31 pairs of spinal nerves, and all their branches Carries sensory (afferent) messages to CNS from sensory receptors Motor (efferent) messages from CNS to muscles and glands, as well as autonomic messages that govern internal organs and blood vessels

Functions of musculoskeletal

Components of musculoskeletal system Skeleton is bony framework of body 206 bones support body like posts and beams of building Bone and cartilage are specialized forms of connective tissue Bone is hard, rigid, and very dense Cells are continually turning over and remodeling Joints, or articulations, are places of union of two or more bones Joints are functional units of musculoskeletal system permitting mobility needed for activities of daily living Muscles Muscles account for 40% to 50% of body's weight When they contract, they produce movement Muscles are of three types: skeletal, smooth, and cardiac Skeletal or voluntary muscles are under conscious control Each skeletal muscle is composed of bundles of muscle fibers, or fasciculi Skeletal muscle attached to bone by tendon, a strong fibrous cord

Cranial Nerve 3, 4, 6

Cranial Nerves III, IV, and VI: oculomotor, trochlear, and abducens nerves Palpebral fissures usually equal in width Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation Assess extraocular movements by cardinal positions of gaze Nystagmus is back-and-forth oscillation of eyes

Cranial Nerve 1

Cranial nerve I: olfactory nerve (not tested routinely) Test sense of smell in those who report loss of smell, head trauma, and abnormal mental status, and when presence of intracranial lesion suspected With person's eyes closed, occlude one nostril and present familiar aromatic substance, e.g., coffee, orange, vanilla, soap, or peppermint Normally person can identify an odor on each side of nose; normally decreased with aging; any asymmetry in sense of smell is important

Cranial Nerve 2

Cranial nerve II: optic nerve Test visual acuity and visual fields by confrontation Using ophthalmoscope, examine ocular fundus to determine color, size, and shape of optic disc

Cranial Nerve 5

Cranial nerve V: trigeminal nerve Motor function: assess muscles of mastication by palpating temporal and masseter muscles as person clenches teeth Muscles should feel equally strong on both sides; try to separate jaws by pushing down on chin; normally you cannot Sensory function: with person's eyes closed, test light touch sensation by touching a cotton wisp to designated areas on person's face: forehead, cheeks, and chin Tests all three divisions of CN V: ophthalmic, maxillary, and mandibular

Cranial Nerve 7

Cranial nerve VII: facial nerve Motor function: Note mobility and facial symmetry as person responds to requests to smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth Have person puff cheeks, then press puffed cheeks in, to see that air escapes equally from both sides Sensory function: (not tested routinely) Test only when you suspect facial nerve injury When indicated, test sense of taste by applying cotton applicator covered with solution of sugar, salt, or lemon juice to tongue and ask person to identify taste

Cranial Nerve 8

Cranial nerve VIII: acoustic nerve (Vestibulocochlear) Test hearing acuity by ability to hear normal conversation and by whispered voice test

Cranial Nerve 11

Cranial nerve XI: spinal accessory nerve Examine sternomastoid and trapezius muscles for equal size Check equal strength by asking person to rotate head against resistance applied to side of chin Ask person to shrug shoulders against resistance These movements should feel equally strong on both sides

Cranial Nerve 12

Cranial nerve XII: hypoglossal nerve Inspect tongue; no wasting or tremors should be present Note forward thrust in midline as person protrudes tongue Ask person to say "light, tight, dynamite," and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct

Cranial Nerve 9 and 10

Cranial nerves IX and X: glossopharyngeal and vagus nerves Motor function Depress tongue with tongue blade, and note pharyngeal movement as person says "ahhh" or yawns; uvula and soft palate should rise in midline, and tonsillar pillars should move medially Touch posterior pharyngeal wall with tongue blade, and note gag reflex; voice should sound smooth, not strained Sensory function Cranial nerve IX does mediate taste on posterior one third of tongue, but technically too difficult to test

Capillary Refill

Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation Color return is normally instant Sluggish color return takes longer than 1 or 2 seconds

Nose: Objective

External nose Normally nose is symmetric, in midline, and in proportion to other facial features. Inspect for any deformity, asymmetry, inflammation, or skin lesions; if an injury is reported or suspected, palpate gently for any pain or break in contour. Test patency of nostrils by pushing each nasal wing shut with your finger while asking person to sniff inward through other naris; this reveals any obstruction, to be explored using the nasal speculum. Sense of smell, mediated by cranial nerve I, is usually not tested in a routine examination. Nasal cavity- Inspect nasal mucosa, noting its normal red color and smooth moist surface. Note any swelling, discharge, bleeding, or foreign body Nasal septum Observe nasal septum for deviation; deviated septum is common and is not significant unless air flow is obstructed. If present in hospitalized patient, document deviated septum in event that person needs nasal suctioning or a nasogastric tube Note any perforation or bleeding in septum. Nasal turbinates Inspect turbinates, the bony ridges curving down from lateral walls. Superior turbinate may not be in view. Middle and inferior turbinates appear the same light red color as nasal mucosa; note any swelling but do not try to push speculum past it. Turbinates are quite vascular and tender if touched. Note any polyps, benign growths that accompany chronic allergy, and distinguish them from normal turbinates.

Subjective data (ADLs vs/Self-care)

Functional assessment of ADLs Do joint (muscle, bone) problems create any limits on your usual ADLs? Which ones? Bathing: Do you have trouble getting in and out of tub or using faucets? Toileting: Do you have trouble urinating or moving bowels? Are you able to get on and off toilet and to wipe yourself? Dressing: Can you do buttons, zippers, fastening behind neck, pulling dress or sweater over head, pulling up pants, tying shoes, and can you get shoes that fit? Grooming: Can you shave, brush teeth, brush or fix hair, and apply makeup? Eating: Can you prepare meals, pour liquids, cut up foods, bring food to mouth, and drink? Mobility: Can you walk, walk up or down stairs, get in and out of bed, get out of house? Communicating: Can you talk, use the telephone, and write?

Cerebellar Function Tests Balance test

Gait: observe as person walks 10 to 20 feet, turns, and returns to starting point; normally person moves with a sense of freedom; gait is smooth, rhythmic, and effortless; opposing arm swing is coordinated; person turns smooth; step length about 15 inches from heel to heel Ask person to walk straight line in heel-to-toe fashion; this decreases base of support and accentuates any problem with coordination; normally person can walk straight and stay balanced You may also test for balance by asking person to walk on toes, then on heels for a few steps

Confrontation Test

Gross measure of peripheral vision; compares person's peripheral vision with yours Position yourself at eye level with person about 2 feet away Direct person to cover one eye with an opaque card and with other eye to look straight at you Cover your own eye opposite to person's covered one; you are testing uncovered eye Hold pencil or your finger as target midline between you and person, and slowly advance it in from periphery in several directions Ask person to say "now" as target is first seen; this should be just as you see the object also Estimate angle between anteroposterior axis of eye and peripheral axis where object is first seen Normal results are about 50 degrees upward, 90 degrees temporal, 70 degrees down, and 60 degrees nasal

Subjective data

Headache Have you had any unusually frequent or severe headaches? When did this start? How often does it occur? Where do you feel headaches? Do headaches seem to be associated with anything? Head injury Have you ever had any head injury? What part of head was injured? Describe. Did you have loss of consciousness? For how long? Weakness Is this generalized or local? Does weakness occur with particular movement? Is it hard to get up out of a chair or reach for an object? With distal or small muscle weakness, it is hard to open a jar, write, use scissors, or walk without tripping? Incoordination Do you have any problem with balance when walking? Any falling? Which way? Do your legs seem to give way? Any clumsy movement? Numbness or tingling Does it ever feel like pins and needles? When did this start? Where do you feel it? Does it occur with activity? Difficulty swallowing Do you have difficulty swallowing solids or liquids? Have you experienced excessive saliva or drooling? Difficulty speaking Do you have difficultly forming words or saying what you intend? When did you first notice this? How long did it last? Significant history Do you have a history of stroke (cerebrovascular accident), spinal cord injury, meningitis or encephalitis, congenital defect, or alcoholism? Environmental and occupational hazards Are you exposed to insecticides, organic solvents, or lead? Are you taking any medications now? How much alcohol do you drink? Each week? Each day? How about mood-altering drugs, such as marijuana, cocaine, barbiturates, and tranquilizers?

Implementation

Health promotion Patient and family teaching Acute care Receiving, transcribing, and communicating medication orders. Accurate dose calculation and measurement Correct administration Recording medication administration Restorative care Special considerations Infants and children Older adults Polypharmacy

Developmental consideration

Infants and children By 3 months fetus has formed skeleton of cartilage Bone growth continues rapidly during infancy and steadily in childhood, until adolescent growth spurt Increase in width or diameter is by deposition of new bony tissue around shafts Lengthening occurs at epiphyses, or growth plates Any trauma or infection at these locations puts growing child at risk for bone deformity Longitudinal growth continues until closure of epiphyses; last closure occurs about age 20 Although skeleton contributes to linear growth, muscles and fat significant for weight increase Muscles vary in size and strength in different people due to genetics, nutrition, and exercise All through life, muscles increase with use and atrophy with disuse Aging adult Bone remodeling is cyclic process of resorption and deposition; after age 40 resorption occurs more rapidly than deposition Net effect is loss of bone density, or osteoporosis Postural changes are evident with aging, and decreased height is most noticeable Shortening of vertebral column caused by loss of water content and thinning of intervertebral disks Decreases in height of individual vertebrae, which occurs in later years from osteoporosis Other postural changes are kyphosis, backward head tilt to compensate for kyphosis, and slight flexion of hips and knees Distribution of subcutaneous fat changes through life; contour different, even if weight is same as when younger Begin to lose fat in face and deposit it in abdomen and hips Contour of muscles becomes more prominent, and muscles and tendons feel more distinct Lifestyle affects musculoskeletal changes Sedentary lifestyle hastens musculoskeletal changes of aging Physical exercise increases skeletal mass and helps prevent or delay osteoporosis Physical activity delays or prevents bone loss in postmenopausal and older women

Ears: Objective

Inspect and palpate external ear Size and shape Ears are of equal size bilaterally with no swelling or thickening Ears of unusual size and shape may be a normal familial trait with no clinical significance Skin condition Skin color consistent with person's facial skin color Skin intact, with no lumps or lesions On some people you may note Darwin's tubercle, a small painless nodule at the helix; this is a congenital variation and not significant Tenderness Move pinna and push on tragus; they should feel firm, and movement should produce no pain Palpating mastoid process should also produce no pain External auditory meatus Note size of opening to direct choice of speculum for otoscope; no swelling, redness, or discharge should be present Some cerumen usually present; color varies from gray-yellow to light brown and black, and texture varies from moist and waxy to dry and desiccated

Ear Exam

Inspect external ear Size and shape of auricle, position and alignment on head Note skin condition Check auricle and tragus for tenderness Evaluate external auditory meatus Otoscopic examination External canal - redness or swelling Cerumen discharge, foreign bodies or lesions Inspect tympanic membrane Color, characteristics, position, and integrity Test hearing acuity

Diagnostic Positions Test

Leading eyes through six cardinal positions of gaze will elicit any muscle weakness during movement Ask person to hold head steady and follow movement of your finger, pen, or penlight only with his or her eyes Hold target back about 12 inches so person can focus comfortably, and move it to each of six positions; hold momentarily, then back to center Progress clockwise; normal response is parallel tracking of object with both eyes

Assessment of dehydration

Look for dehydration in the oral mucous membranes. Normally there is none, and the mucous membranes look smooth and moist. Be aware that dark skin may normally look dry and flaky but this does not necessarily indicate systemic dehydration.

Deep Tendon Reflexes

Measurement of stretch reflexes reveals intactness of reflex arc at specific spinal levels and normal override on reflex of higher cortical levels Limb should be relaxed and muscle partially stretched Stimulate reflex by directing short, snappy blow of reflex hammer onto muscle's insertion tendon Compare right and left sides: responses should be equal Reflex response graded on 4-point scale 4 = very brisk, hyperactive with clonus, indicative of disease 3 = brisker than average, may indicate disease 2 = Average, normal 1 = diminished, low normal, or occurs with reinforcement 0 = no response Subjective scale requires clinical practice; scale not completely reliable; a wide range of normal exists in reflex responses

Objective Throat

Observe oval, rough-surfaced tonsils. Color is same pink as oral mucosa, and their surface peppered with indentations, or crypts; there should be no exudate on tonsils. Tonsils graded in size as follows: 1+ Visible 2+ Halfway between tonsillar pillars and uvula 3+ Touching uvula 4+ Touching each other You may normally see 1+ or 2+ tonsils in healthy people, especially in children, because lymphoid tissue is proportionately enlarged until puberty. Enlarge your view of posterior pharyngeal wall by depressing tongue with tongue blade. Scan posterior wall for color, exudate, or lesions. Touching posterior wall with tongue blade elicits gag reflex; this tests cranial nerves IX and X, the glossopharyngeal and vagus. Test cranial nerve XII, hypoglossal nerve, by asking person to stick out tongue; should protrude in midline; note any tremor, loss of movement, or deviation to side. Notice any breath odor, halitosis. Usually due to local cause; poor oral hygiene, consumption of odoriferous foods, alcohol, smoking, or dental infection.

Objective data

Order of examination Inspection Note size and contour of joint; inspect skin and tissues over joints for color, swelling, and any masses or deformity Presence of swelling signals joint irritation Palpation Palpate each joint, including skin for temperature, muscles, bony articulations, and area of joint capsule; notice any heat, tenderness, swelling, or masses which signal inflammation Palpation (cont.) Joints normally not tender to palpation If tenderness occurs, localize to specific anatomic structures, e.g., skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule

Spinothalamic Tract

Pain: tested by person's ability to perceive pinprick Temperature: test temperature sensation only when pain sensation is abnormal; otherwise, you may omit it because the fiber tracts are much the same. Light touch: apply wisp of cotton to skin in random order of sites and at irregular intervals; include arms, forearms, hands, chest, thighs, and legs; ask person to say "now" or "yes" when touch is felt Compare symmetric points

Subjective data/Health Hx

Past history of skin disease, allergies, hives, psoriasis, or eczema? Change in pigmentation or color, size, shape, tenderness? Excessive dryness or moisture? Pruritus or skin itching? Excessive bruising? Rash or lesions? Medications: prescription and over-the-counter? Hair loss? Change in nails' shape, color, or brittleness? Environmental or occupational hazards? Self-care behaviors?

Objective data

Penlight Tongue blade Cotton swab Cotton ball Tuning fork: 128 Hz or 256 Hz Percussion hammer

Objective data

Preparation Consciously attend to skin characteristics; the danger is one of omission Equipment needed Strong direct lighting, gloves, penlight, and small centimeter ruler For special procedures Wood's light Magnifying glass Materials for laboratory tests: potassium hydroxide (KOH) and glass slide

Objective Data

Preparation Position person standing for vision screening; then sitting up with head at your eye level Equipment needed Snellen eye chart Handheld visual screener Opaque card or occluder Penlight

Expected ROM for joings

Range of Motion (ROM) Ask for active voluntary ROM while stabilizing the body area proximal to that being moved Familiarize yourself with the type of each joint and its normal ROM so that you can recognize limitations For limitations, gently attempt passive motion; anchor joint with one hand while other hand slowly moves it to its limit; normal ranges of active and passive motion should be same Limitation in ROM is most sensitive sign of joint disease Joint motion normally causes no tenderness, pain, or crepitation Do not confuse crepitation with normal discrete "crack" heard as tendon or ligament slips over bone during motion For limitations, gently attempt passive motion; anchor joint with one hand while other hand slowly moves it to its limit; normal ranges of active and passive motion should be same Limitation in ROM is most sensitive sign of joint disease Joint motion normally causes no tenderness, pain, or crepitation Do not confuse crepitation with normal discrete "crack" heard as tendon or ligament slips over bone during motion

Error Reporting

Report all medication errors. Patient safety is top priority when an error occurs. Documentation is required. The nurse is responsible for preparing a written occurrence or incident report: an accurate, factual description of what occurred and what was done. Nurses play an essential role in medication reconciliation.

Risks

Risk recognition is essential to the early identification of factors that affect function developmental abnormalities physical or psychological trauma or disease social and cultural factors- beliefs and perceptions physical environment Risk reduction should be the focus of care for patients with identified risks

Models

Roper-Logan-Tierney Model of Nursing is based on these factors: 12 activities of daily living are central to life Focus is on health can care directed toward health promotion and wellness as opposed to illness Central elements are: Ongoing patient assessment Facilitation of independence maintaining a safe environment breathing communication mobilizing eating and drinking eliminating personal cleansing and dressing maintaining body temperature working and playing sleeping expressing sexuality dying

Tools

Self report- provide information about the patient's perception of functional ability Performance based- actual observation of standardized task, completion of which is judged by objective criteria. Preferred because they avoid potential for inaccurate measurement inherent in self report

Assessment techniques

Skin assessment integrated throughout examination Scrutinize the outer skin surface first before you concentrate on underlying structures Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groin, and inspect them thoroughly These areas are dark, warm, and moist and provide perfect conditions for irritation or infection Always inspect feet, toenails, and between toes

Test Central Visual Acuity

Snellen alphabet chart is most commonly used and accurate measure of visual acuity It has lines of letters arranged in decreasing size Place chart in a well-lit spot at eye level; position person exactly 20 feet from chart; hand person an opaque card with which to shield one eye at a time during test If person wears glasses or contact lenses, leave them on; remove only reading glasses Ask person to read through chart to smallest line of letters possible; encourage trying next smallest line also

Functions of skin and assessment terms

Teach skin self-examination using ABCDE rule to detect suspicious lesions A: asymmetry B: border C: color D: diameter E: elevation and enlargement

Whispered Voice Test

Test one ear at a time while masking hearing in other ear by placing one finger on tragus and rapidly pushing it in and out of auditory meatus Shield your lips so the person cannot compensate for a hearing loss (consciously or unconsciously) by lip reading or using the "good" ear With your head 30 to 60 cm (1 to 2 ft) from person's ear, exhale and whisper slowly some two-syllable words Normally, person repeats each word correctly after you say it

Cover Test

This test detects small degrees of deviated alignment by interrupting fusion reflex that normally keeps two eyes parallel Ask the person to stare straight ahead at your nose, even though gaze may be interrupted With an opaque card, cover one eye; note uncovered eye; normal response is a steady fixed gaze Meanwhile, macular image has been suppressed on covered eye If muscle weakness exists, covered eye will drift into a relaxed position Now uncover eye and observe it for movement It should stare straight ahead If it jumps to reestablish fixation, eye muscle weakness exists Repeat with other eye

Assessment

Through the patient's eyes History: Allergies, medications, diet history, patient's perceptual or coordination problems Patient's current condition Patient's attitude about medication use Factors affecting adherence to medication therapy Patient's learning needs

Eyes: Subjective Questions

Vision difficulty: decreased acuity, blurring, blind spots Pain Strabismus, diplopia Redness, swelling Watering, discharge History of ocular problems Glaucoma Use of glasses or contact lenses Self-care behaviors

Tactile discrimination

tests also measure discrimination ability of sensory cortex Stereognosis: test person's ability to recognize objects by feeling their forms, sizes, and weights Graphesthesia: ability to "read" a number by having it traced on skin Two-point discrimination: test ability to distinguish separation of two simultaneous pin points on skin Extinction: simultaneously touch both sides of body at same point; normally both sensations are felt Point location: touch skin and withdraw stimulus promptly; ask person to put finger where you touched