PN 111 Integumentary and HEENT
How does the nurse locate the salivary glands of a patient?
1.Parotid glands are anterior to the ears near the mandible 2.Submandibular glands are under mandible 3.Sublingual glands, smallest salivary glands, lie on floor of mouth
What cranial nerve would the nurse assess when suspecting facial paralysis
Cranial nerve VII...facial nerve--have the patient close their eyes tightly, smile, frown, puff out cheek. Results should be symmetrical.
What is cyanosis and what does it indicate?
Cyanosis-physical sign causing bluish discoloration of the skin and mucous membranes. Caused by a lack of oxygen in the blood. Cyanosis is associated with cold temperatures, heart failure, Respiratory distress, lung diseases, and smothering-may be seen at nail beds, around mouth, palms of hands or soles of feet. It is seen in infants at birth as a result of heart defects, respiratory distress, or lung and breathing problems. Circumoral pallor (cyanosis around the mouth) is common with infants in respiratory distress (decreased oxygen level)
Which side of the tongue is rough and has hundreds of papillae (taste buds) to distinguish sweet, sour, bitter, and salty tastes.
Dorsal side
What is dysphagia and how would the nurse assess for this condition?
Dysphagia is difficulty swallowing. The nurse would ask the patient to say "ah"...the uvula should move up and stay midline without deviation. If deviation is noted to one side or the other this finding would need further evaluation for dysphagia
What is a scar?
Fibrous tissue replacing normal tissues destroyed by injury or disease or divided after an incision; secondary skin lesion
What is a macule?
Flat, nonpalpable lesions usually < 10 mm in diameter. Macules represent a change in color and are not raised or depressed compared to the skin surface. Examples include freckles, flat moles, and port-wine stains
What does the mnemonic PERRLA stand for and what does is it used for?
It used to assess pupillary response and accommodation of the eyes. It stands for Pupils, Equal, Round, Reactive to Light Accommodation. Pupillary reaction is assessed by shining a light into the patient's eye and looking for direct and indirect constriction (consensual). Accommodation is assessed by holding an object 10-12 inches in front of the patient and asking them to watch the object as the nurse moves the object toward the nose. The pupils should constrict and the eyes should converge (cross). The pupils will constrict (get smaller) when an object is close to the eyes or there is a lot of light. The pupils will dilate (get larger) when an object is further away or there is little light available.
What is should the nurse expect to feel when palpating lymph nodes
Lymph nodes should be soft and moveable without tenderness. The nurse should be aware that malignancy (cancer) causes lymph nodes to be large, discrete, non-tender, and firm to rubbery.
How does the nurse check for corneal light reflex and what does an abnormal finding suggest?
Shine a light at the bridge of the patient's nose (12 to 15 in away)--light should shine symmetrically in each eye—if asymmetry noted consider weak eye muscles or astigmatism—irregular shape of the eye
When assessing arterial pulse points the nurse should expect to feel?
Smooth, bilateral pulsations
Why does the nurse assess the 6 cardinal gazes in a patient's field of vision
The 6 cardinal gazes are assessed to check the movement of the eye (muscle movement) —how well the extra ocular muscles/movement (EOM) (6) are working and to assess cranial nerves III-Oculomotor, IV - Trochlear, and VI -Abducens
When assessing visual acuity the nurse utilizes the Snellen chart to assess what three areas of vision?
The Snellen chart assess for distance visual acuity, color perception
What is presbycusis?
hearing loss due to aging
What is petechiae?
pin point purplish or red discoloration of an area of the skin.
Where does the nurse assess for jaundice
sclera, soles of the hands and bottoms of the feet
What is an ecchymosis?
§Ecchymosis (bruise)-vascular skin lesion--the passage of blood from ruptured blood vessels into subcutaneous tissue, marked by a purple discoloration of the skin. Can indicate a bleeding disorder, trauma, or abuse--specifically if there are multiple bruises in different stages of healing
Clear drainage from the nose can indicate?
Allergies
What are cataracts?
clouding of the lens of the eye
What is a cyst?
A closed, sac-like pocket, in the dermis or subcutaneous layer of skin, of tissue that can form anywhere in the body. It may be filled with fluid, air, pus, or other material. Most are benign
What is hirsutism?
A condition in women that results in excessive growth of dark or coarse hair in a male-like pattern — face, chest and back. Often arises from excess male hormones (androgens), primarily testosterone and endocrine disorders
What is a vesicle?
A fluid filled lesion less than 1 cm in diameter; not in the dermis
What is glaucoma?
A group of diseases that increases intraocular pressure and damages optic nerve leading to blindness. Internal pressure buildup in the eye will cause a loss of peripheral vision and blindness
What is impetigo?
A highly contagious bacterial infection (easily passed to others) caused by staphylococcal or streptococcal pathogens. Very common in children and crowded living conditions §Usually appears as red sores on the face, especially around a child's nose and mouth, and on hands and feet. The sores burst and develop honey-colored crusts
What is jaundice
A yellowing of the skin and eyes
What is a tumor?
An abnormal mass of tissue that is solid and greater than 2 cm in diameter. Results when cells divide more than they should or do not die when they should. May be benign (not cancer), or malignant (cancer). Also called neoplasm.
What is an aura and what type of headache is it commonly seen with?
An aura is a sensation perceived by a patient that precedes a condition affecting the brain. An aura often occurs before a migraine or seizure.
What is acute sinusitis
An infection that is a result of pooling secretions within sinuses. Most common symptom is acute, throbbing pain in affected sinus--Pain over the frontal and maxillary sinuses. May also have fever, thick purulent discharge, and edematous, erythematous nasal mucosa.
How does the nurse assess nevus (moles) or lesions for possible skin cancer (melanoma)
By using the ABCDEF rule---F stands for Familiar
Why does the nurse need to use caution when assisting or moving an elderly patient?
Care should be taken when moving older adults or placing adhesives on the skin. Due to thinning (atrophy) of the skin—skin is much easier to tear
Why should the nurse perform regular assessment of the skin for a patient is who has limited mobility
Clients with limited mobility are at risk for skin breakdown. This is due to constant pressure and a decrease in circulation (Secondary to pressure and body fluid pooling because of inability to feel pressure or decreased ability to change position to relieve pressure). The nurse should examine client's skin, especially over bony prominences (the most common area is the ischial tuberosity (buttocks)), and turn client so that complete skin assessment may be performed often.
How does the nurse assess the 6 cardinal gazes?
Have the patient follow an object, by holding it 12-14 inches from the patient's nose, following it only with the eyes and moving the object in the six cardinal fields of gaze (start in the midline). The movement should be smooth and without hesitancy. Watch for any nystagmus (involuntary movements of the eye) and report for further evaluation
Which part of the ear is considered the nerve center for hearing?
Inner ear
what is a cluster headache?
Intense episodes of excruciating unilateral pain. Lasts ½ to 1 hour and may repeat daily for weeks with some remissions or 6 to 12 weeks with remissions for one or more years. Pain is burning, drilling, stabbing behind one eye (unilateral).
How does the nurse assess capillary refill and what does it indicate
The nurse blanches the end of the nailbed and then releases. The capillary refill should be instant (<2 seconds)—indicates adequate blood flow to tissue--circulation
How does the nurse asses skin turgor and what does an abnormal finding indicate?
The nurse will grasp the skin between two fingers so that it is tented up. Commonly on the hand or chest (for older adults). The skin is held for a few seconds then released. Skin with normal turgor return rapidly back to its normal position. Sluggish or "tented" skin could indicate dehydration.
When inspecting the ears the nurse expects to find?
The pinna (The outer part) of the ear should align directly with the outer canthus (corner) of the eye and be angled no more than 10 degrees or 3 cms from a vertical position.
What is a migraine headache?
The second most common headache syndrome in US, and can occur in childhood, adolescence, or early adult life; young women are most susceptible. May be accompanied by depression, restlessness, irritability, photophobia, nausea, or vomiting and an aura. May last up to 72 hours
What is the expected finding when the nurse palpates the thyroid?
The thyroid gland should be small, smooth, and soft, and the gland should move freely during swallowing. It should be nontender without any hard nodules present.
What is vertigo
Vertigo is sensation that the environment is whirling around. Perception of movement distinguishes dizziness from vertigo.
How does the nurse assess peripheral vision?
With the client facing forward and the nurse behind the patient; the nurse moves an object into the visual field and the client reports when the object is seen on each side at 90 degrees (expected). The findings should be symmetrical.
What is clubbing?
an increase in the angle between the base of the nail and the fingernail to greater than 160 degrees and is caused from CHRONIC hypoxia (lack of oxygen) to the tissues
purulent drainage from an orifice (ears, nose etc...) may indicate?
an infection
What is exophthalmos?
bulging eyes commonly seen with hyperthyroidism
What is the procedure for using the Snellen chart?
§Ensure good natural light or illumination on the chart §Explain the procedure to the patient—if the patient is wearing glasses allow them to keep them on—if glasses are needed for far vision and patient does not have them—chart this in the documentation §Position the patient 20 feet from the chart §Expected vision for an adult is 20/20 §Test each eye separately §Ask the patient to wear any current distance glasses, and to cover one eye with his/her hand and to start reading at the smallest line he/she can read without straining §The smallest line he/she can read will be expressed as a fraction 20/20, 20/30 etc..,(written on the right side of the chart). The upper number refers to the distance the chart is from/ the patient (20 feet) and the lower number is the distance at which the patient can see ◦Top number = distance from chart. ◦Bottom number = distance person with normal vision (20/20) should be able to read line. ◦A patient with 20/30 vision can see at 20 feet what a patient with 20/20 vision can see at 30 feet §A patient can miss one letter on a line and still be considered "passing" that line. If the patient misses two or more letters on a line move up to the next line and reassess §Repeat with each eye and then both eyes together §In the patient's documentation, record the VA (visual acuity) for each eye, stating whether it is with or without correction (glasses), for example: §OD (right eye) 20/30 with glasses §OS (left eye) 20/60 with glasses §OU (both eyes) 20/30 with glasses
How does the nurse conduct the weber test and what would an abnormal finding suggest?
§Place the vibrating tuning fork on the top of the head equidistant from both ears. These vibrations will be conducted through the skull and reach the cochlea. §Ask the patient whether it is heard loudest in either one side or the midline (e.g., "Is the sound louder in your right ear, left ear, or the middle?") §Abnormal: test does not demonstrate lateralization (heard more in one ear than the other) and would suggest hearing loss. This patent should be referred for further testing
What is dizziness
◦Dizziness (syncope) is symptom is a feeling of faintness, Patients may complain of their field of vision narrowing or shrinking
What are the four stages of a pressure ulcer?
◦Stage I = prolonged redness with unbroken skin ◦Stage II = partial-thickness skin loss appears as a superficial abrasion, blister, or excoriation ◦Stage III = full-thickness skin loss with damage to subcutaneous tissue (may note serosanguineous drainage) ◦Stage IV = full-thickness skin loss with invasion of deeper tissue into muscle and/or bone; wound appears as an open ulceration with purulent drainage and peripheral crusting ****Some are unstageable with tunnels and discoloration
What is the cornea?
◦The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. ◦The cornea should be transparent, smooth, and clear.
