University Of Connecticut NURS 5062 ASSESSMENT Exam 1 Review (complete guide) guide
HEENT The head ● Every headache warrants workup for life-threatening secondary causes like meningitis, tumor, SAH ● Red flags: inc. severity/freq over 3 months, thunderclap (SAH), new onset after age 50, aggravated or relieved by change in position, inc. with Valsalva or exertion, assoc. w/ night sweats, fever, weight loss, recent head trauma, presence of CA, HIV, pregnancy, change in pattern from past h/a, assoc. papilledema, neck stiffness, focal neuro deficit ● Severe and sudden= SAH or meningitis ● Migraine/tension headache=episodic, peak over several hours ● Don’t give birth control to women with migraines- increased risk of stroke and MI ● New and persistent, severe=tumor, abscess, mass lesion ● Unilateral=migraine, cluster h/a ● Cluster h/a may be retroorbital ● Tension headache in temporal areas ● N/V common in migraine, tumors and SAH ● Prodrome aura common in migraine- e.g. photopsias (flashes of light), fortifications (zig zags of light), scotomas (areas of visual loss surrounded by normal vision ● Valsalva and leaning forward inc. pain from acute sinusitis ● Valsalva and laying down inc. pain from mass lesions The eyes ● Hyperopia: difficulty with close work, “farsightedness” ● Presbyobia: farsightedness due to age ● Myopia: difficulty with distance, “nearsightedness” ● Differential diagnosis of vision loss: o SUDDEN, UNILATERAL and PAINLESS: ▪ Vitreous hemorrhage ▪ Retinal detachment ▪ Retinal vein occlusion ▪ Central retinal artery occlusion o SUDDEN, UNILATERAL and PAINFUL: ▪ Corneal ulcer ▪ Uveitis ▪ Traumatic hyphema ▪ Acute angle closure glaucoma ▪ Optic neuritis from MS o BILATERAL and PAINLESS ▪ Giant cell arteritis o BILATERAL and PAINFUL ▪ Chemical or radiation exposure o GRADUAL ▪ Cataracts ▪ Macular degeneration o Slow CENTRAL loss ▪ Nuclear cataract ▪ Magular degeneration o PERIPHERAL loss ▪ Open angle glaucoma ● Moving specks/strands= vitreous floaters ● Fixed defects=scotomas, due to lesions in retina or visual pathway ● Flashing lights with new floaters= vitreous body detachment, prompt consult needed ● Diplopia: from lesions in brainstem, cerebellum or weakness/paralysis of EOM from cranial nerve III or VI palsy. ● Ptosis=damage to CN III or damage to sympathetic nerve supply ● Diplopia in one eye with other eye closed= problem with cornea or lens ● Red painless eye= subconjunctival hemorrhage ● Red eye with gritty sensation= viral conjunctivitis The ears ● Conductive loss: problems in external or middle ear o Noisy environment may help ● Sensorineural loss: problems in the inner ear, the cochlear nerve, or central connections in brain o Difficulty understanding speech, worse in noisy environment ● Medications that affect hearing: NSAIDS, ASA, aminoglycosides, Lasix, quinine ● Otitis externa: inflammation of external canal, green/yellow discharge common ● Otitis media: inflection in middle ear. No discharge unless perforation ● Pain in ear can be referred from other structures ● Meniere disease: sx tinnitus, hearing loss, vertigo ● Vertigo: sensation of true rotational movement of the patient or the surroundings. o Problems with labyrinths of inner ear o Vestibular disease The nose and throat ● Acute bacterial sinusitis or rhinosinusitis is unlikely until viral URI symptoms persist 7 days. Both facial pain and purulent drainage should be present for diagnosis. ● Epistaxis o Can originate in paranasal sinuses or nasopharynx o Bleeding from posterior nasal structures may pass into throat instead of out through nostrils o Clarify if hemoptysis or hematemesis is present The mouth, throat, and neck ● Sore throat usually associated with URI ● Centor’s clinical prediction rules for streptococcal and fusobacterium necrophorum pharyngitis 1. Fever 2. Tonsillar exudates 3. Swollen/tender anterior cervical lymph nodes 4. Absence of cough ● Always get rapid strep or throat culture ● Sore tongue- aphthous ulcers, sore smooth tongue of nutritional deficiency ● Hoarseness o Acute: overuse, viral laryngitis o Chronic: refer for laryngoscopy- consider hypothyroidism, reflux, vocal cord nodules, head and neck cancers, neuro disorders ● Hypothyroidism o Cold intolerance o Weight gain o Dry skin o Slowed heart rate ● Hyperthyroidism o Heat intolerance o Weight loss o Velvety moist skin o Palpitations Loss of vision ● Cataracts: clouding of lens ● Macular degeneration: mottling of macula, variations in retinal pigmentation, subretinal hemorrhage or exudates ● Primary open angle glaucoma is leading cause of visual impairment and blindness in the United States o Gradual loss of vision in peripheral fields o Pallor and increasing size of optic cup, which can enlarge to more than ½ diameter of optic disk Hearing loss ● More than 1/3 adults 50 and 80% adults 80 have hearing loss ● Aging is most important risk factor, presbycusis is most common age related cause o Hair cells in ear degenerate o Progressive hearing loss, esp. for high frequency sounds Oral health ● Saliva cleanses and lubricates the mouth. Many medications reduce saliva→ inc risk decay, mucositis, gum disease o Recommend chew sugarless gum, drink more water ● Remove and clean dentures at hs, massage sore gums ● Oral cancer o Tobacco, etoh, HPV major risk factors Anatomy and Physiology and Techniques in Examination The head ● Two salivary glands o Parotid: superficial to and behind the mandible, submandibular deep to the mandible ● Techniques of examination o Press tongue against lower incisors to palpate submandibular ● Enlarged skull= hydrocephalus, Pagets’s disease The eyes ● Conjunctiva: clear mucous membrane o Bulbar: covers anterior eyeball o Palpebral: lines eyelids ● Tear fluid protects conjunctiva and cornea from drying ● Fluid comes from meibomian glands, conjunctival glands, lacrimal glands ● Muscles of iris control pupillary size ● Muscles of ciliary body control thickness of lens, allow eye to focus on near or distant objects ● Fundus o Optic nerve and retinal vessels enter at optic disk o Lateral and inferior to disk is fovea/macular o Fovea is around the point of central vision o Macula surrounds fovea, no discernable margins o You do not see the vitreous body ● Visual field: entire area seen by eye when looking at a central point ● Fields extend farthest to temporal areas ● Lack of retinal receptors at optic disk produces an oval blind spot 15deg temporal to line of gaze ● Binocular vision: two visual fields overlap ● Visual pathways: to see an image, light is reflected from the target, passes through pupil and focused on photoreceptors on retina. The image is upside down and reversed right to left ● OPTIC nerve=CN II=vision ● OCULOMOTOR nerve=CN III=pupil constriction ● The near reaction: when a person shifts gaze from a far object to a near object the pupils constrict (CN III) o Convergence: CN III o Accommodation: increased convexity of the lens caused by contraction of ciliary muscles→brings near objects into focus Techniques of examination Visual acuity ● 20 feet from Snellen chart ● Wear glasses ● Identify the smallest line of print where the patient can identify more than half the letters ● Distance from chart/distance at which a normal eye can read that line Inspection ● Esotropia: inward deviation of eyes ● Exotropia: outward deviation of eyes ● Exophalmous: protrusion in graves disease ● Blepharitis: red inflamed lid margins, +crusting ● Assess adequacy of eyelid closure- failure to close exposes cornea to damage Fundoscopic exam ● Optic disk- round yellow/orange to creamy pink structure ● Inspect fovea→direct light laterally or ask patient to look directly into the light ● If patient is myopic you will need to rotate to negative diopters ● If patient is hyperopic you will need to rotate to positive diopters ● Arteries: light red, smaller, bright ● Veins: dark red, larger, inconspicuous ● Papilledema: swelling of optic disk with anterior bulging of physiologic cup suggestive, assoc. with inc. ICP ● To inspect anterior structures, turn diopter to +10-12, look for opacities in vitreous or lens o Cataracts are densities seen in the lens The ear ● Ossicles (malleus, incus, stapes) in middle ear transform sound vibration into mechanical waves for the inner ear ● Proximal end of Eustachian tube connects middle ear to nasopharynx ● Incus and malleus visible through TM ● Inner ear includes cochlea, semilunar canals, distal end of auditory nerve (CN VIII) Hearing pathways ● External ear through middle ear= conductive phase ● Inner ear and auditory nerve/vestibulocochlear nerve=sensorineural ● AC describes normal first phase of hearing. BC bypasses external ear, stimulates cochlea directly Techniques of examination ● If ear pain, move auricle, press tragus, press firmly behind ear o Auricle and tragus pain=otitis externa o Tenderness behind ear=otitis media ● Otitis externa: canal swollen, narrowed, moist, pale, tender, sometimes reddened ● Chronic otitis externa: canal thickened, red, itchy ● Red bulging drum in purulent otitis media, amber drum with serous effusion ● Effusion, otitis media→decreased mobility ● Perforation→no mobility ● Whisper test o Occlude nontest ear with finger and gently rub tragus o Exhale a full breath before whispering, CN VIII ● If failed whisper test, conduct weber and rinne tests ● Weber o In unilateral conductive hearing loss, sound lateralizes to the IMPAIRED EAR o In unilateral sensorineural hearing loss, sound is heard in GOOD EAR ● Rinne o In conductive hearing loss BC=AC or BCAC o In sensorineural hearing loss ACBC Nose and paranasal sinuses ● Nasal polyps- pale saclike growths, can obstruct air passage or sinuses, assoc. with allergic rhinitis, ASA sensitivity, asthma, chronic sinus infections ● Acute bacterial rhinosinusitis: local tenderness, facial pain, purulent discharge, nasal obstruction, smell disorder, present 7 days Oral mucosa ● Lead poisoning→black line on gingiva ● Torus palatinus: benign midline lump ● CN XII: stick out tongue, check it for symmetry ● Asymmetric protrusion→ tongue deviates toward lesion ● Oral cancer o Highest risk: men 50, smokers, chew tobacco o Squamous cell carcinoma on side or base of tongue o Any persistent nodule, red or white, is suspicious (erythroplakia and leukoplakia) Pharynx ● Patient says “ahh”→rise of soft palate, uvula midline, CN X ● CN X paralysis→uvula deviates away from the lesion Lymph nodes ● Tender nodes=inflammation ● Hard/fixed nodes=malignancy ● Enlarged supraclavicular lymph node especially suspicious for metastasis ● Enlarged or tender nodes call for examination of regions they drain and assessment of lymph nodes elsewhere so you can distinguish between regional and generalized lymphadenopathy ● Generalized lymphadenopathy= HIV, mono, lymphoma, leukemia, sarcoidosis Thyroid ● If thyroid is enlarged listen for bruits ● Localized systolic or continuous bruit=hyperthyroidism from Graves disease or toxic multinodular goiter ● Retrosternal goiters can cause hoarseness, SOB, stridor, dysphasia from tracheal compression ● Thyroid tender in thyroiditis, soft in Graves, hard in malignancy and Hashimoto thyroiditis Special Techniques Eye protrusion (proptosis or exothalmous) ● Stand behind patient and look downward ● Exothalmous present in 60% with Graves Nasolacrimal duct obstruction ● Ask patient to look up, press on lower lid close to medial canthus- this compresses the lacrimal sac. Look for fluid regurgitated out of puncta in the eye ● Discharge of non-purulent fluid from puncta suggests obstructed nasolacrimal duct Evert upper lid to search for foreign body Abnormalities of eyes ● Entropion: inward turning of lid, eyelashes can irritate eye ● Ectropion: lower lid margin turns outward. When punctum of lower lid turns outward, eye no longer drains well, tearing occurs ● Blepharitis: inflammation of eyelids ● Corneal arcus: thin grayish white arc at edge of cornea, can be normal or suggest high cholesterol ● Cataracts: opacity of the lens visible through the pupil ● Anisocoria: unequal pupils Abnormalities of the optic disk ● Physiologic cup is usually ½ diameter of disk ● Normal: orange-creamy pink, disk vessels tiny, disk margins sharp ● Glaucomatous cupping: enlarged cup ● Papilledema: inc. ICP leads to edema of optic disk→margins blurred, no physiologic cup seen Abnormalities of retinal arteries ● Normal o Transparent arterial wall, only the column of blood is visible. Normal light reflex of vessels is narrow ● Retinal arteries in hypertension o Focal or generalized narrowing of the lumen and light reflex o Copper wiring: arteries become full and tortuous, develop increased light reflex with bright coppery luster o Silver wiring: wall of a narrowed artery becomes so opaque so there is no visible blood o AV nicking: the vein appears to stop abruptly on either side of the artery o Tapering: vein tapers down on either side o Banking: vein is twisted on distal side of artery o Cotton wool spots
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nurs 5062 assessment exam 1 review
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every headache warrants workup for life threatening secondary causes like meningitis
