NR 302: HEALTH ASSESSMENT EXAM 2
PERLAA:
Pupils constrict bilaterally with accommodation
HEARING AIDS:
What would you do if your patient was constantly asking you to repeat something or if
they hear you?
Always ask if they are wearing hearing aid
Most people do not like to wear their hearing aid - especially elders
Creates a loud noise – need to be adjusted
TODDLER WELL CHILD VISIT:
Always do anything invasive at the end of a procedure
Nurse should examine the child’s tympanic at the end
BRUXISM:
Grinding of the teeth at night while sleeping
Can cause filling of the teeth
TMJ, unbalanced jaw
Go to the dentist, get a mouth guard, one that fits properly, or go buy over the counter
AFRICAN AMERICAN WITH JAUNDICE:
ALWAYS THE MOUTH
Little pigmentations in the mouth in the oral mucosa
You need to look at the hard palate - top of the mouth
AFRICAN AMERICANS WITH CYANOSIS:
Look at the conjunctiva of the eye
Doesn’t always have to be African American – Spanish/Indian/dark skinned
Cyanosis is the conjunctiva of the eye
GLAUCOMA:
Patient going home and has glaucoma
ALWAYS MAINTAIN SAFETY
Eye drops are the only thing that can help – for the rest of their lives
Keep an eye on their blood pressure and if the patient has diabetes
Patient has a history of glaucoma (is not as uncommon in older adult) other people can
get it, especially diabetes and hypertension because it is caused by pressure
, If untreated, it can lead to blindness.
Only remedy for it is eye drops or surgery like cataracts (for the glaucoma)
PRIORITY: SAFETY! Because they cannot see = cloudy, opaque of the lens
CAPILLARY REFILL:
it should be less than 3 seconds (pinch nail and turns pink right away)
It is an arterial insufficiency (no oxygen flow coming to that area, due to a blockage)
Function of artery- takes blood away from the heart and takes it to our system,
Venal insufficiency- if you had a blockage and the unoxygenated blood cannot get back
into the heart means you’re going to have edema.
SKIN BREAKDOWN:
Always monitor for protein levels
ALBUMIN is the blood test
it is important for the patient to be good nutritional health
provide a diet high in protein
patients who are in end-stage renal disease and is taking protein, we cannot not stop
the protein with them because protein builds and restore body tissues and cells in them,
however, there is a problem- liver is not functioning and when the protein is broken
down and going to be synthesized by the liver, the liver is not synthesizing and the
protein breakdown is lying there in the liver and turns into pneumonia
Pneumonia is very toxic for the brain causing encephalopathy.
If a question, ask about end-stage liver disease/ cirrhosis- either protein or ammonia
will be your answer (THEY LIMIT PROTEIN NOT TAKE IT AWAY)
SPLEEN & LYMPH NODES SUPPORT IMMUNITY
PROTEIN FOR SKIN REPAIR:
if a patient had an ulcer, get an order for blood test, look at albumin levels. If albumin is
low they have poor skin filling.
SUBJECTIVE & OBJECTIVE DATA:
know the differences
SUBJECTIVE DATA OF THE EYES:
Vision difficulty: decreased acuity, blurring, blind spots
Pain
Strabismus, diplopia
Redness, swelling
Watering, discharge
History of ocular problems
PERLAA:
Pupils constrict bilaterally with accommodation
HEARING AIDS:
What would you do if your patient was constantly asking you to repeat something or if
they hear you?
Always ask if they are wearing hearing aid
Most people do not like to wear their hearing aid - especially elders
Creates a loud noise – need to be adjusted
TODDLER WELL CHILD VISIT:
Always do anything invasive at the end of a procedure
Nurse should examine the child’s tympanic at the end
BRUXISM:
Grinding of the teeth at night while sleeping
Can cause filling of the teeth
TMJ, unbalanced jaw
Go to the dentist, get a mouth guard, one that fits properly, or go buy over the counter
AFRICAN AMERICAN WITH JAUNDICE:
ALWAYS THE MOUTH
Little pigmentations in the mouth in the oral mucosa
You need to look at the hard palate - top of the mouth
AFRICAN AMERICANS WITH CYANOSIS:
Look at the conjunctiva of the eye
Doesn’t always have to be African American – Spanish/Indian/dark skinned
Cyanosis is the conjunctiva of the eye
GLAUCOMA:
Patient going home and has glaucoma
ALWAYS MAINTAIN SAFETY
Eye drops are the only thing that can help – for the rest of their lives
Keep an eye on their blood pressure and if the patient has diabetes
Patient has a history of glaucoma (is not as uncommon in older adult) other people can
get it, especially diabetes and hypertension because it is caused by pressure
, If untreated, it can lead to blindness.
Only remedy for it is eye drops or surgery like cataracts (for the glaucoma)
PRIORITY: SAFETY! Because they cannot see = cloudy, opaque of the lens
CAPILLARY REFILL:
it should be less than 3 seconds (pinch nail and turns pink right away)
It is an arterial insufficiency (no oxygen flow coming to that area, due to a blockage)
Function of artery- takes blood away from the heart and takes it to our system,
Venal insufficiency- if you had a blockage and the unoxygenated blood cannot get back
into the heart means you’re going to have edema.
SKIN BREAKDOWN:
Always monitor for protein levels
ALBUMIN is the blood test
it is important for the patient to be good nutritional health
provide a diet high in protein
patients who are in end-stage renal disease and is taking protein, we cannot not stop
the protein with them because protein builds and restore body tissues and cells in them,
however, there is a problem- liver is not functioning and when the protein is broken
down and going to be synthesized by the liver, the liver is not synthesizing and the
protein breakdown is lying there in the liver and turns into pneumonia
Pneumonia is very toxic for the brain causing encephalopathy.
If a question, ask about end-stage liver disease/ cirrhosis- either protein or ammonia
will be your answer (THEY LIMIT PROTEIN NOT TAKE IT AWAY)
SPLEEN & LYMPH NODES SUPPORT IMMUNITY
PROTEIN FOR SKIN REPAIR:
if a patient had an ulcer, get an order for blood test, look at albumin levels. If albumin is
low they have poor skin filling.
SUBJECTIVE & OBJECTIVE DATA:
know the differences
SUBJECTIVE DATA OF THE EYES:
Vision difficulty: decreased acuity, blurring, blind spots
Pain
Strabismus, diplopia
Redness, swelling
Watering, discharge
History of ocular problems
