Health Assessment Test 1 Notes PDF

Health Assessment Notes Ch. 1 - understanding health assessment Health Complete physical, social, and mental well-being and not merely the absence of disease and infirmity A balance of body, mind, and spirit Influen...

Health Assessment Notes Ch. 1 - understanding health assessment Health Complete physical, social, and mental well-being and not merely the absence of disease and infirmity A balance of body, mind, and spirit Influenced by individuals external environment and physiological-biological, behavioral, and economic-political factors CDC → 5 determinants of health 1. Genetics and biology (age, sex) 2. Individual behavior (alcohol use, unprotected sex, smoking) 3. Social environment (income and lifestyle) 4. Physical environment (where the individual lives) 5. Health services (insurance, access to health care) 3 levels of prevention 1. Primary prevention → prevention of disease and disability focuses on improving an individual's overall health and well-being a. Immunizations, health and safety education b. Limit exposure to hazards and risks, healthy lifestyle changes 2. Secondary prevention → early screenings to detect disease in early stages (asymptomatic), identify risk factors, access early treatment a. Colonoscopy (colon cancer), testing for glaucoma, identify risk factors for substance use disorder 3. Tertiary prevention → restoration of health after illness or disease has occurred to prevent death and disability a. Rehabilitation for stroke patients, inpatient treatment for clinical depression 5 steps of the nursing process - ADPIE 1. Assessment a. Collect and analyze data about the individual → Physiological, psychological, psychosocial, economical, spiritual, cultural practices and beliefs 2. Diagnosis a. Potential or actual health problems or needs with a patient using both subjective and objective data 3. Planning/outcomes a. Working with the individual as a copartner in care to meet the needs or snort and long-term goals of the individual - is measurable and achievable  4. Implementation a. The nursing and individual actions and plan of care to meet the individuals goals 5. Evaluation a. Assesses whether the short and long-term goals have been met or are unmet Clinical reasoning ○ Individuals history, physical signs, symptoms, laboratory data, diagnostic imaging to arrive at a diagnosis and assess and formulate a plan Clinical judgment ○ An interpretation or conclusion about a patients needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response Intuition ○ A feeling that guides an individual in a specific direction although the individual cannot understand its exact reason (gut feeling) Psychomotor skill - 4 techniques of physical assessment 1. Inspection (looking) 2. Percussion (tapping different areas of the body to assess underlying structures) 3. Palpation (using your hands to feel surface characteristics) 4. Auscultation (listening for sounds) QSEN 6 core competencies 1. Patient-centered care 2. Teamwork & collaboration 3. Evidence based practice 4. Quality improvement 5. Safety 6. Informatics Ch.2 - interviewing a patient for health history Therapeutic communication encompasses: Empathy and compassion Unconditional regard Genuineness Respect Caring Types of health history Comprehensive health history: looks at the whole patient and reviews all body systems; this health history takes time. ○ EX. reviewing the patient systems from head to toe is routinely done during an annual examination Focused or problem based health history: focuses specifically on an acute problem or symptom that the patient is experiencing. Patients being seen in urgent care or the ER will have this type of health history. ○ EX. if a patient is having difficulty breathing, the health history would focus on the respiratory and cardiac systems. Follow up history: occurs after a patient has been seen; it concentrates on new data since the last history. ○ EX. a patient was originally treated and worked up for heart palpitations and is being seen two weeks later to evaluate the treatment. Health history Data is collected from 2 types of sources Primary source: patient who is being interviewed and assessed Secondary source: family members, significant others, or medical records of patient Ch. 3 - Taking health history Health History Purpose Document a database of past and present health including a medical history of medical problems, hospitalizations, and surgeries. Document family history Identify psychosocial factors influencing health and well-being. Identify self-care and health promotion practices. Determine strengths and weaknesses of the patient Identify teaching needs Identify discharge needs or case management referrals.  1. Reason for seeking care 2. History of present illness 3. Biographical data (general info about patient) 4. Military History 5. Medications (prescriptions, vitamins, herbal/non herbal, OTC) 6. Immunizations 7. Past medical history 8. Family History 9. Psychosocial Assessment a. Behavioral: daily habits, healthcare practices, and daily activities. b. Environmental: physical and social environment (i.e., allergens, asbestos, housing, water). c. Social: human-to-human interaction, relationship to individuals, groups, institutions, organizational systems, culture, and spirituality. d. Financial and economic: i.e., household management. e. Ex. Education, occupation, housing environment, finances, exercise, sleep/rest, smoking, safety, Support system, stress/coping mechanisms f. Substance use (drug and alcohol) g. Sexuality (reduce STIs) 10. Functional assessment 11. Cultural assessment 12. Spiritual Assessment 13. Review of body systems (get symptoms of patient currently) Ch.5 - assessment techniques Perform Hand Hygiene Hand hygiene includes both hand washing with either plain or antiseptic-containing soap and water for at least 20 seconds or use of alcohol-based products (gels, rinses, foams) that do not require the use of water. The CDC recommends using Alcohol Based Hand Rub (ABHR) with 60-95% alcohol in healthcare settings Transmission based precautions Contact → gloves and gown ○ used for patients with known or suspected infections that represent an increased risk for contact transmission. ○ Put on PPE upon room entry and properly discard before exiting the patient’s room to contain pathogens  Droplet → surgical mask ○ pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. ○ Limit transport and movement of patients outside of the room to only medically necessary purposes. If transport or movement outside of the room is necessary, instruct patient the to wear a mask and follow respiratory hygiene/cough etiquette Airborne → N95 mask ○ patients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, or Covid-19). ○ The placement of this patient would be in an airborne infection isolation room (AIIR). 5-1 Inspection Direct Inspection: carefully observing and inspecting a specific area or the whole individual Indirect inspection: using specific equipment to implore visualization of an area Requires using 3 senses (See, hear, smell) Natural lighting 5-2A Palpitation Palpitation: feeling with your fingers or hands to assess parts of the body 5-4 A Direct Auscultation Auscultation: used to listen to and assess cardiovascular, respiratory, gastrointestinal, and peripheral vascular sounds produced by the body Direct: listen and assess sounds produced by the body without a stethoscope Indirect: listen to sounds produced by the body with an amplification device Ch. 6 - general survey & vital signs Assessment Steps 1. Greet the patient and introduce yourself to the patient. 2. Explain your role and the purpose of the assessment. 3. As you begin interviewing the patient, make the following general observations about the patient: Physical appearance Health: Does the patient look healthy, chronically ill, or ill? Age: Does the patient look his or her stated age? Patient hygiene, grooming, appropriate dress for climate or season; note body odors and breath Body structure: tall, short, muscular, thin, or overweight; symmetry of body structures Behavior and mental status Level of consciousness (LOC): alertness and orientation Behavior: calm, restless, cooperative, eye contact, clarity of speech Facial expression: relaxed, stressed, frowning, facial grimacing, symmetrical Mood: happy, depressed, flat affect Speech: clear, difficulty articulating words, slurring speech Mobility Gait: steady and straight, difficulty walking, limping, or using an assistive device (i.e., cane, rolling walker) Posture: stands or sits up straight; stooped posture, slumping in chair Range of motion (ROM): ability or inability to move all joints and extremities; participates in the exam Signs of pain, respiratory, cardiac or gastrointestinal distress Pain: complaints of pain, facial grimacing, limited movement, guarding Respiratory distress: signs of difficulty breathing, chest retractions, or skin color changes Cardiac distress: complaints of chest pain, skin color changes Gastrointestinal: complaints of abdominal pain, holding or rubbing stomach, guarding abdomen General discomforts: fatigue, decreased endurance, general muscle weakness Normal Findings Health: appears healthy with no signs of illness, pain, or debilitation Physical appearance: ○ Age: patient looks stated age ○ Hygiene: well groomed, appropriately dressed for climate, no odors ○ Body structure: well-built, symmetrical body structures Level of consciousness: alert and oriented × 4 (person, place, time, situation); calm and cooperative; may or may not have direct eye contact (depends on culture), speech clear, facial expression relaxed and symmetrical; mood calm; reports understanding the reason for assessment Mobility: ○ Gait: steady and symmetrical, no difficulty walking ○ Posture: stands straight, sits up straight without support ○ Range of motion: ability to move all joints and extremities, actively participates in the exam Distress: No signs of general discomfort or pain, no signs of respiratory, cardiac, or gastrointestinal distress Abnormal Findings Physical appearance ○ Thin and frail, cachectic (wasting syndrome), looks tired, fatigue may be a sign of acute or chronic illness ○ Age: patient looks much older than stated age; may indicate chronic stress or illness ○ Patient hygiene: unkempt grooming, inappropriate dress for climate, clothing that is too tight or too loose may indicate weight gain or weight loss; odors of the body or breath Behavior and mental status ○ Level of consciousness: disoriented, decreased mentation [Psychosocial assessment (Ch. 3); Neurological assessment (Ch. 17); Older Adult assessment ○ Behavior: inappropriate; Neurological assessment ○ Mood: depressed, flat affect [Mental Health assessment (Ch. 3)] ○ Speech: difficulty articulating words, slurring speech; Older Adult assessment Mobility ○ Gait and posture: unsteady, difficulty walking, limping, poor posture; Neurological assessment (Ch. 17)] ○ Range of motion: inability to move all joints and extremities; unable to participate in the exam [Musculoskeletal assessment (Ch. 16)] Distress: signs of respiratory distress; signs of cardiac distress; signs of pain; signs of gastrointestinal distress Vital Signs Temperature ○ regulated by the thermoregulatory center in the hypothalamus that balances heat production and heat loss. ○ Body temp. varies with the time of day and the site of measurement and changes with age, basal metabolic rate, environmental factors, and during exercise. Pulse rate ○ Pulse rate reflects heart rate; the number of times your heart beats per minute (bpm). ○ Pulse is the rhythmic expansion as the force of blood moves against the walls of the arteries. This generates a rhythmic wave of pressure that is felt at various points in the body as a pulse. Respiratory rate ○ The respiratory center is located in the medulla oblongata and pons in the brain stem; this portion of the brain controls the rate and depth of respirations. The main organs of the respiratory system are the lungs ○ Breathing frequency; the number of breaths taken within 60 seconds. ○ Respiratory rate (RR) equals one inhalation and exhalation of a breath.  Blood pressure ○ BP is the force of circulating blood being exerted on the walls of the large arteries of systemic circulation as it is being pumped out of the heart. This pressure within the circulatory system is influenced by: Cardiac output is the volume of blood pumped out by the heart in 1 minute. Stroke volume is the volume of blood pumped out by the heart during each contraction. ○ BP is recorded as two numbers—the systolic (pressure in arteries as the heart contracts) over diastolic (pressure in arteries as the heart relaxes between beats). The measurement is written one above or before the other, with the systolic number on top and the diastolic number on the bottom 6-2A Assessing oral temperature Normal Findings 97.5°F to 99.5°F or 36°C to 37.5°C Abnormal Findings < 97.7°F to > 100.4°F or < 36.6°C to > 38°C Hypothermia = 100.4 Fever (pyrexia) = > 100 or 37.8°C. 6-2B Assessing Tympanic temperature Eardrum is close to hypothalamus in brain that regulates body temp Tympanic thermometer: uses infrared radiation and a thermopile detector at TIP to measure the infrared energy given off from patients eardrum 6-3 Assessing Pulse Two areas to check ○ Radial pulse→ most common with a regular heart rate ○ Apical pulse→ more reliable and accurate location to assess heart rate 6-3A Palpating the radial pulse To assess the heartbeat through the wall of the radial peripheral artery at wrist 6-6 Assessing BP Many factors can affect bp: gender, age, lifestyle, family history, exercise, body position, stress, pain, medication, diseases Systolic BP: pressure exerted against the inner walls of blood vessels during the maximum push of the blood pulse as the left ventricle contracts Diastolic BP: pressure is the force exerted during relaxation and dilation of the heart as it refills with blood prior to its next contraction, it's the minimum pressure of blood pulse  Chapter 7 - PAIN Pain impulses are initiated by activation of free nerve endings (pain receptors) called nociceptors Pain threshold is the level at which the brain first perceives a stimuli as painful. Pain tolerance is how much pain and how long the patient is willing and able to endure the pain. Intractable pain is constant pain that is resistant to treatment or incurable; it continues even with interventions that attempt to alleviate the pain. An example of intractable pain is pain from advanced cancers. ○ Very severe, unremitting pain. ○ Affects every aspect of the patient’s life Sources of Pain Cutaneous pain originates from skin/ subcutaneous tissue (superficial pain) ○ Sharp pain with short duration. ○ Ex. skin laceration. Colicky pain fluctuates in intensity from severe to mild and occurs in waves ○ Related to spasms in the intestines. Nociceptive pain results from damage or inflammation to the sensory nerves (nociceptors) in soft tissue ○ Dull, sharp, or achy pain. ○ 2 types of nociceptive pain Somatic pain is transmission of pain carried along the sensory fibers. Sharp, intense Visceral pain is activation of the nociceptors in the thoracic, abdomen, or pelvic viscera. Vague, achy, deep Neuropathic pain is caused by injury or damage to nerves in the peripheral or central nervous system ○ Feels sharp, stings, burns, and the patient may experience numbness and tingling sensations. Phantom limb syndrome is a poorly understood type of neuropathic pain that is felt in a body part that has been removed. Transmission of pain Radiating pain starts in one area and spreads out to another part of the body (e.g., toothache that radiates to the ear or head). Referred pain is felt in an area away from the actual source of the pain Pain Assessment OLDCARTS → used to assess pain and symptoms in general Onset ○ When did the pain begin? Location/Radiation ○ Where do you feel the pain? Does the pain radiate? Duration ○ How long does the pain last? Is it constant or intermittent? Character ○ What does the pain feel like? Aggravating or alleviating factors ○ What makes the pain worse? What makes the pain better? Related symptoms ○ What symptoms do you have with the pain? Treatment ○ How do you relieve the pain? What medications do you take? Who has treated your pain? Severity ○ How would you rate or describe the severity of the symptom? ○ Use a pain scale and the patient’s own words. ○ How does it affect your daily activity? OPQRST → specific to pain O = onset of pain ○ When did you first feel pain? P = provocation and palliates ○ What causes the pain? ○ What makes pain better or worse? Q = Quality ○ What does the pain feel like? Describe it to me R = radiation and region ○ Where is the pain located? Can you point to it? ○ Is it confined in one place? ○ Does the pain radiate? If so, where to? ○ Did it start elsewhere, and is it now localized to one spot? S = Severity ○ How severe is the pain? ○ Rate the pain on a scale of 0 to 10 (0 being no pain and 10 being worst pain possible) T = timing or temporal ○ When did the pain start? ○ Is it present all the time? ○ Are you pain-free at night or during the day? ○ Are you pain-free on movement? ○ How long does the pain last? SCALES Numeric rating scale (NRS) ○ Most common ○ Scale of 0 - 10 ( 0 is no pain and 10 is worst pain) ○ Everyone has different pain levels (take into consideration) Wong-Baker Faces Pain rating Scale ○ Used in pediatrics and if language barrier ○ Point to the face that best shows your reaction to the pain Verbal Descriptor Pain Scale or Verbal Rating Scale (VRS) ○ Patients asked to select the adjective or phrase that best characterizes their level of pain ○ Patient who is able to describe pain using words such as mild, moderate, severe Iowa Pain thermometer (IPT) ○ Modified verbal descriptor scale made up of 7 pain describing words associated with 7 varying levels of pain intensity ○ Patients asked to visualize a thermometer with the temperature rising and relate it to their findings of pain (as temp rises so does feeling of pain) ○ Measure pain in patients who have difficulty communicating verbally or have cognitive deficits Pain Assessment in Nonverbal patients (more objective compared to others) Critical Care Pain Observation Tool (CPOT) ○ Facial expression, body movements, muscle tension and ventilator compliance ○ For patients who cannot verbalize ○ Not alert and oriented x4 Pain Assessment in Advanced Dementia Scale (PAINAD) ○ Cognitive impairment, observe patient for minimum of 5 minutes ○ Can also be used for stroke patient or patient who is confused and cannot communicate well Ch. 8 - Skin, Hair, Nails Layers of skin Epidermis ○ Is an avascular, outer layer of the skin that is replaced every 3 to 4 weeks. ○ Pigmentation is determined by the number, size, and distribution of melanosomes, membrane-limited vesicles found within melanocytes; genetics plays a key role. Dermis subcutaneous layer ○ Deepest layer of the skin that attaches the dermis layer of skin to bones and muscle. Hair There are two types of hair: ○ Vellus: the fine, soft, nonpigmented hair over most of our body ○ Terminal: usually pigmented, dark, coarse, and thicker; develops during puberty; examples: pubic, axillary, and chest hair Hair changes can be related to diet, stress, genetics, infections, and endocrine disorders. Nails The cuticle acts as a protective seal; if damaged, it can be an entryway for bacteria. The lunula is a crescent-shaped white opaque area near the nail root. Nail Beds are pink due to highly vascular epithelial cells. Growth: Fingernail growth is approximately 1 mm per week. (slower in summer bc of hormones) Nail changes can be related to nutrition, stress, systemic disease, vitamin or iron deficiency, infection, and nail biting or picking. Skin Disorders with Familial Tendencies Acne: An inflammatory disease of the sebaceous follicles of the skin, marked by comedones, papules, and pustules. Skin Cancer: A malignancy of the cells. Eczema: A chronic inflammatory skin disorder that causes the skin to become scaly, itchy, inflamed, and irritated. Lupus: A systemic autoimmune disease that occurs when the body’s immune system attacks their own tissues and organs, characterized by a distinctive facial butterfly rash unfolding across both cheeks. Psoriasis: A chronic immune disorder that causes the skin to develop silvery, scaly plaques. Seborrhea dermatitis: An inflammatory skin condition causing flaky, yellow scale to form on the scalp, ears, and face. Changes in skin color Albinism: Inherited disorder caused by the total or partial absence of an enzyme that produces melanin. Carotenemia: A yellowing of the skin due to increased dietary intake of carotene in the diet, from foods such as carrots, sweet potatoes, pumpkin, corn, yams, spinach, and beans. The sclera of the eye does not become yellow. Central cyanosis: Bluish discoloration to the skin related to decreased circulating oxygen; best assessed in the oral mucosa, conjunctiva of the eyes, lips, and tongue. Erythema: Red, pink skin color; may indicate inflammation, fever, or increased blood flow. In carbon monoxide poisoning, the individual will have a bright red cherry face and upper trunk.  Jaundice: Yellowing of the skin due to excessive levels of bilirubin in the blood. Hyperpigmentation: Darker skin color. Hypopigmentation: Lighter skin color. Pallor/Pale: Pale skin is seen in anemia, a decrease in circulating red blood cells or blood flow, or absence of oxygenated blood. Peripheral cyanosis: A blue, gray, slate, or dark purple discoloration of the skin or mucous membranes caused by deoxygenated or reduced hemoglobin in the blood; may occur with decreased cardiac output. Vitiligo: Autoimmune disorder that causes smooth, white patches of skin all over the body. Skin Texture Moles ○ Most adults have 10-40. Usually found above the waist on areas exposed to the sun. They are seldom found on the scalp, breast, or buttocks Lesions ○ Primary → occur in reaction to the external or internal environment. May be present at birth or develop during lifetime. Secondary → progressive changes in primary lesions, trauma, or injury to the primary lesion. Conditions affecting skin texture ○ Autoimmune diseases: Can cause inflammation, redness, loss of hair, and changes in skin texture. ○ Acne vulgaris: A skin condition originating from sebaceous glands that can cause blemishes, cysts, bumps, pustules, and inflammation of the skin. ○ Eczema: Causes chronic inflammation of the skin; itchy, dry, scaly patches of skin; this skin disorder has familial tendencies. ○ Hormonal conditions: Can change the texture of skin to be dry, oily, or moist; may change skin color. ○ Rosacea: An inflammatory skin condition causing redness, swelling, and spider-like blood vessels to develop on the middle of the face. Rashes ○ can be acute or chronic and related to diet, stress, medications, allergies, hormone imbalance, autoimmune disease, kidney disease, toxic reactions, digestive problems, body imbalances, chemicals, and sun exposure Focused assessment 1. Explain assessment 2. Inspect patient hygiene (odor or breath) 3. Patients color a. Assess for cyanosis in the lips, oral mucosa, tongue, and extremities. b. Assess for pallor of skin in the lips, fingernails, and mucous membranes. c. Assess for jaundice of skin in the lips, sclera of the eyes, and across the rest of the body.  4. Palpate for temperature - comparing side to side using the dorsal surface of your hands 5. Palpate skin thickness: thinnest skin = eyelids; thickest skin = soles of the feet, palms of the hands, and elbows. Assess the hands and feet for calluses caused by pressure areas and rubbing 6. Palpate skin turgor. a. best location to assess skin turgor = clavicle area (also done on the lower arm or abdomen) b. Pinch the skin between two fingers and let go. In a well-hydrated person, the skin returns to the flat position immediately. In the dehydrated person and someone who has lost a large amount of weight, the skin remains tented and slowly returns to the flat position 7. Palpate skin moisture a. Excessive moisture can be an endocrine disorder like hyperhidrosis 8. Assess for nevi, rashes, lesions, scars, and masses, making sure to identify location, distribution, pattern and configuration, color, and size, making sure to use a paper tape measure to measure in centimeters a. Magnifying glass may be necessary to best assess skin lesion b. Assess moles using: i. A -asymmetry—one half is unlike the other half. ii. B -border—an irregular, scalloped, or poorly defined border. iii. C -color—is varied from one area to another; has shades of tan, brown or black, or areas of white, red, or blue. iv. D -diameter—usually greater than 6 mm (the size of a pencil eraser) but they can be smaller. v. E -evolving—a mole or skin lesion that looks different from the rest or is changing in size, shape, or color 9. Assess tattoos and body piercings for signs of inflammation, infection, or allergic reaction. 10. Document findings Normal Findings - Good hygiene, no odors, uniform color, skin warm/moist - Skin turgor is less than 3 seconds - No abnormal lesions - Nevi are uniform brown color, regular borders, less than 6 mm - Tattoos and body piercings show no signs of redness, swelling, or inflammation Abnormal findings Skin turgor is greater than 3 seconds, may be related to fluid loss.  Moisture-associated skin damage (MASD) causes erythema, inflammation, and skin erosion due to prolonged exposure to sources of moisture (urine, stool, saliva, wound drainage, or perspiration). Vascular Lesions ○ Ecchymosis: a bruise caused by bleeding under the skin or mucous membranes; occurs as a result of local trauma ○ Hematoma: an elevated collection of clotted blood within the tissue caused by a break in a blood vessel. ○ Telangiectasia is caused by vascular dilation of a small group of blood vessels; it occurs anywhere on the body but most often on the face and legs. ○ Petechiae are tiny, pinpoint hemorrhages caused by superficial bleeding from the capillaries of the skin; measure less than 3 mm; may be related to platelet deficiencies. ○ Purpura is a hemorrhagic red or purple spot or rash that is flat and does not blanch; measures 3 to 10 mm; may be associated with platelet disorders Skin Cancer Lesions ○ Basal cell carcinoma presents as a pearl white, dome-shaped papule with overlying random telangiectasia; enlarges slowly and may ulcerate in the center; most common form of cutaneous malignancy ○ Squamous cell carcinoma is a malignant cutaneous malignancy arising from keratinocytes of the skin or mucosal surfaces; thick, rough, scaly with a crusted surface and irregular borders; second most common type of skin cancer ○ Malignant melanoma is a malignancy of the melanocytes arising in the skin; develops from a pre-existing lesion usually with an increase in size, change in color or appearance of a nevus; vary considerably in appearance; curable with early detection Inspecting Hair and Scalp Abnormal findings Brittle or thin hair Lesions on scalp; scalp red and tender Alopecia (hair loss) may be due to nutritional deficiencies, medications, illness, endocrine disorders, radiation, or the physiological changes of aging (Fig. 8-14). Alopecia areata of the scalp, or spot baldness, is a loss of hair in patches involving the scalp or beard; thought to be related to an autoimmune disorder. Folliculitis is inflammation of a hair follicle developing on the face, arms, legs, or buttocks; white pustules appear around the hair follicle; may be related to Staphylococcus aureus infection. Hirsutism is the excessive growth of thick, dark hair in women where normally the hair does not grow, including areas such as the face, chest, abdomen, arms, and legs; usually caused by abnormality of androgen production, metabolism, medications, or hormonal therapies.  Seborrhea dermatitis (cradle cap) in infants, are chronic, greasy scales that accumulate and thicken on the scalp with or without redness; may extend to the forehead, eyebrows, and face. Tinea capitis (scalp ringworm) is a fungal infection of the scalp causing round, patchy hair loss, pustules, and scale on the skin. Tinea versicolor (pityriasis versicolor) is a fungal infection of the skin causing discolored patches or spots occurring anywhere on the body. Inspecting Fingernails and toes Normal Findings Nails are smooth, short, of uniform thickness, and well groomed. Nail base angle is 160 degrees. Nails firmly adhere to the nailbed. Nailbeds are pink. Nails are nontender to palpation. Capillary refill is less than 2 seconds. No redness, exudates, or signs of infection or inflammation are found. Dark-skin individuals may have pigmented bands in their nails. Aging nails have longitudinal ridging of the nail (Fig. 8-16). White spots in the nail may result from forms of mild trauma Abnormal Findings Beau’s line is a white, horizontal groove across the nail bed, usually caused by disease, toxic reaction, or trauma. Onychomycosis is thickening, yellow discoloration, and scaling of the nail bed due to a fungal infection; more common in diabetics and older individuals Paronychia is a skin infection around the nail causing erythema, swelling, and tenderness at the nail fold. Pitting of nails is a sign of psoriasis; affects both fingernails and toenails; appears as indentations in different sizes, shapes, and depths; nails can disintegrate easily. Splinter hemorrhages appear as red streaks in the nails, caused by bleeding from capillaries under the nails. Spoon nails are flat or concave; outer edges flare out; dips or waves are visible on the surface of the nail; may be hereditary, related to a nutritional or systemic disease. Ch. 9 - Assessing the head, face, mouth, and neck Head - Divided into 2 parts 1. Cranium 8 cranial bones Frontal bone is most important Cranial vault is large part of skull Diagnostics  Computed tomography (CT) ○ CT scan of the head is ordered when a more detailed picture is needed for diagnosing a stroke or pathology within the brain and treating injuries. ○ Can be done with or without contrast. The contrast material (iodine dye) is used to make structures/organs easier to visualize. Magnetic resonance imaging (MRI) ○ detailed picture of organs, soft tissues, bone, and virtually all other internal body structures. ○ Most sensitive imaging diagnostic test that provides more detail to identify disease or abnormalities. ○ This test provides even more detail than a CT scan and may be ordered if the information is not being seen using other diagnostic tests. 2. Face 14 facial bones Temporal artery ; major artery of the head that branches from within the external carotid artery, has a palpable pulse above the zygomatic arch, and is palpable in front of each ear. Temporomandibular joint; a hinge joint connecting the upper temporal bone (part of the skull) and the mandible (lower jawbone); allows the jaw to move forward, backward, and side to side; an articular disc made up of fibrocartilaginous tissue is positioned between the two bones. Parotid glands; the largest salivary glands that secrete saliva into the mouth through the Stensen’s ducts. These glands are located superficial to and behind the mandible, and the ducts are on each side of the oral cavity. Submandibular gland is located within the lower mandible; this gland drains saliva through the Wharton’s ducts into the lower oral cavity. 3. Sinuses air-filled spaces/hollow cavities that surround the nasal cavity and decrease the weight of the skull. Sinuses give resonance to voice during speech. There are 4 pairs of paranasal sinuses Diagnostics Computed tomography (CT); scan of the sinuses is an imaging test that uses x-rays with or without contrast dye to create detailed pictures of the air-filled spaces inside the face (sinuses). ○ May help to diagnose infection, nasal polyps, birth defects, or abnormalities of the sinuses. 4. Nose 2 nostrils lines with mucous membranes Nasal septum made up of cartilage and blood vessels Turbinates are bony structures covered by soft mucosa, cleanse, moisten, and warm air as it passes through nostrils to lungs Adenoids : clusters of lymphatic tissues behind the nose 5. Mouth Oral mucosa: mucous membrane epithelium lining inside the mouth. It is the first portion of the alimentary canal for ingestion and digestion of food. Lips Cheeks Soft palate; composed of muscle and connective tissue; responsible for closing off the nasal passages during the act of swallowing; uvula hangs midline from the soft palate. Hard palate; thin, horizontal plate of the skull, located in the roof of the mouth; covered with stratified squamous epithelium. Jaw bone (mandible): largest and strongest bone of the face. Salivary glands: (parotid, submandibular, and sublingual) secrete saliva to start the process of digestion and moisten the mucosa. Stensen's ducts (parotid duct); in the upper buccal mucosa; this is the route saliva flows from the parotid gland into the mouth; ducts are pink; may be darker in dark-skin people. Wharton’s ducts; located on each side of the lower oral cavity; they transport saliva produced in the submandibular gland and drain saliva produced by the sublingual glands Teeth: rooted in the gums; 32 permanent teeth in an adult. Primary function is for chewing and breaking down food to initiate digestion of food. Gingiva (gums) are covered by mucous membranes; tough insoluble protein mucosa; area around the root of a tooth; attaches to the surface area of the tooth root (cementum) and the alveolar bone, thickened ridge of bone that contains the tooth socket. Tongue is a muscle located in the floor of the mouth; anchored to the hyoid bone and styloid process of the temporal bone; organ of taste; covered with moist mucosa; there are arteries, veins, and nerves in the tongue. It consists of symmetrical halves; separated by a fibrous septum, middle line; papillae, tiny bumps on the tongue, create a rough texture on about two-thirds of the top of the tongue; thousands of taste buds cover the surface of the papillae; aides in swallowing, and speech. 6. Throat The anterior part of the neck in front of the vertebrae makes up the nasopharynx (behind the nose) and oropharynx, which lies at the back of the mouth between the soft palate and hyoid bone. The laryngopharynx is the lower part of the pharynx from the hyoid bone to the cricoid cartilage; it consists of the pharynx, larynx, trachea, and esophagus. Trachea (windpipe) is a cylindrical tube composed of cartilage and membranes; measures about 4.5 inches in length; ¾ of an inch to 1 inch in diameter; always larger in males than females. Epiglottis is the leaf-shaped flap that separates the trachea from the esophagus; prevents aspiration of food and fluids. Tonsils are soft masses of lymphatic tissue located in the back of the pharynx; part of the body’s immune system. Diagnostics Swallowing evaluation; initiated when difficulty swallowing foods or fluids (known as dysphagia) is observed or reported. ○ A referral to a speech language pathologist is made. The speech pathologist will observe the muscles of the face and throat. The patient will be observed closely eating and drinking different textured foods and fluids to assess for dysphagia. Modified barium swallow study is a radiologic procedure that assesses swallowing using a fluoroscope, an instrument used for viewing x-ray images on a screen. ○ The patient is given barium sulfate, a white chalky mixture, to drink during the procedure. This metallic compound highlights the upper digestive tract on x-rays to identify abnormalities. Fiberoptic endoscopic evaluation of swallowing requires a small, flexible, lighted endoscope outfitted with a camera to be passed through the nose into the pharynx. ○ The physician is able to assess the structures of the throat and assess swallowing. Throat culture is commonly done to identify the organism causing a bacterial, viral, or fungal infection. ○ A throat culture is completed by swabbing the back of the throat and placing a sample in a culture medium; results take 1 to 2 days. Rapid strep test results are ready in 10 to 15 minutes. 7. Neck It protects the nerves that carry sensory and motor impulses from the brain to the body. major muscles supporting the neck are the sternocleidomastoid and trapezius muscles Hyoid bone - The base of the tongue rests on this bone and aids in tongue movement and swallowing; this is the only bone that is not attached to another bone in the body. Thyroid cartilage - protects the vocal folds Cricoid cartilage - a ring of cartilage around the trachea Larynx - part of the respiratory system as air passes through to the trachea; it is known as the voice box Trachea (windpipe) - Thyroid - gland has a major role in metabolism, iodine absorption, and hormone production Carotid arteries - on each side of the neck; transport oxygenated blood supply to the brain Jugular veins - bilaterally on each side of the neck; transport deoxygenated blood from the brain, face, and neck to the heart through the superior vena cava Lymph nodes - made up of reticular connective tissue filled with lymphocytes (white blood cell); Clusters of lymph nodes are found in the head and neck area and are named after their anatomical location Diagnostics Thyroid-stimulating hormone (TSH) ○ a blood test that evaluates thyroid gland functioning. TSH stimulates the thyroid gland to produce the T3 and T4 thyroid hormones. ○ Results can assess an overactive thyroid gland (hyperthyroidism) or underactive thyroid gland (hypothyroidism). An abnormal value indicates an excess (hyperthyroidism) or deficiency (hypothyroidism) of thyroid hormone available to the body. Triiodothyronine (T3) ○ a blood test that is used with the TSH and T4 blood tests to diagnose an overactive thyroid gland. ○ This hormone is converted from the T4 hormone in the tissues. This test is commonly ordered if the TSH test is abnormal and the T4 levels are normal. The T3 test differentiates causes of thyroid malfunction and helps to diagnose hyperthyroidism. Free thyroxine (Free T4) ○ a blood test to assess the functioning of the thyroid gland. T4 is directly secreted by the thyroid gland. ○ This test is commonly ordered with the TSH test to differentiate causes of thyroid dysfunction Thyroid ultrasound ○ a noninvasive diagnostic test that uses sound waves to create an image of the thyroid gland tissues. The ultrasound will detect abnormalities such as a nodule, lesion, cancer, or thyroid disease. Thyroid scan ○ a nuclear medicine test to assess the functioning of the thyroid gland, masses, or inflammation. Radioactive iodine in a pill or liquid form is given to the patient. The scan will evaluate the overall activity, size, and shape of the thyroid gland. 9-1 Inspecting and Palpating HEAD 1. Gloves 2. Inspect head = size, shape, configuration, movement 3. Palpate head = tenderness, masses or depressions 4. Remove + discard gloves Normal Findings Head is symmetric, midline, round Normocephalic; a person’s head is normal shape and size for his or her age Head erect and still; no involuntary movements No pain, tenderness, masses, or depressions during palpation Abnormal findings Pain, tenderness, a mass, involuntary movement, depression of skull Macrocephaly is an abnormally large head size 9-2 Inspecting the FACE 1. Stand in front of the patient and assess for appearance and shape of face a. Round, oval, square, bloated, disfigured 2. Symmetry a. Nasolabial folds (the distance from the corner of each nostril to the corner of the lip bilaterally; should be equal measurements. b. Palpebral fissures; inspect the distance between the upper and lower eyelids; should be equal distances. 3. Facial expression a. Does the patient make eye contact? b. Flat affect: showing no emotion of facial expressions. c. Sad or happy affect. 4. Involuntary movements 5. Condition and texture of skin 6. Edema 7. Document findings Normal Findings Face (round, oval, or square) Bilaterally symmetrical facial structures Nasolabial folds and palpebral fissures equal Expression relaxed; makes eye contact No involuntary muscle movement; no visible pulsations Skin smooth and clear, No edema Abnormal Findings Asymmetry of the face may be related to abscess, infection, enlargement of parotid gland, neurological disorders. Flat affect may indicate depression or chronic pain. Acromegaly is a syndrome of growth hormone excess by the pituitary gland; characterized by enlargement of the bones of the face, hands, and feet. Parkinson’s disease causes a “mask like” facial appearance. Kidney diseases may cause swelling of the face or around the eyes (periorbital edema). Cardiac, respiratory, and autoimmune disorders may present with different facial changes  9-4 Inspecting and Palpating the NOSE 1. Stand in front of the patient and inspect the nose for the 2. Gently palpate the nose for tenderness or swelling a. Symmetry b. Alignment of septum c. Color d. Swelling e. Drainage 3. Document Abnormal Findings Asymmetry Deviated septum Redness, bruising, lesions Tenderness or swelling while palpating Nasal drainage: amount (scant, moderate, copious), color (clear, yellow, green, bloody), consistency (thin, thick), with odor 9-4A Assessing the Patency of the NOSE 1. Ask the patient to press on the right naris to occlude the passageway. 2. Ask the patient to inhale through the left naris with his or her mouth closed. 3. Ask the patient to press on the left naris to occlude the passageway (Fig. 9-11). 4. Ask the patient to inhale through the right naris with his or her mouth closed. 5. Document your findings. Abnormal Findings Absence of sniff may be an indication of nasal congestion or obstruction; obstruction may be related to a foreign object. Rhinitis, an inflammation of the mucosa in the nose causing nasal congestion and sneezing, may be related to a viral or bacterial infection. Nasal polyp is a soft, painless, growth that protrudes into the nasal cavity; one or several may hang down like tear-drops or grapes, which may block your nasal passages; can form as a result of allergic conditions, asthma, immune disorders, or chronic inflammation 9-6 Inspecting and Palpating the MOUTH When inspecting and palpating the mouth, you are assessing the structures of the mouth for redness, tenderness, lesions, or abnormalities. To adequately perform these steps, you need a penlight (or other tangential lighting), gloves, tongue depressor, sterile gauze, and additional PPE (if needed)  9-6A Inspecting the LIPS 1. Stand in front of the patient and inspect the lips for: 2. Color 3. Lesions 4. Moisture 5. Swelling 6. Symmetry Normal Findings Pink, moist, no lesions, swelling, or cracking of skin Lips are symmetric Upper lip is everted Abnormal Findings Lips are inverted Swelling, erythema, lesions, cracking of skin Pallor of lips may indicate decreased perfusion related to respiratory or cardiovascular problems. Angular cheilitis is inflammation at the corners of the mouth; sore, cracked corners of the lips; commonly caused by yeast infections, dry mouth, or vitamin deficiency. Angioedema is edema of the lips; usually related to an allergic reaction (Fig. 9-14). Herpes simplex virus manifests with cold sores or blisters on the lips. 9-6B Inspecting the TEETH 1. Inspect teeth for: a. Color b. Dentures,caps, or missing teeth c. Tooth decay 2. Ask patient to clench their teeth and assess for malocclusion, malposition of the teeth Normal findings Color of teeth white to an ivory color. ○ Teeth may be stained yellow from smoking or brown from drinking tea or coffee. ○ Age-related darkening (yellow or brown). Clean, free of debris, Smooth edges 32 teeth or 28 teeth if wisdom teeth have been removed. ○ The upper incisors should overlap the lower incisors; back teeth should meet. Abnormal findings Color is dark brown or black; Loose, broken, painful teeth; tooth decay  Malocclusion of the teeth: ○ Protrusion of the upper and lower incisors ○ Failure of the upper incisors to overlap the lower incisors ○ Problems with the bite ○ Back teeth do not meet 9-6C Inspecting and Palpating the Buccal Mucosa 1. Gloves 2. If a patient has full or partial dentures, have them remove the dentures for inspection and palpation of the gum area. 3. Inspect and palpate the buccal mucosa and gums. 4. Gently use a tongue depressor to hold the tongue out of the way for full visualization of the gums and mucosa 5. Remove and discard gloves when the assessment is completed. Normal findings Pink, smooth, moist, no lesions, swelling, or bleeding Tight margin around each tooth No tenderness with palpation Abnormal findings Red or white, inflamed, or bleeding mucosa; presence of lesions ○ Aphthous stomatitis (canker sore) is a common inflammatory disease of oral mucosa (mouth, lips, tongue, mucous membranes) manifested by single or multiple painful erosions or ulcers. ○ Gingivitis is the mildest type of periodontal disease; red, swollen, bleeding gums. ○ Gingival hyperplasia is an enlargement or overgrowth of the gum tissue; firm and nonpainful; may be related to systemic illness, side effects of medications such as phenytoin (Dilantin (used for seizure disorders)), and poor oral hygiene. ○ Periodontal disease is a chronic infection of the gums. The gums pull away from the teeth and create open spaces that collect bacteria which causes chronic inflammation. The accumulation of bacteria damages and destroys the teeth, tissue, and underlying bone. ○ Thrush is a candidiasis fungal infection that creates thick, white to yellow patches on the tongue or buccal mucosa; occurs frequently with a weakened immune system and antibiotic therapy. Tenderness with palpation  9-6D Inspecting and Palpating 1. Put on gloves. 2. Using tangential lighting, inspect the anterior hard and posterior soft palate 3. Inspect Stensen’s ducts on each side of the soft palate. a. Stensen’s ducts are the openings of the parotid glands on the buccal mucosa that allow saliva to flow from the parotid gland 4. Using your index finger, gently palpate the following structures a. Hard palate b. Soft palate 5. Remove and discard gloves when the assessment is completed. Normal findings Transverse rugae, irregular ridges are firm, pink to light red; moist Stensen’s ducts are draining No tenderness Soft palate is pink, moist; no lesions or ulcerations Integrity of hard and soft palate intact Nodular bony ridge down the middle of the posterior hard palate Abnormal findings Deep red color, ulcerations, lesions, or growths Hard palate is a shade of yellow if jaundice is present. Torus palatinus is an abnormal growth that develops midline in the hard palate; surgically removed if the growth causes discomfort; may be hereditary 9-6E Inspecting and Palpating the TONGUE 1. Put on gloves. 2. Inspect the dorsal surface of the tongue for color, lesions, or coating on the tongue 3. Ask the patient to stick out his or her tongue and assess the: a. Lateral edges of the tongue b. Fine tremors (fasciculations) of the tongue c. Position of tongue is midline (hypoglossal nerve, cranial nerve XII) d. Voluntary movement of the tongue 4. Ask the patient to touch the roof of the mouth with the tongue; inspect the: a. Floor of the mouth b. Frenulum, which is a small fold of mucous membrane dividing the tongue in half; secures the tongue c. Ventral surface of the tongue d. Wharton’s ducts:  i. Wharton’s ducts appear on each side of frenulum that transports saliva produced in the submandibular gland and drains saliva produced by the sublingual glands. 5. Using a sterile gauze, gently palpate the tongue for any lumps or nodules 6. Discard the gauze. Remove and discard gloves when the assessment is completed. Normal findings Color pink and saliva present Papillae on dorsal surface Midline position Ventral surface smooth, pink, moist No lumps or nodules with palpation Wharton’s and Stensen’s ducts visible Abnormal findings Cracked, dry, red, presence of ulcers or lesions, bleeding, thick white or yellow coating on tongue Atrophic glossitis is a smooth red or pink tongue; may indicate nutritional deficiencies. Hairy tongue is a white to dark overgrowth, hairy surface that may indicate systemic immune suppression or too much bacteria. Leukoplakia are white spots or patches on the mucous membrane of the tongue. The spots are smooth, irregular in size and shape; may become malignant (Venes, 2021). Squamous cell carcinoma of the tongue presents as a thickened white or red patch or plaque; may develop nodularity or ulceration; usually laterally on the tongue. 9-7 Inspecting the NECK 1. Ask the patient to sit up straight with neck in the normal position and then slightly hyperextended. 2. With the patient sitting up straight, assess the neck for symmetry and swelling. 3. Have the patient turn his or her head to assess range of motion (ROM) (Fig. 9-26): a. Turn neck side to side. b. Bend neck forward. c. Extend neck backward. d. Bend neck toward each shoulder. Normal findings Neck is symmetrical; no swelling No pain with range of motion Full ROM of neck Abnormal findings Asymmetrical Pain with movement Unable to perform neck ROM movements Torticollis is the contraction or contracture of the muscles of the neck that causes the head to be tilted to one side. It is often accompanied by rotation of the chin to the opposite side with flexion. Usually torticollis is a symptom of some underlying disorder Chapter 10 - the EARS 10-1 - Inspecting the EARS 1. Stand in front of patient and assess both ears for a. Color, landmarks, shape, size, symmetry b. Darwin’s tubercle is a congenital deviation that is a small cartilaginous protuberance on the helix of the ear 2. Assess the angle of attachment by doing the following a. Draw an imaginary line from the external canthus of the eye to the top of the helix b. Draw an imaginary line perpendicular to the ear c. Assess the angle of attachment Normal Findings Color of skin and face are same Equal size and shape bilaterally, normal size = 4-10cm Symmetrical No deformities, inflammation, nodules, or drainage Angle of attachment less than 10 degrees Abnormal Findings Color is blue, red, white, or pale Asymmetrical Lesions Drainage Cauliflower ear occurs from repeated trauma or hitting the ear; a blood clot forms under the skin or there is damage to the cartilage causing a change in shape and structure of the ear; commonly seen in wrestlers or individuals who play contact sports. Microtia is a congenital deformity; the pinna is underdeveloped or incompletely formed; may involve one or both ears; less than 4 cm (approximately 1.5 inches) in vertical height in adults. Macrotia is abnormally large ears; greater than 10 cm (approximately 4 inches) vertical height in adults. Tophi are hard, whitish, or cream-colored, nontender deposits of uric acid crystals indicative of gout.  10-2 palpating the EARS 1. Stand on the right side of the patient. 2. Gently palpate the right ear (Fig. 10-4). a. Auricles (Pinna) b. Tragus c. Earlobes d. Mastoid process 3. Stand on the left side of the patient and palpate the left ear. 4. Document your findings. Normal Findings No tenderness Firm consistency Abnormal Findings Swelling or tenderness may indicate inflammation Lumps or nodules are present 10-3 Assessing Hearing (CN VIII) A tuning fork is a device that vibrates at a specific frequency when it is struck; it is used in simple tests for hearing and to assess vibration sense. 3 types of hearing loss ○ Conductive hearing loss occurs when sound is not conducted through the outer ear canal to the eardrum and the tiny bones (ossicles) of the middle ear, which may be reversible. Sound may be blocked by earwax or a foreign object located in the ear canal; the middle ear space may be impacted with fluid, infection, or a bone abnormality; or the eardrum may have been injured ○ Sensorineural hearing loss, which is considered inner ear hearing loss, occurs when there is damage to the inner ear (cochlea), or to the nerve pathways from the inner ear to the brain; speech may sound unclear or muffled; most common type of permanent hearing loss ○ Mixed hearing loss includes both conductive and sensorineural hearing loss. Chapter 11- the EYES Extraocular structures Eyebrows and eyelashes: specialized hairs protect the eyes Eyelids: protect and lubricate the eyes ○ Small oil producing glands line the inner edge keeping the eyes moist and clean  ○ Tarsal plates: firm lines of connective tissue within the eyelids that contain meibomian glands, which open on the lid margin and produce tear fluid ○ Palpebral fissure: distance between the upper and lower lids Conjunctiva: thin membrane covering the front of the eye (bulbar conjunctiva) and inner eyelids (palpebral conjunctiva) ○ Produces mucus to lubricate the eye ○ Permits movement of the eyeball Lacrimal glands: the tear ducts that continually release tears and protective fluids to clean, lubricate, and moisten the eyes ○ Lacrimal sacs are the small pumps that drain the tears or fluid. ○ Tears and fluid drain into the nasolacrimal duct into the nose keeping the nasal mucosa moist. ○ Tear fluid: protects the conjunctiva and cornea from drying; produced from the meibomian gland, conjunctival gland, and lacrimal glands Intraocular structures Sclera: white avascular tissue that protects the eye and maintains the shape of the eye Extraocular rotator muscle: six small muscles connect to the sclera to control eye movements, secure the eyeball in the sockets, and allow sight in different directions ○ Superior rectus: raises the eye ○ Superior oblique: rotates the eye ○ Medial rectus: moves the eye toward the nose ○ Inferior oblique: rotates the eye ○ Inferior rectus: lowers the eye ○ Lateral rectus: moves the eye away from the nose Aqueous humor: water-like fluid that fills the anterior (space between cornea and iris) and posterior chambers (space between iris and front of the lens); helps to maintain the eyeball shape; supplies nutrition to the eye. Choroid: vascular layer of the eye between the retina and sclera; supplies blood to the retina Iris: the middle layer of the eye composed of connective tissue and smooth muscle; colored part of the eye; muscles within the iris control pupillary size allowing the pupil to contract and dilate and focus on near and distant objects Lens: transparent, biconvex structure that refracts light to be focused on the retina; changes shape and thickness to be able to create clear images Pupil: black part of the center of the iris; determines the amount of light that enters the eye; average diameter of 2 to 4 mm in bright light and 4 to 8 mm in the dark Posterior chamber: space between the iris and the front of the lens; filled with aqueous humor that nourishes parts of the eye Cornea: dome-shaped, avascular, transparent surface that covers the front part of the eye; covers the iris, pupil, and anterior chamber; allows light to enter and focus; considered to be the window of the eye; contains nerve endings responsible for tears, pain, and the blink reflex Fundus: posterior section of the eye that includes the retina, choroid, fovea, macula, optic disc, and retinal vessels  Macula: yellow spot in the retina that is responsible for central vision; most sensitive area of the retina; fovea is the central indentation in the macula responsible for our highest visual acuity Optic disc: bright spot on the retina where the optic nerve leaves the eye; optic nerve connects eye to brain, has more than one million nerve fibers Retina: multilayered tissue, sensory portion that lines the back of the eye; contains millions of photoreceptors (rods and cones) that convert light rays into electrical impulses (central and peripheral vision) and transports these impulses to the optic nerve for interpretation in the brain. Retinal blood vessels, arteries, and veins: supply blood to the retina Diagnostics Comprehensive dilated eye examination ○ a painless procedure that allows the ophthalmologist or optometrist to examine the internal structures of the eyes. During this examination, the patient has his or her eyes dilated with mydriatic eye drops. These drops are short-acting ciliary muscle paralytics that dilate the pupil Tonometry ○ a device to measure intraocular pressure (IOP) within the eye. This is done through a comprehensive dilated eye examination, a test to determine risk for, or presence of, glaucoma. Increased pressure within the eye can damage the optic nerve, causing loss of vision. Health history Past medical history Cataracts: a clouding of the lens that causes blurry, decreased, or lost vision. Glaucoma: a buildup of intraocular pressure that damages the eye’s optic nerve causing loss of peripheral vision. (6x more likely in african americans than caucasian) Macular degeneration: a deterioration of the central part of the retina causing loss of central vision. Current vision history Loss of visual acuity refers to the inability to see objects clearly. ○ Visual acuity is assessed by having the patient read letters from a chart at a distance of 20 feet. The most common chart is the Snellen Chart (Box 11-1). ○ Normal vision is 20/20. The top number is your distance in feet from the chart. The bottom number is the distance at which a person with normal eyesight can read the same line. ○ Individuals are considered “legally blind” if their vision with glasses or contact lenses is 20/200 or worse Loss of visual field refers to the inability to see from side to side or up and down without moving the eyes or turning the head.  ○ Loss of visual field results from eye damage, injury, disease, or a tumor that completely or partially obstructs areas on the visual pathway causing partial loss of vision. The patient may experience a blind spot in their field of vision. Farsightedness (hyperopia): difficulty focusing on near objects; visual image is focused behind the retina instead of on the retina. Nearsightedness (myopia): distant objects appear blurred because the visual image becomes focused in front of the retina instead of on the retina. Double vision (diplopia): may be related to a problem with the extraocular muscles, cranial nerves, or systemic disease. Night blindness (nyctalopia) is the inability to see well at night or in faint light; it is related to a disorder of the cells in the retina that are responsible for vision in dim light or a vitamin A deficiency. Smoking tobacco may impair the ability to see at night 11-1 - inspecting the eyes 1. Explain the technique to the patient. 2. Stand in front of the patient and tell the patient to look straight ahead. 3. Inspect the eyelids. a. Assess that the eyelids open and close completely. b. Assess for any drainage. 4. Inspect the eyelashes for a. Distribution b. Drainage c. Crusting 5. Inspect the eyebrows. a. Assess symmetry. b. Assess distribution of hair and any scaly, flaky skin. 6. Inspect the cornea. a. Use a light source to inspect side to side the cornea for smoothness and clarity. 7. Inspect the lens. a. Use a light source to inspect side to side the lens of the eye for clarity. b. Use light source to inspect the color and round shape (Fig. 11-6). 8. Assess the sclera for color and smooth surface area. 9. Inspect the conjunctiva. a. Put on gloves, then use your thumbs to slide the bottom eyelids down to assess the mucosa of the lower conjunctiva (Fig. 11-7). i. Ask the patient to look up. & Inspect the color of the mucosa. 10. Inspect the lacrimal duct. a. Wearing gloves, inspect and palpate the lacrimal duct for any swelling or excessive tearing 11. Assess palpebral fissures.  a. Assess the distance of the upper lid to the lower lid for symmetry (Fig. 11-9). b. Compare the palpebral fissures on each side of the face. 12. Assess for abnormal involuntary eye movements. 13. Discard your gloves and document your findings. Normal Findings Eyes symmetrical; no protrusion Upper and lower eyelids close completely; no redness or drainage; no drooping of an eyelid (ptosis); upper eyelid covers half of the iris. Eyelashes equally distributed; no drainage or crusting Eyebrows evenly distributed; no scaly or flaky skin; symmetrical Cornea clear with no opacities Lens transparent with no opacities Pupils equal in size Iris blue, green, brown, or hazel in color, smooth Sclera white Conjunctiva pink and moist with no colored draining Lacrimal ducts clear with no swelling Palpebral fissures equal bilaterally No abnormal involuntary movement Abnormal Findings Eyes are asymmetrical or protruding ○ Exophthalmos is a protrusion of the anterior portion of the eyeball; common in hyperthyroidism; may cause patient to have dry eyes and difficulty closing the lids. ○ Periorbital edema is swelling in the tissues around the eye. Eyelids do not open and close completely or presence of yellow, white, or green drainage ○ Ectropion is an everted eyelid (turns outward); lower eyelid is most commonly affected. ○ Entropion is an inverted eyelid (turns inward); lower eyelid is most commonly affected. Eyelashes have yellow, white, or green drainage; crusty ○ Hordeolum, a stye, is an infection of a follicle of an eyelash that causes redness, inflammation, and a lump at the site. Eyebrows are asymmetrical, have uneven distribution of hair, with flaky or scaly skin underneath them Cornea is not smooth; opaque appearance ○ Corneal abrasion is a painful scratch to the clear surface of the eye, usually related to trauma to the eye.  Lens has clouding; may be indicative of cataract ○ Cataract is opacity of the lens caused by aging, long-term exposure to ultraviolet light, metabolic disorders, trauma, or medications. Pupils are not equal in size may indicate an eye or neurological injury or disorder. Sclera is yellow with thickening ○ Scleral jaundice (Icterus) is a sign of elevated bilirubin in the blood; occurs with patients who have a liver disease. Conjunctiva is red and inflamed ○ Conjunctivitis is a bacterial or viral infection causing erythema of the sclera and yellow-green drainage of the conjunctiva. ○ Subconjunctival hemorrhage is bleeding from broken blood vessels under the clear surface of the eye; may be related to coughing, sneezing, clotting disorders, or be spontaneous. ○ Pterygium is a gelatinous, abnormal growth of the conjunctiva; occurs more commonly on the nasal side of the eye. Lacrimal ducts are red, swollen and not draining ○ Blocked lacrimal duct causes excessive tearing because tears cannot drain properly. Palpebral fissures are not equal bilaterally; may be related to a genetic disorder Abnormal involuntary movement, such as twitching or repetitive blinking, may be related to eye, brain, or genetic disorders 11-7 - testing for convergence and accommodation (CN II, CN IV, CNVI) 1. Explain the technique to the patient. 2. Hold your finger or a penlight in front of the patient’s eyes about 14 inches in front of his or her nose. 3. Instruct the patient to focus on your finger or object for 30 seconds. 4. Instruct patient to follow your finger or object as you move it toward his or her nose 5. Assess for convergence or the eye and pupil size (pupils should constrict). 6. Document your findings. Normal Findings Both eyes converge and both pupils constrict (accommodation) simultaneously to focus on a near object. Abnormal Findings Pupils do not converge or constrict; may be related to an eye muscle dysfunction.  11-8 inspecting pupil size and consensual pupil response (CN II and CN III) 1. Explain the technique to the patient. 2. Stand in front of the patient. 3. Use the penlight to inspect the pupils. 4. Assess the color + shape of each pupil. 5. Assess symmetry. 6. Assess direct reaction. Shine light into the right eye pupil. 7. Assess consensual reaction. Put your nondominant hand between the patient’s two eyes. Shine light into the left eye pupil and assess the right eye; right eye should constrict and have a consensual response 8. Repeat steps 7 and 8 in the left eye. 9. Measure the size of each pupil in millimeters (Fig. 11-17). 10. Document your findings. Normal Findings Pupils constrict in response to light. Both eyes have a consensual response on constricting to direct light. Pupil is round and black. Both pupils are equal size. Pupil diameter is 2 to 8 mm Abnormal Findings Pupils are unequal in size or both dilated or constricted or fixed. Anisocoria is unequal size of the pupils; may be harmless or a medical emergency; causes may be related to genetics, medications, or a neurological disorder or injury Mydriasis is bilateral dilated and fixed pupils; may be caused by eye drops, stimulation of sympathetic nerves, anesthesia, or central nervous system injury. Miosis is an abnormal constriction of the pupils; may be caused by a stroke, medications, or brain damage. Horner syndrome is a sign of a medical condition that affects one side of the face; drooping eyelid, constricted pupil (miosis). THINGS TO KNOW Communication - Translation is a legal issue - Descriptions change, consent for procedure with language barrier, Some things you cannot translate  - If in the room doing health history, can family members translate? Yes but not ideal. - HH gets into detailed topics that may not be fully explained and would be held back if a family member is translating - Family members can translate basics, but for consent, discharge, and procedural education you must get a legal translator - To become a official translator there are many tests you have to take - Legal responsibility for nurse to use translation services - If def the hospital has a 24/7 person there for them - Do not ask family member to translate - You don't know if the fam member is actually asking and interpreting the info to you correctly - If nursing assistant calls and says patient this.. what do you do? Assess the patient - Part of adpie, always Assess first - Inspect, palpate, percussion, auscultation - Auscultate first for abdomen and carotid arteries Project concert - New - Hours log = clinical and lab - Reflective journal = successful competencies and clinical - Put in date, hours, faculty (johnston for this course) - Location: USD simulation lab - Type of hours: lab - Press submit (not save, save does not actually get it to instructor) Reflection journal (only if successful w competency and for clinicals) - Date of completion of competency - Simulation lab (location) - Procedures : if you did IV, head to toe, dressing change, etc - Important to put in skills and reflections in good detail for later use (interviews resume) - 1 log for all competencies - Click assessment (completed)