Johns Hopkins School of Nursing Week 2 Nutrition, Skin, HEENT PDF

Welcome to Week 2 Johns Hopkins School of Nursing Learning Objectives 1. Obtain an accurate nursing history of the nutrition status, skin, hair, nails, neck, Head, Eyes, Ears, Nose, Throat (HEENT), mouth, and sinuses. 2. Perform a physical assessment of the skin, hair, nails, ne...

Welcome to Week 2 Johns Hopkins School of Nursing Learning Objectives 1. Obtain an accurate nursing history of the nutrition status, skin, hair, nails, neck, Head, Eyes, Ears, Nose, Throat (HEENT), mouth, and sinuses. 2. Perform a physical assessment of the skin, hair, nails, neck, mouth, sinuses, and HEENT. 3. Differentiate between normal and abnormal findings of the skin, hair, nails, neck, mouth, sinuses, and HEENT. 3  Week 2: Assessing Nutritional Status Johns Hopkins School of Nursing Assessing Nutritional Status – Highlights ► Nutrition The process by which substances in food are transformed into body tissues and provide energy for the full range of physical and mental activities that make up human life. – Essential nutrients: carbohydrates, proteins, fats, vitamins, minerals, and water ► Nutritional Status Results from the relationship or balance between nutrient intake and the body’s requirements, and the body’s ability to digest, absorb, and use the nutrients. ► Nutritional Assessment Identifies risk factors for obesity (excessive body fat) and for dietary deficits (malnutrition and undernutrition). Assesses hydration status. 5 Assessing Nutritional Status – Highlights ► Hydration - Recommend at least 64 ounces daily (8 glasses) ► Dehydration Clinical findings: electrolyte imbalances, tenting (skin turgor), thready pulse, low BP, increased HR, sunken eyes, dry tongue ► Overhydration or fluid retention Increased risk in those with kidney, liver, and cardiac diseases (heart failure) – Clinical findings: pitting edema, visible neck veins, ascites, difficulty breathing (heart failure), increased BP, HR can be increased, decreased, or no change ► Food allergies vs intolerances Allergies: mild (hives, eczema, redness, pruritis, N/V/D, abdominal pain) – Severe: anaphylaxis including swelling (lips, tongue, mouth), cyanosis, hypotension, dyspnea… Intolerances result from digestive system irritation (inability to break down) – bloating, N/V/D… 6 Nutritional Status – Subjective Highlights ► What are your height and ► Do you have food allergies ► Describe how your food is usual weight? and/or foods that you stored, cooked, and served. ► Have you lost or gained cannot eat? How is it dated and labeled? weight recently? How much? ► Do you have any chronic ► Do your religious beliefs or Over what period of time? illnesses? culture have dietary ► Are you now or have you ► What current medications, restrictions or recently been on a specific natural herbs, and vitamins/ requirements? diet? 24-Hour Diet Recall. supplements are you taking? ► Do you follow an exercise ► Any recent changes in ► Do any closely related family regimen? appetite, taste, or smell? Any members (grandparents, recent difficulties chewing or parents, or siblings) have swallowing? chronic illnesses such as ► Have you had any recent digestive disorders, heart occurrences of vomiting, disease, or diabetes? diarrhea, or constipation? 7 Nutritional Status – Objective Highlights ► Observe client’s general status and appearance. ► Measure height, weight, waist circumference, and BMI Height begins to wane in the fifth decade of life because the intervertebral discs become thinner and spinal kyphosis increases. ► Measure skin turgor, pitting edema, and other signs of fluid imbalances ► Intake and Output (inpatient settings) Fluid is normally retained during acute stress, illness, trauma, and surgery. Imbalances in either direction suggest impaired organ function and fluid overload or inability to compensate for losses, resulting in dehydration. 8 Assessing Nutritional Status – Diabetes Resources USDA - MyPlate Diabetes Plate – American Diabetes Association 9  Week 2: Assessing Skin, Hair, and Nails Johns Hopkins School of Nursing Assessing Skin, Hairs, and Nails – Highlights ► Skin The skin is the largest organ of the body. It is a physical barrier. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. The skin also provides individual identity to a person’s appearance. ► Hair Consists of layers of keratinized cells, found over much of the body except for the lips, nipples, soles of the feet, palms of the hands, labia minora, and penis. ► Nails Located on the distal phalanges of fingers and toes, are hard, transparent plates of keratinized epidermal cells that grow from the cuticle 11 Skin, Hairs, and Nails – Subjective Highlights ► Are you experiencing any current skin ► Have you had any hair loss, problems such as rashes, lesions, dryness, unusual increase in hair growth, or oiliness, drainage, bruising, swelling, or change in the condition of your changes in skin color? hair? Describe. ► How long have you had this symptom? ► Are you experiencing any pain, ► What aggravates the problem? itching, tingling, or numbness? ► What relieves it? ► Have you had any change in the ► Have you tried any over-the-counter condition or appearance of your remedies or been prescribed any nails? Describe. medication for the problem? 12  (Cyanosis, Jaundice, Macule, Purpura, Hematoma, Objective Highlights Papule, Petechia, Vesicle, Ecchymosis, Cyst, Pustule, Wheal/Hive) Petechia Purpura Ecchymosis Hematoma Cyst Macule Papule Pustule Acanthosis Nigricans Vesicle Wheal/hive Cyanosis Jaundice 13  (Spider angioma, Fissure, Keloid scar, Ulcer, Name That Skin Lesion Telangiectasis, Cherry angioma) Fissure Keloid Scar Cherry Angioma Ulcer Spider angioma Telangiectasis 14 Name That Skin Assessment (Mole, Skin tag, Vitiligo, Striae) Vitiligo Skin tag Striae Mole 15  Skin Cancer What is the most serious skin cancer? Malignant melanoma Skin Cancer risk factors: ABCDE Sun exposure Malignant Melanoma A = Asymmetry Moles Fair skin B = Border Light hair Basal Cell Carcinoma (BCC) C = Color Age D = Diameter Actinic keratosis Family History/ E = Evolving genetics Squamous Cell Carcinoma Ultraviolet radiation (SCC) 16 Name That Hair Assessment (Folliculitis, Alopecia, Tinea capitis, Lice) Lice Alopecia Folliculitis of scalp Tinea capitis 17  (Paronychia, Koilonychia, Pitting, Name That Nail Condition Longitudinal ridging, Yellow nail syndrome) Koilonychia Longitudinal ridging Pitting Yellow nail syndrome Paronychia 18 Methicillin Resistant Staphylococcus aureus (MRSA) ► Clinical manifestations Appear as an infected area (can be from broken skin such as a cut) Erythema Edema Pain Warm to the touch Pus and drainage (blister) Patient may have a fever ► Serious infection that requires antibiotic treatment (e.g., Vancomycin) Complications include sepsis, respiratory failure, amputation, death 19 Assessing Skin, Hair, and Nails – Highlights 20  Week 2: Assessing the Head and Neck Johns Hopkins School of Nursing Assessing the Head and Neck – Highlights Family History of Headaches/Migraines Concussion, stroke, head injury Medications, supplements, herbs Headaches, nosebleeds, nasal drainage, sinus pressure Lifestyle/Health practices Any new lumps or lesions Dizziness, lightheadedness, loss of consciousness Trouble chewing or swallowing Weakness or numbness Radiation Smoking/ETOH/Recreational drugs Posture Movement of head and neck 22 Assessment - Head Headache? HIT it! 23 Assessment - Face Inspection of the Face Symmetry Features Movement Expression Skin condition You are speaking to your patient and suddenly you notice one side of their face has a slight droop and although their voice sounds a bit garbled, it seems they are saying they are having trouble with their vision. What is your assessment? Possible stroke 24 Assessment - Face Palpation Temporal artery Tenderness, warmth, thickness TMJ What is the TMJ assessment process? Place index finger over front of each ear, have patient open and close jaw What are you palpating for? Crackling, ROM, pain 25 Assessment - Neck Inspection/Observation ROM - smooth movement Lymph nodes Trachea - looking for deviation from midline Thyroid - “Adam’s apple” - usually assessed from behind patient (in front of patient if necessary) - have patient swallow water - looking for symmetrical movement 26 Assessment – Thyroid Dysfunction 27 Lymphatic System Palpation of Lymph Nodes Have patient sit in upright position Palpate in a gentle, circular manner Compare size/shape, delimitation, mobility, consistency and tenderness What is the term for lymph nodes that are > 1cm? Lymphadenopathy 28  (Cushing Syndrome, Lymphadenopathy, Abnormal findings of head and face Acromegaly, Goiter) Lymphadenopathy - Lymph nodes > 1 cm Acromegaly Cushing Syndrome Goiter 29  Week 2: Assessing the Eyes Johns Hopkins School of Nursing Subjective data assessment of the eyes What questions would you ask in collecting subjective data during your eye assessment? Any recent visual changes? Do you experience floaters? Do you experience blind spots? Do you have difficulty seeing at night? Are you experiencing double vision? Do you experience any sensitivity to light? Do you have any eye pain or itching? Do you have any redness, swelling or discharge? What medications do you take? Have you been tested for glaucoma? Do you wear glasses? 31 Assessment - Eyes What is this? Snellen chart What are we testing for? Distant Visual Acuity How is it used? ✓ Client covers one eye and reads chart top to bottom ✓ Top number is? always 20 as it represents distance from chart ✓ Bottom number is? the last full line the client could read ✓ Document if patient was wearing glasses 32 Assessment - Eyes What is this test? Jaeger test What are we testing for? Near visual acuity How is it used? ✓ Held approximately 14 inches from eye, read with alternate eye covered then both eyes together ✓ Documented by smallest line read 33  Assessment - Eyes ❑ Eyelids and eyelashes Unequal ❑ Alignment of eyeball pupils ❑ Lacrimal apparatus This is called… ❑ Sclera Anisocoria ❑ Conjunctiva ❑ Pupils Dilation of the Constriction pupil. This is of the pupil. called… This is Mydriasis called… Miosis 34 Assessment - Eyes What are we testing for in this picture? Accommodation and convergence of pupils How is this test performed? ✓ Hold object away from client ✓ Slowly move toward nose ✓ Look for accommodation and convergence 35 Assessment - Eyes What are we assessing in this picture? Cardinal fields of gaze How is this performed? ✓ Have patient track object with eyes What are we looking for? Smooth and Symmetrical eye movements What is this? Nystagmus What may be the cause if eye movements are not smooth and symmetrical? What is Weak extraocular muscles; dysfunction of nystagmus? cranial nerve Oscillating movement of the eye 36 Assessment of Eyes You ask the patient to stare at your eye or nose with one eye closed (your corresponding eye closed as well). Hold your hand off to the side and have them tell you how many fingers you are holding up. What is this test? Confrontation test What are we testing? Visual Fields 37  (Pterygium, Ptosis, Exophthalmus, Ectroption, Abnormalities of the eye Arcus Senilis, Blepharitis) Ectropion Ptosis Blepharitis Arcus senilis Pterygium Exophthalmos 38 Abnormalities of the eye (Scleral jaundice, Subjunctival hemorrhage, Cataracts, Glaucoma) Subconjunctival hemorrhage Cataracts Glaucoma Scleral jaundice 39  Week 2: Assessing the Ears Johns Hopkins School of Nursing Assessment of Ears – Subjective Data What question would you ask? ✓ How is your hearing? ✓ Have you had any trouble hearing? ✓ Have you had any ear infection, discharge from ears, pain? ✓ Any dizziness? ✓ Ever feel like the room is spinning? ✓ Ever hearing a buzzing, crackling, whistling or ringing sound? ✓ Any pain? ✓ Ear infections? ✓ Trauma to ears? 41  What is happening here? Patient A states, “Sometimes, I suddenly feel like the room is spinning. I feel like I am being pulled to one side and can’t keep my balance. I even get nauseous.” What do you think your patient is experiencing? Vertigo What may cause this? Labyrinthitis (inflammation of inner ear or auditory nerve) Ear infection Meniere’s Disease (inner ear disorder) 42 Inspection and Palpation Inspection Auricle – redness, swelling Ear canal - use of otoscope to inspect ear canal and tympanic membrane for redness, swelling, discharge, foreign bodies Tympanic membrane – use of otoscope to inspect for color and contour Grasp auricle firmly but gently and pull upward and outward to straighten ear canal Palpation Auricle – lumps, tenderness 43 Assessment - auditory What is the Whisper test and how do you perform the Whisper test? Have patient cover tragus Stand 1-2 feet behind patient Whisper two syllabus word Ask patient to repeat word Repeat on opposite ear 44  Assessment - Auditory What is the Weber test and how do you perform the Weber test? Evaluates conduction of sound waves through bone Strike tuning fork with back of hand and place in center of head or forehead Sound is heard better in affected ear with conductive hearing loss Sound is heard better in unaffected ear with sensorineural hearing loss 45 Assessment - Auditory What is the Rinne test and how do you perform the Rinne Test? Place the base of a struck tuning fork on the mastoid bone behind the ear. Have the patient indicate when sound is no longer heard. Move fork (held at base) beside ear and ask if now audible. In a normal test, AC > BC; patient can hear fork at ear. With conductive loss, BC > AC; patient will not hear fork at ear. AC = Air conduction BC = Bone conduction https://www.uptodate.com/contents/image?imageKey=PC%2F58032&topicKey=PC%2F15359&source=see_link 46 Assessment - Auditory What is the Romberg test and how do you perform the Romberg Test? Inner ear problems Patient stands with feet together and arms at sides Closes eyes for approximately 20 seconds Observe for swaying If significant swaying or need to step forward, Romberg test is positive – possible vestibular disorder 47 Abnormal findings What is Otalgia? Earache What is Tinnitus? Ringing or other noises in one or both ears What is Presbycusis? Gradual hearing loss commonly related to aging – loss of high-pitched sounds at first 48  Otitis Media, Otorrhea, Otitis Externa, Cerumen. Abnormal findings Tophi Otorrhea Cerumen Tophi Otitis Externa Otitis Media 49  Week 2: Assessing the Mouth, Throat, Nose, and Sinuses Johns Hopkins School of Nursing Gathering Subjective Data for Mouth, Nose and Throat What questions would you ask? Pain Change or loss of taste or smell Drainage from nose Difficulty breathing through nostrils Mouth lesions/ulcers Redness, swelling, bleeding Swallowing Sore throat Allergies Cancer Smoker/ETOH Grind teeth Dentures 51 Vocabulary Epistaxis Odynophagia Nosebleed Painful swallowing Anosmia Gingivitis Loss of smell Gum disease Ageusia Halitosis Lack of taste Bad breath Dysphagia Xerostomia Difficulty swallowing Dry mouth 52 Nose Throat and Sinuses Equipment: Penlight Nasal speculum attached to otoscope Gloves Cotton gauze pads Tongue blade Inspection Palpation 53 Objective data collection of mouth Inspect the lips Inspect the teeth Inspect the buccal mucosa Inspect and palpate the tongue Palpate and percuss sinuses 54  (Vitamin B12 deficiency, Candida Albicans, Abnormalities of the mouth Acute tonsillitis, Canker sore, Black Hairy tongue) Candida Albicans Black hairy tongue Carcinoma of tongue Canker sore Acute tonsilitis Vitamin B12 deficiency 55 Assessment of Throat and Tonsils Throat Inspect for color consistency Where is the Uvula? Midline Tonsils Grading scale: 0 Tonsil have been removed 1+ Tonsils are visible 2+ Tonsils are midway between tonsillar pillars and uvula 3+ Tonsils touch the uvula 4+ Tonsils touch each other (kissing tonsils) 56 Assessment of Nose Inspect and palpate Color Shape Tenderness Symmetry Patency of airflow Septum Mucosa Masses/polyps 57 Assessment of Sinuses Palpate for tenderness (Frontal and maxillary sinuses) 58 Question 1 ► You are completing a health assessment on a new client. You note that the client has dry, brittle hair and dry, flaky skin with poor turgor. What might this indicate? a) Excessive physical activity b) Poor personal hygiene c) Poor nutritional status d) Damage from an environmental cause 59 Question 1 ► You are completing a health assessment on a new client. You note that the client has dry, brittle hair and dry, flaky skin with poor turgor. What might this indicate? a) Excessive physical activity b) Poor personal hygiene c) Poor nutritional status d) Damage from an environmental cause 60 Question 2 ► The nurse is using the mneumonic ABCDE to assess a client’s mole. What should the nurse document for the C? a) Color b) Category c) Consistency d) Characteristics 61 Question 2 ► The nurse is using the mneumonic ABCDE to assess a client’s mole. What should the nurse document for the C? a) Color b) Category c) Consistency d) Characteristics 62 Question 3 ► A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the least several months. She claims to frequently feel lethargic and listless and states that, “I can never seem to get warm, no matter what the thermostat is set at.” How should the nurse proceed with assessment? a) Order tests to rule out an overactive thyroid gland b) Assess for other signs and symptoms of Cushing’s syndrome c) Palpate the patient’s parotid gland for enlargement d) Assess the patient for hypothyroidism 63 Question 3 ► A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the least several months. She claims to frequently feel lethargic and listless and states that, “I can never seem to get warm, no matter what the thermostat is set at.” How should the nurse proceed with assessment? a) Order tests to rule out an overactive thyroid gland b) Assess for other signs and symptoms of Cushing’s syndrome c) Palpate the patient’s parotid gland for enlargement d) Assess the patient for hypothyroidism 64 Question 4 – NGN (Bowtie) 65 Question 4 66 Question 4 67 Question 5 ► An older adult client presents at the clinic, reporting otalgia in the right ear. Physical assessment reveals cerumen impacted in the client’s ear. Removing this mechanical blockage may have what outcome for this client? (Select all that apply). a) Increase the size of ear canal b) Provide less rigidity in outer ear c) Improve hearing d) Enhance socialization e) Prevent injury 68 Question 5 ► An older adult client presents at the clinic, reporting otalgia in the right ear. Physical assessment reveals cerumen impacted in the client’s ear. Removing this mechanical blockage may have what outcome for this client? (Select all that apply). a) Increase the size of ear canal b) Provide less rigidity in outer ear c) Improve hearing d) Enhance socialization e) Prevent injury 69 Question 6 ► A clientis having their tonsils removed. The client asks the nurse what function the tonsils serve. Which of the following would be the most accurate response? a) “The tonsils aid in digestion.” b) ”The tonsils help to guard the body from invasion of organisms.” c) “The tonsils contain nerves that provoke sneezing.” d) “The tonsils regulate the airflow to the bronchi.” 70 Question 6 ► A clientis having their tonsils removed. The client asks the nurse what function the tonsils serve. Which of the following would be the most accurate response? a) “The tonsils aid in digestion.” b) ”The tonsils help to guard the body from invasion of organisms.” c) “The tonsils contain nerves that provoke sneezing.” d) “The tonsils regulate the airflow to the bronchi.” 71  ► Bruyere, H. J. (2009). 100 case studies in pathophysiology. Lippincott Williams & Wilkins. References ► Silvestri, L. A., & Silvestri, A. E. (Eds.). (2023). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier, Inc. ► Weber, J. & Kelley, J. (2022). Health assessment in nursing (7th ed.). Philadelphia: Lippincott, Williams, & Wilkins. ► Image credits are listed in the notes section on applicable slides. Otherwise, image credits are for Weber & Kelley, 2022. 72 Questions?