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E.III HEENT
EIII HEENT 314/315 powerpoint
| Question | Answer |
|---|---|
| normal shapped head | normocephalic |
| Cranial bones: = 8 bones | 1 Frontal 2Parietal 1Occipital Temporal Mastoid process |
| Suture lines | immovable sagittal, coronal, squamosal lambdoid |
| Facial bones: = 14 bones | 2 maxilla, 2 zygomatic 2 inferior conchae2 nasal 2 lacrimal, 2, palatine, 1 vomer 1 mandible |
| Muscles: name & where located | Masseter-over jaw ,Sternocleidomastoid-- very palpable ,Trapezius—next to above ,Buccinator—around mouth ,Zygomaticus– above masseter Temporalis –temporal area |
| Arteries and veins | Temporal artery nCarotid artery nJugular vein |
| Other structures | Lymph nodes nThyroid gland-between cricoid cartilage and trachea nTrachea |
| ? largest endocrine gland in the body? | thyroid gland |
| assessment of head focuses on | cranium,face, thyroid gland, and lymph node structures |
| Trachea | air passasge extending frrom the throat and and larynx to the main bronchi |
| cricoid cartilage | ringlike cartilage forming the lower and back of the larynx |
| spinal accessory-contraction of trapezius and sternocleidomastoid muscles | CN XI spinal accessary |
| The largest of the 3 main parts of the salivary glands located on either side of the face just below & in front of the ears | Parotid gland |
| Paired muscles that allow movement and provide support to the head & neck | Trapezius & sternocleidomastoid |
| The largest of the endocrine glands situated in the front and sides of the neck just below the thyroid cartilage | Thyroid gland |
| cervical vertebra (C7) that can be easily palpated when the neck is flexed | vertebra prominens |
| A salivary gland on either side of the tongue | sublingual gland |
| A horseshoe-m shapped bone at the base of the tongue; the only bone in the body not directly attached to another bone | hyoid bone |
| The thyroid cartilage located just above the cricoid cartilage | Adam's apple |
| Lymph nodes in the neck names | Preauricular, posteriorauricular occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical chain, |
| The aging patient | Facial bones, orbits-more prominent-skin sags, lost cutaneous fat, decreased moisture Face may look smaller if teeth are missing |
| prodromal stage | . The primary stage of certain infectious diseases during which prodromal symptoms appear. Also called incubation period, latent stage, |
| diffuse = | Widely spread or scattered; not concentrated. |
| Analgesics Antipyretics | OTC medicines that are effective in treating pain alsoare effective at reducing fever, |
| vertigo, = | a. The sensation of dizziness. |
| tinnitus, = ` | A sound in one ear or both ears, such as buzzing, ringing, or whistling, occurring without an external stimulus and usually caused by a specific condition, such as an ear infection, the use of certain drugs, a blocked auditory tube or canal, o |
| what is the correct method 4 palpating thyroid gland discuss size texture, smoothness, presence of nodules or masses | posterior approach, client lower chin 2 chest turn neck 2 right client swallow not palpable if can LOBES=smooth firm nontender, right often 25% lgr than left |
| Abnormal findings 4 thyroid gland | diffuse enlargement= hyperthyroidism, graves disease, endemic goiter, enlarged tender =thyroiditis Multiple nodules = metabolic proceswses rapid enlargement of 1 nod =?malignancy |
| What is the significance of Ausculating a thyroid gland how is it done? | Auscultate thyroid only if enlarged use bell listen 4 bruits |
| How is the C& vertebrae inspected & palpated? | client= flex neck chin 2 chest ear 2 shoulder, twist L & R bward 4ward C7 vertebrae prominens visibable palpable |
| Discuss changes that may occur in aging C7 vertebrae | cervical curvature may increase = Kyphosis. Fat may accumulate around the cervical vertebrae (women)=dowagers hump |
| discuss normal & abnormal characteristics of the lymph nodes. | compare bilaterally, assess size shape delimitation, mobality, consistancy, & tenderness |
| delimitation | = nodes position or boundry normal =discrete orabnormal = confluent ie chronic infection = merge |
| normal size & shape lymph nodes | round < 1 cm Not P. in older clients. Abnormal = > 1 cm |
| Mobility of lymph nodes | normal = moviable side 2 side Up & down Abnormal = enlarge fixed in 1 place |
| Consistency of lymph nodes | normal= + fibrotic & fatty in older clients normal = soft abnormal= hard & firm |
| Tenderness & location of lymph nodes | normal= not sore or tender abnormal = tender enlarged =? acute infections |
| Subjective students assess-8 parameters | nHead injuries nDizziness = BP meds ears cardiac nero PV, nNeck pain, stiff neck , acute vs. chronic muscular meningitis arthritis Surgeries nLumps or swelling infection tumorLimited ROM nAlcohol use in pregnancy-FAS nfontanelles |
| Elderly-dizziness and pain and ADL’s Health promotion: | Glasses or contacts nLast eye exam nHelmet use nSeat belts |
| Subjective | Family hx: nCancer nStrokes nBrain tumor nHypertension nMigraines |
| Problem based history | Headache nFrequency nDuration nWake up at night nNausea and vomiting nLocation-bilateral-unilateral nLoss of vision nSeverity n |
| Headache cont | Taking any Meds-oral contraceptives nFatigue nIrritability nPhotophobia nDiet nCaffeine nStress nLifestyle: Type A |
| Foods that trigger headaches | Alcohol Onions nAvocado Tea & Coffee nBananas Yogurt nChocolate nCitrus fruits nProcessed meats nNuts |
| Types of Headaches | nMigraine nTension nHormonal nTumor nCluster |
| Common Risk Factors with Head and Neck Disorders | Tension headaches nMigraine headaches nHead injury nThyroid cancer |
| Tension h/a risk factors | Stress nAnxiety nPoor dental hygiene |
| Migraine risk factors | Family hx nPerfectionist tendencies nFatique bright lights nTrigger foods |
| Risk factors for head injuries | more common in ederly & young males Sports nPrevious injuries nNot wearing helmet nCar accidents nAlcohol and drug abuse nFirearms nSeat belts |
| Examination of head | Asians believe the soul resides in the head so ask for permission to examine |
| Inspecting and palpating | Size nShape nSymmetry nLumps & bumps-sebaceous cyst, lice, fungus wear gloves Palpate hair & scalp |
| Face | Facial expression nSymmetrical features nBell’s Palsy nDysmorphism nTics |
| Dysmorphism | An anatomical malformation. |
| Head face cont. | Wear gloves if suspect lesions nPalpate sinuses – 4 pairs of sinuses – can only palpate frontal and maxillary. nPalpate sinuses w/ percussion or put hands on person with fingers and press. Pt should feel pressure.transillumination nPalpate temporal arter |
| transillumination | The passing of a light through the walls of a body part or organ to facilitate medical inspection. |
| Risk factors for thyroid cancer | Toxins nFamily hx nOccupational hazards nPrevious radiations to head/neck nEnvironmental |
| Neck Lymph nodes | Start in front-preauricular front, post auricular(mastoid), occipital, submental,submandibular, jugulodigastric, superficial cervical-along SCM, deep cervical, posterior cervical, & superclavicular. You may not be able to feel these. You are checking fo |
| IF NODES ARE PALPABLE-DETERMINE | MOBILITY nCONSISTENCY nTENDERNESS |
| normal nodes are | MOVABLE,DISCRETE,SOFT AND NON-TENDER |
| Neck assessment cont. | nThyroid: get behind neck to check it. nMay not feel thyroid if it is not enlarged nHave patient swallow. Thyroid should move up. Thyroid should be symmetrical, no nodules. You can have pt. bend neck to right & left and feel for thyroid this way.auscu |
| EYES | (blank) |
| trigeminal neuralgia | Paroxysmal shooting pains of the facial area around one or more branches of the trigeminal nerve, of unknown cause, but often precipitated by irritation of the affected area. Also called tic douloureux.what cranial nerve ? |
| reduction of blood supply 2 brain can be caused by | acessing carotid arteries @ the same time |
| client visits er= sudden head & neck stiffness temp 100 nurse suspects? | meningeal irration |
| female visits clinic frequently experiences severe recurring headaches can last several days + nausea & vomiting, type of headache=? | migraine |
| adult client visits clinic has headaches recently intense stabbing late evening document presence of ? | cluster headaches |
| client = clinic = depressed complains of dull aching tifht and diffuse headaches last several days nurse documents ? | tension headaches |
| older client w/ daughter =severe headaches start in morning worse when coughalso feels dizzy nurse refers 4 further evaluation symptoms charastic of ? | tumor-related headaches |
| Nurse preparing 2 do a head & neck assessment client immigrated from Cambodia the nurse should first? | ask client if touching the head is permissable |
| during assessment nurse observes that clientsskull & facial bones lgr & thicker than usual nurse should acess client 4? | acromegaly |
| acromegaly | A chronic disease of adults marked by enlargement of the bones of the extremities, face, and jaw that is caused by overactivity of the pituitary gland. |
| during assessment nurse observes that clientsskull bones are acron shapped and enlasrged nurse should refer the client to a physician for possible?? | Paget's disease |
| Paget's disease | Paget's disease is a chronic bone disorder that typically results in enlarged, deformed bones due to irregular breakdown and formation of bone tissue. Paget's disease can cause bones to weaken and may result in bone pain, arthritis, bone deformities and f |
| assessing adult head & neck = asymmetry in front of client earlobes nurse refers 2 dr. suspects client is most likely experiencing a/an ? | parotid gland enlargement |
| parotid gland | Either of the pair of salivary glands situated below and in front of each ear. |
| Preparing t acess neck of adult client to inspect movement of thyroid gland nurse should ask client to? | swallow a small sip of H2O |
| assessing older clients neck= clients trachea is pulled 2 left side nurse should??? | refer client to doc 4 further evaluation |
| Cushing's syndrome | Physically, patients develop an abnormal fat distribution that sometimes leads to feelings of insecurity or unattractiveness. Clinically, people with Cushing syndrome are often at risk for a variety of significant medical problems including diabetes, high |
| scleroderma | Progressive disease of the connective tissue of the skin and internal organs. |
| what might cause a clients tracheato be pulled 2 the left side? | right sided pleural efusion will move trachea 2 left collapase on left will pull to left |
| EYE Subjective questions on health hx: | Vision nPain Acute? nStrabismus nHx. Diabetes nSurgeries nDischarge, watering nRedness, swelling |
| eye cont. | Glasses/contacts nFloaters nGlaucoma nFamily hx. nSelf care nOccupational hazards |
| eye cont. | Smoking nCataracts nWear sunglasses in sunlight nContacts / glasses & sports nCutting grass/wood nClean contacts |
| Common Risk Factors R/T ye | Exposure to UV light nTrauma nIncreasing age nDiabetes nSmoking nAlcohol nGlaucoma nHypertension |
| Blindness Risk Factors | Hypertension nEye injury |
| Aging adult | Decreased tear production nLipid material on cornea nPupil size decreases nLens loses elasticity nPresbyopia ave age 40 yr 70 yr-beginning of cataracts nMore light to read < adaptation to darkness nMacular degeneration |
| Tests: nVisual acuity – snellen chart – | stand 20 ft. from chart, tell pt. to read letters. Cover one eye – read lowest line possible. Do both eyes. |
| 20/30 vision | person can see at 20 feet what a person with perfect vision can see at 30 feet. nNear vision- card 14 inches |
| Ophthalmoscope know technique | (blank) |
| Visual field – use ??? test | confrontation test |
| Corneal light reflex- | light seen in same spot in both eyes (Hirschburg) |
| Diagnostic positions test – | 6 cardinal positions |
| Inspect external ocular structures ie = | conjuctiva, sclera,cornea, etc. |
| Pupillary light reflex- | normal constriction of pupils to bright light |
| Consensual light reflex | nml eye vs blind eye (CN II) |
| Fixation- | tracking target to keep image fixed on fovea n when impaired? |
| Accommodation | – constriction & convergence |
| PERRLA | An acronym used in the medical field to describe a quick, normal eye examination. It stands for Pupils Equal, Round, Reactive to Light and Accommodation. |
| Confrontation test- | 2 feet- cover same eye-tests peripheral vision |
| Cover test- | test for muscle weakness- strabismus-phoria-trophia-exo-eso |
| strabismus | A visual defect in which one eye cannot focus with the other on an object because of imbalance of the eye muscles. Also called squint. |
| phoria | The relative directions of the eyes during binocular fixation on a given object in the absence of an adequate fusion stimulus. |
| Nystagmus | lateral gaze may be normal, other positions- no |
| Nystagmus | An involuntary, rhythmic movement of the eyes. |
| Ophthalmoscope -Myopia | nearsighted-red |
| Myopia | A visual defect in which distant objects appear blurred because their images are focused in front of the retina rather than on it; nearsightedness. Also called short sight. |
| Ophthalmoscope Hyperopia- | farsighted-black |
| Hyperopia- | Abbr. H) An abnormal condition of the eye in which vision is better for distant objects than for near objects. It results from the eyeball being too short for light rays to properly focus on the retina, thus forming a blurred image. Also called farsighted |
| Ophthalmoscope how to | start at O both have normal vision O-both have normal vision nFocus scope on an outside object nStart at 10 inches nOptic disc color, shape, margins, nVessels nMacula-1DD-2DD temporal to disc |
| --IICP | intercranial preassure |
| Papilledema | Swelling of the optic disk inside the eye (the portion of the optic nerve that collects nerves from the light sensitive layer of the eye, the retina); often caused by increased pressure inside the head. |
| the optic nerves from each eyeball cross the? | optic chiasma` |
| Ear | A&P nHelix nAntihelix nTragus nAntitragus nLobule nMastoid process |
| Tympanic membrane Ear | nAnnulus-border nCone of light nOssicles nMalleus nIncus nStapes |
| Middle ear-function | nConduction of sound vibration-outer ear to central hearing apparatus-middle ear nProtects inner ear by reducing loud sound amplitude nEustachian tube allows for equal air pressure both sides of TM |
| Inner ear | nBony labyrinth-inflammation-vertigo nSensory organs nVestibule nSemicircular canals ncochlea |
| Q’s to ask: 4 ear | nEaraches nInfection nHearing loss nDischarge nTinnitus nOccupational noises nSelf care behaviors |
| subjective | Vertigo nHow do you clean your ears? nTubes in ears? nMedications and? and? nDrainage nTeeth nInjuriesSwimming |
| nInspection : | nSize nShape nPosition nTenderness nMeatus nSymmetry |
| Otoscope ear tests | nPull ear up and back.tilt head opposite shoulder. Insert scope-keep traction until scope is removed nLook for tympanic membrane, should be pearly gray. nHave patient hold nose-swallow-check movement nHearing acuity nVoice test-tragus nFormal testing nBe |
| Weber test | lateralization-vibrating tuning fork center of head-should hear equally-both ears- bone conduction |
| Rinne test | AC>BC bilaterally-vibrating tuning fork at mastoid then outer ear |
| Nose-subjective | Trauma nSmoke nAllergies nPain nNose bleeds nAltered smell nFrequent coldsMeds nDischarge nSinus h/a nSnoring |
| Nose, Mouth & throat | Mouth pain nSore throats n Difficult swallowing n Herpes nCoughing nEsophageal reflux nVomiting nSurgeries nExam: inspect & palpate the nose nCheck patency smell (cranial nerve I) nSpeculum – to look up into nose- turbinates |
| Nose, Mouth & throat | Look at tonsils & grade nThroat- tongue blade nLips nMouth nTongue nBuccal mucosa nPalate nuvula nSore throat, altered taste, teeth, dysphagia, bleeding gums |
| dysphagia | Difficulty in swallowing. |
| assessing eyes of adult client nurse uses a wisp of cotton 2 stimulate the clients? | corneal reflexes |
| sudden changes in vision oftenassociated with? | head trama |
| if a client is experiencing gradual vision loss the nurse should? | check the clients blood preassure |
| client sometimes sees spots in fron tof his eyes the nurse should? | tell client these often occur with aging |
| peripheral vision is declining with blind spots on left side nurse refer client 4 possible? | glaucoma |
| consistant blind spot in right eye after a head trama nurse should? | refer the client to an ophthalmologist |
| ophthalmologist | physician who specializes in ophthalmology.=The branch of medicine that deals with the anatomy, functions, pathology, and treatment of the eye. |
| client has a hard time seeing while driving @ night nursw should explain to client that night blindness is often associasted with? | vitimin A deficiency |
| client has been experiencing double vision for the past few days nurse refe5s client 2 DOC 4 evaluation of possible? | increases intracranial preassure |
| intracranial preassure | The overall pressure within the skull. |
| increased intracranial preassure | intracranial preassure |
| client frequently experiences burning & itching in both eyes client should b assessed 4 ? | allergies |
| client has a throbbing aching pain in right eye nurse should asess clients eye 4 | a foreign body in the eye |
| excessive tearing in left eye asess eye 4? | lacrimal obstruction |
| lacrimal | Of or relating to tears. |
| healthy client w/ no past vision problems thorough eye examination is recommended every? | 2 years |
| painful eyes due to contact lenses in too long instruct client that prolonged wearing of contact lenses can lead to ? | corneal damage |
| corneal | Pertaining to the cornea. =The transparent convex anterior portion of the outer fibrous coat of the eyeball that covers the iris and the pupil and is continuous with the sclera. |
| sclera. | The tough white fibrous outer envelope of tissue covering all of the eyeball except the cornea. Also called sclerotic, sclerotic coat. |
| risk 4 cateracts= | ultra violet light exposure |
| preparing to examine clients eyes with a snellen chart nurse should? | position client 20 feet away from chart |
| client tested 20/40 on distant visual acuity test using a snellen chart the nurse should ? | refer client to an optometrist |
| optometrist | A person who is professionally trained and licensed to examine the eyes for visual defects, diagnose problems or impairments, and prescribe corrective lenses or provide other types of treatment. |
| visual fields tested = temporal field is 90 degrees in both eyes nurse =? | document findings in the clients record |
| near visual acuity tested in a 45 year old client nurse explains 2 client that = impared near vision and possible causes nurse =client understood instructions when client says presbyopia = | decreased accomodation |
| presbyopia | Inability of the eye to focus sharply on nearby objects, resulting from loss of elasticity of the crystalline lens with advancing age. |
| accomodation | Accommodation is the process by which the eye increases optical power to maintain a clear image (focus) on the retina <ref>Cassin, B. and Solomon, S. Dictionary of Eye Terminology. Gainsville, Florida: Triad Publishing Company, 1990.</ref>. |
| inward turning of clients left eye nurse documents ? | estoropia |
| estoropia | A form of strabismus in which one or both of the eyes deviate inward. |
| strabismus | A visual defect in which one eye cannot focus with the other on an object because of imbalance of the eye muscles. Also called squint. |
| phoria | The relative directions of the eyes during binocular fixation on a given object in the absence of an adequate fusion stimulus. |
| client needs more info for positions when states that positions test requires covering of each eye seperately | positions test assesses the muscle strength of the eye, assesses the functioning of the cranial nerves innervating the eye muscles, requires the client to focus on an object |
| Ear assessment cone of light is located ? | external ear |
| ossicles in middle ear include the malleus, incus and the ? | stapes |
| sensory receptors in the ear that help to maintain both static and dynamic equilibrium are located in the semicircular canals and the ? | vestibule |
| static equilibrium | Having no motion; being at rest; quiescent. |
| dynamic equilibrium | Of or relating to energy or to objects in motion. |
| equilibrium | A condition in which all acting influences are canceled by others, resulting in a stable, balanced, or unchanging system. |
| perceptive hearing | transmission of sound waves in the inner ear |
| conductive hearing | transmission of soundwaves through the external ear and middle ear = |
| tinnitus | A sound in one ear or both ears, such as buzzing, ringing, or whistling, occurring without an external stimulus and usually caused by a specific condition, such as an ear infection, the use of certain drugs, a blocked auditory tube or canal, or a head inj |
| after examining frontal sinuses proceed 2 | maxillary |
| painful mouth ulcer = | aphthous stomatitis |
| aphthous stomatitis | canker sore small, painful ulcer or sore, usually of the mouth. |
| rough crusty eroded area in mouth nurse =? | refer 4 further evaluation |
| client = frequent nosebleeds past month nurse =? | refer client 4 further evaluation |
| poor fitting dentures = greater risk 4/ | ASPIRATION |
| ASPIRATION | Expulsion of breath in speech. |
| grinding teeth may b a sign of ? | stress anxiety |
| risk factors 4 oral cancer ? | diets low in fruits and vegetables is possible risk factor 4 oral cancer |
| b 4 examining mouth nurse should first ? | don clean gloves 4 procedure |
| painful cracking in corners of the lips diet assessed 4? | riboflavin |
| riboflavin | An orange-yellow crystalline compound, C17H20N4O6, the principal growth-promoting factor in the vitamin B complex, naturally occurring in milk, leafy vegetables, fresh meat, and egg yolks. Also called lactoflavin, vitamin B2. |
| most common sight 4 oral cancer is ? | area underneath the tongue |
| using a tongue depressor in mouth assessment nurse should plan 2? | depress tongue blade slightly off center |
| 4+ tonsils = | tonsils that r touching each other |
| preparing nose inspection w/ otoscope nurse plans to ? | position the handle of the otoscope 2 1 side |
| after nose assessment nurse explains thick yellow discharge client understands = | upper respiratory infection |
| method used to P maxillary sinuses | press yo w/ thumbs on sinuses |
| grade 3+ tonsils | touch the uvula |
| most common sight of tongue cancer? | side of tongue |
| cracking @ corner of lips seen in riboflavin deficiency | Cheilosis |
| method used 2 test 4 fluid in sinuses? | transillumination |
| press up on brow on each side of nose= ? | method used 2 P frontal sinuses |
| signifiance of a red glow w/ transillumination | sinus filled w/ air= |
| inspection using otoscope w/ short wide tip attachment? | method for assessing the internal nose |
| methods used to acess for sinus tenderness | Palpation & Percussion |
| Openings found on bubuccal mucosa across from second upper molars | stensen ducts |
| bony protruberance in the midline of the hard palate= | torus palatinus |
| absence of a red glow w/ transillumination | sinus filled w/ fluid or puss |
| common sight of nasal bleeding | Kiesselbach's area |
| variation looks split or partically severed may b associated with a submucous cleft palate | bifid uvula |
| normal variation that occurs in the crease between the upper and lower lip = crease that | Lip pits |
| Openings found on either side of the frenulm of the floor of the mouth = | Whartons ducts |
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