Physical Health Assessment: Head, neck, and neurological

Orientation deficit is a gap in the client’s what?

awareness of person, place, or time

Disorientation can be what?

acute or chronic

What can acute disorientation can be caused by?

infections, dehydration, low oxygen levels, medications, and other imbalances

What can chronic disorientation be presented with?

can be present with some neurological disorder

What is an example of change in orientation?

a manifestation of a medical emergency such as a stroke

What are some signs that a client might be having difficult with swallowing?

coughing or excessive salivation

What is the expected resting size for a pt’s pupils to be?

between three and five millimeters

A unilateral weakness or an inability to follow simple instructions can be an indication of a what?

stroke

Document and notify the provider of your findings immediately if the orientation deficit is what?

is a new finding

If a stroke is suspected ensure the client is what?

NPO until a swallow assessment is performed

The use of a bed alarm that alerts the nurse if a client rises off the bed may also be implemented for what reason?

for a client who is unable to follow command

A client who is suspected of experiencing an orientation deficit has an increased risk of what?

increased risk of injury and should be place don fall precautions

The face should have a what?

a relaxed expression

Slightly asymmetry of what is expected?

facial features

What is hirsutism

Excessive growth of coarse hair usually distributed in a male-pattern that occurs mostly in women

Clients who have suffered a stroke can have what?

have limb weakness or paralysis and are at an increased risk of falls so implement fall risk precautions

When a patient looking far away their pupils should what?

dilate equally

When a patient is looking at a close object their pupils should do what?

constrict equally

When shining the light directly onto the pupil of one of the client’s eyes, both pupils should do what?

constrict simultaneously and equally

Discharge that is yellow, green, or has dried to a crust can indicate what?

an infection or the presence of a foreign body in the ear

Watery clear or blood-tinged drainage from the canal can indicate what?

the presence of an existing skull fracture

Frontal sinus is located where?

above the eyes

Maxillary sinus is located where?

below the eyes

Sinuses can become inflamed and swollen from what?

both seasonal allergies and infection

What color of the mucosa will appear if a client has allergies

pale, swollen, and greyish-blue

What color of the mucosa will appear if a client has the common cold

appear reddened and swollen

If the nasal drainage is clear discharge its associated with what?

allergies

If the nasal drainage is mucoid discharge its associate with what?

the common cold

If the nasal drainage is yellow or green purulent discharge its associate with what?

bacterial infection

If the nasal drainage is foul-smelling discharge its associate with what?

especially that is present on only one side of the nose, is found when there is a foreign body in the nose or the presence of a chronic sinus infection

An inability to draw in air indicates what?

an obstruction

Obstruction is a common finding with the common cold, it could also be due to what?

a physical obstruction

If a pt is experiencing allergies or a sinus infection the interior of their sinuses will be what?

inflamed and swollen

When assessing a pt’s mouth, the client should be in what positon?

sitting or lying position

Clients who has darker skin tones can have more what?

dark pigmented mucosa with areas of hyperpigmentation

Clients who have darker skin tones can have patchy pigmentation of what?

dark pink to brown hums

Masses in the neck can cause what?

the trachea to shift

Observe pt for any signs of respiratory distress such as what?

increased RR, inability to complete sentence without taking a breath, and use of accessory muscles

Observe the stiffness with neck movement and assess what?

the client’s ability to swallow secretions or fluids

Prevention involves educating clients about what?

unhealthy behaviors that contribute to head and neck injuries and disease

Encourage clients to brush their teeth at twice a day and to floss to control what?

to control cavities and gum disease

Which type of data tends to indentify the problem?

subjectiveWhi

Which type of data tends to confirm the problem?

objectiveC

Changes and trends are more important than what?

longer

Cranial nerve impact can occur when what?

a pt can no longer smell, may be an infection or a neurological disorder

A pt reports difficult swallowing… why is concerning?

aspirational, nutritional issues, and cranial dysfunction

A pt cannot shrug shoulder. Which cranial nerve is involved in

cranial nerve eleven

Cranial nerve eleven controls which function

able to shrug shoulders and turn head from side to side

Normal, Monitor, or Urgent AxO x4

Normal, assessing neurological disorders, and looking for a chronic or acute condition that (EX: acute : oxygen, dehydration, head trauma, stroke) (EX: chronic: dementia and alzhemiers)

PERRLA

normal and assess for cranial nerve 3

Gradual hearing loss over several years

monitor and assessing and cranial nerve 8

Sudden hearing loss

Urgent and assess for cranial nerve 8

Unequal pupils after head injury

urgent and assess cranial nerve 3

Difficultly swallowing

Urgent and assess cranial nerve 9 and 10

Facial droop

Urgent and assess for cranial nerve 7

New confusion

urgent and assess neurological disorders (acute or chronic)

Unable to smell coffee

Monitor and assess cranial nerve 1