NURS 222 Exam 3

What does Confrontation Test test?

Tests Visual Field

How to perform Confrontation test

Stand 2 feet away. Both of you cover opposing eye. Wiggle finger and advance from periphery; several directions. You and patient should see object at same time.

What does Corneal Light Reflex test?

Assesses parallel alignment of eye axes And inspects extraocular muscle function

How to perform Corneal Light Reflex test

Shine light at bridge of nose, 12 inches away. Patient stares ahead. The light should reflect in exactly the same spot on each cornea.

What does the Cover test test?

Only done if corneal light reflex is asymmetric. Inspect Extraocular Muscle Function.

How to perform Cover test

Stare ahead, cover one eye with card-it should be a steady gaze. Next, uncover eye and look for steady gaze. Repeat. Should observe steady gaze in opposite eye as you cover. Should observe steady gaze in tested eye as you uncover it.

What does Diagnostic Positions test?

CN III, IV, VI. Inspect extraocular muscle function.

How to perform Diagnostic Positions test

Have patient keep both eyes open. Keep target 12 inches away from patient. “Follow my pen”. Move yo the 6 positions, hold, then back to center (2, 3, 4, 8, 9, 10 o’clock positions)
Should see parallel tracking or “OU” (= in both eyes)

Inspect External Eyeball structures (General)

Observe that patient can move easily around room without groping.

Inspect external Eyeball structures (Eyebrows)

Observe that eyebrows are present. Eyebrows move symmetrically, no lesions.

Inspect external Eyeball structures (Eyelids and lashes)

Observe that upper lid can overlap superior iris. Closes completely. Lashes are even and curve outwards.

Inspect external Eyeball structures (Eyeballs)

Observe that eyeballs are aligned. No sunken or protrusion appearance.

Inspect external Eyeball structures (Conjunctiva and sclera)

Using thumbs, slide lower lid down. Eyeball should be moist and glossy. Conjunctivae should be clear revealing color below (should be pink over lower lids and white over sclera)

Inspect external Eyeball structures (Lacrimal apparatus)

Feel along upper lid for swollen gland. Press finger against sac, not nose. NO swelling should be present on upper lid. No liquid should be regurgitated from puncta.

Inspect Anterior Eyeball Structures (Cornea and lens)

Shine light from side and check for smoothness and clarity of cornea, anterior chamber, and lens. No cloudiness or irregular ridges should be found.

Inspect Anterior Eyeball Structures (iris and pupil)

Iris should be flat, round with even color throughout.
Pupils should be round, regular, and equal in size (~ 3-5 mm). Measure them

Inspect Anterior Eyeball Structures (Test pupillary light reflex)

Darken the room. Have patient gaze into distance. Advance penlight from side. Pupils should constrict (= direct light reflex)
Simulataneous constriction of other pupil (consensual) Record R 3/1= 3/1 L

Inspect Anterior Eyeball Structures (Accommodation)

Have patient focus on a distant object. “Shift your gaze to my finger” (~ 3 inches away). Pupils should constrict. Convergence of axes of eyes.

snellen test

a test of visual acuity using a Snellen chart

snellen test (results)

Patient stands 20 feet away to read chart. Numerator is 20, or however far away the patient stand to read the chart. Note smallest line where patient can read and record visual acuity for that line. This is the denominator. The larger the denominator, the poorer the patients vision is. 20/20 is normal.

Strabismus

Is a congenital condition where both eyes do not focus on an object simultaneously; these eyes appear crossed. Impairment of the extraocular muscles or their nerve supply causes strabismus.

presbyopia

Impaired near vision in middle age and older adults caused by loss of elasticity of the lens and associated with the aging process.

cataracts

increased opacity of the lens, which blocks light rays from entering the eye. Cataracts develop slowly and progressively after age 35 or suddenly after trauma.

glaucoma

Intraocular structural damage resulting from elevated intraocular pressure. Obstruction of the outflow of aqueous humor causes this. Without treatment the disorder leads to blindness.

photophobia

A morbid fear of light. Tears, headaches, bright colored spots in vision

Diplopia

visual impairment in which an object is seen as two objects. Double vision.

Floaters

spots in vision that look like black or gray specks or strings that drift across the eyes.

aniscoria

Unequal pupil sizes

Ptosis

drooping of the upper eyelid caused by muscle paralysis and weakness

ear exam steps

1. Health History
Earaches/ear pain? Trauma to head? Any ear infections? Now or in past? Discharge from ears? Any hearing loss currently? Any loud noises at home or job? Any ringing/buzzing in ears? Taking any medications? Ever felt vertigo (subjective and objective? How do you clean your ears? Use ear protection from loud noises or while swimming? Last hearing test?
2. Inspect external ear
Size/Shape of auricle, Position and alignment on head, skin condition (color, lumps, lesions,), Check for movement of auricle and tragues for tenderness, evaluate external auditory meatus (size, swelling, redness, discharge, cerumen, lesions, foreign bodies)
3. Otoscopic examination
External Canal, cerumen, discharge, foreign bodies, lesions, redness or swelling of canal wall.
4. Inspect tympanic membrane
Should be pearly grey, shiny, translucent, flat. Membrane should be intact.
5. Test Hearing Acuity
CN VIII, whispered voice test

presbycusis

age related hearing loss

Otosclerosis

Abnormal bone growth within the ear. Causes hearing loss due to the ear’s inability to amplify sound.

Vesicular breath sounds

Heard in peripheral and lateral lung fields as well as over clavicles.
Longer inspiration and shorter exhalation

Bronchial breath sounds

Heard over and around the trachea. Harsh. Shorter inspiration and longer exhalation.

Bronchovesicular

Heard over main bronchi anteriorly and posteriorly. Equal inspiration and exhalation

bruit

Audible vascular sound associated with turbulent blood flow.

Murmurs

Due to structural defects in valves
Blowing and swooshing sound
Velocity of blood increasing
Viscosity of blood decreasing

regurgitation

backflow of blood through a defective heart valve

tachycardia

abnormally rapid heartbeat

bradycardia

abnormally slow heartbeat

orthopnea

form of dyspnea in which the person can breathe comfortably only when standing or sitting erect

tachypnea

Fast breathing; > 20 breaths per minute

Bradypnea

Slow breathing; <12 breaths per minute

eupnea

normal relaxed breathing

Cheyne stokes respirations

Cycles of alternating apnea and hyperventilation associated with a critical condition

hyperpnea

energetic respiration that occurs normally after exercise or abnormally with fever or various disorders

apnea

Stopped respiration w/o breathing. Temporary cessation of breathing.

arteriosclerosis

Thickening and hardening of arterial walls

dyspnea

difficult or labored respiration

layers of heart wall (outside to inside)

Pericardium (surrounds and protects heart)
Myocardium (muscle wall, responsible for pumping and contracting)
Endocardium (lines inner surfaces of heart)

heave

move or cause to move in a specified way, direction, or position

pulmonary ventilation

process of air flowing into the lungs through inspiration and out of the lungs through expiration

Right sided heart failure

Usually happens due to a respiratory problem. Blood backs up into the body. Blood cannot go forward. Leads to peripheral edema.
Key signs: JVD, peripheral edema, enlarged spleen/liver

left sided heart failue

Blood backs up to the lungs, blood cannot go forward to the body. Drowning in blood. Leads to crackles, dyspnea, orthopnea, confusion, memory loss

Path of blood flow from Vena Cava to heart

Vena Cava -> R. Atrium -> Tricuspid Valve -> R. Ventricle -> Pulmonary valve -> Pulmonary Artery -> Lungs -> Pulmonary Vein -> L. Atrium -> Mitral Valve -> L. Ventricle -> Aortic Valve -> Aorta

Conduction system of heart

1. SA Node (pacemaker)
2. AV node (delays signal to allow atria time to contract before ventricles stimulated
3. Bundle of His
4. R/L Bundle Branches (septum)
5. Purkinje Fibers: cause ventricles to contract (apex)

Peripheral Pulses

Brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial
Graded with +1, +2, +3, +4, +5 (+2 is normal)

Pretibial edema

caused by poor circulation or fluid retention.

Crackles

Popping/crackling in the lungs

wheezing

Musical-ish sounds

pleural friction rub

Leather rubbing together

Ronchi

Snoring sound

stridor

a whistling sound when breathing; indicates obstruction of the trachea or larynx

Aortic Area

Located 2nd intercostal space, right sternal border, S2 louder than S1

Pulmonic Area

Located 2nd intercostal space, Left sternal border, S2 louder than S1

Erb’s Point

Located 3rd intercostal space, left sternal border, S1=S2

Tricuspid Area

Located 4th Intercostal space, left sternal border, S1 louder than S2

Mitral (apical) Area

Located 5th intercostal space, left midclavicular line, S1 louder than S2

Respiratory Assessment

1. Health History
Cough? Any shortness of breath? Any chest pain with breathing? Past history of lung disease? Cigarettes, age started, how many per day, for how long, have you tried to quit? Any living or work conditions that affect your breathing? Last Tb skin test, chest X-ray? Last flu vaccine?
2. Inspection
Any deformities of the thoracic cage? Respirations-rate, rhythm, accessory muscle use. Skin color and condition. Nails (clubbing). Person’s position. Facial expression. Level of consciousness (person, place, time, situation)
3. Palpation
Confirm symmetric expansion. Tactile Freitas (hands vertical on either side of spine, have patient speak). Skin temperature and moisture. Detect any lumps, masses, tenderness. Trachea.
4. Auscultation
Listen to posterior, lateral, anterior. Note any abnormalities.

Heart Assessment

1. Health History
Chest Pain/Tightness, shortness of breath, use more than one pillow to sleep, do you have a cough, tire easily, facial skin ever turn blue or ashen, swelling of feet/legs, awaken at night to urinate, past history of heart disease, change in usual/daily activities, medications? Smoking? Cardiac risk factors (diabetes, hypertension, high cholesterol, obesity, sedentary lifestyle, age)
2. Neck
Carotid Arteries: observe and palpate the R and L; grade, equality
3. Precordium
Skin color and condition. Chest wall pulsation. Location of apical impulse if able to feel. Can you see the impulse. Apical pulse, rate, rhythm.
4. Auscultation
Identify an atomic area to listen. identify S1 and S2, note any variation.

Valves of heart

AV: Triscuspid (Right A/V) and Mitral (Left A/V)
Semilunar: Pulmonic and Aortic

Peripheral vertigo

impaired balance with the ability to walk

Central vertigo

more severe instability, cannot walk or stand without falling

Grading tonsils

+1: Visible
+2: Halfway between tonsillar pillars and uvula
+3: touching uvula
+4: touching each other

tongue normal findings

Should be pink, moist, roughened with papillae