Nursing exam 2 (Kent state)

HEENT

head, eyes, ears, nose, throat

What is assessed in a HEENT assessment?

carotid arteries, jugular vein, lymph nodes, thyroid gland, and trachea

What could facial drooping mean?

Stroke or bells palsy

Ptosis

eyelid drooping

Normocephalic

normal skull size relative to body

hydrocephalus

accumulation of cerebral spinal fluid in the ventricles of the brain

TMJ

temporomandibular joint (Mandible and maxilla)

snellen chart

used to measure visual acuity

extraocular movements

six directions of gaze

what does assessing visual fields check?

peripheral vision

nystagmus

Involuntary rapid eye movements

exophthalmos

bulging eyes

What causes exophthalmos?

over activity of the thyroid gland or hyperthyroidism

strabismus

crossing of the eyes

Conjunctivitis

inflammation or infection of the conjunctiva

sclera

white of the eye

PERRLA

pupils equal, round, reactive to light and accommodation

How are pupils measured?

In millimeters

cataracts

clouding of the lens in the eye that affects vision

Glaucoma

increased intraocular pressure leading to vision loss

macular degeneration

loss of central vision

hyperopia

can see far but not near

Myopia

can see near but not far

presbyopia

age related farsightedness, can't see things near, occurs around 40

astigmatism

curvature of eye, light does not focus easily

retinopathy

damage to blood blood vessels in eyes

cerumen

ear wax

how do you straighten ear canal for adults?

back and up

vertigo

dizziness

tinnitus

ringing in the ears

ototoxicity

injury to auditory nerve

how do you straighten ear canal for infants?

back and down

romberg test

balance test

hemoptysis

bloody drainage from nose

nose deformity

deviated septum

how do asses inflammation or swelling in sinus

palpate frontal and maxillary facial areas

pallor lips

anemia

cyanosis

bluish color, respiratory or cardiovascular dysfunction

cherry colored lips

carbon monoxide poisoning

edema

swelling

clear drainage

chronic sinus problems

yellow or green drainage

infection

sweet fruity odor

diabetes

ammonia odor

kidney failure

erythema

redness of the skin

primary

knowledge to prevent illness

secondary

screenings

tertiary

rehab

look at social determinants of health slide

ok

SOAP (and SOAPIE)

subjective

objective

assessment

plan

implementation

evaluation

PIE charting

Problem

Intervention

Evaluation

SBAR

Situation (what is happening right now)

Background (what are the circumstances that led to this)

Assessment (what do I think the problem is)

Recommendation (what should we do to correct the problem)

three things for evidence-based practice

proven by research, an expert, a patient has to agree

PICO

problem, intervention of interest, comparison of interest, outcome of interest

critical thinking

thinking of several other interventions

clinical judgement

access severity of each situation

Alertness/Orientation

A & O ×4

Person Place Time Reason

Gaslow Coma Scale

test for level of consciousness

language

cerebral cortex function

understand spoken or written words

express thoughts

Aphasia

loss of speech

aphasia (sensory)

can't understand written or verbal speech

aphasia (motor)

can't write or speak

dysphasia

difficulty speaking

dysphagia

difficulty swallowing

olfactory (1)

smell

optic (2)

vision

Oculomotor (3)

extraocular eye movement

trochlear (4)

up and down eye movement

trigeminal (5)

face sensation/jaw movement

abducens (6)

side to side (lateral) eye movement

facial (7)

facial expressions, taste in front of tongue

auditory (8)

hearing

glossopharyngeal (9)

gag/swallow, taste on back of tongue

vagus (10)

swallow, pharynx sensation

accessory (11)

movement of shoulders

hypoglossal (12)

tongue movement

radiculopathy

damage or disease of a nerve

stenosis

narrowing

Motor function

cerebellar function

coordination, balance, equilibrium, posture

Who is most at risk for osteoporosis?

postmenopausal women

what is the number one cause of kyphosis?

osteoporosis

what is the number one cause of osteoporosis?

steroid use

what do steroids do?

make bones thin

flexion

bending at the joint

Extension

Straightening of a joint

Hyperextension

moving joint beyond the normal point

Pronation

palm down

Supanation

palms up

Abduction

movement away from the midline

Adduction

movement towards midline

Eversion

turning the sole of the foot outward

Inversion

Turning the sole of the foot inward

Dorsiflexion

bending of the foot or the toes upward

plantar flexion

bends the foot downward

circumduction

circular movement

atrophy

muscle wasting

prone

face down

supine

face up

sims

pt lies on left side

fowlers

sitting up