Physical assessment Quiz 2 WCU

CN I

Olfactory (sensory)

smell

CN II

Optic(sensory)

vision

CN III

Oculomotor (motor)

eye movement, pupil constriction

CN IV

Trochlear (Motor)

Down and inward movement of eye

CN V

Trigeminal Nerve;

Both

Sensory--cutaneous sensations from face and mouth

Motor--opening jaw, chewing from maxillary and mandibular (mastication)

CN VI

abducens(motor)

lateral eye movement

CN VII

Facial (motor and sensory)

facial expression, taste

CN VIII

Vestibulocochlear(sensory)

hearing and balance

CN IX

glossopharyngeal (motor)

gag reflex, swallowing and speech

CN X

Vagus(Sensory and motor)

autonomic functions of viscera (glands, digestion, heart rate)

CN XI

Accessory Nerve(Motor)

Moving head and swallowing

CN XII

Hypoglossal(Motor)

Tongue movement

What does it mean when using the Snellen chart, the pt's vision is 20/30.

The patient can see at 20 ft what a person with normal vision can see at 30

Which CN is responsible for Vision (Snellen chart)?

CN II (optic) Vision

Glaucoma

Pt describes a change in vision, the loss of peripheral vision

presbyopia

impaired vision as a result of aging

(farsightedness)

Astigmatism

a condition in which the eye does not focus properly because of uneven curvatures of the cornea; Pt will see floaters

hyperopia

Condition in which a person can see things in the distance but has trouble seeing at close range.

myopia

nearsightedness

patient sees faraway objects as blurry

PERRLA

pupils equal, round, reactive to light and accommodation

What condition could be occurring if pt's intraocular pressure is 26?

Glaucoma

What should the tympanic membrane look like?

pearly gray color

normal finding on the Rinne test

AC>BC

air conduction is greater than bone conduction

Questions nurses should ask during ear assessment

Do you use hearing devices?

Are you taking any medications for the ears?

Are there any changes to your hearing?

Do you suffer from frequent ear infections?

Proper way to use the otoscope

pull pinna up and back

Tonsillitis

inflammation of the tonsils

Red, swollen tonsils. White or yellow coating or patches on the tonsils

black hairy tongue

fungal infection of the tongue

tongue has black on it

direct percussion

percussion technique is used for the sinuses

Transilluminating the sinuses looks for what in the sinus cavity?

Reddish glow indicating normal air filled sinus

2 ways to test for CN8

Romberg Test

Whisper test

macular degeneration

deterioration of macula lutea of retina; patient notices loss of vision in center of visual field

Symptoms include blind spots and loss of central vision - can lead to visual disability

Glaucoma Symptoms & Treatment

Symptom: loss of peripheral vision, blurred vision, vision loss

treatment: lower intraocular pressure and possibly surgery

Cataracts

clouding of the lens of the eye that effects vision. Usually related to aging

Blepharitis

inflammation of the eyelid; Staphylococcal infection leads to red, scaly, and crusted lids. The eye burns, itches, and tears

Basal Cell Carcinoma

Most common and least severe type of skin cancer; often characterized by light or pearly nodules. Usually seen on the lower lid and medial canthus. It has a popular appearance

chalazion

small, hard, cystic mass (granuloma) on the eyelid

hordeolum (stye)

staph infection of a sebaceous gland in the eyelid

entropion

The inversion of the edge of an eyelid, turning inward

Ectropion

The eversion of the edge of an eyelid, turning outward.

Ptosis

Drooping of the eyelid; occurs with cranial nerve damage or systemic neuromuscular weakness

periorbital edema

swelling of the tissues surrounding the eye or eyes;

occurs with crying, infection, trauma, and systemic problems including kidney failure, heart failure, and allergy

conjuctivitis

inflammation of the conjunctiva (pink eye); Infection of the conjunctiva usually due to bacteria or virus but which may result from chemical exposure.

the eye will have liquid coming out

Iritis

inflammation of the iris, usually marked by pain,

pupil is often irregular

arcus senilis

gray-white arc or circle around the limbus of the iris that is common with aging

Pingueculae

Yellowish nodules that are thickened areas of the bulbar conjunctiva. Caused by prolonged exposure to sun, wind, and dust.

Xanthelasma

raised yellowish plaque on eyelid caused by lipid disorder

Lifespan Considerations for Infant

The red reflex should be elicited from birth

Binocular vision develops at 6 weeks of age

Lateral deviations are normal until 4 months of age

Lifespan Considerations with Pregnancy

Dryness of the eyes

Vision changes - due to shifting fluid in cornea, blurriness, distorted vision, and can happen up to 6 weeks postpartum

Cranial Nerve III damage

Unilateral dilated pupil has no reaction to light or accommodation and occurs with oculomotor nerve damage. Ptosis with eye deviating down and laterally may be present.

Argyll Robertson pupils

Non-Reactive to light. Occurs with CNS disorders, including tumor, syphilis and narcotic use

Miosis

Fixed and constricted pupils. May occur with use of narcotics, damage to pons, or result of treatment for glaucoma

anisocoria

a condition in which the pupils are unequal in size

Mydriasis

Fixed and dilated pupils. May occur with sympathetic nerve stimulation, glaucoma, CNS damage or deep anesthesia.

Focus Assessment: Extraocular muscle

Movement of the eyes - follow finger 6-12 inches in front of the eyes - 6 cardinal fields of gaze

Visual fields - tests the peripheral vision fields

Focus Assessment: Visual acuity

The degree of detail the eye can discern in an image

Near vision = newspaper print - Rosenbaum

Snellen Chart = 20 ft in front of the patient

Eye assessment questions to ask

"When was the last eye exam and findings?" (2 years is recommended)

"Any medications for eye disorders?"

"Do you wear corrective glasses or contact lenses?"

"Have you ever been diagnosed with a disease of the eye?"

"Do you have any family history of eye disorders?"

Assessment of nose questions to ask

"Are you experiencing any problems with your nose or sinuses?"

"Any discharge, frequent nose bleeds?"

"Have you had any nasal surgeries or injuries?"

"Any recreational drug use?"

Any medications including OTC for nasal decongestion?"

Romberg Test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed

-expected finding: client should be able to stand with minimal swaying for at least 5 seconds

Weber test

Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard.

NORMAL findings: the sound is heard in the center of the head, or equally on both ears

Rhine test

Compares Air conduction (AC) with bone conduction (BC). Place fork on mastoid process, then quickly place next to ear canal comparing how long pt could hear the tuning fork in each location.

If the AC (air conduction) is greater than BC (bone conduction) then its normal; If BC is greater than AC this is conductive deafness. A negative test indicates a minimum air-bone gap of 15-20