health assesment exam 1

internal factors of communication

Refer to the personal attributes, emotions, and psychological states that influence how individuals interact and convey messages during communication. examples: liking others, empathy, ability to listen, respect, self awareness

external factors of communication

Refer to the environmental and situational elements that impact communication. examples: privacy, physical environment (light, temperature), distractions, dress, eye contact

verbal and nonverbal communication should be

congurant

which is more trust worthy verbal or non verbal communication

nonverbal, because a patient will express what

cranial bones used as landmarks

frontal, parietal, temporal, occipital

facial cranial nerves

cranial nerve V (trigeminal) and VII (facial)

blood supply to the head

temporal artery

salivary glands

parotid, submandibular, sublingual

decrease in saliva caused by

dehydration, medications, age

what structures form the neck

cervical vertebrae, ligaments, sternocleidomastoid muscles, trapezius muscles

how many cervical vetrbrae are there

7

what to check for when assessing the neck

portion to the body, left and right symmetry, range of motion, tenderness, and lumps

what does pregnancy do to the thyroud gland

increases its size

what does getting older do to the thyroid gland

decreases its size

thyroid gland

largest endocrine gland in the body, located around the trachae

what 2 hormones does the thyroid gland produce

T3 and T4

is a normal thyroid palpable

no

lymphatic system

A network of tissues and organs that help rid the body of toxins, waste, and other unwanted materials. It plays a crucial role in immune function and fluid balance.

if you find a nodule when palpating the lymph nodes it is less concerning if it is

movable, less than a cm, non tender, soft, by itself

what lymph nodes do we palpate

pre auricular, posterior auricular, occipital, submental, submandibular, jugulodigastric, cervical chain (superior, deep, posterior), supraclavicular

during infection lymph nodes

swell, becuase they need to drain the excess fluid and fight off pathogens

lympodema

lympathic swelling caused by a buildup of lymph fluid due to impaired lymphatic drainage. common after a mastectomy

patant

airway is free and clear, no blockage

septum

separates the nose into 2 nares

septum appears red

acute infection, cold or sinus infection

septum appears pale

chronic infection, allergies

septum appears pink

normal findings, no infection

turbinates

are structures in the nasal cavity that help warm, humidify, and filter the air we breathe. superior, middle, and inferrior.

which turbinate is visible when looking in the nose

inferior turbinate

sinuses

frontal, maxillary, ethmoid, sphenoid

which sinuses do we palpate?

frontal and maxillary sinuses

what are we looking for when palpating sinuses?

We are looking for tenderness, swelling, or blockage that may indicate sinusitis or other sinus issues.

symptoms of sinusitis

headache, drainage, pressure, dental pain, ear pain

frontal sinus location

Located in the forehead, above the eyebrows

maxillary sinus location

Located in the upper jaw, beneath the eyes, one on each side of the nose

hard palate

anterior part of the roof of the mouth made up of bone

soft palate

posterior part of the roof of the mouth made up of muscle that is mobile

uvula

free prjection hanging down from the middle of the soft palate, initiates gag reflex, when making the ahhhhh sound uvula moves up allowing you to asses the rest of the mouth

functions of the nose

smell, passage of inspired and expired air, humidification/filtration/warmth of inspired air, resonace of laryngeal sounds

functions of mouth

passage of air for vocalization/non-nasal expiration, passage for food, liquids, saliva, starts digestion by mastication and salivary secretion, taste

structure of throat

oropharynx (back of mouth to pharynx), tonsils, nasopharynx

tonsil assesment

0= no tonsils visible

+1= tonsils barely visible

+2= tonsils partially visible
+3= tonsils touching the uvula
+4= tonsils touching each other

which scores in a tonsil assesment are normal

0-2+

health history head neck and face

ask the patient about head/neck injuries or trauma, dizziness, neck pain or limitation of ROM(range of motion), lumps or swelling, botox, thyroid problems

if a patient comes in with a head injury what should the nurse also asses?

patients description of the event (did someone see them fall, syncope episode or tripping) state of consciousness after the injury (alert, dazed, confused, combative), predisposing factors, associated symptoms (nausea, headaches, diplopia, blurry vision, incontinence, neck pain, laceration/ecchymosis, medications

whats the first thing the nurse should ask the parent if a baby has fallen?

did they cry immediately or at all?

drainage from ears or nose after a head or neck injury

could indicate cerebrospinal fluid leak or skull fracture.

the thyroid effects

everything in your body

stiff neck medical term

torticollis

meningtis

inflamation of menages caused by infection, symptoms include fever, headache, rash, light sensitivity, treatments include antibiotics and a spinal tap for indenfication

subjective data- stiff neck

previous neck injury/strain, head injury, swelling, fever, bacterial/viral illness (nucchal rigidity, cant bend neck), radiation to arms or back?, predisposing factors like computer work or MVA (motor vechile accident), efforts to treat

what could be causing a stiff neck?

tech neck, sleeping wrong, MVA, trauma to head and/or neck, menigtis

subjective data- mouth and throat

sores or lesions, toothache, gaps or decay in teeth, hoarseness, dysphagia (diffuculty swallowing) reduced sense of smell or taste

herpes

cold sores, vaping increases risk

side effects of antibiotics

yeast infections like thrush or candidia

subjective data- nose

discharge, frequent colds, sinus pain, trauma (deviated septum), epistaxis (bloody noses), allergies, altered smell

objective data- head

inspect and palpate the skull for its size and shape, feel temporal artery (score 0-3), TMJ space (cranial nerve V, looking for tension or crepitus), inspect face (Cranial nerve VII)

range of motion movements

touch chin to chest, turn head to right and left, touch ears to shoulders, extend head back, shrug shoulders

what cranial nerves effect the face

cranial nerve VII or facial nerve

normocephalic

normal size head

hydrocephalic

abnormal accumulation of cerebrospinal fluid in the brain, resulting in an enlarged head. common in babies after birth

macrocephalic

abnormally large head

microcephalic

abnormally small head

TMJ space cranial nerve

cranial nerve V or trigeminal nerve

inspecting the neck

size, symmetry, muscles

palpating the neck

trachea is midline

cranial nerve for smell

cranial nerve 1 or the olfactory nerve

inspect the nose

symmetry, position, patency or nares, use penlight to note the color of turbinates, hair, colorseptal defects or deviations and any lesions.

inspect the lips

color, moisture, integrity, lesions, peircings

inspect the teeth

presence, condition (cavities)

inspect the tongue

color, surface characteristics (white coating?), moisture, lesions, peircings (CN XII- move side to side) and any abnormalities in texture or mobility.

lips cranial nerve

Cranial nerve VII or facial

tongie cranial nerve

cranial nerve XII or hypoglossal

palates and uvula cranial nerves

Cranial nerve IX anf X or glossopharyngeal and vagus

TMJ assesment

tightness associated with stress, grinfing teeth at night, or physical malformation treatment: muscle relaxants, antianxiety, night mouth guards, surgery symptoms: jaw can fail to open (trismus), spasm over jaw, pain in ear or temple

types of headaches

migraines, clustern hypertension, muscular tension (band)

migraine

vascular, unilateral, photosensitivity, nausea, menses-associated

cluster headaches

grouped, often nocturnal, tearing unilateral

hypertension headache

dull, constant, increased with stress; check for retinopathy (light sensitivty and small blood vessels in the back of the eye), papilledema (swelling of optic nerve)

muscular tension headache

band like, diffuses, occipital

headaches from most common to rare

tension, migraine, cluster

biggest concern with headaches

sudden onset headahce

hydrocephalus

refer to unusual shapes, sizes, or features of the head that may indicate underlying medical issues.

acromegaly

a hormonal disorder that results in excessive growth and height, often caused by a tumor on the pituitary gland, leading to enlarged bones and tissues.

torticollis

is a condition characterized by abnormal muscle contractions in the neck that cause the head to tilt or turn.

FAST test

Face (smile) Arms (put them out) Speech (talking) Timing. used to asses eldery patients who cant communicate effectively

bell’s palsy

CN VII (facial), half face is affected, can not raise or wrinkle brow, close eye, whistle, show teeth, smile

hyperthyroidism

weight loss, fine hair/hair loss, warm skin, thin nails, proptosis (bulginh eye bulbs), hot, goiter, tachycardia, diarrhea, amenorrhea (lack of period), muscle weakness

hypothyroidism

cold, weight gain, coarse/breakable hair, scaly dry skin, thick nails, puffy eyes, constipation, menorrhagia (long and heavy periods), lethargy

myxedema

serve hypothyroidism

abnormal findings- nose

epistaxis, foreign bodies, perforated septum, acute rhinitis, allergic rhinitis, sinusitis

epistaxis

nose bleeds

allergic salute

line on nose found after repeated rubbing of nose due to allergies, common in children

rhinitis

cold

carcinoma

cancer commonly found in the nose

perforated septum

holes found in nasal septum, common after cocaine use or repeated nose picking

furuncle

a painful, pus-filled bump that forms in nose due to infected hair follicles.

nasal polyps

noncancerous growths in the nasal passages or sinuses which can cause blockage and breathing difficulties.

choanal atresia

A congenital condition where the back of the nasal passage is blocked, often resulting in respiratory distress in newborns.

abnormal findings in the mouth- mucosa related

aphthous ulcers, leukoplakia, candidiasis infection