HEALTH ASSESSMENT EXAM #3

In the PNS there are 12 cranial nerves, what do they do?

these peripheral nerves carry information from sensory receptors to the CNS and from the CNS to muscles, glands, and internal organs and blood vessels.

• afferent (sensory) - info towards the CNS from sensory receptors

• efferent (motor) - info from CNS to muscles, glands

  + autonomic messages that impact/control internal organs and blood vessels

What is the function of the cerebral cortex?

memory, thought, reasoning, sensation, and voluntary movement

What is the function of the frontal lobe?

frontal lobe controls personality, behavior, emotions, and intellectual function

Where is Broca’s area? What does it do?

Broca’s area is found in the frontal lobe.

• controls speech

What is the function of the temporal lobe?

the temporal lobe controls smell, taste, and hearing (sensory lobe)

Where is Wenicke’s area? What does it do?

Wernicke’s area is found in the temporal lobe

• control language comprehension

What is the function of the parietal lobe?

the parietal lobe controls sensation

what is the function of the occipital lobe?

the occipital lobe is the visual receptor center

what causes damage to cerebral cortex?

specialized neurologic cells are deprived of blood supply

what are the effects of damage to the cerebral cortex?

• impaired ability to understand and process language

• motor weakness

• paralysis

• loss of sensation

Where do the cranial nerves extend? what do they supply? Is there an exception?

• cranial nerves mainly supply head and neck

• C1-C3 extend from cerebrum

• C3-C12 extend form midbrain and brain stem

EXCEPTION: vagus nerve travels to heart, respiratory muscles, stomach, and gallbladder

what are some balance tests that can be done to a pt?

gait walking test - watch a pt as they walk 10-20 ft, turn, and come back (assess how they are walking)

tandem walk - heel-to-toe walking

what is RAM and what are some tests that can be done to test this?

RAM = Rapid alternating movements

tests that can be done:

• “patty cake” - have pt essentially play patty cake with thighs/knees, using both hands and turning hands over (dorsal to ventral), increasing speed

  OR

• finger to finger test - touch thumb to each finger and them go the other way, starting with the index finger

• finger to nose test

• heel to shin test

what is abnormal when looking at gait?

pt should walk with a sense of freedom

abnormal would be:

pt being:

• stiff

• wide box of support

• staggering

• lack of swinging or rigid arms

• unequal rhythm of steps

what is ataxia?

uncoordinated or unstable gait

what is abnormal to see in Romberg test?

patient should not be swaying, falling, or widening their feet

• if these occur then it’s a positive Romberg (loss of balance w/ closed eyes)

what is normal to see when looking at Tandem walk?

patient should walk in a straight line and stay balanced

what are some anterolateral (spinothalamic) tests?

• to test pain: have pt identify between sharp and dull sensations (2 seconds between each stimulus)

• light touch: touch cotton to skin in random sites, order, and intervals and have pt tell you where they feel the touch

What is the vibration (tuning fork) test?

• put vibration fork over bony prominent

• have pt tell you when they start and stop feeling vibration on bony prominent

  • pt’s with neuropathy will not feel anything

what is the position (kinesthesia) test?

• have pt close their eyes, move an extremity (ex. finger) in a certain direction and have pt identify in what direction the extremity was moved

• ask pt what way it was moved

what is stereognosis?

have pt close their eyes, put an item in their hands, pt should be able to ID the object with their eyes closed (should be able to ID based on shape, weight, and size)

what is graphestesia?

have pt close their eyes and draw on pt’s palm a number, pt should be able to read what was on palm with eyes closed wha

what is two-point discrimination?

tests the pt’s ability to sense two separate pinpoints at the skin - should be able to tell nurse that they felt two pokes on their arm for example

• nurse should ask if they feel 1 or 2 points and pt should be able to ID 1 or 2 and where

what is the extinction test?

touch both sides of the body at the same (for example, poke forearm bilaterally at the same time).

• pt should be able to tell nurse they felt both sensations

• nurse should ask how many did they feel

what is point location?

• have pt close their eyes, poke wherever on their body, and have pt tell them where they poked by pointing at the location with their finger

How do you test DTR?

• limb should be relaxed and muscle partially stretched

• short, snappy blow with reflex hammer at muscle’s insertion tendon with relaxed hold on hammer

• bounce, do not let hammer rest on tendon

• use the flat end of hammer when tendon is wider

What are some gerontological considerations in aging adults for the eyes? 

• Pupil size decreases (normal pupil size is 2-3; older adults normal pupil size is 1-2) 

• Presbyopia: lens lose elasticity, lens become hard and glasslike, which decreases the ability of the eye to change shape and accommodate for near vision 

  
  

HOW TO USE THE SNELLEN CHART? 

• Shield one eye at a time during test 

• If the person wears contact lenses or glasses, leave them on; remove only reading glasses 

• Have pt read till the smallest line possible; encourage to try the next smallest line also 

• If the pt is unable to see even the largest letters, shorten distance to chart until the person is able to see it, adn record the distance (ex. 10/20) 

HOW TO USE THE JAEGER CARD? 

• Used for pt’s who report increasing difficulty with reading 

• Hold the card 14 in away from the eye (35cm); this distance equals print size on 20-foot chart 

• Test each eye separately 

• If pt is wearing contacts/glasses remove them 

• Normal result is 14/14 in each eye, read w/o hesitancy and w/o moving the card closer or farther away

ABNORMAL FINDINGS: EYELID ABNORMALITIES 

• Periorbital edema: caused by crying, infection, trauma, Chronic Heart Failure, and Chronic Kidney Disease 

• Exophthalmos (protruding eyes) 

• Enophthalmos (sunken eyes) 

• Ptosis (drooping upper lif) - CN III damage, sympathetic nerve damage (Horner syndrome), congenital 

What are some visual clues that can help you ID if a person has hearing loss? 

• Lip reading or watching your face and lips 

• Frowning or straining forward to hear 

• Posturing head to catch sounds with the better ear

• Misunderstand questions, frequently 

• Irritable or shows startle reflex when you raise your voice 

• The person's speech sounds garbled, vowel sounds distorted 

• Inappropriately loud voice 

• Flat, monotonous tone of voice 

Whispered Voice Test → 

• Stand 2 feet away behind pt 

• Test one ear (uncovered ear) at a time while one ear is covered

• Whisper 3 random number/letter combinations 1-2 ft away from ear 

• Passing score is correct repetition of 4-6 possible numbers and letters 

How do you conduct a Weber Test?

assess whether sound is heard louder in one ear compared to the other when a tuning fork is placed on the midline of the forehead 

• Normal: sound heard equally in both ears

• Abnormal: heard better on one ear 

• Conductive hearing loss (affected ear) sounds is heard louder in the affected ear (where there’s conductive hearing loss) — sound lateralizes to poorer ear 

• Sensorineural Hearing loss (unaffected ear) sound is heard louder in the better ear (where there’s no sensorineural loss) — sound lateralizes to better ear 

How do you conduct a Rinne test?

 how well a person hears a tuning fork when placed on the mastoid bone (bone conduction) v. when placed near the ear (air conduction) 

• Normal: air conduction is better than bone conduction 

• Conductive hearing loss (negative Rinne): bone conduction is better than air conduction 

• Sensorineural hearing loss: air conduction (AC) is better than bone conduction (BC) 

What do the Montgomery’s glands do?

they are sebaceous glands that produce a protective lipid material during lactation

What is the area most common for cancer?

Tail of Spence, upper outer quadrant

What are some normal considerations for older women when looking at their breasts?

• after menopause, estrogen and progesterone release from the ovaries decreases causing —> glandular tissue atrophy at the breast (sagging)

• decreased breast size - which may cause inner structures to be more noticeable and palpable (may start to feel a lump that has always been there)

• lactiferous ducts are more palpable and feel firm + stringy b/c of fibrosis and calcification

• axillary hair product decreases

what is gynecomastia?

when breast tissue in men becomes large unilaterally (temporary during adolescent years)

• this could also happen in older men b/c of low testosterone production

what do changes in overlying skin of lumps mean?

• erythema and warmth = inflammation

• dimpling = indication of cancer or radiation therapy

• swelling = outside of puberty is abnormal (although they might get swollen before period due to a surge of progesterone)

What are some breast cancer risk factors?

• two or more primary family members have had breast cancer at an early age

• oral contraceptives

how often should you be doing a self-breast exam?

monthly

when should you start going for mammography?

start at 40-44 y.o.

when can you start annual mammographies?

starts at the age of 45-54 y.o.

when can you start biennial (every other year) mammographies?

over the age of 55

how does a normal breast look like?

• common to have slight asymmetry in size

• skin should be smooth and even color throughout

• no redness, bulging, or dimpling

• no lesions

• no edema

When doing the shrug test in front of the mirror, what should you see?

breasts should move at the same time, symmetrically as you shrug your shoulders (h

what is diaphoresis?

excessive sweating

what does ABCDE mean in relation to skin?

A - Asymmetry

B - border

C- color

D- diameter

E - evolution

what is the normal pupil size in general? what is the normal pupil size for elderly?

normal pupil size is 2-3; older adults normal pupil size is 1-2

What are some abnormalities you can find in the mouth?

• circumolar pallor: shock/anemia

• cyanosis": hypoxemia

• cherry red: carbon monoxide poisoning, acidosis from aspirin poisoning, or ketoacidosis

• cheilitis: cracking on the corners

• lesions at mouth could indicate Herpes complex

What is the tonsil size scale

1+ - visible *normal

2+ - ½ way between tonsillar pillar and uvula *normal

3+ touching uvula

4+ tonsils touching each other

**biggest concern is ability to breathe

what is the DTR scale?

• 4 - very brisk, hyperactive, with clonus (usually indicative of disease) *clonus= you feel and see rapid, rhythmic contraction; involuntary twitching 

• 3 - brisker than average, may indicate disease 

• 2 - average, normal 

• 1 - diminished, low normal, or occurs with reinforcement 

• 0 = no response, indicates paralysis

Babinski reflex

• Babinski reflex: babies are born with this (toes fan outward) 

• With reflex hammer draw an upside down “J” starting from bottom of heel and inward across ball of foot

• Normal response: plantar flexion of toes and inversion and flexion of flexion of forefoot 

• Abnormal response: great toe extension and toes fanning outwards 

• Negative: toes scrunch inward 

• Positive: toes fan out 

risk for CVA (stroke)

• HTN 

• Smoking 

• Heart disorders 

• F.A.S.T. (STROKE SIGNS) 

F- face drooping *usually seen on one side

A- Arm and leg weakness 

S - speech difficulty – slurring, not making sense 

T - time to call 911 

Other symptoms: vision loss, dizziness, confusion, incontinence, and tingling or numbness throughout   the body 

Most common causes of decreased visual functioning in older adults: 

• Cataract formation - lens opacity, resulting from clumping of proteins in lens 

  • D/T altered metabolic processes in lens – water accumulation, changes in lens fiber structure that alters transparency 

  • S&S: abnormal color perception, glare that worsens at night, and gradual decrease in vision 

  • Tx: changes in glasses prescription, strong reading glasses/magnifiers, increase lighting, lifestyle adjustment (surgery only if these are not acceptable) 

• Glaucoma - increase IOP; chronic open-angle glaucoma is the most common type; high IOP causes optic nerve atrophy and peripheral visual field loss → CAUSES NERVE DAMAGE TO OPTIC NERVE 

  • Risk factors: increased age, AA, genetic (possibly) 

  • Early dx and tx are important to prevent blindness 

Types: 

1. Primary open-angle glaucoma: outflow of aqueous humor is decreases in trabecular meshwork → clogs drainage channels → damage to optic nerve 

2. Angle-closure glaucoma: reduction in outflow of aqueous humor from angle closure 

• Acute or chronic  

• Age-related macular degeneration (AMD) - breakdown of cells in macula of retina; loss of central vision (see a spot right in the middle) **MOST COMMON CAUSE OF VISION LOSS 

Two types: 

1. Dry (nonexudative) - closer vision is impaired; slow progression and painless loss of vision 

2.  Wet (exudative) - rapid onset; AMD-related blindness 

• Risk factors: light-colored eyes, family history, smoking, HTN, 

• S&S: blurred/darkened vision; blind spots; distortion of vision 

  • To diagnose use AMSLER GRID 

• Diabetic retinopathy - vision loss caused by uncontrolled diabetes 

STRABISMUS - double vision

• Pt can’t focus both eyes to one object 

  • One eye deviates in (esotropia) 

  • One eye deviates out (exotropia) 

  • One eye deviates up (hypertropia) 

  • One eye deviates down (hypotropia) 

• Causes: thyroid disease, neuromuscular problems of the eye muscles, retinal detachment repair, and cerebral lesions