NUFT 204: Head, Neck, Neuro & Health Assessment

When preparing for a physical exam, what should a nurse do?

• ensure proper infection control (PPE, hand hygeine)

• physical prep of the patient (proper positioning)

• considering patients age group

What are the 2 common positions for a head-to-toe exam?

• supine

• sitting

Techniques of physical assessment: What does inspection involve?

carefully looking, listening, and smelling to distinguish normal from abnormal

Techniques of physical assessment: What does palpation involve?

touching of body to gather info

When palpating the skin, what are you looking for?

abnormalities in:

• temp

• moisture

• texture

• turgor

• tenderness

• thickness

When palpating the abdomen, what are you looking for?

abnormalities in:

• distention

• tenderness

• masses

Using the palmar surface of the hands and fingerpads is used to determine what?

• position

• texture

• size

• consistency

• masses

• fluid

What part of the body is most sensitive to vibration?

palmar surface of the hand and fingers

When assessing body temp, what body part is best to use?

back of the hand

What involves tapping the skin with the fingertips to vibrate underlying tissues and organs?

percussion

What is indirect percussion?

tapping over the middle finger

What is direct percussion?

striking the finger/hand directly against the body

What is listening to detect variations from normal over the lungs and abdomen?

ausculation

What are the 5 percussion tones?

• tympany

• resonance

• hyperresonance

• dullness

• flatness

What is loud and high pitches sound heard over the abdomen?

tympany

What sound is heard over normal lung tissue?

resonance

What sound is heard in overinflated lungs?

hyperresonance

What sound is heard over the liver?

dullness

What sound is heard over bone and muscle?

flatness

Explain AA0X4

Awake, alert, oriented to person place time and situation X4

During the neurological examiniation, what is being performed?

• mental status

• level of consciousness

• behavior and appearance

• language

• intellectual function

• motor function

• cranial nerve function

When you see someone has +3-+4 edema, what should you immediately check?

lungs

What is sensory aphasia?

language disorder caused by damage to the posterior part of the left temporal lobe

What is expressive aphasia?

a language disorder resulting from damage to the Broca's area in the frontal lobe

What do we use to assess the level of consciousness?

glasgow coma scale

How do we interpret the glasgow coma scale?

3 criteria:

• eye opening response

• verbal response

• motor response

When assessing intellectual function, what exactly are we evaluating?

• memory

• knowledge

• association

• judgement

What test do we use when assessing motor function?

rombergs test

When we assess the motor function of a patient, what are we specifically evaluating?

• coordination

• strength

• balance

What is the technique when assessing reflexes?

position the limb, tap the tendon briskly, compare corresponding sides

Someone has a score of 0 or 1+ in the reflex grading scale, what does that indicate?

hypoactivity

Someone has a score of 3+-4+ in the reflex grading scale, what does that indicate?

hyperactivity

What is a normal grade on the reflex grading scale?

2+

A 0 on the reflex grading scale indicates what?

no response

A 1+ on the reflex grading scale indicates what?

sluggish or diminished response

A 2+ on the reflex grading scale indicates what?

active and expected response

A 3+ on the reflex grading scale indicates what?

brisker then expected response

A 4+ on the reflex grading scale indicates what?

a very brisk/hyperactive response, possibly with clonus

When assessing the neck, what exactly do we focus on?

• neck muscles

• lymph nodes

• thyroid gland

• caratoid and jugular vein

• trachea

How do we assess the head?

inspection and palpation

When assessing the eyes, what are we looking for?

• visual activity

• extraocular movements

• visual fields

• external eye structures

• internal eye structures

List the external eye structures.

• position/ alignment

• eyebrows

• eyelids

• lacrimal apparatus

• conjunctive/ sclerae

• corneas

• pupils/ irises

Break down the mnemonic PERRLA.

p: pupils

e: equal

r: round

r:reactive to light

a: accomadating

What does accomodation mean when assessing the eyes?

the patient fixes on a distant object and then asked to look at a close object

What should the result be when assessing accomodation?

The pupils should constrict when focusing on a near object and dilate when returning to a distant object

THINK: DILATE= DISTANCE CONSTRICT= CLOSENESS

What is the ability of the eyes to move inward (medially)

to focus on a near object?

convergence

Explain the convergence test.

1. ask patient to focus on finger or pen light 12-15 inches from nose

2. slowly move it toward the bridge of the nose

3. observe how well the eyes converge (constrict)

4. note when patient sees double or an eye drifts outward

What are the six cardinal directions of gaze controlled by six eye muscles that allow the eyes to move together smoothly and symmetrically in all directions?

extra-ocular eye movements

What are the 6 cardinal fields of gaze?

Moving object in an H pattern:

right—→up—→down

left—→up——>down

What are normal results when doing the H test?

smooth movements in all directions, patient only follows with eyes and doesnt move head

What are abnormal results when doing the H test?

• jerky movements

• lagging

• double vision

Explain the peripheral vision confrontation test.

having the patient cover one eye and report when they see a moving object in their peripheral field of view.

What is conjunctivitis?

inflammation of the conjunctiva, often resulting in redness, irritation, and discharge from the eye

What is cellulitis?

a bacterial infection of the skin and underlying tissues, characterized by redness, swelling, warmth, and pain, often accompanied by fever.

What is a stye?

painful, red bump on the eyelid caused by an infection of the eyelash follicle or oil gland, often resulting in swelling and tenderness.

What is happening here?

patient has a stye

What is happening here?

patient has pink eye

What is happening here?

patient has cellulitis

What do we assess when looking at the ears?

• auricles (outside of the ear)

• ear canals

• eardrums

• hearing acuity

• ototoxicity

What are the 3 types of hearing loss?

• conduction

• sensorineural

• mixed

What is used to assess hearing and distinguish between conductive and sensorineural hearing loss?

weber and rinne tests

Explain the Weber test.

• strike turning fork

• place on center of skull/ forehead

• ask “do you hear it equally in both ears or more than one”

Explain the Rinne test.

• strike the fork

• place on mastoid process

• when no longer heard, move in front of the ear canal

• ask if they can hear it now

What does the weber test really assess?

which ear can hear better

What does the Rinne test really assess?

compares air conduction (AC) to bone conduction (BC)

What is a normal positive Rinne test?

AC>BC

What is a normal weber test?

heard equally in both ears

During the Weber test, if the sound lateralizes to the affected ear, what does that indicate?

conductive hearing loss

During the Weber test. os the sound lateralizes to the unaffected ear, what does that indicate?

sensorineural hearing loss

If the results of the Rinne Test are BC>AC, what does that indicate?

conductive hearing loss: earwax, fluid, infection

If the results of the Rinne Test are AC>BC but both are reduced, what does that indicate?

sensorineural hearing loss: nerve damage

How does we assess the sinuses?

palpation

What do we assess when looking at the mouth?

• lips

• buccal mucosa

• gums

• teeth

• tongue and floor of mouth

• palate

• pharynx

• tonsils

Where are the sinuses located?

• above the eyes

• in between the eyes

• deeper part behind the nose and eyes

• cheeks below the eyes

If a patient has 20/20 vision that indicates?

normal vision

If a patient has 20/40 vision what does that indicate?

patient sees at 20 ft what a normal-vision person sees at 40

If a person has 20/200 vision or worse, what does that indicate?

legal blindless