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NR 302 Exam 2 Study Guide / NR302 Exam 2 Study Guide (Latest 2021/2022): Health Assessment I: Chamberlain College of Nursing
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Skin/Nails/Hair
▪ Test i under i clavicle ▪ Mobility iis ithe iease iof iskin ito irise ▪ Turgor i is i its i ability i to i retrun i to i place i promptly i when i released o Vascularity i or i bruising ▪ Cherry i (senile) i angiomas ● Small i (1 ito i 5 imm), i smooth, i slightly i raised i bright i red idots ithat icommonly i appear ion i the itrunk i in i all i adults iolder ithan i 30 i years
bone, iand ithe imastoid iprocess ibehind ieach iear. iThere iis inot itenderness itoipalpation. ● Symptoms iassociated iwith imigraine iheadaches- iheadache iof ivascular iorigin. o Aura- ivisual ichanges isuch ias iblind ispots ior iflashes iof ilight, itingling iin ian iarm iorileg, ivertigo. o Prodome- iChange iin imood, ibehavior, ihunger, icravings, iyawning. o N/V, iPhotophobia i(sensitivity ito ilight), iPhonophobia, iAbdominal iPain, iPersonilooks isick, ifamily ihx iof imigraine. ● Hydrocephalus - iObstruction iof idrainage iof iCSF iresults iin iexcessive iaccumulation,iincreasing iintracranial ipressure, i& ienlargement iof ithe ihead. ● Acromegaly- i Excessive isecretion iof iGH ifrom ipituitary igland iafter ipuberty icreates ian ienlarged iskull i& ithicken icranial ibones. o Elongated ihead, imassive iface, iovergrowth iof inose iand ilower ijaw, iheavy ieyebrowiridge, iand icoarse ifacial ifeatures. ● Facial ideformities iassociated iwith ifetal ialcohol isyndrome iand idown isyndrome- o Fetal iAlcohol isyndrome i(FAS) i- inarrow ipalpebral ifissures, iepicanthal ifolds, iflatimidface, ishort inose, ilow inasal ibridge, ithin iupper ilip. o Down iSyndrome i(Trisomy i21) i- ihead iand iface icharacteristics imay iinclude iupslanting iof ieyes iw/ iinner iepicanthal ifolds; iflat inasal ibridge, ismall ibroad, iflatinose, ibrown ineck iw/ iwebbing; ismall ihands iw/ isingle ipalmar icrease. ● Assessment iof iinfant iskull i– ianterior iand iposterior ifontanels, ibulging ifontanels o Assess iFontanels- igently ipalpate iskull iand ifontanels iwhile iinfant iif iclam i& isomewhat isitting iposition i(crying, ilying idown, ior ivomiting imay icause ithe ianteriorifontanel ito ilook ifull iand ibulging). iSkull ifeels ismooth i& ifused iexcept iat ithe ifontanels. iFontanels ifeel ifirm, islightly iconcave, iand iwell idefined iagainst ithe iedges iof ithe icranial ibones. ▪ Anterior- imay isee islight iarterial ipulsations. ▪ Posterior- imay inot ibe ipalpable iat ibirth. ▪ Bulging ifontanel- itrue itense, ioccurs iw/ iacute iincreased iintracranialipressure. ● Discuss ibraden iscale iand ipressure iulcer istages o Braden iScale- imost icommon iused iassessment iscale ifor ipressure iulcer irisk. o Stage iI- i Intact iskin iappears ired ibut iunbroken. iLocalized iredness iin ilightly ipigmented iskin idoes inot iblanch i(turn ilight iwith ifingertip ipressure). iDark iskiniappears idarker ibut idoes inot iblanch. o Stage iII - i Partial iThickness i skin ierosion iwith iloss iof iepidermis ior ialso ithe idermis. iSuperficial iulcer ilooks ishallow ilike iabrasion ior iopen iblister iwith iaired-pink iwound ibed. o Stage iIII - i Full ithickness i pressure iulcer iextending iinto ithe iSubQ i& iresembling iaicrater. iMay isee isubQ ifat ibut inot imuscle, ibone, ior itendon. o Stage iIV - i Full ithickness i pressure iulcer iinvolves iall iskin ilayers i& iextends iinto isupporting itissues. iExposes imuscle, itendon, ior ibone, iand imay ishow islough i(stringy imatter iattached ito iwound ibed) ior ieschar i(black ior ibrown inecrotic itissue).
o Total iscore iranges ifrom i 6 ito i23; ia ilower itotal iscore iindicates ia ihigher irisk ifor ipressure iulcer idevelopment. iThe ihigher inumber ithe ilower ithe irisk. iThe ilowerinumber ithe ihigher ithe irisk.
Neck/Lymph iNodes Assessment iof ineck, itrachea, iand ilymph inodes
You ialso ishould ibe ifamiliar iwith ithe idirection iof ithe idrainage ipatterns iof ithe ilymph inodes i(Fig.i13-7).
Can iyou ifeel ilymph inodes? iYesiThe iNeck Inspect iand iPalpate ithe iNeck iSymmetry
The ifollowing icriteria iare icommon iclues ibut iare inot idefinitive iin iall icases:
Assessing iThyroid iGland
Usually iyou icannot ipalpate ithe inormal iadult ithyroid. iIf ithe iperson ihas ia ilong, ithin ineck, iyou isometimes ifeel ithe iisthmus iover ithe itracheal irings. iThe ilateral ilobes iusually iare inot ipalpable;ipalpable ilobes ifeel irubbery ibut ismooth. iCheck ithem ifor ienlargement, iconsistency, isymmetry,iand ithe ipresence iof inodules. Abnormalities: Enlarged ilobes ithat iare ieasily ipalpated ibefore iswallowing ior iare itender ito ipalpation i(see ilarge igoiter iin iFig. i13-14, iB) ior ithe ipresence iof inodules ior ilumps. iSee iTable i13-4, iThyroid iHormoneiDisorders, ip. i277. Anterior iApproach.
Simple iDiffuse iGoiter i(SDG) Goiter, ia ichronic ienlargement iof ithe ithyroid igland, iis icommon iin iwide iregions iof ithe iworld i(especially imountainous iregions) iwhere ithe isoil iis ilow iin iiodine. iIodine iis ian iessential ielement iinithe iformation iof ithyroid ihormones.
Summary iChecklist: iHead, iFace, iand iNeck, iIncluding iRegional iLymphatics iExamination
Ear i– iP. i 777 iand i 787 Assessment iof iear i– itympanic imembrane i(describe iwhat itympanic imembrane iboth inormal iand iabnormal) i– iexample i– irecent ihead itrauma iand iinfection
Absent ior idistorted ilandmarks Air/fluid ilevel ior iair ibubble ibehind ithe idrum iindicates iserous iotitis imediaiPosition-Retracted idrum idue ito ivacuum iin imiddle iear Bulging idrum ifrom iotitis imedia Integrity iof iMembrane-Perforation ishows ias idark ioval iarea ior ias ia ilarger iopening ion itheidrum i(Table i8-1)Vesicles ion idrum Test iHearing iAcuity iWhispered iVoice iTest Person iis iunable ito ihear iwhispered iitems Whisper- iis ihigh-frequency isounds i& iis iused ito idetect ihigh-tone ilossiTuning iFork iTest Conductive iloss ifrom isensorineural iloss i(Tablet i15-7, ip.350)iDevelopmental iCompetence Infants i& iYoung iChildren Low-set iears ifound iwith itrisomy i13, i18, i 21 Large, iprominent iears; imisshapen iears; i& icreases ion iearlobes iare inonspecific ibut ioccuriwith icertain isyndromes i& iunderlying iear istructure iabnormalities Preauricular iskin itags imay ioccur ialone ior iwith iother ifacial ianomaliesiAbnormal iresponse iis ino imovement iof ithe ieardrum Drum ihypomobility iindicated ieffusion ior ia ihigh ivacuum iin ithe imiddle iear iNewborn’s i 1 st^ i 6 iweeks i= idrum iimmobility iis ithe ibest iindicator iof imiddle iear iinfectioniForeign ibody i(Tablet i15-4, ip. i345) The iAging iAdult (Table i8-1) iEar iCanal ior iTympanic iMembrane iAbnormalities Retracted i Drum- i Landmarks-prominent iMalleus i handle-shorter i & i more i horizontaliShort iprocess- ivery iprominent Light i reflex i is i absent i or i distorted Drum i is i dull i& i lusterless i& i does i not imove Signs i indicate i obstructed i Eustachian i tube i & i serous i otitis i media Excessive i Cerumen- i Excessive i cerumen i production i or i impacted i because i of i a i narrow i tortuous i canalior ifaulty icleaning imethod
i. Appears ias ia iround iball ipartially iobscuring ithe idrum ior itotallyioccluding ithe icanal ii. Total iocclusion ithe iperson iexperiences iear ifullness iandiimpaired ihearing B. Acute i(Purulent) iOtitis iMedia- i. Absent ior idistorted ilight ireflex iis ian iearly isign ii. Redness i& ibulging i 1 st^ inoted iin isuperior ipart iof idrum i(parsiflaccida), ialong iwith iearache i& ifever iii. Fiery ired ibulging iof ientire idrum ioccurs, iwith ideep ithrobbingipain, ifever, i& itransient ihearing iloss iv. Pneumatic iotoscopy ireveals idrum ihypomobility C. Otitis iMedia iwith iEffusion- i. Amber-yellow idrum, ian iair/fluid ilevel iwith ifine iblack idividingiline, ior iair ibubbles ivisible ibehind idrum ii. Symptoms: ifeeling iof ifullness, itransient ihearing iloss, ipoppingisound iwith iswallowing i(Serous iOtitis iMedia i& iGlue iEar) D. Perforation- i. Drum irupture ifrom iincreased ipressure ior itrauma ii. Appears iround ior ioval idarkened iarea ion idrum iii. Central iperforations ioccurs iin ipars itensa, imarginal iperforationiat ithe iannulus E. Otitis iExterna- i. Severe iswelling iof icanal; iinflammation; itenderness ii. Canal ilumen- inarrowed ito i¼ iits inormal isize iii. An iinfection iof ithe iouter iear, iwith isevere ipainful imovement iofipinna i& itragus, iredness i& iswelling iof ipinna i& icanal, iscanty ipurulent idischarge, iscaling, iitching, ifever, i& ienlarged iender iregional ilymph inodes iv. Hearing iis inormal ior islightly idiminished v. Swimmer’s iear- icanal ibecomes iwaterlogged i& iswells; iskinfoldsiare iset iup ifor iinfection
Discuss ifunctions iof icerumen
**- Yellow iwax ithat ilubricates iand iprotects ithe iear.
Visual ifields- i Assess iperipheral ivision iwith ithe iconfrontation itest iin ichildren iolder ithan i 3 iyears iwhen ithe ipreschooler iis iable ito istay iin iposition. iAs iwith ithe iadult, ithe ichild ishould isee ithe imoving itarget iat ithe isame itime iyour inormal ieyes ido. iOften ia iyoung ichild iforgets ito isay i“now” iori“stop” ias ithe imoving iobject iis iseen. iRather, inote ithe iinstant ithe ichild's ieyes ideviate ior ihead ishiftsiposition ito igaze iat ithe imoving iobject. iMatch ithis inearly iautomatic iresponse iwith iyour iown isighting. i Pg. i 303
Assessment iof iCranial inerve iV:(Trigemenal iNerve) Motor iFunction: i Assess ithe imuscles iof imastication iby ipalpating ithe itemporal iand imasseter imuscles ias ithe iperson iclenches ithe iteeth i(Fig. i23-9). iMuscles ishould ifeel iequally istrong ion ibothisides. iNext itry ito iseparate ithe ijaws iby ipushing idown ion ithe ichin; inormally iyou icannot. Abnormal iFindings: i Decreased istrength ion ione ior iboth isides. iAsymmetry iin ijaw imovement;iPain iwith iclenching iof iteeth. Sensory iFunction: i With ithe iperson's ieyes iclosed, itest ilight itouch isensation iby itouching ia icottoniwisp ito ithese idesignated iareas ion iperson's iface: iforehead, icheeks, iand ichin i(Fig. i23-10). iAsk itheiperson ito isay i“Now” iwhenever ithe itouch iis ifelt. iThis itests iall ithree idivisions iof ithe inerve: i(1) iophthalmic, i(2) imaxillary, iand i(3) imandibular. Abnormal iFindings: i Decreased ior iunequal isensation. iWith ia istroke, isensation iof iface iand ibodyiis ilost ion ithe iopposite iside iof ithe ilesion. Scotoma= iis ia iblind ispot isurrounded iby iareas iof inormal ior idecrease ivisoniHyperopia- i Farsightedness. Presbyopia- i This iglasslike iquality idecreases ithe iability iof ithe ilens ito ichange ishape itoiaccommodate ifor inear ivision Myopia- i Nearsighted. Astigmatism- i is ia irefractive idisorder icaused iby ia ichange iin ithe inormally iround icurvature iof ithe icornea. iThe ichange icauses ilight irefraction ito ifocus ion itwo iareas ion ior inear ithe iretina iresulting iiniblurred ior idouble ivision.
Use iof iophthalmoscope i– i(only iwith imyopia iand ihyperopia)