Exam 2 Flashcards
(137 cards)
1
Q
Family violence
A
controlling, corrosive behaviors seen to the intentional acts of violence inflicted in those familial or intimate relationships
2
Q
factors affecting violence
A
Culture race Ethnicity Economy addiction vicious cycle- do not know any other way of life
3
Q
Different types of family violence
A
Intimate partners- Physical, sexual, or psychological harm by a current or former partner or spouse. Increasing among men leaving with men (do not feel comfortable looking for help,70%)
Child abuse: Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation.
Elder mistreatment- includes elderly people who live in facilities and home
4
Q
Types of abuse
A
- Physical abuse- pushing, shoving, slapping, choking
- Physiological- insult blaming the victim
- Children or pets- to manipulate the victim
- Economic- preventing the victim from getting a job or controlling the financial aspect of the relationship
- Sexual- forcing the victim to perform sexual acts
5
Q
Abuse assessment general survey
A
-observe how the patient appears
-Eye contact
-Mental status
-Evalutate vital signs
-Inspect skin (head and kneck)
-Several bruising injuries, healing in different stages
-Afraid to show you certain things
-Pain in abdomen, nausea, vomiting
-Burns, cigarette burns
Lacerations, cuts, bites
-If abuser in the room, they may have different behavior
-Describes self as accident prone
-Low self-esteem
-Anxiety, depression
-Substance abuse
-If partner wants to answer for client
-Does partner refuse interpreter
-Inspecting the eyes
-Inspect ears
-Inspect abdomen
-Check genitalia and rectal area
-Muscoskeletal system- do they have fractures?
assess neurological system
-Assess safety of returning home
-Ask if they feel safe returning home
-Ask when they are alone
-Abuser is staying there with the victim
-Assess and explain injuries
-Assess recent
-Look for discrepancies (in what client and partner says)
-Document all this
6
Q
culture
A
totality of socially transmitted behavioral patterns beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population of people to guide their worldview and decision making
7
Q
factors affecting approach to providers
A
- Ethnicity- how close are they to the primary culture
- Generational status- older family members may make the decisions for the younger client, or client looking for assistance from the elderly
- Education- can they read and understand English, need a translator (not a family member, have same gender translating)
- Religion- includes religious rule that can influence who or when someone can assess the patient, or if someone is in the room with them
- Previous health care experiences- had a bad experience with their provider, make it so that they can trust you
- Occupation and income level- they worry about how to pay for the health care, be very sick but if they cannot afford it then they will stay at home most times
- Communication needs/preferences- cultures have different ways of communicating, some soft spoken, some wont make eye contact, some very loud (accept different ways)
8
Q
modifications to be considered for a culturally competent interview
A
- Communication- adapt to them
- Time- give them time
- Space- adapt to spacing
- Eye contact and face positioning- Eye contact can sometimes be rude to some cultures, do not force
- Body language and hand gestures- making a lot of gestures, adapt to patients
- Silence- can be very rude in some cultures, or very comfortable with it
- Touch- be yourself but let them do what is correct, ok to hug in some cultures, others it is very inappropriate
9
Q
stereotyping
A
All members of a particular culture expecting group members to hold the same beliefs and behave in the same way.
10
Q
Ethnocentrism
A
Perception that one’s worldview is the only acceptable truth and that one’s beliefs, values, and sanctioned behaviors are superior to all others
11
Q
factors that affect disease and health state
A
-Biomedical variations- what is at the root of the disease
-Nutrition/dietary habits- are they eating enough, are they eating meat, do practices require nutrition intake
-Family roles and organization, patterns- some cultures the adult will eat first and more, or what is the better food
-Workforce issues- are they using protection at work, type of work safe
-High-risk behaviors- are they protecting themselves if they are riding motorcycle, sexually
-Pregnancy and childbirth practices- some believe pregnant women cannot eat something
-Death rituals
Religious and spiritual beliefs and practices
-Health care practices
-Health care practitioners
-Environment
12
Q
Risk Factors for Nutrition Disorder and Disease
A
- Lower socioeconomic status (SES)
- Lifestyle
- Poor choices
- Makes nutritious food unaffordable
- Some people work too much, consume fast food, vending machines
- Dieting constantly, not taking what body needs
- Chronic Diseases- crohns disease, sclerosis, cancer (body does not absorb nutrition)
- Dental or other factors- may have loose teeth or will be unable to chew food (a lot do not have their dentures, lacking protein)
- depressed people have a lack of appetite
- Medication side effects make you lose taste sensation
- Limited access- an elderly person may not have access to food, or not enough, don’t have means or transportation
- eating disorders
- demented (forget to eat)
- Alzheimer’s (forget movement of eating)
- client just refuses to eat
- illness or trauma (extensive burns)
- obesity
13
Q
Structure and Function of Skin
A
- Largest organ of the body
- Physical barrier: Protects underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration.
- Vital role in temperature maintenance
- Fluid and electrolyte balance, absorption, excretion
- Sensation
- Vitamin D synthesis
14
Q
Skin
A
- Epidermis: Outer layer of skin
- Dermis: Inner layer of skin -Sebaceous glands:attached to hair follicles
- Sweat glands: eccrine and apocrine glands
- Subcutaneous layers: a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.
15
Q
Hair
A
- Vellus: Peach fuzz, short, pale, fine, and present over the body.
- Terminal: Particularly scalp and eyebrows, is longer, generally darker, and coarser than vellus.
16
Q
Nails
A
Nail body: Extends over the entire nail bed and has a pink tinge
Lunula: Crescent-shaped area located at the base of the nail.
17
Q
Religion
A
Rituals, practices, and experiences involving a search for the sacred- find out and assess if religious practices are safe for them, support it, invite and encourage family in to pray, give them privacy and time
- Shared within a group
- Some faiths, this idea of religion encompasses the concept of spirituality and is a natural outflow of that idea
- Others may view spirituality as a separate concept, possibly disconnected from any religious institution
- never impose own beliefs on patient
18
Q
Spiritual Assessment
A
-Explore the client’s religious and spiritual background
-Observe nonverbal and verbal communication patterns in the presence of others
-Focus questions:
Daily spiritual experiences
Religious Beliefs
- Be aware of own beliefs so you can understand other peoples
19
Q
Factors involved in nutrition
A
- Healthy diet should consist of 45% to 65% carbohydrates with 75% of those carbohydrates being complex (grains, starchy vegetables)
- Certain diseases, disorders, or lifestyle behaviors can place clients at risk for undernutrition or malnutrition and can exacerbate or facilitate disease processes (alcohol, eating disorders, drugs)
- malnutrition- lack of nutritional needs
- Increased caloric consumption- especially of food high in fat and sugar, with decreased energy expenditure has led to near-epidemic obesity.
20
Q
Risk Factors for Nutrition Disorder and Disease
A
- Lower socioeconomic status (SES)
- Lifestyle
- Poor choices
- Makes nutritious food unaffordable
- Some people work too much, consume fast food, vending machines
- Dieting constantly, not taking what body needs
- Chronic Diseases- crohns disease, sclerosis, cancer (body does not absorb nutrition)
- Dental or other factors- may have loose teeth or will be unable to chew food (a lot do not have their dentures, lacking protein)
- depressed people have a lack of appetite
- Medication side effects make you lose taste sensation
- Limited access- an elderly person may not have access to food, or not enough, don’t have means or transportation
- eating disorders
- demented (forget to eat)
- Alzheimer’s (forget movement of eating)
- client just refuses to eat
21
Q
Skin Cancer
A
-Most common of cancers
Melanoma
-Basal Cell Carcinoma
-Squamous cell carcinoma
22
Q
Risk Factors of skin cancer
A
- Sun exposure
- non-solar sources of ultraviolet radiation
- medical therapies
- family history and genetic susceptibly
- moles
- pigmentation irregularities
- fair skin that burns and freckles easily; light hair
- age
- actinic keratosis
- male gender
- Chemical exposure
- Human papillomavirus
- Xeroderma pigmentosum
- Long-term skin inflammation or injury
- Alcohol intake; smoking
- Inadequate niacin in diet
- Bowen disease (scaly or thickened patch) (SCC)
- Depressed immune system
23
Q
Risk Reduction in Skin Cancer
A
- Reduce skin exposure.
- Use sunscreen.
- Wear long-sleeve shirts and wide-brimmed hats.
- Avoid sunburns.
- Wear sunglasses that wrap around.
- Education
- Have annual skin cancer screenings.
24
Q
ABCDE mnemonic to assess skin lesions
A
Asymmetry Border Color Diameter Evolution
25
Cultural Variations of skin cancer
- Asians are less susceptible to skin cancer
- African Americans, Asians, and Hispanics are susceptible to melanoma
- Asian Americans and African Americans tend to present with more advanced disease at diagnosis
26
Nursing History of skin, hair, and nails assessment
- Personal health history
- Family history
- Lifestyle and health practices
- Exposure to sun or chemicals
- Daily care of skin, hair, and nails
- Usual diet and exercise patterns
27
Methicillin-Resistant Staphylococcus aureus (MRSA): community-acquired
Assess for community-acquired MRSA risk factors:
- Participating in contact sports
- Sharing personal items such as towels or razors
- Suppression of immune system function (e.g., HIV, cancer, or chemotherapy)
- Residing in unsanitary or crowded living conditions (e.g., dormitories or military barracks)
- Working in the health care industry
- Receiving antibiotics within the past 3 to 6 months
- Young or advanced age
- Men having sex with men
- Hemodialysis
28
Measures to Reduce Risk Factors for MRSA
- Keep wounds covered.
- Do not share personal items.
- Avoid unsanitary or unsafe nail care practices.
- If treatment has been started, do not stop until recovery is complete.
- Use universal precautions when touching others to avoid contact with contaminated body fluids. Wash your hands.
- Clean sports equipment between uses to avoid spread of infection.
- Wash clothes, sheets, towels, razors, and other personal items before and after use.
- Clean hands often.
29
Assessment of skin, hair, and nails: Present Health Concerns
- Body odor problems
- Skin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation)
- Changes in lesion appearance
- Feeling changes (pain, pressure, itch, tingling)
- Hair loss or changes
- Nail changes
30
Nursing History of skin, hair, and nails
- Personal health history
- Family history
- Lifestyle and health practices
- Exposure to sun or chemicals
- Daily care of skin, hair, and nails
- Usual diet and exercise patterns
31
Interview for nutritional and hydration history
-Nutritional screening tools
-Collection of subjective data: The nursing health history
History of present health concern
Personal health history
Family history
Lifestyle and health practices
32
Physical Assessment
- Overall appearance
- Body build
- Muscle mass
- Fat distribution
- Measure skin folds for fat distribution
- Measure waist
33
Client Preparation for skin, hair, and nails assessment
- Ask the client to remove all clothing and jewelry.
- Have the client sit comfortably.
- Ensure privacy.
- Maintain comfortable room temperature
34
Equipment for skin hair and nails assessment
- Gloves
- Examination light and penlight
- Mirror for client’s self-examination of skin
- Magnifying glass
- Centimeter ruler
- Wood light
- Examination gown or drape
- Assessment Tool 14-1, Braden Scale For Predicting Pressure Sore Risk
- Assessment Tool 14-2, PUSH Tool to Measure Pressure Ulcer Healing
35
Inspection for skin, hair, and nails assessment
- Inspect skin coloration
- Note any distinctive odor
- Generalized color variations
- Skin breakdown
- Primary, secondary, or vascular lesions
36
Palpation of skin, hair, and nails assessment
- Lesions
- Texture
- Temperature and moisture
- Thickness of skin
- Mobility and turgor
- Edema
37
Primary Skin Lesions
- Macule and patch: Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple, red). Examples include freckles, flat moles, petechiae, rubella, vitiligo, port wine stains, and ecchymosis.
- Papule and plaque: Elevated, palpable, solid mass. Examples of papules include elevated nevi, warts, and lichen planus. Examples of plaques include psoriasis and actinic keratosis.
- Nodule and tumor: Elevated, solid, palpable mass that extends deeper into dermis than a papule. Examples of nodules include keloid, lipoma, squamous cell carcinoma, poorly absorbed injection, and dermatofibroma. Examples of tumors include larger lipoma and carcinoma.
- Vesicle and bulla: Circumscribed elevated, palpable mass containing serous fluid. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox, pictured below), poison ivy, and second-degree burn. Examples of bulla include pemphigus, contact dermatitis, large burn blisters, poison ivy, and bullous impetigo.
- Wheal: Elevated mass with transient borders that is often irregular. Size and color vary. Caused by movement of serous fluid into the dermis; it does not contain free fluid in a cavity (e.g., vesicle). Examples include urticaria (hives, pictured below) and insect bites.
- Pustule: Pus-filled vesicle or bulla. Examples include acne (pictured below), impetigo, furuncles, and carbuncles.
- Cyst: Encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis. Examples include sebaceous cyst and epidermoid cyst (pictured below).
38
Secondary Skin Lesions
Erosion: Loss of superficial epidermis that does not extend to the dermis. It is a depressed, moist area. Examples include rupture vesicle, scratch mark, and aphthous ulcer (aphthous stomatitis, commonly called a canker sore, pictured below).
Ulcer: Skin loss extending past epidermis, with necrotic tissue loss. Bleeding and scarring are possible. Examples include stasis ulcer of venous insufficiency (stasis dermatitis with venous stasis ulcer, pictured below) and pressure ulcer.
Scare: Skin mark left after healing of wound or lesion that represents replacement by connective tissue of the injured tissue. Young scars are red or purple, whereas mature scars (pictured below) are white or glistening. Examples include healed wound and healed surgical incision.
Fissure: Linear crack in the skin that may extend to the dermis and may be painful. Examples include chapped lips or hands and athlete’s foot. Interdigital tinea pedis with fissures and maceration is pictured below.
39
Vascular Skin Lesions
- Associated with bleeding, aging, circulatory conditions, diabetes, pregnancy, and hepatic disease.
- Petechia: Round red or purple macule.
- Ecchymosis: Round or irregular macular lesion that is larger than petechial lesion. The color varies and changes: black, yellow, and green hues.
- Hematoma: A localized collection of blood creating an elevated ecchymosis. It is associated with trauma.
- Cherry angioma: Papular and round, red or purple lesion found on the trunk or extremities. It may blanch with pressure. It is a normal age-related skin alteration and usually not clinically significant.
- Spider angioma: Red arteriole lesion with a central body with radiating branches. It is usually noted on the face, neck, arms, and trunk. It is rare below the waist. Compression of the center of the arteriole completely blanches the lesion. It is associated with liver disease, pregnancy, and vitamin B deficiency.
- Telangiectasis: Bluish or red lesion with varying shape (spider-like or linear) found on the legs and anterior chest. It does not blanch when pressure is applied.
40
Nail Risk Reduction
- Wear leather shoes except for sports.
- Avoid wearing closed shoes all the time.
- Wear socks that wick away moisture.
- Avoid going barefoot in damp public areas.
- Avoid too much perspiration or water (wear gloves for hands).
- Avoid trauma to nails.
- Avoid unsanitary or unsafe nail care practices.
- If treatment is started, do not stop until recovery is complete.
41
Pressure Ulcer Risk Reduction
- Inspect the skin at least daily
- Use risk assessment tool (such as Braden Scale or PUSH tool)
- Document.
- Keep patient dry/clean
- Limit friction
- For dry skin: use moisturizers; avoid low humidity and cold air.
- Avoid vigorous massage.
- Use careful positioning, turning, and transferring techniques
- Refer nutritional supplementation needs to primary care provider or dietitian
- Refer incontinence condition to primary care provider.
- Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products.
42
Inspection and Palpation of the scalp and hair
Inspection and palpation
- General color and condition, cleanliness, dryness or oiliness, parasites, and lesions
- Amount and distribution of scalp, body, axillae, and pubic hair
43
Nail Assessment
Nails
- Inspection: Nail grooming and cleanliness, nail color and markings, shape of nails
- Palpation: Assess texture and consistency, capillary refill
44
Common Nail Disorders
- Longitudinal ridging: Parallel ridges running lengthwise. May be seen in the elderly and some young people with no known etiology.
- Half-and-half nails: Nails that are half white on the upper proximal half and pink on the distal half. May be seen in chronic renal disease.
- Pitting: Seen with psoriasis.
- Koilonychia: Spoon-shaped nails that may be seen with trauma to cuticles or nail folds or in iron deficiency anemia, endocrine or cardiac disease.
- Yellow nail syndrome: Yellow nails grow slow and are curved. May be seen in AIDS and respiratory syndromes.
- Paronychia: Local infection
45
Nails Disorders Risk Factors
- Nails in moist environment
- Nail injury, trauma, or irritation
- Repeated irritation (especially water, detergents)
- Immune system disorders
- Skin conditions such as psoriasis or lichen
- Some trades or professions
- Contagion from one digit to another or one person to another
- Possibly family predisposition
46
Nail Risk Reduction
- Wear leather shoes except for sports.
- Avoid wearing closed shoes all the time.
- Wear socks that wick away moisture.
- Avoid going barefoot in damp public areas.
- Avoid too much perspiration or water (wear gloves for hands).
- Avoid trauma to nails.
- Avoid unsanitary or unsafe nail care practices.
- If treatment is started, do not stop until recovery is complete.
47
Physical assessment equipment: Nutrition
- Balance beam scale with height attachment
- Metric measuring tape
- Marking pencil
- Skin calipers
48
Anthropometrics Measurements
- Height and weight
- Body mass index (BMI) Estimate total body fat
- Waist circumference Determine extent of abdominal visceral fat in relation to body fat
- Mid-arm circumference Assess skeletal muscle mass
- Triceps skin-fold thickness Evaluate subcutaneous fat stores
- Mid-arm muscle circumference Evaluate muscle reserve
49
BMI
weight in kilograms/height in meters squared
50
height and weight with aging
elderly- starts at 50 years
Vertebral disks become thinner
Spine is bending
Body weight decreases, lose muscles
51
Hydration Assessment
- Weight- assess hydration by weight
- Intake and output- monitor everything they eat, drink, and pee (measured on chart), medications
- Skin turgor- skin will tent if dehydrated
- Pitting edema- skin will be indented
- Skin for moisture- dry, cracking
- Venous filling- dangle feet or arms and see how long it take to feel the veins
- Neck veins in supine position with head elevated 45 degrees- if fluid overload will see jugular vein distended
- Tongue furrows- can see hydration, cracks, sticky saliva
- Eyeball palpation
- Eye position
- Lung sounds- dehydrated, rubbing sound. Over hydrated, crackles and gargles
- Blood pressure- dehydrated, low BP. Fluid overload, BP high
52
factors affecting hydration
- High temperatures
- Lack of fluid intake (water)
- Excess intake of alcohol
- Diuretics
- Illnesses
- Impaired thirst mechanisms
- High fevers
53
over hydration signs and symptoms
- Weight gains of 6 to 10 lb in a week
- Pitting edema
- Visible neck veins
- Cracking lung sounds
- Elevated pulse rate and blood pressure
54
dehydration signs and symptoms
- Weight losses of 6 to 10 lb in 1 week
- Tenting
- Filling or emptying of venous filling more than 6 to 10 seconds
- Flat veins in supine client
- Tongue is dry
- Sunken eyes
- Blood pressure decreased with elevated pulse rate
- Radial pulse rate +1 and thready
- pulse weak and fine
55
Common Changes in Aging in skin, Hair, and Nails
```
Skin
-Pale
-Skin lesions
-Dry
-Loses turgor
Hair: Thinner
Nails: Thickened, yellow, brittle
```
56
External Structure of the eye
- Eyelids
- Lateral (outer) and medial (inner) canthus
- Eyelashes, conjunctiva
- Lacrimal apparatus
- Extraocular muscles
57
External Eye Assessment
- Inspect the eyelids and eyelashes.
- Observe the position and alignment of the eyeball in the eye socket.
- Inspect the lacrimal apparatus.
- Palpate along the side of the nose and assess for any blockage or pain or drainage. Starting on the lower orbital rim. Do on both sides (bilateral).
58
Internal Structure of the eye
- Sclera, cornea, iris, ciliary body
- Pupil, lens, choroid, retina, optic disc
- Physiologic cup, retinal vessels
- Anterior chamber, posterior chamber
59
Vision
- Visual Field: What a person sees with on eye
- Visual pathways
- Visual reflexes
- Pupillary light reflex: causes the pupils to immediately restrict when exposed to bright light. Direct reflex, protects and prevents damage to the photo receptors in the eye, limits the amount let into the eye.
- Accommodation: functional reflex allowing the eyes to focus on near objects.
60
Cataract
- Opacity or clouding of the eye's lens
| - Leading cause of blindness worldwide
61
Risk Factors for Cataracts
- Increasing age: Lens becomes harder, harder to move, not as elastic.
- Diabetes mellitus: Diabetes effects the periphery, the blood flow in small vessels.
- Excessive alcohol use
- Exposure to sunlight (Ultraviolet B light)
- Exposing to ionizing radiation, such as that used in X-rays and cancer radiation therapy.
- High blood pressure
- Obesity
- Previous eye injury, inflammation, surgery: Scar tissue buildup.
- Prolonged steroid use
- Cigarette smoking
62
Risk Reduction for Cataracts
- Wear sunglasses that block UVB rays
- Avoid smoking or quit smoking
- Avoid excessive alcohol intake
- Avoid eye injuries
- Maintain a healthy weight
- Use eye protection equipment if necessary
- Seek medication treatment for prolonged or unusual eye inflammation or any eye injury
- Regular eye examination.
63
Collecting Subjective Data for the eyes
- History of present health concern
- Past health history
- Family History
- Lifestyle and health practices
64
Collecting Objective data for the eyes
First prepare the client
65
Equipment needed for physical assessment on the eyes
-Snellen or E chart: Distant Visual Acuity Testing. Normal acuity is 20/20 with or without corrective lenses. At the eye doctor when they have you cover one eye at a time and read as far down as you can. (E chart is a substitute for the Snellen chart, for people who cannot read the letters on a Snellen chart.) The top number is always 20, that stands for the 20 feet. The bottom number is used for the last readable line on the chart.
-Allen chart: Visual acuity in children. There are symbols. This would replace the Snellen chart.
-Ishihara chart: Test color blindness. Look at the circles and tell you the numbers they see.
- Rosenbaum/Jaeger Chart: Near Visual Acuity. Handheld vision chart, 14 inches from the eye. Normal acuity is 14/14 with or without corrective lenses. (Jaeger test is more of a reading.)
Penlight
-Opaque cards: Testing Extraocular Muscle Function.
-Cover test: Use opaque card to cover an eye to observe for eye movement.
66
Older Adult Considerations for the eyes
- Presbyopia is a common condition in clients over 45 years of age.
- Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients, appearing first on the medial side of the iris and then on the lateral side.
- Arcus senilis, a normal conditional in older clients, appears as a white arc around the limbus.
- Though usually abnormal, entropion and ectropion are common in older clients.
67
Validating and Documenting Findings
- Health promotion diagnoses
- Risk Diagnoses
- Actual Diagnoses
- Collaborative problems
- Medical Problems
68
The lens flattens to focus on close objects and bulges to focus on far objects.
False, the lens bulges to focus on close objects and flattens to focus on far objects.
69
Exposure to ultraviolet radiation increases the risk for development of cataracts.
True
70
When testing near visual acuity, the client should be asked to remove his or her glasses
False
71
Structure of the External Ear
- Auricle (or pinna)
- Portion visible without any tools
- External auditory canal
- S shaped in an adult
- Outer part curves up and back
- Inner part curves down and forward.
72
Structure of the Middle Ear
- Tympanic cavity-small, air-filled chamber in the temporal bone
- Separate from the external ear by the tympanic membrane
- Distinct landmarks include the handle and short process of the malleus
- Umbo, cone of light, pars flaccida, pars tensa
- Round and oval windows
- Three auditory ossicles; the malleus, the incus, and the stapes
- Eustachian tube
73
Structure of the inner Ear
- Also known as the labyrinth
- Fluid filled and made up of boney and inner membranous labyrinth
- Bony labyrinth has three parts; cochlea, vestibule, and semicircular canals.
- Inner cochlear duct contains the spiral organ of Corti
- Vestibular nerve and cochlear nerve; eight cranial nerve.
74
Hearing Loss
- Conductive hearing loss: Something blocks or impairs the passage of vibrations from getting to the inner ear.
- Sensorineural or perceptive hearing loss: Damage is located in the inner ear.
75
Risk Factors for Hearing Loss
- Aging, especially due to many years of exposure to sounds that can damage inner ear cells
- Heredity, with genetics that are related to susceptibility to ear damage
- Occupation loud noises as regular part of the working environment
- Recreational noises and exposure to explosive noises.
- Ototoxic medications
- Illnesses, especially with high fever
- Noise exposure
- Smoking
- Cardiovascular risk factors
- Genetic and Family susceptibility
- Premature birth
- Hypoxia during birth
- Rubella, syphilis, or certain other infections in pregnant mother
- Inappropriate use of ototoxic drugs during pregnancy
- Neonatal jaundice, which can damage the otic nerve in a newborn baby
- Infectious diseases such as meningitis, measles, mumps, and chronic ear infections in childhood as well as in later life
- Head injury or injury to the ear
- Wax or foreign bodies blocking the ear canal
76
Risk Factors for Otitis Media
- Age
- Group childcare
- Babies fed from a bottle, especially lying down
- Season of fall and winter, due to exposure to colds, flue, and increased allergies
- Poor air quality
- Family history
- Cleft palate
- Down syndrome
- Ethnicity
- Enlarged adenoids
77
Risk Reduction to Preserve Hearing
-Avoid sound exposure louder than a washing machine
-Avoid recreational risks that involve loud sounds or risks of head or ear injury
-Avoid listening to extremely loud music for long periods of time
-Wear hearing protectors and take breaks from the noise in loud noise environments
-Have haring checked periodically, especially after age 50
-If hearing loss is detected, obtain and use devices to improve hearing
-Immunize children against childhood diseases, including measles, meningitis, rubella, and mumps
-Be immunized against rubella before pregnancy if a women of child-bearing age
-If pregnant, get screening for syphilis and other STIs, adequate antenatal and prenatal care, and diagnoses and treatment for baby born with jaundice.
-Avoid the use of ototoxic drugs unless prescribed by a qualified health care worker and properly monitored for correct dosage.
-If you have a newborn, avoid feeding from bottle while infant is lying on back
-Have newborn infant screened for hearing
-Get treatment for ear infections as soon as they are noticed; follow up with health care provider after symptoms to be gone to make sure that there is no fluid left in the ear.
-Get treatment for tonsil and adenoid infections and inflammation
-Keep child home from day care if possible when there is an outbreak of ear infections
-Teach child to avoid putting foreign bodies in ears
Avoid use of instruments to remove wax from ears due to chance of impacting it further. See professional care for wax removal.
78
Nursing History of Ears and Hearing
- Changes in hearing
- Other symptoms
- Personal Health history
- Family history
- Lifestyle and health practices
79
External Ear Structures
Inspection and Palpation
- Inspect the auricle, tragus, and lobule for size, shape, position, lesions/discoloration, and discharge
- Palpate the auricle and mastoid process for tenderness
80
Internal Ear: Otoscopic Examination
Inspection
- Inspect the external auditory canal for discharge, color, consistency of cerumen, canal walls, and nodules
- Inspect the tympanic membrane for shape, consistency, and landmarks.
81
Expected Changes with aging of the ear
- Presbycusis common after 50 years of age
- Negative self-image with hearing aid
- Elongated earlobes with linear wrinkles
- Harder cerumen builds up cilia in ear canal become more rigid
- Coarse, thick wire-like hair may grow at ear canal entrance
- Eardrum appears cloudy
82
Abnormalities of the External Ear and Ear Canal
- Tophi, postauricular cyst
- Malignant lesion
- Otitis externa
- Build-up of cerumen in ear canal
- Polyp, exostosis
83
Nursing Process
- Validating and documenting findings
- Diagnostic reasoning
- Nursing Diagnoses
- Collaborative problems
84
The inner ear is an air-fille cavity
- False, the inner ear is a fluid-filled cavity
| - Middle ear is air filled
85
With sensorineural hearing loss, bone conduction sound is hear long than air conduction sound
False
86
Structure of head
- 8 cranial bones
| - 14 face bones
87
Structure of neck
- Hyoid bone
- Several major blood vessels
- Larynx
- Trachea
- Thyroid gland
88
What does the cervical vertebrae consist of?
C1-C7
89
What can cause traumatic brain injury?
- Motor vehicle accidents
- Motorcycle/bicycle/pedestrian accidents
- Presence of violence
- Gun shot wounds
- Excessive alcohol intake
- Infants (shaking baby syndrome)
- elderly falls
90
Risk factors for traumatic brain injuries
infants/kids:
- environment,
- open windows
- lack of supervision
- lack of education (check family too)
- lack of protective equipment (sports, bicycles)
- lack of knowledge and use of safety when driving or noncompliant
- Driving under the influence
- Living in a violent environment
elderly:
- unsafe environment at home (stairs, clutter, ambulating (falls))
91
Risk reduction for traumatic brain injuries
- Buckling your child in the car
- Wearing a seat belt every time
- Safe driving
- Wearing helmets
- Safer living areas seniors/children
- Maintain regular physical activity
- Screen children for safety (windows, smoke)
- Educate family about infant shaking syndrome
92
Subjective data for head and neck
Interview:
- History of current health problem
- past health
- family
- Lifestyle and health practices
- exercise,
- drinking
- drugs
- wear a seatbelt
- is environment safe
93
Equipment needed for head and neck assessment
- Gloves
- Penlight or flashlight
- Small glass of water (when palpating thyroid)
- Stethoscope (for auscultating thyroid)
94
physical assessment of the head
- Inspect the size, shape, configuration
- Consistency
- Involuntary movement
- Palpate the head (for tenderness and bumps)
abnormalities
- lesions
95
physical assessment of the face
Inspect the face:
- Symmetry
- Features
- Movement
- Expression
- Skin condition
Palpate:
- Temporal artery: tenderness and elasticity
- Temporomandibular joint (TMJ): range of motion (ROM), swelling, tenderness, crepitation
96
physical assessment of the neck
Inspect:
- Symmetry
- Position
- masses
- Cervical vertebrae
- Neck ROM
Palpate:
- Trachea
- Thyroid gland
- Thyroid cartilage
- Cricoid cartilage
- Lymph nodes
-Auscultate an enlarged thyroid gland
97
altered thyroid function
- Increased sensitivity to cold/heat
- Constipation/diarrhea
- Depression/poor concentration
- Fatigue
- Heavier menstrual periods
- Pale, dry skin
- Thin, brittle hair or nails
- Weakness
- Unintentional weight gain/loss
98
abnormal findings of the head and neck
- Acromegaly: enlarged facial features, see it mostly with a birth defect
- Cushing syndrome: moon shaped face, red cheeks, sometimes increased facial hair
- Scleroderma: muscles are way too tight, sometimes when its advanced patient wont have facial expressions, tight muscles on face, short lifespan
- Hypothyroidism: see it on face as well
- Bell palsy: facial droop, one side paralyzed
- Exophthalmos: bulging of the eyes om the hypothyroidism
- CVA: similar to bell palsy, paralyzed side of face but patients half of body is paralyzed too
99
older adult considerations for older adult
- Arthritis or osteoporosis: may effect the neck ROM
- Facial wrinkles- elasticity of face will be less
- The temporal artery- weak, when assess pulse the pulse may be decreased over artery
- Kyphosis- cervical curvature may increase especially on females
- Decrease Range of Motion (ROM)- neck
- Thyroid gland- feel more nodular/irregular (not enlarged) because of the fibrotic changes
100
validating and documenting findings for head and neck
- Health promotion diagnoses
- Risk diagnoses
- Actual diagnoses
- Collaborative problems
- Medical problems
- Do research
- Ask patients to validate the findings
- Educate patients/family
101
headache types
- sinus (sinus area)
- tension (forehead)
- migraine (radiating on half side of face)
- cluster (behind eye)
102
structure of the mouth
- Aka Oral cavity
- Mouth is formed by lips, cheeks, hard and soft palate, ungula, tongue, and muscles
- Oral cavity contains tongue, gums, teeth, and the opening of the salivary glands
- First part of digestive system
- Plays a huge role on tasting food
- Where production of saliva takes place
103
structure of the throat
- Aka pharynx
- Located behind mouth and nose
- Serves as a muscular passage for food and air
Formed by:
- Oropharynx
- Nasopharynx
- Laryngopharynx
- Contains palatine tonsils, pharyngeal tonsils (adenoids), and lingual tonsil
104
structure of the nose
- Consists of external covering of skin and an internal cavity
- External nose: bridge, tip, and 2 oval openings (nares)
- internal nose: nasal cavity, nasal septum, and the castleback area that is composed for the superior middle and inferior terbinades
- internal nose has cilia- little hairs that help trap dust and moisten warm air going to the lungs, plays a big role in the sense of smell
105
structure of the sinuses
- Frontal
- Maxillary
- Ethmoid
- Sphenoid
- Assist with speech
- The ciliary help trap dust or debris
106
risk factors for cancer of the oral cavity
- Using tobacco products
- Heavy alcohol use
- Drinking alcohol and smoking together
- Being infected with a certain types of HPV
- Being exposed to sunlight (lip cancer only)
- Male gender
- Age over 55
- Fair skin
- Poor oral hygiene
- Poor diet/nutrition
- Weakened immune system
- Graft-versus-host disease: when the donor bone marrow or stem cells attack their recipient
- Genetic syndromes such as Fanconi anemia (affect bone marrow, decreasing production of blood cells ), dyskeratosis congenitan (progressive bone marrow failure)
- Lichen planus (when immune system attacks skin cells or mucous membranes)
- Use of mouthwash with high alcohol content
- Irritation from dentures (could cause them to stop eating so then they are at an even bigger risk)
107
risk reduction for cancer of the oral cavity
- Stop smoking
- Limit alcohol consumption
- Balanced diet- increase proteins, lower sugar
- Precautionary measures at workplace
- Practice regular oral hygiene
- Avoid excessive exposure to ultraviolet light
- Avoid sources of oral irritation
- use sunscreen
108
Equipment for mouth, throat, nose, and sinuses
- Gloves
- Cotton gauze pads
- Penlight
- Tongue blade
109
Mouth assessment
Inspection:
- Teeth
- Gums
- Under lips
- Buccal mucosa
- Stensen (located on inside of cheek, 2nd molar) /Wharton ducts (under the tongue)
- tongue
Palpation
- Tongue
- Lips
- gums
Notice odor
110
Throat and Tonsils assessment
Inspect:
- Color
- Consistency
- Torus palatinus (bone growth on the upper palate)
- Uvula. (say ahhh, check for ulcers or lesions)
- Tonsils for color and consistency; grading scale (1+, 2+, 3+, 4+).
- 1+ the tonsils are visible, can see a little bump, normal (or don’t see anything)
- 2+ midway from the wall to the uvula
- 3+ the tonsil will be touching the uvula
- 4+ both tonsils are touching each other, this can be an emergency for at risk of obstructing an airway (kids a lot)
111
Nose assessment
Inspect:
- External nose
- Internal nose
Palpate:
- external nose
- Patency of airflow
- Use penlight
- External- position, consistency, asymmetry
(Cover one side of the nose to see if each side is taking and then do the other side)
- Internal- swelling, exudate, drainage, bleeding, check septum with the light (make sure it is not perforated)
112
sinus assessment
- Palpation for tenderness
- Percussion and transillumination for air versus fluid or pus
- Palpate above eyes
- Transillumination- have patient open mouth and put penlight over skin, if senses are normal you will be able to see the light reflected on the palate, if it is filled with puss then you wont see any transillumination
113
Abnormal findings of the mouth
- Herpes simplex type I: common cold sores
- Cheilosis of lips: fissures or scaly lips
- Carcinoma of lip
- Leukoplakia: patches seen in smokers or alcoholics
- Hairy leukoplakia: white patches on the tongue
- Smooth, reddish, shiny tongue without papillae due to vitamin B12 deficiency
- Lesions from dentures (ask them to remove dentures for inspection)
114
Abnormal findings of the mouth and throat
- Black, hairy tongue
- Carcinoma of the tongue
- Canker sore
- Gingivitis
- Receding gums
- Periodontitis
- Kaposi sarcoma lesions
- Acute tonsillitis and streptococcal pharyngitis
115
abnormal findings of the nose and sinuses
- Nasal polyp: little white spots
- Perforated septum: caused by trauma or some drugs like snorting cocaine
Abnormal sinus findings:
- Everything related to infection
Headaches, heaviness in the front of face
116
cultural variations for mouth throat, nose and sinuses
- Pink lips are normal in light-skinned clients, as are bluish or freckled lips in some dark-skinned clients, especially those of Mediterranean descent
- Talon cusps on incisors and circular cusps on molars in Asian, Pacific Islanders, and Native Americans
- Torus palatinus in female Eskimos, Native Americans, and Asians (extra bone growth on the palate)
- Bifid uvula in Native Americans and Asians (like a split uvula)
117
Age Related Changes in the Mouth, Nose, Throat, and Sinuses
- Gums recede
- Some systemic (or ischemic cant understand her) and fibrotic changes in the mouth
- Tooth surface is warn down
Lose the ability of smell and taste
- Sense of smell and taste is very important for nutrition (mortality rate can be 5 years)
- Dried oral mucosa
- More frail
- Varicose veins under tongue
118
Thorax Cage
- Thorax: Extends from the base of the neck superiorly to the level of the diaphragm inferiorly. Contains lungs, distal portion of the trachea, and bronchi.
- Sternum: Composed the manobia, the body, and the xyphoid process. Lies on the center of the chest anteriorly
- Ribs: 12 pairs of ribs in thoracic cage
119
Thoracic Cavity
- Mediastinum: Contains trachea, bronchi, esophagus, heart, and great vessels, central area in thoracic cavity.
- Trachea: Flexible structure, lies anteriorly to the esophagus
- Bronchi: The trachea splits into the right and left main bronchi.
- Lungs: Cone shape, elastic structures. Right lung has 3 lobes, left lung has 2 lobes.
- Pleural membranes: Thin double wire membranes covering the thoracic cavity and some organs.
120
Anterior vertical lines used for ascultation
The lines are the right mid-clavicular line, the midsternal line, and left mid-clavicular lines. (Pg. 383)
121
Posterior vertical lines used for ascultation
-Right scapular line, vertebral line, and the left scapular line. (Pg. 383)
122
Lateral Vertical Lines used for ascultation
-First line is the anterior axillary line
-Middle line is the midaxillary line
-The last line is the posterior axillary line
(Pg. 383)
123
Lung Diseases
Lung Cancer
COPD: Chronic breathing problem, causing cough, obstruction of the airways, phlegm.
Asthma
Pneumothorax: Leaking of the air into the space, the lung collapses.
Pulmonary embolism: Blocking of one or more arteries in the lung.
124
Lung Cancer Risk Factors
- Cigarette smoking/second-hand smoke
- Genetic predisposition
- Exposure to toxins
- History of previous lung cancer
- Gender
- Asbestos, radon, and environmental exposure
- Workplace pollutants
- History of Hodgkin disease
- Poor diet
- Beta-carotene supplements
125
Lung Cancer Risk Reduction
- Join smoking cessation program
- Stop smoking
- Avoid exposure to second-hand smoke
- Avoid exposure to asbestos or radon
- Limit exposure to toxins
- Seek medical assistance
126
Subjective Data Collection for Thorax and Lungs
- History of present health concern
- Past health history
- Family history
- Lifestyle and health practices
- Why are you coming to see us today? Are you having any shortness of air, any cough, any phlegm, what type of cough are you having?
- Any history of pneumonia, bronchitis, asthma, COPD, lung cancer.
- Any family members with the diseases above.
- Do you smoke, drink, exercise, illegal drugs used, vaping?
127
Objective Data Collection for Thorax and Lungs
- Explain procedure to client
- Have the client remove all clothing from the waist up
- Ask the client to sit in an upright position
- Start with observing quality and pattern of respirations, the rate, breathing characteristics: rhythm, depth, rate. Labor or noisy breathing.
128
Equipment for Thorax and Lungs Assessment
- Examination gown and drape
- Gloves; stethoscope
- Light source
- Mask; skin marker and metric ruler
129
Inspection of Thorax and Lungs
- Respirations
- Rate/Pattern
- Nasal flaring
- Pursed lip breathing
- Color
- Color and shape of nails
- Client positioning
- Accessory muscles
- Position of scapulae
- shape and configuration
130
Palpation of Thorax and lungs
- Tenderness and sensation
- Crepitus: crackling sensation
- Surface characteristics: Put on gloves and use fingers to palpate any lesions.
- Fremitus: vibrations of air in the bronchial tubes transmitted to the chest wall.
- Chest expansion
131
Percussion of Thorax and Lungs
- Tone—resonance: is the normal tone elicited over normal lung tissue.
- Diaphragmatic excursion: Ask the client to exhale forcefully and hold the breath.
132
Auscultation of anterior of Thorax and Lungs`
Anterior:
-Adventitious sounds: Sounds added or superimposed over normal breath sounds and heard during auscultation (Crackles or Wheezes)
-Breath sounds
-Bronchial: (High pitch, short during inspiration and long during expiration.)
-Bronchovesicular: (Moderate pitch, same duration during inspiration and expiration)
-Vesicular: (Low pitch, long duration in inspiration and short duration in expiration)
(Do Not attempt to listen through clothing or other material)
133
Auscultation of Posterior of Thorax and Lungs
Posterior:
-Adventitious sounds: Sounds added or superimposed over normal breath sounds and heard during auscultation (Crackles or Wheezes)
-Breath sounds:
-Bronchovesicular: (Moderate pitch, same duration during inspiration and expiration)
vesicular
Voice sounds
-Bronchophony: Voice transmission is soft, muffled, and indistinct.
-Egophony: Voice transmission will be soft and muffled.
-Whispered pectoriloquy: Transmission of sound is very faint and muffled.
134
Thoracic Deformities and Configurations
Barrel chest
Pectus excavatum (funnel chest)
Scoliosis
Kyphosis
135
Older Adult Considerations for Thorax and Lungs
```
Tenderness or pain costochondral junction
Dyspnea
Decreased chest pain
Weak cough
Decreased deep breathing
Kyphosis
Decreased thoracic expansion
Prominent sternum and ribs
```
136
Analysis of Data (Thorax and Lungs)
Selected Nursing Diagnoses:
- Health promotion and education
- Risk
- Actual
- Selected Collaborative Problems
137
Spiritual Beliefs
In whatever form spirituality is incorporated into client care, the nurse should be:
- Respectful,
- Open, and willing to discuss spiritual issues
- Avoid conveying a judgmental attitude toward the client’s spiritual beliefs and religious practices.
