Exam 3 Flashcards
(49 cards)
1
Q
Cranial Nerve XII
A
- Name: Hypoglossal
- Function: movement of tongue
- Type: Motor
- Tests: stick out tongue, move side to side & push tongue against cheeks w/ resistance
2
Q
Male Genitourinary System Preparation
A
- Experienced colleague
- Confident, relaxed, unhurried & business-like
- Non-judgemental, verbalize assessment plan & findings
- Reassure patient if has an erection
3
Q
Electronic Health Records (EHR)
A
- Physician order entry & clinical decision support
- Allows all providers to access health info, place orders, & receive timely pt updates
- Incr pt safety
>dcr transcription & prescribing errors
>notfy of med interactions, dosage adjustments & additional required testing
>scanning med admin
>checklists
4
Q
Age Related Changes for Female Reproductive
A
- Menopause can occur from 35-60 (usually late 40s or early 50s)
- 1-2yrs reduced ovarian function
- Changing menstrual flow & pattern
- Reduced estrogen
- Drying & shrinkage of vagina
- Shrinkage of uterus
- Ovarian atrophy
- Sacral ligament relaxes
- Shortening cervix
- Sexual desire / sexual expression
- Vagina shortens, narrows, loses elasticity
- Mons pubis appears smaller
- Labia & clitoris dcr in size
- Pubic hair thins
- Without intercourse:
>vaginal atrophy
>epithelial atrophy
>fragile surface
>bleeding risk & vaginitis
>alkaline pH
>reduced glycogen
>reduced vaginal secretions
>dyspareunia
5
Q
Abnormal Female & Male Anal Findings
A
- Dcrd tone
- Incrd tone (anxiety, inflammation)
- Tenderness
- Polyps
- Internal & external hemorrhoids
- Carcinoma
- Inflamm, lesions, scars, fissures
- Fistula
- Pilonidal cyst
- Rectal prolapse
6
Q
Urinary & Vaginal Health (hlth promotion for female reproductive)
A
(urinary)
- Hydration
- Voiding at 4-6hr intervals
- Prevention of cystitis (bladder infection)
(vaginal)
- Treat vaginal infections promptly
- STI prevention
- HPV vaccination
- Risk of infection (douching alters acidic pH, oral contraceptives incr glycogen in vaginal secretions & antibiotics kill normal flora)
7
Q
Anal & Rectal Health Promotion for Female & Male Reproductive
A
- Keep anal area clean & dry
- Avoid scratching anus
- Don’t put objects in anus that don’t belong there
- Avoid straining during defecation
- Eat a high fiber diet
- Avoid lifting extremely heavy items
8
Q
Age Related Changes for Male Reproductive
A
- Fertility
- Dcr in: sperm production, testosterone, pubic hair, penis size, dartos muscle tone & testes size
- Scrotal sac dangles
- Slowed sexual response time: medication/stimulants
- Slowed time for erection
- Age does not = less libido
- Causes for withdrawal from sexual activity: death of spouse, depression, work, family conflict, medication, alcohol, or drug use, privacy, economy, emotions, nutrition, & fatigue
9
Q
Cervical Cancer Screenings (hlth promotion for female reproductive)
A
- w/in 3 yrs of 1st vaginal intercourse or age 21
- screen for HPV
- annual pap smear until age 30
- after 20 incr time frame to 2-3yrs after 3 consecutive normal pap smears
- maternal ingestion of DES = annual screening recommended
10
Q
Abnormal Prostate Findings
A
- Enlarged smooth gland w/ no central groove (BPH)
- Nodules
- Pain, tenderness, swelling
- Inability to move prostate
- Excessively hard (fixed)
11
Q
Female Genitourinary System Assessment Preparation
A
- Empty bladder
- Positioned away from door
- Ask if want a person present
- Explanation of exam
- Inform of any pain or discomfort
12
Q
Required Equipment for Head-to-Toe
A
- Platform scale w/ height attachment
- Sphygmomanometer
- Stethoscope w/ bell & diaphragm
- Thermometer
- Pulse oximeter
- Paper & pencil/pen
- Flashlight or penlight
- Otoscope/ophthalmoscope
- Tuning fork
13
Q
Expected Changes in Nose, Mouth, & Throat for Aging Adult
A
- Dryness in mouth (xerostomia)
- Lost or broken teeth
- Changes in sense of taste or smell
- Prominent nose
- Mouth & lips fold in
- Yellowing of teeth
- Gum margins recede
- Tongue smoother
- Buccal mucosa thinner
14
Q
Nose Subj Data & Health Hx
A
- Discharge
- Frequent URIs
- Sinus pain
- Trauma
- Epistaxis (nosebleeds)
- Surgeries
- Allergies
- Smell alts
15
Q
Cranial Nerve XI
A
- Name: (Spinal) Accessory
- Function: movement of trapezius & sternomastoid muscles
- Type: Motor
- Test: shrug shoulders & rotate head against resistance
16
Q
Cranial Nerve I
A
- Name: Olfactory
- Function: Smell
- Type: Sensory
- Test: recalling familiar smell with eyes closed
17
Q
Cranial Nerve IX
A
- Name: Glossopharyngeal
- Function: (motor); pharynx - phonation & swallowing / (sensory); taste
- Type: Motor & Sensory
- Tests: (motor); swallow & gag reflex / (sensory); taste on 1/3 tongue
18
Q
Cranial Nerve II
A
- Name: Optic
- Function: Vision
- Type: Sensory
- Tests: Snellen chart (visual acuity), Confrontation test (seeing fingers at same time as pt), Ophthalmoscope to view optic disc
19
Q
Occipital Lobe
A
Primary visual center
20
Q
Neurological Developmental Considerations for Older Adults
A
- General loss of muscle & muscle tone in face, neck & around spine
- Dcrd muscle strength
- Impaired fine coordination & agility
- Loss of vibratory sense at ankle
- Dcrd or absent achilles reflex
- Loss of position sense at great toe
- Irregular pupil shape
- Dcr in reaction time
- Incrd delay at synapse
- Sensation of pain & touch may be diminished
- Diminished sense of taste & smell
- Slowing of motor system
- Dcr in muscle strength & agility
- Possible muscle tremors & dyskinesias
- Progressive dcr in cerebral bld flow
21
Q
Health Promotion for Female Reproductive System
A
- Perimenopausal period 40-55yrs hormonal shifts resulting in vasomotor instability
- Hormone replacement therapy discussion
>benefits: reduce irritability, hot flashes, maintain bone density
>risks: fluid retention, vaginal bleeding, DVT, incrd breast cancer
22
Q
Cerebellum
A
Motor coordination of voluntary movements, equilibrium, & muscle tone
23
Q
Cranial Nerve IV
A
- Name: Trochlear
- Function: Down & inward movement of eye
- Type: Motor
- Test: Cardinal Field of Gaze
24
Q
Internal Ear Assessment
A
(pull pinna up & back - adult)
- Cone of Light: 5 o’clock = right eardrum
- Cone of Light: 7 o’clock = left eardrum
- Look for redness or fluid
- Scars look like white patches
- Describe drum color
- Check for holes or perforations
25
Health Promotion For Male Reproductive
- High fiber, dietary supplements
- Fluid intake
- Laxative use
- last digital rectal exam, fecal blood colonoscopy or sigmoidoscopy
- PSA (prostate specific antigen) blood test
- Monogamous relationships; better for preventing STIs/STDs
- Safe sex
26
Prostate Health Promotion
- Diet rich in fruits & veggies
- Use of herbs; palmetto & soy (not scientific)
- Exercise & maintain health weight
- Fluid intake
- Enlarged prostate: limit fluid intake 3-4hrs before bed
27
Sinus Assessment
- Palpate frontal & maxillary sinuses
- Should feel pressure but no pain
- Non-palpable: ethmoid & sphenoid
28
Cranial Nerve III
- Name: Oculomotor:
- Function: (motor); Extraocular eye movement & opening eyelids / (sensory); pupil constriction & lens shape
- Type: Motor & Parasympathetic
- Tests: (motor); follow moving target / (parasympathetic); PERRLA
29
External Ear Assessment
- Size, shape, & placement
- Condition of skin
- Move pinna & push on tragus
- Palpate mastoid process
30
Initial Assessment
- Performed once preferably in early part of day
- Complete head-to-toe acute care assessment
- Provides baseline so that changes can be detected early & a baseline prior to any invasive procedure
31
Cranial Nerve VI
- Name: Abducens
- Function: lateral movement of eye
- Type: Motor
- Test: follow moving target
32
Parietal Lobe
Primary center for sensation; touch, taste, temperature
33
Cranial Nerve V
- Name: Trigeminal
- Function: (motor); muscles of mastication / (sensory); ophthalmic, maxillary, & mandibular
- Types: Sensory & motor
- Test: (motor); palpate temporal masseter muscles / (sensory); touching face w/ cotton & blunt pin on jaw, cheek, & forehead
34
Cranial Nerve X
- Name: Vagus
- Function: (motor); pharynx & larynx - talking & swallowing / (sensory); sensation from carotid body, carotid sinus, pharynx, viscera
- Types: Motor & Sensory
- Tests: (motor); say "ah" / (sensory); taste on 1/3 tongue
35
Neurologic Health Hx
- Headache
- Head injury or spinal cord injury
- Dizziness/vertigo
- Seizures
- Tremors
- Weakness
- Incoordination
- Numbness or tingling
- Difficulty swallowing or speaking
- Environmental/occupational hazards
36
Abnormal Female Genitalia Findings
- Pigmented nevi or lesions
- Nits or lice
- Swelling, inflammation, redness
- Excoriation
- Nodules
- Rash
- Polyps
- Foul smelling irritating discharge: yellow, white, or gray-green, curdlike
- Tenderness
- Urethral discharge
- Induration along urethra
- Pain
- Incontinence
- Pallor
- Cyanosis
37
Method & Purpose for SBAR
- Used to improve verbal communication & reduce errors
- Situation
- Background
- Assessment
- Recommendation
38
Male Testicular Self-Exam (TSE)
- Teach self care at 13yrs
- Normal testicle: egg-shaped, movable, rubbery, smooth surface
- Abnormalities: lumps, bumps, lesions
- Notify Provider: firm, painless lump, hard area, overall enlarged testicle
- Testicular Cancer: rare before 15yrs, typically 15-35, associated w. cryptorchidism, no early symptoms, early detection & before metastasis = 100% cure rate
39
Documenting Health Assessment (head-to-toe) Findings
- Not documented = never happened
- Record soon after assessment
- Chart relevant, normal, or negative findings
>charting by exception
>WNL or WNL except
40
Temporal Lobe
- Hearing
- Memory
- Language
41
Sequence of Head-to-Toe
- Health hx
- General appearance
- Measurement
>empty bladder prior to exam & put on gown
- Skin
- Vital signs
- Head & face
- Ears
- Eyes
- Nose
- Mouth & throat
- Neck
- Chest
>anterior & posterior
- Female or male breasts
- Heart
- Abdomen
- Inguinal area
- Upper extremities
- Lower extremities
- Musculoskeletal
- Neurologic
- Male or female genitalia
- Rectum
42
Cranial Nerve VIII
- Name: Vestibulocohlear
- Function: hearing acuity
- Type: Sensory
- Test: hearing normal conversation, whisper test, Weber tuning fork (heard midline w/out lateralization), Rinne tuning fork (AC>BC)
43
Sexual & Fertility Health (hlth promotion for female reproductive)
(sexual)
- Open expression
- Referral PRN
(fertility)
- Treat STIs promptly
- Ovarian cancer is silent: seek health care for persistent pelvic pain, lower abdominal pain/bloating or changes in bowel & bladder habits
- Fertility work-up if no pregnancy w/in a full yr of unprotected vaginal intercourse
44
Key Observations of Mouth, Lips, Tonsils, Uvula, & Palates
- Lips, buccal mucosa, & mouth intact
- Sores & lesions
- Uvula rising to midline (CN X) & gag reflex (CN IX & X)
- Strength of tongue
- Smooth tongue movement (CN XII)
- Tonsils present & rating
- Lingual fenulum, veins, & sublingual duct intact
45
Frontal Lobe
- Personality
- Behavior
- Emotions
- Intellectual function
46
Focused Assessments
- Focus on a specific problem
- Limited or short term
- Mini database smaller & more targeted
- EX:
>postoperative assessments
> new cast application for a fracture extremity (CMS = circulation, movement, & sensation)
47
Cranial Nerve VII
- Name: Facial
- Function: (motor); temporal, zygomatic, & buccal nerves / (sensory); taste on 2/3 of tongue - sweet, salty, sour, bitter
- Types: Motor & Sensory
- Tests: (motor); temporal - frown, wrinkle forehead, lift up eyebrows. zygomatic - close eyes tightly try to open. buccal - puff out cheeks & smile / (sensory); apply taste on 2/3 tongue
48
Mouth & Throat Subj Data & Health Hx
- Sores & Lesions
- Pain
- Bleeding gums
- Toothache
- Hoarseness
- Dysphagia
- Taste Alts
- Smoking
- ETOH consumption
- Surgeries
- Self care behaviors
49
Reassessment
- Performed whenever nurses see changes in pts
- Certain procedures require a schedule of continuous reassessments
- Pts admitted for observation
