Assessment3

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vanwin
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210113
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Assessment3
Updated:
2013-03-30 19:46:13
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nursing
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assessment jarvis
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  1. Full mental health exam is needed when
    • Behavioral changes: memory loss, inappropriate social behaviors
    • aphasia: language impairment due to brain injury
    • brain lesions: stroke/CVA, trauma, tumor
    • symptoms of mental illness
  2. Appearance
    • Posture
    • - normal: straight, erected, relaxed
    • -abnormal: pacing, tensed muscles= anxiety, hunched over = depressed
    • Body movement
    • - normal: coordinated, smooth & even
    • - abnormal: restless, fidgety = anxiety, or slow= depression
    • - cogwheel = parkinsons
    • dress/ grooming & hygiene
    • -norm: appropriate for season, clean, shaven
    • -abnormal: disheveled, dirty, not shaven-
    • unilateral neglect- depression/ mental status
  3. Behavior
    • Level of Consciousness
    • Speech: smooth, articulated, appropriate volume/ fast = anxiety, slow = depressed, distorted = stroke
    • Affect&mood: relaxed & cooperative " how do you feel today,
    • - flat, no expression = mental illness
    • - schizophrenia: mood swings, bizarre moods
  4. Cognition
    • Orientation: Person, place & time
    • Recent memory:
    • Remote memory:
    • New learning: 4 unrelated words & repeat them back
  5. Mini Cog Exam
    • tell them 3 random words
    • ask them to draw a clock at a certain time
    • then ask them to repeat the words again
    • 1-2 words = possible dementia
    • no words = dementia
    • abnormal clock = cognitive impairment
  6. Thought Process
    • normal: logical
    • abnormal: illogical
    • - obsession - repetitive thoughts
    • - compulsion - repetitive behavior
  7. Assess suicidal thoughts if _____
    • They exhibit:
    • sadness, grief, despair, hopelessness
    • Ask:
    • have you ever thought of harming yourself?
    • are you thinking about it right now?
    • do you have plans?
  8. Major Depressive Disorder
    • If pt. shows 5 or more symptoms for 2wks:
    • depressed
    • fatigued
    • wt loss
    • agitation
    • worthlessness
    • diminished interest
    • inability to think
    • insomnia/ hypersomnia
    • death
  9. Aging
    • response time = slower
    • recent memory may decrease
    • Same: intellect & remote memory
  10. Neurological Assessment Subjective Data
    • headache
    • headinjury
    • dizziness/vertigo
    • syncope (random fainting)
    • seizures
    • tremors
    • incoordination
    • stroke/ CVA
    • meningitis
    • dysphagia
    • dysphasia
    • dysarthria
    • aphasia
  11. Cranial Nerve I & II
    Olfactory: close eyes & test each nostril separately

    Optic: visual acuity, snellen chart
  12. Cranial Nerve III IV VI
    • muscles around the eye, tested together
    • PERRLA = III
    • Extraoccular movements/ cardinal field of gaze test
  13. Nystagmus & Ptosis
    Nystagmus: jerking of the eye

    Ptosis: droopy eyelid on one side
  14. Cranial Nerve V
    • Trigeminal nerve: opthalmic, maxillary, mandibular
    • sensory: light touch
    • corneal reflex: cotton swab ( involuntary blinking)
    • motor: masticatoin
  15. Cranial nerve VII
    • Facial:
    • motor: symmetry of movements & strength
    • sensory: taste sweet, salt & sour (uncommon test)
  16. Bells Palsy
    asymmetry of the face, cranial nerve VII impairment
  17. Cranial Nerve VIII
    • Acoustic: hearing acuity
    • Whisper test:
  18. Cranial Nerve IX, X
    • Glossopharyngeal & vagus
    • motor: tongue blade, test pharynx movement
    • uvula, soft palate, gag reflex
  19. Cranial nerve XI & XII
    • Spinal acessory nerve:
    • sternomastoid & trapezius muscle; turn head & shrug shoulder against resistance

    Hypoglossal: tongue stick out
  20. Cerebellar Function Coordination & Balance Tests
    • Tandem walking: heel to toe(soberity)
    • Romberg: stand stil, test balance (positive = fall)
    • shallow knee bed/ hop in place
    • rapid alternating movements
    • finger to finger
    • finger to nose
    • heel to shin
  21. Deep Tendon Reflexes
    • Graded 0-4: 0 = none 2= normal 4= clonus
    •  Reinforcement: raise hand up to relax other muscles
    • clonus: short, jerking motion on stimuli
  22. Glascow Coma Scale
    • Eyes: 4
    • Verbal: 5
    • Motor: 6
    • max score = 15
    • 7 or < = coma
  23. Sensory Assessment
    • eyes need to closed
    • pain: sharp/ dull
    • light touch: hyperthesia =lots of sensation!
    • vibration: low pitched tuning fork
    • mono-filament: can't feel = peripheral neuropathy
    • proprioception/ position sense/ kinethesia
    • sterognosis: object in palm & they tell you what it is
    • graphethesia
  24. Health History Questions; Head. neck & lymph
    • Headaches
    • Head injuries did they loose LOC
    • dizziness
    • neck pain
    • lumps & swelling
  25. Inspect & palpate head
    • normocephalic
    • microcephalic
    • macrocephalic
    • symmetrical
  26. Inspect & palpate Neck
    • symmetry of muscles
    • range of motion
    • lymph nodes - advanced technique
    • trachea @ midline
    • thyroid - advanced technique
  27. Developmental considerations for Head
    children and infants have bigger heads compared to body size= more prone to head injury
  28. Palpating lymph nodes
    • normal: <1cm & nonpalpable
    • lymphadenopathy: >1cm/ infection, allergies or cancer
    • Infection: enlarged, painful, tender, warm, movable, maybe bilateral
    • Malignant: enlarged, non tender, unilateral, fixed, hard to palpate
  29. Head & Neck Abnormality
    • Acromegally: excess growth hormone; pituitary tumor, facial bone over growth
    • CVA/stroke: asymmetry, whole body
    • Bell's palsy: asymmetry, only affect face
    • multiple thyroid nodues
    • thyromegaly
    • assymmetry
  30. Eye subjective information
    • pain: sudden = 911
    • difficulty w/ vision: decreased acuity, blurry, blindspots = tumor, halo = glaucoma
    • photophobia
    • strabismus (misalignment)
    • redness
    • swelling
    • water discharge = possible infection
    • past hx & self care
  31. Eye Test Tools
    • snellen chart
    • hand held vision screen
    • card to cover eye
    • pen light
    • opthalmoscope
  32. Eye Acuity Tests
    • Snellen chart: stand 20ft away, numerator = distance away, nominator = line read, smaller = better
    • E chart: for children & pts that don't know the alphabet
  33. Near Vision & Visual fields test
    • Near vision test: hold chart 14 inches away, 14/14 if they get it all right
    • - presbyopia: when they have to move it farther to read it

    Visual fields: right & left eye/ confrontation test. When they cover one eye and something comes from the side, they'll say when they can see it, not very accurate
  34. Eye Muscle Function Tests
    • Corneal light reflex: when the light reflect in the same spot on both eyes
    • cover test: cover 1 eye, pt look forward then take away cover, if covered eye moves into position = muscle weakness
    • extraoccular movements/ EOMS/ 6 cardinal fields of gaze
  35. Strabismus & Phoria
    • Strabismus: disparity in eye alignment
    • Phoria: mild eye weakness
  36. Inspect Extraoccular structures
    • Eyebrows: symmetrical
    • Eyelids & lashes
    • eyeball alignment
    • conjunctiva & white sclera
    • lacrimal apparatus
  37. Inspect anterior eyeball structures
    • cornea: clear w/ lens underneath
    • iris & pupil: flat & round
    • -size, shape & eual
    • -pupillary light reflext
    • -accommodation
  38. PERRLA
    • pupils
    • equal
    • round
    • reactive to
    • light
    • accomodation
  39. Developmental Considerations
    • older adults:
    • - decreased vision
    • -deceased peripheral vision
    • - decreased tears, dry eyes
    • Arcus senilis: white ring on top of eyes, not medically significant
  40. Eye Abnormalities
    • exopthalmos: eyes buldges out; b/c Graves disease, hyperthyroidism
    • Conjunctivitis: pink eye
    • Periorbital edema: w/ renal failure, allergic rx, CHF
    • Presbyopia
    • Lid lag: hyperthyroidism
    • macular degeneration: loss of central vision
  41. Ear Subjective information
    • ear aches
    • infections
    • discharge/ otorrehea
    • hearing loss, sudden = refer
    • tinnitus; ringing
    • vertigo; loss of balance
    • hearing & screening protection
    • amt of ear wax
  42. Tools for Ear Inspection
    • Advanced technique;
    • 3yrs or older = pull up & back
    • younger = down & back
  43. Objective Data Ear Inspection & palpation
    • Placement & alignment: low set ear might indicate mental illness/ kidney problems
    • hearing acuity: whisper test
  44. Types of Hearing Loss
    • conduction: transmission of sound into ear, cause- wax/ otosclerosis
    • Sensorineural: defect in inner ear, cause: CN8 impairment, aging, ototoxic drugs, loud noises.
  45. Developmental considerations; ears
    • otoscope last for infants
    • presbycusis in older adults
    • otitis media, ear infections in children, they might have speech impairment
  46. Nose, Mouth & throat Subjective Data
    • nose discharge: color & amt
    • colds
    • sinus pain
    • hx, of nose bleeds (epistaxis)
    • allergies
    • changes in smell
    • sore throat
    • bleeding gums
    • tooth aches
    • hoarseness; how long
    • dysphagia
    • xerostomia/ decrease saliva
    • smoking & alcohol
    • altered taste
    • self care
  47. Inspection of Mouth
    • gingivitis
    • gingival hyperplasia- dilantin/ pregnancy
    • oropharynx
    • buccal mucosa- ulcers
    • cyanosis of lips
  48. Early Signs of dehydration in Elderly
    • dry mucosa,
    • breathing through mouth
    • furrowed tongue
    • acute confusion
  49. Oropharynx grading
    • I:  see anterior & posterior pillars
    • II: see only anterior, covers posterior
    • III: touches uvula
    • IV: kissing tonsils
  50. Abnormal Nose Mouth & Throat
    • Leukoplakia: cancerous, refer
    • cadidiasis/ Thrush
    • yeast infection

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