Unit 2 Test - nursing.docx - Unit 2 Test Neck Head o Changes with aging Bony structure more pronounced Skin sags wrinkles Increased skin lesions

Unit 2 Test - nursing.docx - Unit 2 Test Neck Head o...

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Unit 2 Test Neck & Head o Changes with aging Bony structure more pronounced Skin sags & wrinkles Increased skin lesions Hypo/hyper thyroidism o Acute Assessment Stabilize head and neck Careful assessment for bleeding, swelling, loss of mobility, or pain o Neck pain Tension? Associated with fever and headache? Cardiac etiology? o Lymph nodes Bad: Fixed Irregular Hard Rubbery o History Personal history related to head and neck Medications Family history Common symptoms: Headache Neck pain Limited neck movement Facial pain Lumps or masses Signs/ symptoms of hypo/hyper thyroidism o Physical exam Inspection Head: o Centered, proportional to body, erect, without tremors, ticks or unusual movements o Cranium round o Facial symmetry Hair: o Look for distribution, quantity, texture, cleanliness Endocrine issue
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Nits Alopecia o Wear gloves Neck: o Neck muscles symmetrical, trachea midline, no obvious masses/nodes Palpate Scalp: o Symmetry without tenderness, masses, lesions, or differences in firmness Masses: o Texture, size, consistency Eyes: o Sensory organ of sight o Know: Inner canthus Outer canthus Lid Pupil Cornea Iris Conjunctiva sclera Palpebral fissure o Aging Structure Drooping Wrinkles Eyes sit deeper Decreased tear production Vision Decline in vision, depth perception, night vision o Urgent assessment Penetration Acute glaucoma Vision loss Mechanical, thermal, radiant, chemical, electrical, kinetic Asses for: Foreign bodies, lacerations, hyphema Extraocular movements o History Allergies Eye conditions
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Surgery Eye protections Family history Risk factors Medications Symptoms: Pain Trauma/surgery Visual change Blind spots, floater, halos Discharge Change in ADLs o Visual acuity Distance Mark floor 20 ft. away Occlude one eye at a time read smallest letter Higher bottom number worst visual acuity is Allen – pictures Snellen – letters Near >40 yrs. age Jaeger test o Can use newspaper Hold 14 inches away from eye o One eye at a time o Strabismus – eyes cross a lot Corneal light reflex Look at bridge of nose In front of patient with light Both corneas should be same For lazy eye Cardinal fields of Gaze Hold head steady 12-14 in. from face Move finger/light around to see if patients’ eye can move symmetrically with you 9 cardinal fields nastagmus o Physical exam Eyebrows & eyelashes Symmetry, hair Eye shape
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can vary Parallel Alignment Bulbar conjunctiva Lift upper lid and stretch down lower lid and have patient look right and left PERRLA Pupils equal, round, react to light, accommodation Ear o Sensory organ of the body used for hearing and maintaining equilibrium o Know: External Middle
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  • Fall '18
  • Linda Shroyer
  • neck pain,  Cardiac etiology,  Scalp,  Dental health,  Foreign bodies

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