appropriate, native language Speech clear and concise, vocabulary extensive Hearing No obvious hearing deficit. No hearing aids what can she hear? Personal hygiene Clean and well kempt Measurements and Vital Signs Weight 5’ 2” Height 150 BMI 27.4 Radial pulse: rate rhythm 72 and regular Respirations: rate depth 18, regular depth Blood pressure (indicate if sitting or lying) 116/64 sitting Temperature (if indicated) Pain assessment Denies pain at this time Skin Hands and nails Skin intact, no obvious deformities . Nails? Color and pigmentation Pink normal pigmentation, appropriate for ethnicity Temperature warm Moisture dry Texture smooth Turgor Appropriate, no tenting noted Presence of lesions? No lesions noted 7
Head and Face Scalp Hair Cranium Scalp smooth, no lesions or flaking Hair intact, no alopecia or thinning noted Cranium smooth no obvious deformities Face (cranial nerve VII) Cranial nerve 7 is grossly intact what did you see? Temporal artery and temporomandibular joint No clicking noted in jaw, temporal artery is palpable and equal bilaterally Maxillary sinuses and frontal sinuses Maxillary and frontal sinuses are without tenderness Eyes Visual fields (cranial nerve II) Visual fields intacts, no obvious deficits Extraocular muscles, corneal light reflex, and cardinal positions of gaze (cranial nerves III, IV, VI) H test within normal limits, holds gaze appropriately, Cranial nerves 3, 4, and 6 grossly intact External structures No deformities, eyes evenly spaced and intact Conjunctivae, sclerae, and corneas Conjunctivae clear no drainage, sclerae and cornea without drainage, redness or deformity Pupils Pupils bilaterally equally reactive to light and accommodate apppropriately appropriately Describe the purpose of an Opthalmascope for assessing the eyes Assess red reflexes, retina, optic disc and blood vessel in the fundus of the eye Ears External ear External ear structures without deformities Any tenderness? Denies tenderness Purpose of the otoscope Asses the internal ear drums Test hearing (cranial nerve VIII) and conduct the voice test Cranial nerve 13 grossly intact, hearing without obvious deficit Explain the Weber and Rinne tests Weber rinne Rinne tests for air and bone conduction in the inner ear structures. A tuning fork is struck 8
and placed on the mastoid bone, the length of the time the patient can hear the sound is measured then the fork is moved to the ear canal. The fork is then struck on the top of the head and moved toward each ear. The normal is that air conduction is longer than bone conduction of sound and that each ear should hear the sound equally. This test can help determine whether hearing loss is conductive or sensorineural. Nose External nose External nose without obvious deformites deformities Patency of nostrils Nares patent bilaterally Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinates The purpose of the speculum is to visualize the inner structures of the nasal cavity and nares. To determine if they are patent, if there is inflammation,
You've reached the end of your free preview.
Want to read all 13 pages?
- Spring '16
- Shelley Ashby
- HPI, Nipple discharge