Jones’ upper and lower extremities, spine, and hips to assess for her strength and ROM, limitations in mobility, pain, crepitation, which can identify joint disease or injury as a result of Ms. Jones’ fall (Jensen, 2015; Shadow Health, 2019). The neurological assessment was utilizing testing techniques. The finger-to-nose test, rapid alternating hand movement test, and heel-to-shin-coordination test were done to assess for any abnormalities in Ms. Jones’ coordination which can be caused by a cerebellar disease and can be found in patients with a history of falling (Jensen, 2015; Shadow Health, 2019). The sensory function tests were done to test her ability to sense light, dull and sharp touches to upper and lower extremities. Diabetic patients often struggle with neuropathy and patients will have
HEALTH PROMOTION TEACHING TOOL 10 decreased sensations with these tests (Jensen, 2015; Shadow Health, 2019). The stereognosis and graphesthesia test were done to evaluate cortical sensory function, inability to identify objects may be an indication that the sensory cortex has been compromised resulting from a stroke. This may also be a result from a patient with diabetes who has neuropathy in the hands (Jensen, 2015; Shadow Health, 2019). The DTRs were assess for abnormalities such as hypo or hyperreflexia, and the presence of clonus which can be an abnormal neurological finding. The last test was the monofilament test. This test was completed to her bilateral feet to assess sensation related to her diabetic neuropathy. D. Established Norms Based on my assessment findings, each of Ms. Jones’ body systems has been broken down and described as established norms for the healthy adult, versus what was found on the assessment as an abnormal finding. The established norms for a healthy adult should reveal in the HEENT assessment, pigmentation that is consistent throughout the body, no lesions, no pustules, benign freckles and moles, no wounds or ecchymosis. Hair should be equally and symmetrically distributed across the scalp, hair shafts smooth, shiny, no evidence of breakage or infestations. Eyes should have steady gaze, movement should smooth and symmetrical, PERRLA, and sclera be clear and free from infection. Vision should be 20/20, inspection to the interior eyes should reveal no retinopathic changes or hemorrhages noted, and peripheral vision intact (Jensen, 2015; Shadow Health, 2019). The normal ear assessment reveals no signs or symptoms of infection, perforation or scar tissue on the tympanic membrane, patient can repeat words heard on the whisper test without errors Nasal mucosa should be moist, septum midline, no bleeding, swelling, polyps or exudate present. Frontal and maxillary sinuses should be nontender. The thyroid should be
HEALTH PROMOTION TEACHING TOOL 11 smooth with no nodules or goiter present. There should be no lymphadenopathy to the axillary and supraclavicular lymph nodes. Oral mucosa should be moist without ulcerations or lesions noted, uvula should be found at the midline (Jensen, 2015; Shadow Health, 2019). In my assessment, Ms. Jones’ findings on the HEENT assessment revealed her visual acuity was 20/20
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