Nursing Fundamentals II HEENT, Pain, Sleep, IVs

olanjones's version from 2016-07-19 15:43

HEENT Physical exam

Question Answer
HeadObserve: Size in relation to body, Symmetry, Facial structure, Eye/Jaw movement - Inspect and palpate skull, face, hair, scalp
EyesInspect skin/lashes, symmetry of eyebrows, lacrimal processes, conjunctiva, sclera, cornea, iris, EOMs (6 muscles); Red reflex (with ophthalmoscope), Hirschberg test (corneal light reflection), PERRLA
EarsInspect external ear (size, shape, position); Move pinna, push tragus, feel mastoid process; Inspect external auditory canal & TM (color, position, clarity, mobility), light reflex (5:00 in R ear, 7:00 in L), Hearing acuity (normal volume & whisper)
NoseInspect shape, nostrils (flaring?), signs of inflammation, septum, patency (insert tip of speculum 1 cm); Palpate external nose, sinuses, Transillumination (with pen light)
MouthInspect lips, buccal mucosa, gums, teeth, tongue, hard & soft palate, throat/tonsils, floor of mouth
PharynxInspect position, size, color general appearance of tonsils & uvula, gag reflex, presence of swelling, exudates, lesions

Eyes / Ears

Question Answer
Presbyopialoss of elasticity of lens, lack of accommodation for close objects (begins in 40s)
Astigmatismuneven curvature of cornea that prevents horizontal or vertical rays from focusing on the retina
Hyperopiafarsightedness; refractive error - light rays focus behind retina
Myopianearsightedness; refractive error - light rays focus in front of retina
Diplopiadouble vision
Mydriasisenlarged pupils
Miosiscontricted pupils
Aniscoriauneven pupils (can indicate a CNS disorder)
Amblyopia"lazy eye" reduced vision not correctable by corrective lenses and not caused by eye disease
Strabismus"cross eyed" eyes do not look in the same direction at the same time
Ptosisdrooping eyelid
Macular degenerationloss of center field of vision, can be dry (retina deteriorates), or wet (leaky blood vessel grow under retina)
Cataractsopacity of the lens or its capsule, not painful, occurs gradually (usually occurs around 65 or older)
Glaucomadisturbance in circulation of aqueous fluid which increases intraocular pressure causing optic nerve damage and loss of visual fields. Is preventable, painless, and permanent - leads to blindness if untreated
What are the three parts of the ear?external, middle, inner
Conduction hearing lossinterruption of the sound waves in the inner or outer ear via air conduction
Sensorineural hearing lossresult of damage to inner ear, CN VIII, or hearing center of the brain


Question Answer
Chronic painpersists 6 months or longer, pt may not mention pain until asked, continues beyond healing
Acute painmild to severe, client reports pain, resolves with healing
Visceral painarising from organs, or hollow viscera: poorly located, cramping, throbbing, aching
Physiologic painsignals tissue damage, signal is sent by properly functioning, intact nerves
Somatic painarising from damage to skin, muscle, bone, connective tissue: sharp, aching (type of physiological pain)
Neuropathic painarising from damaged or malfunctioning nerves: electrical, burning, zinging
Dysesthesiaunpleasant abnormal sensations (mimics patho of neuropathic pain)
What are the 4 phases of nociceptive pain pathway?Transduction (signal received), Transmission (signal travels to somatic sensory cortex), Modulation (message sent back down from brain to inhibit or intensify signal), Perception (subjective experience of pain)
What is the NIPS pain scale? Neonatal Infant Pain Scale (points for facial expression, crying, breathing, arms, legs, alertness)
What is the FLACC pain scale?Face, Legs, Activity, Cry, Consolability - used to assess children btwn 2 months - 7 years, or people who are unable to communicate their pain
What is the Wong-Baker pain scale?Facial expressions representing levels of pain - patient should choose the face that best decries his/her pain


Question Answer
What is sleep?an altered state of consciousness in which the individual's perception of & reaction to the environment are decreased
Why does wakefulness occur?Daylight causes less melatonin, Highest levels of cortisol are in the morning, Increased acetylcholine, dopamine, and noradrenaline
What is NREM sleep?non rapid eye movement; 75-80% of sleep is this type - it is essential for restoring energy and growth hormones. Deprivation can result in immunosuppression, low pain tolerance, fatigue, insulin resistance
What are the stages of NREM sleep?Stage I (very light), Stage II (light), Stage III (delta/deep)
What is REM sleep?rapid eye movement "dream-sleep"; occurs every 90 minutes (lasts 5-30 mins) - brain is highly active (learning, thinking, organizing regions of brain stimulated)
Insomniamost common sleep complaint, often due to worry/stress, often affects older people, females
What are interventions for insomnia?Stimulus control (create environment that promotes sleep), Cognitive therapy (develop positive thoughts/beliefs about sleep), Sleep restriction (limit time in bed in order to get to sleep/stay asleep)
Hypersomniasufficient sleep but cannot stay awake (CNS damage, kidney/liver/metabolic disorders, hypothyroid)
Parasomniasbehaviors that may interfere with sleep & may occur during sleep (bruxism, enuresis, somnambulism)
Narcolepsyexcessive daytime sleepiness caused by lack of hypocretin (sleep attacks, cataplexy)
What does a sleep assessment consist of?Sleep & Health history (rule out medical or psychiatric causes/meds), Physical exam, Sleep diary, Diagnostic studies (often in a sleep lab)
What sleep hygiene techniques may be used to improve sleep?Create a bedtime ritual with a restful and comfortable environment (noise, temp, light); Nurses should schedule care around patient's sleep to promote relaxation


Question Answer
Infiltrationunintended administration of nonvesicant drug/fluid into subcutaneous tissue: s/s coolness of skin around site, skin blanching/tautness, edema at/above/below insertion site, absence of or pinkish blood return, size difference from opposite arm/hand
Extravasationinfiltration of vesicant drug/fluid into subcutaneous tissue: s/s (same as infiltration plus) burning or stinging pain, redness followed by blistering, tissue necrosis, & ulceration
Phlebitisinflammation of the vein (can be mechanical, chemical, or bacterial): s/s redness at site, skin warm, swelling, palpable cord along the vein, increase in temperature
IV pump is based on volume, what is always standard about the drip rate?it is a micro drip factor - always 60 gtts/mL

Recent badges