NR 302Exam 2 review

Eyes- Chapter 14
1. ASSESSMENT OF THE EYES
a. PERRLA- Pupils Equal Round Reactive (to) Light Accommodation
b. Cardinal Gaze looking for muscle weakness in movement
c. Visual Fields- assess peripheral vision; use confrontation test for children
2. EYE EXAMINATION - summary
a. Test visual acuity
i. Snellen eye chart
1. The larger the denominator, the poorer the vision
2. Use a picture chart for those who cannot read
ii. Near vision 40yoa+
1. Using a Jaeger card, the client should test their near vision
2. Normal result is 14/14 (inches the card is held away from eye/normal person can read the card at)
b. Test visual fields- Confrontation test
i. Tests for loss of peripheral vision; compares clients peripheral vision with yours
ii. You cover your opposite eye from the patient with the opaque cards and test the peripheral vision by moving a finger
from the center to different periphery directions. Ask the client to say now when they can first see the finger coming
from different directions (50 degrees upward, 90 degrees temporally, 70 degrees inferiorly, 60 degrees nasally) pg 292
c. Inspect extraocular muscle function
i. Corneal Light Reflex (Hirschberg Test)
1. Assessing the parallel alignment of the eye axes by shining a light toward persons eyes
2. Tell the client to look straight forward. Shine the light from 12 inches away
3. The lights reflection should be in the same place on the cornea in both eyes
a. Asymmetry indicates muscle weakness or paralysis
ii. Cover test (if indicated)
iii. Diagnostics Positions Test
1. Normal response is parallel tracking of the object or finger with both eyes when completing the H test or
cardinal gaze.
2. Testing for any muscle weakness
d. Inspect external eye structures
i. General avoiding obstacles and relaxed facial expression
ii. Eyebrows symmetry, no scaling or lesions
iii. Eyelids and lashes skin is intact without redness, swelling, discharge, or lesions; eyelashes are distributed evenly
iv. Eyeball alignment no protrusion or sunken appearance (blacks may have a slight protrusion)
v. Conjunctiva and sclera inspect orbital rim; eyeball looks moist and glossy; conjunctiva is clear; pink over the lower
lids and white over the sclera; dark skinned people have small brown macules on sclera and yellowish fatty deposits
beneath the the lids away from the cornea(do not mistake for jaundice)
vi. Lacrimal apparatus with your thumbs, slide the outer part of the upper lid up along the bony orbit to expose under the
lid; inspect for redness or swelling
e. Inspect anterior eyeball structures
i. Cornea/lens shine a light from side and check for smoothness and clarity; look for any areas of cloudiness
ii. Iris/pupil normally appears flat, with a round regular shape and coloration;
1. Size, shape, equality 3-5 mm for adult; small amount of ppl have anisocoria
2. Pupillary light reflex darken the room (pupil dilation) and shine a light from the side and check for
constriction; should see direct light reflex(of same side pupil) and consensual light reflex(other eyes pupil)
3. Accommodation checking for pupillary constriction and convergence on the axes of the eyes; client stares at
something far away and then at your finger held 3 inches from clients nose
f. Inspect ocular fundus(internal surface of retina)
i. Optic disc
1. Color creamy yellow-orange to pink
2. Shape round or oval
3. Margins distinct and sharply demarcated, although the nasal edge may be slightly fuzzy
4. Cup-disc ratio distinctness varies; when visible, physiologic cup is a brighter yellow-white than rest of the
disc; its width is not more than one-half the disc diameter
ii. Retinal vessels
1. Number paired artery
2. Color arteries are brighter than veins
3. Artery-vein ratio 2/3 or 4/5 for artery and vein width
4. Caliber arteries and veins show a regular decrease in caliber as they extend to the periphery
5. Arteriovenous crossings an artery and vein may cross paths; if outside of 2 DD(diameter of the disc), then
there is a problem
6. Tortuosity mild vessel twisting
7. Pulsations are present in veins near the disc as their drainage meets the intermittent pressure of arterial
systole

3.

4.

5.

6.

iii. General background of the fundus color varies from light red to dark brown-red, generally corresponding with the
persons skin color. Your view of the fundus should be clear; no lesions should obstruct the retinal structures.
iv. Macula 1 DD in size and located 2 DD temporal to the disc; inspect last because it can cause some watering and
discomfort and pupillary constriction. The normal color of the area is somewhat darker than the rest of the fundus but is
even and homogeneous.
ASSESSMENT OF CRANIAL NERVIE V(Trigeminal Nerve)
a. Motor: Palpate from temporal down jawline; should be equally strong on both sides
b. Sensory: Assessing patients ability to feel touch to forehead, cheeks, and chin; have patient close eyes and use a cotton wisp to
touch face
DISCUSS THE FOLLOWING
a. Hyperopia- farsighted
b. Presbyopia- decreased in power of accommodation with aging; near vision
c. Myopia near sighted
d. Astigmatism abnormal lens shape; distorted vision
USE OF OPTHALMOSCOPE
a. Hold the thing right up to your eye, braced firmly against the cheek and brow. Extend the index finger onto the lens selector dial
so you can refocus as needed during the procedure without the taking your head away from the thing. Keep both your eyes open;
just view the field through the thing
ABNORMALITIES
a. Acute Glaucoma (Glaucoma = an optic nerve neuropathy characterized by loss of peripheral vision cause by increased
intraocular pressure) sudden increase in intraocular pressure; pupil is oval, dilated; cornea looks steamy; anterior chamber is
shallow; sudden clouding of vision; sudden eye pain; halos around lights; requires emergency treatment
b. Myopia (in assessment with ophthalmoscope) the globe is longer than normal and light rays focus in front of the retina; to
compensate use a negative diopter(red number or concave lens)
c. Hyperopia (in assessment with ophthalmoscope) the globe is shorter than normal; the light rays would focus behind the retina;
to compensate use a positive diopter
d. Astigmatism - a refractive disorder caused by a change in the normally round curvature of the cornea. The change causes light
refraction to focus on two areas on or near the retina resulting in blurred or double vision.
e. Presbyopia (in assessment with Jaegar card) when the person moves the card farther away
f. Ectropion- lower eyelid is loos and rolling out; does not approximate to eyeball; excess tearing because tears do not drain
correctly over corner and toward medial canthus; eyes feel dry and itchy; increased risk for inflammation of conjunctiva; occurs
in aging as a result of atrophy of elastic and fibrous tissues but may result from trauma
g. Entropion lower lid rolls inward because of spasm of lids or scar tissue contracting; constant rubbing of lashes may irritate
cornea; feels a foreign body sensation
h. Ptosis(dropping upper lid) neuromuscular weakness; oculomotor cranial nerve III damage, or sympathetic nerve damage; a
positional defect that gives a person a sleep appearance and impairs vision
i. Blepharitis (inflammation of eyelids) red, scaly, greasy flakes and thickened, crusted lid margins occur with staphylococcal
infection or seborrheic dermatitis of the lid edge; burning, itching, tearing, foreign body sensation, and some pain
j. Anisocoria- unequal pupil size; CNS disease even though it appears in 5% of population
k. Periorbital Edema- occurs with local infxn, crying, systemic conditions(congestive heart failure, renal failure, allergy,
hypothyroidism); lids are swollen and puffy, lid tissues are loosely connected; excess fluid is apparent
l. Exophoria (during cover test) the pupil of the covered eye will have a temporal(outward) drift when the cover is taken off
m. Strabismus- squint, cross eyed; important screen measure between ages 3 and 5; causes disconjugate vision because one eye
deviates off the fixation point; to compensate, the brain begins to suppress data from the weaker eye causing visual acuity in
other eye to begin to deteriorate from disuse
i. Esotropia- inward turning of eye
ii. Exotropia- outward turning of eye
n. Esophoria (during cover test) the pupil of the covered eye will have a nasal(inward) drift when the cover is taken off
o. Mydriasis- dilated and fixed pupils; stimulation of sympathetic nervous system, reaction to sympathomimetic drugs, use of
dilating drops, acute glaucoma, or past or recent trauma; sign of CNS injury, cardiac arrest, or deep anesthesia

Ears- Chapter 15
1. ASSESSMENT OF EAR
a. Tympanic Membrane
2. EAR EXAMINATION
a. Inspect external ear
i. Size and shape of auricle microtia(ears smaller than 4cm); macrotia(ears larger than 10cm)
ii. Position and alignment on head- symmetric
iii. Note skin condition (color, lumps, lesions) skin color is consistent with facial color; no lumps or lesions; Darwins
tubercle is a small, painless nodule at the helix which is not significant
iv. Check movement of auricle and tragus for tenderness move the pinna and push on the tragus. They should feel firm
and movement should produce no pain; palpating mastoid process also does not produce pain; pain anywhere indicates
inflammation
v. Evaluate external auditory meatus (note size, swelling, redness, discharge, cerumen, lesions, foreign bodies)- some
cerumen is usually present; color varies from gray-yellow to light brown and black

b.

Otoscopic examination tilt the persons head slightly away from you toward the opposite shoulder; pull the pinna up and back
on an adult; hold the pinna gently but firmly; do not release traction on the ear until you have finished the examination and the
otoscope is removed
i. External canal- note the size of the meatus
ii. Cerumen, discharge, foreign bodies, lesions make sure there is nothing that is not supposed to be there
iii. Redness or swelling of canal wall- there should be none, only with infection(otitis)
c. Inspect tympanic membrane
i. Color and characteristics-shiny and transluscent, with a pearly gray color; cone of light is 5oclock in right ear and
7oclock in the left year(reflection of otoscope light); yellow-amber occurs with OM with effusion; red color with acute
OM
ii. Note position (flat, bulging, retracted)- the eardrum is flat and slightly pulled in at the center; retracted drum is caused
by vacuum in middle ear with obstructed Eustachian tube; bulging drum is caused by increased pressure in OM.
iii. Integrity of membrane-inspect for perforations or scarring(perforations shows as a dark oval area or as a larger opening
on the drum; scarring indicates repeated ear infections)
d. Test hearing acuity
i. Note behavioral response to conversational speech
1. Person lip-reads or watches your face and lips closely rather than your eyes
2. Frowns or strains forward to hear
3. Postures head to catch sounds with better ear
4. Misunderstands your questions or frequently ask you to repeat
5. Acts irritable or shows startle reflex when raising voice(recruitment)
6. Persons speech sounds garbled, possibly vowel sounds distorted
7. Inappropriately loud voice
8. Flat, monotonous tone of voice
ii. Whispered voice test- whispering three letters or numbers or both two feet away from the patient
1. Used to check if there is a high-tone loss
iii. Tuning Fork Tests-measure hearing by air conduction(AC); not recommended for use in the practices
1. Weber Test hit tuning fork place on frontal lobe; patient should hear sound equally loud in both ears and
sound does not lateralize
2. Rinne Test- hit tuning fork place on mastoid bone (patient should state when the sound stops) place
outside of ear(patient should state when the sound stops); sound tis heard twice as long by air conduction as
by bone conduction(BC); AC>BC
iv. Romberg Test measures ability of the vestibular apparatus in inner ear to help maintain standing balance; also asseses
cerebellum and proprioception
3. FUNCTIONS OF CERUMEN
a. Lubricates and protects the ears; sticky barrier that helps keep foreign bodies from entering and reaching the sensitive tympanic
membrane
4. USE OF OTOSCOPE
5. TERMS TO KNOW
a. Presbycusis- hearing loss occurs with 60% of those 65yoa+
b. Cranial Nerve VIII- Vestibucochlear nerve
c. Otosclerosis- common cause of conductive hearing loss in young adults between 20-40yoa; bone formation that impedes the
transmission of sound and causes progressive deafness
d. Objective vertigo- feels as if room spins
e. Subjective vertigo- feels as if person is spinning
Neck, Lymph Nodes Chapter 16
1. ASSESSMENT OF NECK, TRACHEA, LYMPH NODES
a. Neck- muscles should be symmetric
i. Range of Motion- note for any limitations
ii. Any nodes palpable? Should be moveable, discrete, soft, and nontender
b. Trachea is midline (note for tracheal shift); should be symmetric on both sides
c. Lymph Nodes
i. Preauricular, posterior auricular, occipital, submental, submandibular, jugulodigastirc, superficial cervical, deep
cervical, posterior cervical, supraclavicular
2. CAN YOU FEEL LYMPH NODES
a. YES
b. Normal modes should feel soft, moveable, discrete, and nontender
c. Should be assessed in systemic order so you do not forget one
d. If nodes are enlarged or tender, check the area they drain to for source of problem
e. Lymphadenopathy- enlargement of lymph nodes (>1 cm) from infxn, allergy, or neoplasm
3. ASSESSMENT OF HYPOTHYROIDISM/ HYPERTHYROIDISM
a. Hypothyroidism deficiency of thyroid hormone (therefore decreased metabolism)
i. Inspection: fatigue; cool, dry skin; puffy hands, feet, face; coarse hair; puffy eyes****(puffy= edema)
b. Hyperthyroidism increased production of thyroid hormone from overactive gland (increased metabolism)
i. Inspection: nervousness, fatigue, bulging eyeballs, infrequent blinking, shortness of breath
4. THYROID DISEASE AND IODINE

a.
b.
c.

Function: produces thyroid hormone in sufficient amount to meet bodys needs

i. To produce thyroid hormone, iodine is needed
Insufficient iodine leads to a reduction of thyroid hormone, which leads to enlargement of thyroid gland (goiter, mental
retardation with children)
Iodine
i. Adult: 150mcg/daily
ii. Children 90-120 mcg/daily
iii. Pregnant 200 mcg/daily

Head Chapter 13
1. HEAD ASSESSMENT
a. Normocephalic a term that denotes a round symmetric skull that is appropriately related to body size. Be aware that normal
includes a wide range of sizes
i. To assess shape, place your fingers in the persons hair and palpate the scalp. Cranial bones that have normal
protrusions are: forehead, side of parietal, occipital, mastoid process behind ear
b. Migraine headache occur about twice a month each lasting one to three days; alcohol, stress, menstruation, eating chocolate
and cheese precipitate migraines; n/v, visual disturbances are associated with it; associates with family history of migraines;
commonly one sided; pain is behind the eyes, the temples or forehead; throbbing, pulsating pain; aura, prodrome, photophobia,
phonophobia; ab pain; person looks sick
i. Interventions: lie down; darken room; use eyeshade; sleep; take NSAID early, try to avoid opiod
c. Hydrocephalus obstxn of drainage of CSF
i. Face looks small compares with enlarged cranium; dilated scalp veins; frontal bossing; setting sun eyes; cranial
bones thin, sutures separate, percussions reveals a cracked pot sound
d. Acromegaly excessive secretion of growth hormone; enlarged skull and thickened cranial bones
i. Elongated head, massive face, overgrowth of nose and lower jaw, heavy eyebrow ridge, and coarse facial features
e. Facial deformities
i. Fetal alcohol syndrome severe cognitive and psychosocial impairment
1. Short palpebral fissures, flat midface, short nose, indistinct philtrum, thin upper lip, epicanthal folds, low nasal
bridge, minor ear abnormalities, micrognathia
ii. Down syndrome upslanting eyes with inner epicanthal folds, flat nasal bridge; small, broad, flat nose; protruding,
thick tongue, ear dysplasia; short, broad neck with webbing; small hands with single palmar crease
2. HEAD, FACE, AND NECK, INCLUDING REGIONAL LYMPHATICS EXAMINATON
a. Inspect and palpate the skull
i. General size and contour- normocephalic (symmetric and smooth)
ii. Note any deformities, lumps, or tenderness
iii. Palpate temporal artery, temporomandibular joint
1. Palpate the temporal artery above the zygomatic bone between the eye and top of the ear
2. The temporomandibular joint is just below the temporal artery and anterior to the tragus. Palpate the joint as
the person opens the mouth and note normally smooth movement with no limitation or tenderness
b. Inspect the face
i. Facial expression is appropriate to behavior and reported mood
ii. Symmetry of movement(cranial nerve VII) expect symmetry of eyebrows, palpebral fissures, nasolabial folds, and
side of the mouth
1. Marked asymmetry with central brain lesion or peripheral cranial nerve VII damage (Bell palsy)
iii. Any voluntary movements, edema, lesions
1. Edema in the face occurs first around the eyes and the cheeks where the subQ tissue is relatively loose
2. Note grinding of jaw, tics (involuntary), fasciculation, or excessive blinking
c. Inspect and palpate the neck
i. Active ROM
1. Ask person to touch chin to chest, turn head right and left, try to each eat to the shoulder (w/o elevating
shoulders), and extend head backwards should be smooth and controlled
2. Test cranial nerve XI by resisting the person as they shrug their shoulders and turns their head to each side
3. Note enlargement of salivary and lymph glands
4. Note any pulsations
ii. Enlargement of salivary glands, lymph nodes, thyroid gland
1. If any nodes are palpable, note their location, size, shape, delimitation, mobility, consistency, and tenderness.
Normal nodes feel movable, discrete, soft, and nontender
2. Swellings on Head or Neck
a. Toricollis (Wryneck) hematoma inn one sternomastoid muscle, causing head tilt to one side
b. Simple Diffuse Goiter chronic enlargement of thyroid gland
c. Thyroid-Multinodular Goiter
d. Pilar Cyst(Wen) swelling on scalp that contains sebum and keratin
e. Parotid Gland Enlargement AIDS, mumps
iii. Position of trachea
1. Conditions of tracheal shift

a.

3.

4.

Pushed to unaffected or healthy side aortic aneurysm, tumor, unilateral thyroid lobe enlargement,
pneumothorax
b. Pulled toward the affected or diseased side large atelectasis, pleural adhesions, fibrosis
d. Auscultate thyroid (if enlarged) for bruit
i. Bruit is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope
INFANT SKILL ASSESSMENT- growth of head predominates growth of chest; a newborns head may feel asymmetric and the involved
ridges more prominent because of the molding of the cranial bones during engagement and passage through the birth canal (this only
lasts for a few days or a week after birth)
a. Anterior and Posterior fontanels fontanels are spaces where the sutures intersect
i. Gently palpate the skull and fontanels while the infant is clam and somewhat in a sitting position (crying, lying down,
or vomiting may cause the anterior fontanel to look full and bulging
ii. The skull should feel smooth and fused except at the fontanels; the fontanels feel firm, slightly concave, and well
defined against the edges of the cranial bones
iii. Anterior fontanel- may see slight arterial pulsations; may be small at birth and enlarge to 2.5cm*2.5cm; closes between
nine months and two years
iv. Posterior fontanels- may not be palpable at birth; if it is, is measures 1 cm and closes by one to two months
b. Bulging Fontanels
i. Occurs with acute increased intracranial pressure
BRADEN SCALES AND PRESSURE ULCERS
a. Braden Scale used to assess the risk for obtaining a pressure ulcer. The greater the number, the lower the risk.
i.
b.
Pressure
Ulcer
Stages
i.
Stage
One
intact
skin
appears
red but

unbroken; localized redness without blanching

ii. Stage Two partial thickness skin erosion with loss of epidermis or also the dermis; looks shallow like an abrasion or
open blister with red-pink wound bed
iii. Stage Three full thickness ulcer extending into the subQ and resembling a crater; may see fat but not muscle, bone or
tendon
iv. Stage Four full thickness involves all skin layers; exposes muscle, tendon, or bone; may show slough or eschar
***once ulcer reaches stage three or four, the wound size must be measured weekly to provide info about wound healing***
Skin, Nails, Hair Chapter 12
1. SKIN, HAIR, AND NAILS EXAMINATION
a. Inspect the skin
i. Color
ii. General pigmentation
iii. Areas of hypopigmentation, hyperpigmentation
iv. Abnormal color changes
b. Palpate the skin
i. Temperature use dorsa of hands to palpate the person; should be warm skin; hypothermia and hyperthermia are bad
ii. Moisture look for diaphoresis or dehydration
iii. Texture normal skin feels smooth and firm
1. Hyperthyroidism skin feels smother and softer like velvet
2. Hypothyroidism skin feels rough, dry, and flaky
iv. Thickness uniformly thin over most of body, except where callus forms
v. Edema masks normal skin color and obscures patho conditions b/c the fluid lies between the surface and the
pigmented and vascular layers

2.

3.

4.

vi. Mobility and turgor check near the clavicle; mobility = ability of skin to rise; turgor = ability of skin to return to place
promptly when released
vii. Vascularity or bruising
c. Note any lesions
i. Asymmetry
ii. Border change
iii. Color change
iv. Diameter greater than 6mm
v. Elevation or evolution
d. Inspect and palpate the hair
i. Texture fine or thick hair
ii. Distribution vellus hair is all over body; terminal hairs grow at eyebrows, eyelashes, and scalp
iii. Any scalp lesions
e. Inspect and palpate the nails
i. Shape and contour slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded
ii. Consistency- surface is smooth and regular; nail thickness is uniform
iii. Color- translucent nail plate with pink nail bed underneath; dark skinned have brown-black pigmented areas or linear
bands or streaks along nail edge
f. Teach skin self-examination
ASSESSMENT FOR
a. Adolescence
i. acne
b. Older Adult
i. Keratosis(seborrheic and actinic)
ii. Xerosis, acrochordons(overgrowths of normal skin that form a stalk and are polyp like), Thinner skin, rate of hair
growth decreases, nail growth rate decreases, decreased skin turgor
c. Darker Skin tones
i. Keloids, Pseudofolliculitis, Melasma
ii. Have areas of lighter pigmentation on the palms, nail beds, and lips
DISCUSS
a. Xerosis- dry skin
b. Pruritus skin itching
c. Psoriasis
d. Lichenification prolonged, intense scratching eventually thicken skin and produces tightly packed sets of papules; looks like
moss
e. Vesicle elevated cavity containing free fluid, up to 1cm (ex. Blister, herpes simplex, chickenpox, shingles, contact dermatitis)
f. Macule- spot less than 1cm (ex. Freckles, flat nevi, petechiae)
g. Papule- something you can feel that is less than 1cm (ex. Mole, lichen planus, wart)
h. Tumor larger than a few cm in diameter firm or soft, deeper into dermis
i. Milia common variation; tiny white papules on the cheeks and forehead and across the nose and chin caused by sebum that
occludes the opening of the follicles.
j. Stork bites common vascular birthmark; salmon patch flat, irregularly shaped red or pink patch found on the forehead,
eyelid, or upper lip; fades during the first year
k. Mongolian spots common variation of hyperpigmentation in Black, Asian, American Indian, and Hispanic newborns; blue to
black to purple macular areas at the sacrum or buttocks; caused by deep dermal melanocytes; gradually fades during the first
year
l. Ecchymosis purplish patch resulting from extravasation of blood into skin, >3mm in diameter
m. Purpura confluent and extensive patch of petechiae and ecchymoses; >3mm
n. Petechial tiny punctuate hemorrhages, 1-3mm, round and discrete, dark red, purple, or brown in color
o. Bulla larger than 1cm; usually single chambered; ruptures easily (ex. Burns, pemphigus, friction blister)
p. Wheal superficial, raised, transient, erythematous slightly irregular shape from edema (ex. Mosquito bite, allergic rxn)
q. Nodule solid, elevated, hard or soft, larger than 1 cm
r. Uremia
s. Cyanosis- bluish mottled color from decreased perfusion; do not confuse cyanosis with common and normal bluish tone on the
lips of dark-skinned persons of Mediterranean origin
t. Jaundice- yellowish skin color indicated rising amounts of bilirubin in the blood
u. Carotenemia produces a yellow orange color in light skinned persons but no yellowing in sclera or mucous membranes;
caused by ingesting excessive amounts of foods that are high in carotene, a Vitamin A precursor
v. Hirsutism shaggy or excessive hair
CLUBBING OF NAILS
a. In early clubbing the angle straightens out to 180 degrees and the nail base feels spongy to palpation. Then the nail becomes
convex as the digit grows. Cause: congenital cyanotic heart disease, lung cancer, and pulmonary diseases