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Health Assessment
HEENT
63
Nursing
Undergraduate 3
10/07/2009

Additional Nursing Flashcards

 


 

Cards

Term
Cluster Headaches
Definition

Occur more than once a day & last for less than 1 hour to about 2 hours; most painful

 

Unilateral with burning or stabbing pain over the eye, temple, forehead, & cheek; may occur w/ nasal stuffiness or discharge, red teary eyes, or drooping eyelids

 

Relieved with movement

Term
Migraine Headaches
Definition

Occur at periodic intervals, may last from a few hours to 1-3 days; occurs with menstrual periods

 

Unilateral with throbbing pain; may be accompanied by visual disturbances, nausea, & vomiting

 

Relieved with rest

Term
Sinus Headaches
Definition
Tenderness over frontal or maxillary sinuses
Term
Tension Headaches
Definition

Most common type

 

Gradual onset; front or back of the head; viselike (described as a tight band around head)

Term
Posttraumatic Headaches
Definition

Secondary to a head injury or concussion

 

Dull, generalized head pain; lack of ability to concentrate, giddiness, or dizziness

Term
Dizziness
Definition

Feeling of faintness experienced within the client

 

Have client define what he or she means by "dizziness" - what is the perception of movement?

Term
Virtigo
Definition

Sensation of movement, usually rotational motion such as whirling or spinning

 

Cardinal symptom of vestibular dysfunction

 

Subjective - sensation that one's body is spinning

Objective - sensation that objects are spinning around the body

Term
Presyncope
Definition
Feeling of faintness & impending loss of consciousness; often cardiovascular
Term
Disequilibrium
Definition
Feeling of falling; often a locomoter problem
Term
Presbycusis
Definition
Hearing loss associated with aging, particularly with high frequencies; occurs gradually
Term
Nasal Discharge
Definition

Bacterial infection - thick or purulent green-yellow, malodorous

 

Foreign body or chronic sinusitis - unilateral, foul-smelling

 

Allergies - watery

 

Neoplasm, trauma, or opportunistic infection (fungal disease) - bloody

 

Nose bleed (epistaxis) - secondary to trauma, chronic sinusitis, malignancy, or a bleeding disorder; cocaine abuse

Term
Hirshberg's test - Corneal Light Reflex
Definition

Light reflections should appear symmetrically in both corneas

 

Asymmetrical reflections - may indicate weak extraocular muscles

Term
Corneal Arcus
Definition
White opaque ring encircling limbus
Term
Coloboma
Definition
Congenital defect of the iris
Term
Iridodialysis
Definition
Circumferential tearing of the iris from the sclera caused by blunt trauma
Term
PERRLA
Definition

Pupils are

Equal

Round and

React to

Light and

Accomodation

 

Accomodation - remember C's and D's

- Pupils constrict when focusing on a close object

- Pupils dilate when focusing on a distant object

Term
Miosis
Definition
Pupillary constriction to less than 2 mm
Term
Mydriasis
Definition
Pupillary dilation greater than 6 mm
Term
Nystagmus
Definition
Involuntary movement of the eyeball
Term
Anisocoria
Definition
Unequal pupil size
Term
Glaucoma
Definition

Eyeball that is very firm and resists palpation; increase in intraocular pressure

 

Open-angle - no specific symptoms; gradual loss of vision

Closed-angle - complain of sharp eye pain & seeing a halo around lights

Term
Darwin tubercle
Definition
Small, painless nodule; normal deviation
Term
Cauliflower ear
Definition

Thickened, disfigured auricle; from repeated episodes of trauma

 

Children - suspect abuse

Term
Hematoma
Definition

Caused by a direct trauma from a contact sport or a blow to the side of the head

 

Children - suspect abuse

Term
Tophi
Definition

Small, hard, whitish yellow, nontender nodules on helix; contain uric acid crystals

 

Sign of gout

Term
Sebaceous Cyst
Definition
Nodule found behind earlobe in postauricular fold; very painful if it becomes infected
Term
Ear discharge
Definition

Bloody or clear - suspicion of possible skull fracture

 

Purulent or crusty - infection or presence of foreign body

Term
Vitamin B deficiency
Definition

Cracks & erythema in corners of mouth

 

Smooth or beefy-red colored, edematous tongue with slick appearance

Term
Caries
Definition
Brown spots in crevices or between teeth
Term
Malocclusion
Definition

Protrusion of upper or lower incisors or upper incisors that do not overlap the lower ones

 

Underbite

Term
Abnormal Tongues
Definition

Hairy tongue with yellow-brown to black elongated papillae - occurs secondary to antibiotic therapy, superinfection, or pipe smoking

 

Enlarged tongue - mental retardation or hypothyroidism

Term
Aphthous Ulcers
Definition

White, round, or oval ulcerative lesions with a red halo

 

Canker Sore

Term
Leukoplakia
Definition
White patch or plaque found on the oral mucosa that cannot be scraped off
Term
Erythroplakia
Definition
Red patch found on the oral mucosa
Term
Edematous & Erythematous Tonsils
Definition

With or without exudates - indicates infection

 

Grades:

1+ visible

2+ halfway between tonsilar pillars & uvula

3+ nearly touching the uvula

4+ touching each other

Term
Goiter
Definition

Enlarged thyroid; may be seen as fullness in the neck; seen in hypothyroidism

 

Hear a bruit (abnormally large volume of blood flow)

Term
Chalazion
Definition
Firm, nontender nodule in the eyelid
Term
Hordeolum (Sty)
Definition
Acute infection originating in the sebaceous gland of the eyelid; painful, red, & edematous
Term
Conjunctivitis
Definition
Inflammation of the palpebral or bulbar conjunctiva; eye appears red, w/ thick, sticky discharge on the eyelids in the morning
Term
Corneal abrasion or ulcer
Definition
Caused by incomplete lid closure or poor lacrimal gland function; Intense pain, foreign body sensation, & photophobia; Tearing and redness observed
Term
Strabismus
Definition

Abnormal ocular alignment in which the visual axes do not meet at the desired point

 

Nonparalytic (muscle weakness) or Paralytic (motor imbalance)

Term
Cataract
Definition

Opacity of the crystalline lens

 

Clients report cloudy or blurred vision, glare from lights, double vision, poor night vision; Red reflex is absent

Term
Diabetic Retinopathy
Definition

Changes in retinal capillaries

 

Described as a curtain coming down over eye; Blindness

Term
Thyroid Cancer
Definition

Most common type of endocrine malignancy

 

Usually no symptoms; as tumor grows - changes in voice & problems w/ swallowing or breathing

Term
Acute otitis media (AOM)
Definition

Infection of middle ear

Early stages - TM inflamed, red, bulging, immobile

Late stages - TM has discoloration (white & yellow drainage) & opacification

 

Purulent drainage w/ sudden relief of pain - suggests perforation

Term
Otitis media w/ effusion (OME)
Definition

Inflammation of the middle ear space resulting in accumulation of serous fluid

 

Clogged sensation, problems w/ hearing & balance; some report clicking or popping sound

 

TM is retracted & is yellow or gray w/ limited mobility

Term
Conductive Hearing Loss
Definition

Caused by interference of air conduction to the middle ear

 

Decreased ability to hear & reports muffled tones

Term
Sensorineural Hearing Loss (SNHL)
Definition

Caused by structural changes, disorders of inner ear, or problems w/ auditory nerve

 

Gradual & progressive bilateral deafness w/ a loss of high-pitched tones; have difficulty filtering background noise

Term
Rhinophyma
Definition

Hypertrophy of the nose caused by rosacea

 

Papules, pustules, telangiectasia, & tissue hypertrophy of the nose

Term
Candidiasis (Thrush)
Definition

Opportunistic oral infection

 

Soft white plaques on the tongue, buccal mucosa, or posterior pharynx

Term
Lymph Nodes
Definition

may or may not be palpable; should be soft, mobile, nontender, & bilaterally equal


enlarged, tender, & firm but freely moveable - infection of head or throat

 

unilateral, hard, asymmetric, fixed, & nontender - suspect malignancy

 

Occipital nodes - base of skull

Preauricular - front of ear

Postauricular - behind ear

Anterior & posterior cervical chain - w/in the neck

Parotid - along the angle of the jaw

Submental & submandibular - under the mandible

Supraclavicular - under the clavicle


Term
Cranial Nerve III (Oculomotor)
Definition

Pupils constrict

 

Looking up, looking down & away

Term
Cranial Nerve IV
Definition
Looking down & in
Term
Cranial Nerve V (Trigeminal)
Definition

Ophthalmic branch

 

Corneal reflex (blink)

Term
Cranial Nerve VI
Definition
Looking laterally, to the side
Term
Cranial Nerve VII (Facial)
Definition

Motor branch

 

Corneal reflex (blink)

Term
Cranial nerve VIII (Acoustic)
Definition
Tests auditory functioning; Vestibular function (balance)
Term
Cranial Nerve IX & X (Glossopharyngeal & Vagus)
Definition
Soft palate rises symmetrically w/ the uvula remaining in midline position
Term
Cranial Nerve XI (Spinal Accessory)
Definition
Shrug shoulders against the resistance of hands pressing down
Term
Cranial Nerve XII (Hypoglossal)
Definition
Protrusion of the tongue
Term
Weber's Test
Definition

Place tuning fork on the midline of client's skull; should hear tone equally in both ears

 

- Lateralization to affected ear suggests conductive hearing loss

- Lateralization to unaffected ear suggests sensorineural hearing loss

Term
Rinne Test
Definition

Compares air conduction of sound to bone conduction; should be AC>BC by 2:1

 

If BC>AC - conductive hearing loss

If AC>BC but less than 2:1 ration - sensorineural hearing loss

Term
Thyroid
Definition

Often not detected - considered normal

 

If felt: should feel small, smooth, soft, & should move freely during swallowing, should be nontender

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