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Tuning fork
measure hearing by AC (air conduction) and BC (bone conductivity)
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Weber's test
- Place tuning fork on top of head in the center, patient should be able to feel the vibrations in both ears.
- determines conductive or sensorineural hearing loss
- Conductive loss = client “hears” the sounds in their poor ear. The good ear is distracted
- by background noise, conducted air, which the poor ear has trouble hearing. Thus the poor ear receives most of the sound conducted by bone vibration.
- With sensorineural loss the client reports lateralization of sound to the good ear, because of limited perception of the sound due to nerve damage in the bad ear, making sound seem louder in
- the unaffected ear.
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Conductive hearing loss
hearing loss due to problems with the bones of the middle ear
- Weber's : CAM
- Conductive - Affected ear - Mechanical problem
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Sensorineural hearing loss
hearing loss due to failure of the auditory nerve
Weber's test : SUN- Sensorineural - Unaffected ear - Nerve damage
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Rinne Test
- striking a tuning fork and placing behind the person's ear (mastoid) to measure BC. ask the person to tell you when they cannot hear the sound anymore, then move the fork right by the ear canal to measure AC.
- AC is normally twice as long as BC
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Aging adult ear
- ear drum may be more opaque, thicker, and duller than in younger adult
- coarse hair at ear canal
- elasticity loss of pinna (wrinkling)
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Presbycusis
gradual nerve degeneration in ear
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Labyrinthitis
- inflammation of the bony labyrinth, which are a series of intricate structures in the inner ear that play a role in hearing and balance.
- causes vertigo
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Relationship-based healthcare focuses on
holistic health
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What question would the nurse ask to determine the patient’s ADL?
Do you need assistance getting bathed?
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According to Leavell & Clark levels of prevention a patient receiving a vaccine is utilizing
primary prevention
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The nurse is caring for a patient with a infectious drainage from an abdominal wound. The nurse would wear gloves and
a gown
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What website would you access to determine the status of an ecoli outbreak in Mexico?
WHO.int
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Skin Physical Exam
- Inspect and Palpate
- Color
- Temperature
- Moisture
- Texture
- Edema
- Bruising
- Lesions
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Measuring Edema
- press down on area and measure:
- +1 : 2 mm
- +2 : 4 mm
- +3 : 6 mm
- +4 : 8 mm
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Inspecting Nails
- •Shape and contour: profile
- •Consistency
- •Color: Capillary
- refill
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Aging Skin
•Loss of elastin, collagen, subcutaneous fat
•Reduction of muscle tone
•Wrinkling occurs because the underlying dermis thins
•Sweat glands decrease in number
•Senile purpura - skin discoloration (purple marks)
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Aging Hair/Nails
- •Decreased functioning melanocytes causing hair to turn grey and thin
- •Change in hair distribution
- •Female facial hair
- •Nails may appear thickened, yellow, and brittle because
- of decreased circulation in extremities.
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Convergence
- the occurrence of two or more things coming together
- happens with accommodation
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Consensual
light on opposite pupil
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Macular Degeneration
loss of central vision
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Cataract
- an eye disease that involves the clouding or opacification of the natural lens of the eye
- decreases night vision
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Peripheral Vision Test
confrontation test (moving objects)
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Red Reflex
light off inner retina
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Extraocular eye muscles test
6 cardinal fields of gaze (H test)
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Aphthous Ulcers
canker sore
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Older Adult (nose, mouth, and throat)
- Oral mucosa is often drier and more fragile due to degeneration of epithelial lining
- of salivary glands.
- Ability to smell and taste decreases with age.
- Tooth surface become abraded.
- Gums recede and the teeth erode at the gum line
- Cavities form around the neck of the tooth, exposing the nerve and making the tooth hypersensitive.
- Some tooth loss may occur from bone resorption (osteoporosis)
- Natural tooth loss is exacerbated by years of inadequate dental care
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Early signs of oral cancer include:
- A sore that does not seem to heal
- A smooth or leathery white patch or lump
- A prolonged sore throat or feeling that something is in the throat
- Difficulty chewing
- Restricted movement of the tongue or jaw
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