Ears, MNTS, Thorax and Lungs, Breast

• Epistaxis


  Nose bleeds (Kiesselbach plexus - vessels)
• Ludwig Angina


  Infection in floor of the mouth which is a swelling that pushes the tounge up and back causing airway obstruction.
• Aspiration


  Occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed.
• Abrupt loss of sense of smell


  May indicate a brain tumor.
• Where is Palatal Tori located?

  Roof of the mouth
• Where is Tori located?

  Bottom of the mouth
• Specialty Techniques for Ear Assessment

  Audiogram, Rinne Test, Weber Test, and Rombers Test
• What test used for hearing acuity?

  Whisper Test
• Whisper Test


  Evaluates for loss of high frequency sounds.
• Rinne Test


  To determine whether the hearing is equal in both ears.
• Weber Test


  Differentiate the cause of unilateral hearing loss.
• Romberg Test


  Testing for balance
• What you should inspect in the ears?

  Symmetry, tone is uniform
• What parts you will palpate in ears?

  Auricle/pinna, and masoid
• Normal findings in Ear Assessment

  * Tympanic membrane is pearly gray with well-defined landmarks

  * Light reflex present at 5 o'clock in right ear and 7 o'clock in left ear

  * Tympanic membrane moves when patient blows against resistance

  * No redness, swelling, tenderness, lesions, drainage, foregn bodies
• Abormal findings in Ear Assessment

  * Chalky patches on tympanic membrane

  * Severe pain

  * Redness, swelling, narrowing, pain

  * Drainage

  * Hard, dry, very dark yellow cerumen

  * Reddened tumpanic membrane
• Common Nursing Diagnosis associated with Ear


  * Impaired Sensory perception

  * Acute pain

  * Risk for infection
• Common Nose, Sinus & Mouth Symptoms


  * Facial pressure/pain/headache

  * Snoring or Sleep Apnea

  * Obstructive breathing

  * Epistaxis or nose bleed

  * Halitosis or bad breath

  * Ansomia or decreased or loss of smell

  * Cough

  * Pharyngitis or sore throat

  * Dysphagia or difficulty of swallowing

  * Dental aching/pain

  * Hoarsness or voice changes

  * Oral lesions
• Laboratory & Diagnostic Testing for NMTS


  * Blood Studies

  * Nasal Sinus Cultures

  * Biopsies

  * Throat Culture

  * Allergy Testing (Rarioallergosobent testing)

  * Radiologic Studies (CT Scan/MRI)
• Common Nursing Diagnosis associated with NMTS

  * Impaired Dentition

  * Impaired oral mucous membrane integrity

  * Impaired swallowing

  * Ineffective breathing pattern
• Nursing Interventions related to NMTS


  * Provide oral hygiene every 8 hours

  * Consult with a speech therapist to evaluate swallowing

  * Push fluids to 2 liters to liquefy secretions
• Leukoplakia


  Chalky, white, thick, raised patch with weill-defined boarders
• Baby Bottle Decay


  Occurs in toddlers who take a bottle of milk, juice, or sweetened drink to bed and prolong bottle-feeding past the age of one year
• Black Hairy Tongue


  From over use of antibiotics, hydrogen peroxide, or smoking
• Cleft lip and palate


  The malformation of the palate
• Mucocele


  A pocket of mucus that forms when a minor salivary glands are occlude
• Allergic Rhinitis

  * Also called as Rhinorrhea.

  * Itching of nose and eyes, nasal congestion, and sneezing.
• Perforated Septum


  A hole in the spetum, usually in the cartilaginous part, may be caused by snorting cocaine, chronic infection, trauma from continual picking of crusts, or nasal surgery.
• Acute Tonsillitis and Pharyngitis


  Bright red throat; swollen tonsils, white or yellow exudate on tonsils and pharynx, with swolen uvula.
• Bifid Uvula


  May indicate a submucus cleft plate.
• Common Respiratory Symptoms


  * Chest pain or discomfort

  * Dyspnea or difficulty in breathing

  * Orthopnea or paroxysmal nocturnal dyspnea

  * Cough

  * Sputum or phlegm produced from cough

  * Wheezing or tightness in chest

  * Change in functional ability
• Vesicular Breath


  Sounds are soft, low pitched, and found over fine airways near site of air exchange (lung periphery)
• Bronchial Breath Sound


  Loud, high pitched and found over the trachea and larynx
• Bronchovesicular Breath Sounds


  Found more centrally, over major bronchi that have fewer aveoli
• Wheezing


  It can be heard when there is an airway obstruction such as when you listen to a patient with mild to moderate asthma during an exacerbation.
• Fine Crackles or Rales

  A high pitched sound mostly heard in the lower lung bases. This can be abnormal findings on physical exam suggestive of things like congestive heart failure, pneumonia or atelectasis.
• Coarse Crackles


  Low pitched lung sounds heard in pathologies such as chronic bronchitis, bronchiectasis, pneumonia, and severe pulmonary edema. They are often louder and longer in duration and lower in pitch.
• Squawks


  Short inspiratory wheezes in late inspiration often preceded by late inspiratory crackles.
• Pleural Rub


  nonmusical, short, biphasic explosice sound. It occurs due to inflamed pleural surface rubbing each other during breathing.
• Stridor


  loud, high-pitched, mainly inspiratory, musical soundproduced by upper respiratory tract obstruction. It is louder over the neck than chest wall. It is caused by the turbulent flow passing through a narrowed segment of the upper respiratory tract.