NUR 306 Lecture 1: Nursing 306 Notes 2nd Half
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If sudden and severe, consider subarachnoid hemorrhage related to head injury, meningitis, or stroke: nausea and vomiting. Inspect trachea for any deviation: feel for any deviation, spaces should be symmetric, should be midline, ask patient to sip water and swallow; watch for thyroid movement. Inspect the nose: palpate the nose, palpate the nasal sinuses (maxillary and frontal, maxillary-most common site of sinusitis, frontal-next most common site of sinusitis, anatomy and physiology of mouth and pharynx, gingival margin, upper lip, labial frenuim. In the presence of tonsillar exudates: when there is no cough, history of fever, tender, enlarged cervical nodes, peritonsillar abscess, bulging on one side. If >5 mm, <3 mm, or unequal, measure them: pupillary reaction to light, direct reaction, pupillary constriction in same eye exposed to light source, consensual reaction, pupillary constriction in opposite eye exposed to light source. Bone conduction: place tuning fork next to ear (count seconds)
