The Nurse Practitioner’s Place

Kim over at Emergiblog wrote probably the best reasons for being a nurse that I can think of. Please go over and check it out! It’s worth printing out and putting up on the wall at the new clinic that I’m going to help open the first week of Jan.
I’m so excited! The clinic is almost ready to open and I signed a three year contract to work with the company. Everyone has been so nice!
I did a little pediatric stint again to get some refresher and caught a nice cold. I can sympathize with Kim there as well.
I hope everyone has a wonderful Christmas!

History for Mouth and Pharynx: Dentures, frequent sore throats, halitosis, change in taste, swollen or bleeding gums, mouth or tongue ulcers, dysphagia, patterns of dental care.
Inspect and Palpate the Mouth and Pharynx
· Lips - inspect for color, moisture, swelling, cracking, lesions. Cracking may be Vitamin B deficiency/ dehydration/ braces.
· Bucchal Mucosa - inspect for color, ulcers, nodules. Check floor of mouth - most common site for oral malignancies. Tobacco chewers and smokers are at high risk. Cancer sores (aphthous ulcers) are common on bucchal mucosa and tongue, painful, last for 5-10 days. Causes include stress, trauma, acidic foods. Treat with topical corticosteroid paste such as Triamcinolone (Kenalor in Orabase 0.1%).
· Salivary Glands - should emit clear fluid
o Parotid ducts (Stensen’s Ducts) - adjacent to upper molars
o Submaxillary ducts (Wharton’s Ducts) - under tongue
· Gums and teeth - inspect gums for swelling, bleeding, retraction, discoloration. Should have 32 teeth.
· Pharynx - check hard, soft palate and uvula for color, contour, symmetry and movement. Ask patient to say “ah”. Damage to the glossopharyngeal or vagus nerve (CN IX, X) can cause the soft palate not to rise and uvula to deviate to the uninvolved side. Check tonsils for size, color, lesions.
· Tongue - check for color and smoothness
o Vallate Papillae - seen on posterior dorsum of tongue
o Glossitis - smooth, red tongue suggesting a vitamin deficiency of B12/ niacin/ iron, or drug reaction.
o CN XII (Hypoglossal) - have patient stick tongue out - deviation to one side suggests paralysis of the cranial nerve.
o Leukoplakia - white patches most commonly seen on underside of tongue. They are pre-malignant.
o Thrush - white patches that are generalized over entire mouth. Mucosa is red and painful. Caused by yeast. Commonly seen in children following antibiotic therapy. Also seen in HIV patients.
History for the Neck: neck injury, pain or stiffness; tender or swollen lymph nodes, HA
Inspect and Palpate the Neck
· Muscles - inspect for symmetry, masses and swelling
o Sternocleidomastoid - extend from top of sternum to mastoid process. Responsible for turning the head side to side, and forward flexion of the neck. Divides the neck into 2 triangles. Innervated by CN XI (Spinal Accessory)
§ anterior triangle - trachea, thyroid gland, anterior cervical nodes, carotid artery.
§ posterior triangle - posterior cervical nodes
o Trapezius - extend from the occipital bone to the 7th cervical vertebra and attaches to all thoracic vertebrae, clavicle and scapula. Responsible for shoulder shrugging, backward tilt of the head and raising of the chin, tilting head side to side. Innervated by CN XI.
· ROM - flexion, extension, rotation, lateral bending
· Muscle Strength - turn head, shrug shoulders against resistance
· Lymph Nodes
o pre-auricular - drains eyes and ears
o posterior auricular - drains ear and scalp
o occipital - drains scalp and neck
o tonsillar - drains mouth and nose
o submaxillary - drains mouth and nose
o submental - drains tongue
o superficial cervical - drains ear and scalp
o posterior cervical - drains ear and scalp
o deep cervical - drains mouth, ears and scalp
o supraclavicular - all of above, abdomen, breast, thorax, arm
*Palpate nodes with patient’s head bent slightly forward. Note their size, shape, mobility, consistency, and tenderness. Can be normal to feel small, mobile, non-tender nodes. Enlarged, tender nodes indicate infection. Enlarged, hard, fixed nodes indicate malignancy.
Inspect and Palpate the Thyroid and Trachea - palpate for size, shape, symmetry, tenderness and nodules. Located just below cricoid cartilage. Normal thyroid is barely palpable due to the fact that much of the lobes are covered by the sternocleidomastoid muscles. Palpate the thyroid with patient’s neck slightly flexed. Ask patient to swallow - thyroid will rise with swallowing.
· Thyroid - butterfly shaped gland. Isthmus lies over the trachea but blends in with tracheal rings and can’t be palpated. Lateral portions curve backward and are covered by sternocleidomastoid muscles. Produces T3 and T4 = T7. Thyroid Stimulating Hormone (TSH), produced by the pituitary gland, stimulates the thyroid to produce T3 and T4. Works as a feedback loop.
o enlargement - may be diffusely enlarged in hyperthyroidism and goiter.
o hypothyroid - signs and symptoms include wt gain, cold intolerance, fatigue, dry skin and hair, poor hair growth, constipation, depressed deep tendon reflexes (DTR), mood swings, menorrhagia, periorbital edema, bradycardia, and possibly CHF.
o hyperthyroid - weight loss, heat intolerance, muscle fatigue, insomnia, increased sweating, polyphagia, increased bowel movements, restlessness, irritability, hyperreflexic, tremor, exophthalmos, lid lag, amenorrhea, tachycardia, arrhythmias, palpitations.
o asymmetry - asymmetrical enlargement or nodules may be indicative of malignancy.
· Trachea - inspect and palpate for deviation which may result from masses in the neck, pleural and pulmonary abnormalities, particularly pneumothorax.
History for the Ear:discharge or excess cerumen, infections, PE tubes, itching, tinnitus, otalgia, vertigo, excessive noise exposure, hearing loss in patient or family, use of hearing aids, cleaning habits, tobacco use, use of ototoxic drugs, recent flying or scuba diving
Anatomy - Review structure and function of the 3 compartments.
·External ear - auricle and ear canal
·Middle ear - starts at tympanic membrane (TM) and is connected to the nasopharynx by the Eustachian tube.It is an air filled cavity across which sound is transmitted by way of the 3 tiny bones:
oMalleus
oIncus
oStapes
·Inner ear - transmits nerve impulses to brain via the cochlear nerve.Inner ear is also important in controlling equilibrium.
Inspect and Palpate Auricle - for deformities, lumps, skin lesions. Helix is common site for skin cancers due to sun exposure.
Inspect Ear Canal and Ear Drum
1. Canal - pull auricle up and out for adults, down and out for children. Check for inflammation, exudate, foreign body.
oExternal Otitis (swimmers ear) - marked by inflammation and white exudate, pressure on the tragus is painful. Excessive moisture and high ambient temperatures is most common cause. Excessive cleansing of the protective cerumen is another common cause. Usual causative organisms are pseudomonas, proteus, occasionally staph and strep. Treat by washing excess exudate first, then using antibiotic-steroid gtts. For severe cases, an antibiotic wick may be placed in the ear canal.If infection and inflammation extend outside the canal, an oral antibiotic is recommended.
o Foreign Body - particularly prevalent in the pediatric population. Beads, toys, food, other small objects can set up inflammation and pain particularly if it is pushed up against the tympanic membrane. Insects are also a common cause and can be quite uncomfortable if they are still living. The foreign body must be removed with forceps or ear lavage.
o Cerumen Impaction - common in the elderly who wear hearing aids. Each time the hearing aid is placed in the ear, any cerumen that is present is pushed down into the canal. Eventually occludes the canal and causes pain and loss of hearing.
2. TM - check for color, landmarks, fluid levels, air bubbles.
· Serous Otitis Media - fluid present behind the TM. May clear with decongestants.
· Acute Purulent Otitis Media or Otitis Media with Effusion - red TM, bulging with distortion of the bony landmarks. Probably fever especially in children. Causative organisms are pneumococcus (most common), H. flu, Branhamella catarrhalis, strep and staph. Most common treatment drugs are cephalosporins and sulfa drugs. Complications: anyone who develops or has persis
tence of any of the following symptoms while on antibiotics should be suspicious of an intracranial complication like meningitis, encephalitis, brain abcess or flu due to one of many new viral strains: headache, lethargy, malaise, irritability, nausea and vomiting, onset of fever.
· Bullous Myringitis - characterized by vesicles on TM - usually caused by mycoplasma bacteria. Treat with oral antibiotics.
· Myringotomy - an incision is made in the eardrum - generally for PE tubes.
· Perforations - secondary to infection or trauma. Usually heal spontaneously, delayed healing > 3 months, may need tympanoplasty.
· Scarring - chalky white patches from past infections or dark thin spots from old perforations.
· Cholesteatoma - a cyst-like sac filled with epithelial cells and cholesterol that can occur in the meninges, CNS, bones of the skull, but most commonly enlarges to occlude the middle ear. Enzymes formed within the sac causing erosion of adjacent bones, resulting in deafness. Can be congenital or acquired. May be symptomatic for many years except for progressive hearing loss. May c/o tinnitus, fullness in the ear. Cholesteatomas appear as white, shiny, greasy, flakes of debris in the posteriosuperior quadrant of the TM. May also be accompanied by polyps and a foul smelling discharge. Treatment is surgical.

Examination of Head and Neck
History for Head: frequent HA, trauma, dizziness, syncope, loss of consciousness
· Inspect and Palpate the Head - size, shape, position of eyes, ears, nose and mouth. Note any swelling or asymmetry.
· Acromegaly (excess growth hormone) - produces enlargement of both bone and soft tissue. Elongation of head with bony prominence of forehead, nose and jaw. Soft tissue of nose, lips and ears enlarge.
· Hydrocephaly - increased fluid within the ventricles of the brain.
· Hypothyroidism (myxedema) - dull, puffy face with periorbital edema. Skin is dry, hair course, eyebrows thin on outside.
· Cushing’s Syndrome (excess adrenal hormone production) - moon face, red cheeks, possible mustache. Iatrogenic in patients taking long term, large doses of Prednisone.
· Parkinson’s - decreased facial mobility giving “mask face” appearance with decreased blinking, stare with head flexed forward.
· Bell’s Palsy - results from a paralysis of CN VII. The eye on the affected side cannot close completely, lower eyelid droops, corner of the mouth droops.
· Temporal Arteries - palpate and auscultate the temporal arteries for tenderness and bruits. Temporal arteritis can cause blindness and immediate referral is necessary.
· Temperomandibular Joint - palpate the TMJ for tenderness, crepitus, strength (CN V)
History for Nose: olfaction, nose bleeds, allergies, post nasal drip (PND), frequent colds or sinusitis.
Inspect the Nose: Upper 1/3 is bone, the remainder is cartilage
· Nasal mucosa - note color (normally dark pink), swelling, exudate, bleeding
· Turbinates - winding cavities from outside to pharynx, purpose is to increase surface area of nose for filtration. Inspect for deformity, asymmetry, inflammation. Use otoscope with wide nasal speculum. Can visualize middle and inferior turbinates but not superior.
· Septum - note any bleeding, perforation, deviation. Septal deviation is not significant if there is no airway obstruction
o acute rhinitis (cold) - thick yellow or green nasal discharge, often fever, mucosa red and swollen.
o allergic rhinitis - clear, watery nasal discharge, no fever, mucosa pale and boggy.
Palpate the Sinuses - tender in acute sinusitis. May complain of teeth hurting. Purulent discharge, nasal stuffiness, fever, malaise.
· Maxillary - under cheeks
· Frontal - over eyes
*Can’t directly palpate ethnoid and sphenoid sinuses
Special Maneuvers: Transillumination of the sinuses is accomplishes in a slightly darkened room. A bright focused light is placed directly on the cheek over the maxillary sinuses. The patients mouth is open and the examiner looks for a light glow on the roof of the mouth. Diminished light may indicate full sinus cavities. Unequal light may indicate unilateral sinus fullness. For the frontal sinuses, the light is placed in the upper nasal orbit while the examiner looks for the glow in the frontal sinuses.