NURS1921 Exam IV: HEENT Assessment
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What should be inspected when assessing the head and face?
- Position and alignment
- Lesions, redness, edema or drainage
- Inspect then palpate scalp & hair
- Facial Expression
What should be inspected when assessing the neck?
- Muscle symmetry
- Neck veins
- Carotid arteries
- Enlarged lymph nodes
Pupil equal, Round react to light and accomodate
How are extraocular movements assessed?
- 6 cardinal fields of vision
- Assessing CNIV: Trochlear
What is the Romberg Test used to assess?
- Vestibular function
- Pos. means there is a vestibular disorder
How is the whisper test conducted?
Whisper something from about 2 ft. behind pt.
How is tongue movement assessed?
- Have pt. stick our their tongue and move it from side to side.
- Assessing CNXII: Hypoglossal
How is the gag reflex assessed?
- Use a tongue depressor or swab to elicit gag reflex
- Assessing CNX: Vagus
- NPO if gag reflex isn't working properly
Considerations for older adults
- Visual acuity, peripheral vision and accommodation to darkness decreases
- Conjunctiva of eye may appear yellowed
- Skin around the eye may darken, eyes may appear sunken
- Generalized hearing loss, beginning with high-frequency sounds
- Earlobe elongates
- Sense of smell and taste diminished (sweel/salty first)
- Oral mucosa is drier
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