Assessment3HEENT

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vanwin
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210427
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Assessment3HEENT
Updated:
2013-03-30 19:47:52
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Assessment
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Assessment3
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  1. ´╗┐Sensory Assessment
    • eyes need to closed
    • pain: sharp/ dull
    • light touch: hyperthesia =lots of sensation!
    • vibration: low pitched tuning fork
    • mono-filament: can't feel = peripheral neuropathy
    • proprioception/ position sense/ kinethesia
    • sterognosis: object in palm & they tell you what it is
    • graphethesia
  2. Health History Questions; Head. neck & lymph
    • Headaches
    • Head injuries did they loose LOC
    • dizziness
    • neck pain
    • lumps & swelling
  3. Inspect & palpate head
    • normocephalic
    • microcephalic
    • macrocephalic
    • symmetrical
  4. Inspect & palpate Neck
    • symmetry of muscles
    • range of motion
    • lymph nodes - advanced technique
    • trachea @ midline
    • thyroid - advanced technique
  5. Developmental considerations for Head
    children and infants have bigger heads compared to body size= more prone to head injury
  6. Palpating lymph nodes
    • normal: <1cm & nonpalpable
    • lymphadenopathy: >1cm/ infection, allergies or cancer
    • Infection: enlarged, painful, tender, warm, movable, maybe bilateral
    • Malignant: enlarged, non tender, unilateral, fixed, hard to palpate
  7. Head & Neck Abnormality
    • Acromegally: excess growth hormone; pituitary tumor, facial bone over growth
    • CVA/stroke: asymmetry, whole body
    • Bell's palsy: asymmetry, only affect face
    • multiple thyroid nodues
    • thyromegaly
    • assymmetry
  8. Eye subjective information
    • pain: sudden = 911
    • difficulty w/ vision: decreased acuity, blurry, blindspots = tumor, halo = glaucoma
    • photophobia
    • strabismus (misalignment)
    • redness
    • swelling
    • water discharge = possible infection
    • past hx & self care
  9. Eye Test Tools
    • snellen chart
    • hand held vision screen
    • card to cover eye
    • pen light
    • opthalmoscope
  10. Eye Acuity Tests
    • Snellen chart: stand 20ft away, numerator = distance away, nominator = line read, smaller = better
    • E chart: for children & pts that don't know the alphabet
  11. Near Vision & Visual fields test
    • Near vision test: hold chart 14 inches away, 14/14 if they get it all right
    • - presbyopia: when they have to move it farther to read it

    Visual fields: right & left eye/ confrontation test. When they cover one eye and something comes from the side, they'll say when they can see it, not very accurate
  12. Eye Muscle Function Tests
    • Corneal light reflex: when the light reflect in the same spot on both eyes
    • cover test: cover 1 eye, pt look forward then take away cover, if covered eye moves into position = muscle weakness
    • extraoccular movements/ EOMS/ 6 cardinal fields of gaze
  13. Strabismus & Phoria
    • Strabismus: disparity in eye alignment
    • Phoria: mild eye weakness
  14. Inspect Extraoccular structures
    • Eyebrows: symmetrical
    • Eyelids & lashes
    • eyeball alignment
    • conjunctiva & white sclera
    • lacrimal apparatus
  15. Inspect anterior eyeball structures
    • cornea: clear w/ lens underneath
    • iris & pupil: flat & round
    • -size, shape & eual
    • -pupillary light reflext
    • -accommodation
  16. PERRLA
    • pupils
    • equal
    • round
    • reactive to
    • light
    • accomodation
  17. Developmental Considerations
    • older adults:
    • - decreased vision
    • -deceased peripheral vision
    • - decreased tears, dry eyes
    • Arcus senilis: white ring on top of eyes, not medically significant
  18. Eye Abnormalities
    • exopthalmos: eyes buldges out; b/c Graves disease, hyperthyroidism
    • Conjunctivitis: pink eye
    • Periorbital edema: w/ renal failure, allergic rx, CHF
    • Presbyopia
    • Lid lag: hyperthyroidism
    • macular degeneration: loss of central vision
  19. Ear Subjective information
    • ear aches
    • infections
    • discharge/ otorrehea
    • hearing loss, sudden = refer
    • tinnitus; ringing
    • vertigo; loss of balance
    • hearing & screening protection
    • amt of ear wax
  20. Tools for Ear Inspection
    • Advanced technique;
    • 3yrs or older = pull up & back
    • younger = down & back
  21. Objective Data Ear Inspection & palpation
    • Placement & alignment: low set ear might indicate mental illness/ kidney problems
    • hearing acuity: whisper test
  22. Types of Hearing Loss
    • conduction: transmission of sound into ear, cause- wax/ otosclerosis
    • Sensorineural: defect in inner ear, cause: CN8 impairment, aging, ototoxic drugs, loud noises.
  23. Developmental considerations; ears
    • otoscope last for infants
    • presbycusis in older adults
    • otitis media, ear infections in children, they might have speech impairment
  24. Nose, Mouth & throat Subjective Data
    • nose discharge: color & amt
    • colds
    • sinus pain
    • hx, of nose bleeds (epistaxis)
    • allergies
    • changes in smell
    • sore throat
    • bleeding gums
    • tooth aches
    • hoarseness; how long
    • dysphagia
    • xerostomia/ decrease saliva
    • smoking & alcohol
    • altered taste
    • self care
  25. Inspection of Mouth
    • gingivitis
    • gingival hyperplasia- dilantin/ pregnancy
    • oropharynx
    • buccal mucosa- ulcers
    • cyanosis of lips
  26. Early Signs of dehydration in Elderly
    • dry mucosa,
    • breathing through mouth
    • furrowed tongue
    • acute confusion
  27. Oropharynx grading
    • I:┬á see anterior & posterior pillars
    • II: see only anterior, covers posterior
    • III: touches uvula
    • IV: kissing tonsils
  28. Abnormal Nose Mouth & Throat
    • Leukoplakia: cancerous, refer
    • cadidiasis/ Thrush
    • yeast infection

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