Card Set Information

2014-04-25 17:29:03

nursing assessment of HEENT
Show Answers:

  1. Health History
    • -      
    • Present Problem- what brought you in

    • -      
    • Personal hx- childhood illness

    • -      
    • Family Hx-

    • -      
    • Risk Factors- wearing helmets

    • Extras-asking question like when did this begin?
    • How does this effect your daily life? Have you had any surgeries? Allergies?
    • Stroke fh? Exposure to
  2. Physical Exam of the Head
    - Inspect head and scalp

    - Size/shape/symmetry

    - Proportional to body

    - Hair distribution/cleansiness/hygiene

    - Color, edema, symmetrical movements

    - Tremors ticks unusual movements

    • - Facial feature- nasolabial folds- nose lips
    • should move the same

    • - Description for the shape of pt’s head
    • normocephalic

    - Note the pattern of male baldness
  3. Palpate
    - lumps/tenderness/texture- lumps tenderness abnormal

    - ROM or TMJ- should not hear crutching crepitas

    - Temporal artery- should be present

    • - motor strength- should be equal strength on
    • both sides
  4. Ausculate- temporal artery
    only if you suspect vascular abn.
  5. How do we see?
    - depends on the light wave reflected of the image

    • - light rays pass thru parts of the eye to the
    • back, retina

    - Iris- color portion of the eye

    - Pupil- opening of the eye- lets light in

    - Lens- bends to reflect on the certain parts of the retina- this is usually clear unless u have cataracts

    • - Retina- rods (dim light) cones (bright light)-
    • transfers to the brain for processing
  6. Exam of EYE
    1. History of eyes

    - present illness

    - personal hx

    - Family hx

    - Risk factors

    • - Near sighted Myopia far sighted hyperopia aging
    • (older adults)- presbyopia- need to move objects away in order to see it.

    • - Things that can make u lose your vision- age macular degeneration, glaucoma, diabetic retinopathy, cataracts, opic nerve
    • atrophy, computer use?
  7. 1.Physical eye exam
    - Cover one eye at a time

    - Near vision (14 inches away). 14/14

    - Far vision (snellen chart) 20 feet away 20/20

    • - Document rt/lt/both done with or without
    • glasses/contacts

    - You have to get 5/8 on each row on the chart- if you pass you go down if not u go up…
  8. Visual Fields
    • - Confortation- standing nose to nose 18 inches apart and wigglying fingers on the outside and asking pt to tell u when they
    • see you fingers- note: intact by confortation

    - EOMS (extra ocular movements)- six/nine cardinal positions of gaze involves CN 3,4,6- note: smooth symmetrical movements
  9. Abnormal (eye)
    - Nystagmus- wiggly eye….one eye not following movements

    • - Lid lag (ptosis)- upper eyelid comes over
    • superior part of the iris and when moving eyes downward. Do not see white
  10. Corneal light reflex
    • -      
    • Hirshberg test- Have pt stare off in the
    • distance about 15 feet away. put pen light 12 inches away midline the
    • nose..what you are looking for is to see if the reflection on the pupil are in
    • the same position as the other pupil. eyes should do the same thing. Should be
    • the same or indicates a problem with the eye muscles. Normal parallel alignment
    • with eyes
  11. Pupil response (PERRLA)
    - PERRLA – Pupils equally rounded and reactive to light and accommodation- opening or pupil- dilate/constricts based of light

    • - Consensual response- shining the light in one eye so the pupils can dilate but the same thing should happen on the other side
    • as well

    - Pupils are normally 3-5mm equally round
  12. Accomodation
    - pupils should change wherever you look

    - Convergence- have pt look at finger and bring finger towards the nose…eyes should look crossed eyed. 

  13. PE of external eye
    - eyelids, lashes, brows

    - cornea

    - lens

    - sclera- white

    - iris

    - lacrimal apparatus- tear duct- lubricates eyes
  14. PE of internal eye
    - Red reflex- stand 18 inches away at an angle and go in…u should see a red light which is the retina

    - Optic disc

    • - Macula- degeneration with age- loss of central
    • vision
  15. Main Function of ear
    - hear

    - equilibrium 
  16. How do we hear? AC>BC
    - sound wave travel thru external ear to tympanic membrane

    - Bone Conduction (BC)

    • - Sounds wave vibrate skull bones- transmits
    • vibration to inner ear
  17. Parts of the Ear
    - external ear canal- aricle/pinna and auditory canal

    - middle ear- three bones, eustachian tube

    - inner ear- bony labyrinth
  18. PE of ear
    • - external ear (placement, skin, position
    • drainage)

    - mastoid process

    - external canal

    - ear should be inline with corner of the eye..if down and pushed back it could be down syndrome
  19. Otoscopic Evaluation
    Tympanic membrane-

    Normal findings-

    - Shiny, translucent, pearly gray in color

    - Flat appearing

    - Intact membrane

    • - Cone of light- this is what the light reflects
    • off of
  20. Testing hearing
    - Whisper test – hearing in both ears are intact

    - RInne test ac>bc

    - Weber- equal lateralization of sound
  21. Hearing problems
    - conductive hearing loss- fluid in ear/wax canal

    - sensorineural hearing loss- middle ear

    • - tinnitus- ringing in ear. Not sure where it
    • comes from and it is not many ways to treat. 
  22. Mouth and upper respiratory system
    • Deviated septum- can only breath thru one nostrils. Nose can
    • appear straight but septum deviated. 
  23. Exam of nose and sinus
    - Nose- sensory organ for smell -filters, warms humidifies and transfers air

    PE of the nose

    External structure and nares

    Internal structure of nares

    Sense of smell CN 1

     Exam Sinuses (frontal/maxillary) for pressure and pain
  24. PE of mouth and throat
    • - Exam of mouth, lips, teeth, buccal mucosa-inside
    • cheek, tongue- anterior smooth, prosterior rough

    • Throat (oropharynx) (common channels for respiratory and
    • digestive systems)

    PE exam of throat:

    Anterior hard palate

    Posterior soft palate

    Tonsils- lymphatic system (helps with infections)

    Uvula- that piece that dangles at the back of your throat

    • Posterior Pharynx- glossitis which is the flap trachea and
    • esophagus

    Pharynx throat

    Larynx- voice box
  25. Assessment for taste-
    CN 7- anterior sweet/salty 2/3

    CN 9- posterior bitter/sour 1/3
  26. PE of neck
    - Inspect neck

    - ROM of neck

    - Assess of trachea is midline

    - Assess carotid arteries- bilaterally strong with palpation (don’t check at the same time could slow down heart

    - Assess thyroid gland (usually not palpable or may feel smooth)

    - Graves disease- hyperthyroidism