Health Assessment (NUR 230) The Head and Neck Lecture 3

Common or Concerning Symptoms Head Headache, history of head injury Eyes Visual disturbances, use of corrective lenses, pain, redness, excessive tearing, double vision (diplopia) Ears Hearing loss, ringing (tinnitus), vertigo, pain, discharge Nose Drainage (rhinorrhea), congestion, sneezing, nose bleeds (epistaxis) Oropharynx Sore throat, gum bleeding, hoarseness, Neck Swollen glands, goiter

Head – Inspection and Palpation Hair distribution, quantity Skull – size, contour Face – expression, and symmetry of structure Skin – color, pigmentation Hair distribution, lesions Palpate Hair texture Skull – lumps and lesions Skin – texture, temperature

Eye

Eyes - Inspection Cornea and lens Iris Position and alignment of eyes Eyebrows Quantity, distribution Eyelids Edema, color, lesions Conjunctiva and sclera color, vascular pattern Cornea and lens Iris Pupils – size, shape, symmetry, reaction to light

Eyes – Techniques of Examination Visual acuity Distance/Central vision: Snellen eye chart; position patient 20 feet (6 meters) from the chart Patients should wear glasses if needed Test one eye at a time

Eyes – Techniques of Examination Jaeger chart Rosenbaum chart Visual acuity Near vision: use (Jaeger or Rosenbaum chart (hand-held card) can also use to test visual acuity at the bedside hold 14 inches (about 30 cm) from patient’s eyes

Eyes – Techniques of Examination (cont.) Visual fields by confrontation sitting 60-90 cm from you and at eye level Test one eye at a time The client’s peripheral visual fields are compared to that of the examiner. This test assumes the examiner has normal peripheral vision

Eyes – Techniques of Examination (cont.) Extraocular movements/six cardinal directions of gaze/wagon wheel method The client must keep the head still while following a pen that you will move in several directions to form a star in front of the client’s eyes. Always return the pen to the center before changing direction. Nystagmus: involuntary eye movement

Eyes – Techniques of Examination (cont.) Accommodation An object held about 10 cm from the client’s nose

Ears – Inspection and Palpation Auricle for redness, lesions Ear canal Discharge, foreign bodies, redness, swelling Tympanic membrane (by Use otoscope ) Color, contour Palpation Auricle for lumps, tenderness

Straightening the Ear Canal and Inserting the Speculum

Ears – Hearing acuity Test one ear at a time Whisper test Ask the client to occlude the other ear or the ear may be occluded by the nurse. Cover your mouth so the client cannot see your lips Standing 30-60cm behind patient, softly say “nine-four,” “baseball” Ask the client to repeat the phrase.

Air and bone conduction (AC and BC) Ears – Hearing acuity Rinne Compare time of air vs. bone conduction Place the base of the tuning fork on the client’s mastoid process- and note the number of seconds. Then move the fork in front the external auditory meatus (1-2 cm) If bone conduction is equal or greater than air conduction, then suspect conductive hearing loss Air and bone conduction (AC and BC)

Air and bone conduction (AC and BC) Ears – Hearing acuity Air and bone conduction (AC and BC) Weber Lateralization of sound to impaired ear; suspect unilateral conductive hearing loss

Ears – Romberg test: Ask the patient to remain still and close their eyes (for about 20 seconds). If the patient loses their balance, the test is positive.

Nose – Inspection/Palpation Size, shape Symmetry Lesions/signs of infection Patency test Septum (by use nasal speculum)-deviation, inflammation or perforation Palpate for tenderness, swelling

Mouth and Pharynx - Inspection Lips Note color, moisture, lumps, ulcers, cracking Gums and teeth Note color, presence and position of teeth Roof of mouth Note color Tongue and floor of mouth Note color and texture, ulcers uvula, tonsils, pharynx Note color, symmetry, presence of exudate, swelling, ulceration or tonsillar enlargement

The Mouth and Gums

Under the Tongue

Above and behind the tongue

Neck – Inspection and Palpation Skin color, integrity, shape, and symmetry Masses, scars, enlarged glands or lymph nodes Thyroid gland - enlargement Palpation Trachea – position (should be midline) Thyroid gland: consistency, masses, tenderness

Midline Structures of the Neck

Neck – Thyroid Gland Flex neck slightly forward Place fingers of both hands with index fingers just below the cricoid cartilage Ask patient to swallow; feel for the thyroid isthmus rising up under your finger pads (not always palpable) Note the size, shape, and consistency Identify any nodules or tenderness If enlarged, listen over lateral lobes to detect a bruit

The thyroid can be examined while you stand in front of or behind the patient.