1. Week 7: Hair, skin, nails, head,neck, eyes, and ENT assessment
Anne Dalton, BSN, RN, OCN
Holistic Health Assessment Lecture

2. Skin
This is a review of the A&P of the skin. Note the epidermis, dermis, and subcutaneous tissue layers.

3. Function of the Skin How does the skin guard and protect the body?
What are some of the things the skin can tell you about the status of your patient?
The skin is the body’s defense against various offenders. Pathogens, dirt, temperature regulation, trauma,
Dehydration, scars, sun damage, fluid overload (edema), redness or erythemia, lacerations, body temperature, bruising etc. Have the students come up with these.

4. How does the skin protect?
Protection from the environment
Prevents penetration
Absorption and excretion
Temperature regulation
Identification
Wound repair
Production of Vitamin D

5. Epidermal Appendages Hair Nails Sebaceous glands Sweat glands
Important for fluid balance and thermoregulation
Epidermal appendages: Structures formed by tubular invagination of epidermis down into underlying dermis.
Sebaceous glands: produce sebum which is responsible for keeping the skin moisturized. Lubricates and waterproofs the skin. Found in the most abundance on the face and scalp.

6. The Nail

7. Assessment: Subjective Data
Health history questions:
________
Have the students work in groups for 5 minutes to come up with subjective questions to ask during their assessment.
Note any differences for aging adults.

8. Assessment: Objective Data
Inspection and palpation of Skin
Color, temperature, moisture
Texture, thickness, edema
Mobility and turgor
Vascularity or bruising
Lesions: note size, color, elevation, pattern, etc.
Inspection and palpation of Hair
Color, texture, distribution, and lesions
Color= pigmentation, freckles, moles
Moisture= diaphoresis or dehydration

9. Assessment: Objective Data
Inspection and Palpation of Nails
Shape and contour
Consistency
Color
Capillary refill
Make sure the students understand the importance of cap refill. Ask them to demonstrate how to perform this test. Indicates status of peripheral circulation. Color return is normally instant. 1 to 2 seconds indicates sluggish return.

10. Health Promotion
Teach skin self-examination

11. Skin cancer check

12. Head, Neck, and Face
The skull is a rigid bony box that protects the brain and special sense organs, and it includes the bones of the cranium and the face. Note the location of these bones: frontal, parietal, occipital, and temporal. The cranium is supported by the cervical vertebrae.
Cranial nerve VII (the facial nerve): Facial expressions formed facial muscles the facial nerve

13. Structure of the neck
The neck is delimited by the skull and the inferior border of the mandible above and the manubrium sterni, the clavicle, the first rib, and the first thoracic vertebra below. The carotid artery and internal jugular vein lie beneath the sternomastoid muscle, and the external jugular vein runs diagonally across this muscle. Parts of the respiratory and digestive systems, in addition to nerves and lymphatics, pass through the neck. The major neck muscles are the sternomastoid and the trapezius, which are innervated by cranial nerve XI. The sternomastoid muscle divides each side of the neck into two triangles. The anterior triangle extends to the mandible above and the midline of the body medially. The posterior triangle lies behind the sternomastoid muscle and in front of the trapezius. The thyroid gland straddles the trachea in the middle of the neck. The thyroid cartilage, with a small palpable notch, lies above the thyroid isthmus.

14. The Lymphatic System Describe the function of the lymphatic system
Drainage pattern of the lymph nodes
Lymphatic system: an extensive vessel system, is major part of immune system, which detects and eliminates foreign substances from body
Greatest supply is in the head and neck.

15. Locations of the Lymph Nodes

16. Assessment: Subjective Data
Headache
Ever had a head injury or a blow to the head?
Dizziness?
Neck pain or limitation of neck motion?
Swelling or lumps?
History of head or neck injury?
Headache: make sure they know to characterize the pain. PQRST. How long do they last? Precipitating and alleviating factors. Any associated symptoms with the headache?

17. Assessment: Objective
Inspect and palpate the skull
Size, shape, and symmetry.
No tenderness during palpation
Cranial bones that have normal protusions
Palpate temporal artery above the cheek bone
Palpate temporomandibular joint as the patient opens their mouth.
Cranial bones: forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear
Palpate temporal artery above zygomatic (cheek) bone between eye and top of ear

18. Assessment: Objective
Inspect the face
Note symmetry
Inspect and palpate the neck
Symmetry, range of motion, lymph nodes, trachea, thyroid gland
Two approaches to thyroid exam: anterior and posterior
Only able to palpate if it is enlarged.

19. Sample charting: Subjective

20. Sample charting: Objective

21. Health Promotion: head, neck, and face
The use of helmets when riding a bike to prevent brain injury

22. The Eye: External anatomy

23. The Eye: Tarsal plates
Tarsal plates: within upper lid, they are strips of connective tissue that give it shape

24. The Eye: Internal anatomy
Eye: a sphere of three concentric coats
Outer fibrous sclera
Middle vascular choroid
Inner nervous retina
Inside retina is transparent vitreous body
Only parts accessible to examination are sclera anteriorly and retina through ophthalmoscope

25. The Eye: Internal

26. The Eye: Internal anatomy cont.
Outer layer
Sclera
Cornea
Middle layer
Choroid
Iris
Pupil
Lens
Inner layer
Retina, Optic Disc, Retinal Vessels, and Macula

27. Developmental Considerations: Aging Adult
Cataract formation, or lens opacity, resulting from a clumping of proteins in lens
Glaucoma, or increased intraocular pressure; chronic open-angle glaucoma is most common type
Macular degeneration, or breakdown of cells in macula of retina
Loss of central vision is most common cause of blindness; person is unable to read fine print, sew, or do fine work; loss of central vision may cause great distress

28. Color-blindness video

29. Eye assessment: Subjective
Vision difficulty: decreased acuity, blurring, blind spots
Pain
Strabismus, diplopia
Redness, swelling, watering, discharge
Hx of ocular problems
Glaucoma
Glasses or contacts?
Self-care behaviors
Last vision exam
Strabismus, diplopia: Any history of crossed eyes? Now or in the past? Does this occur with eye fatigue?
Ever see double? Constant, or does it come and go? In one eye or both?
Also ask about seasonal allergies

30. Eye assessment: Objective
Supplies/Equipment needed:
Snellen Eye Chart
Penlight
Opaque card

31. Eye assessment: Objective
Snellen alphabet chart test is used to measure visual acuity:
It has lines of letters arranged in decreasing size
Place chart in a well-lit spot at eye level; position person exactly 20 feet from chart; hand person an opaque card with which to shield one eye at a time during test
If person wears glasses or contact lenses, leave them on; remove only reading glasses
Ask person to read through chart to smallest line of letters possible; encourage trying next smallest line also

32. Eyes: Objective assessment
Inspect external ocular structures
General: begin with external points, work inward
Eyebrows, eyelids, and eyelashes
Eyeballs
Conjunctiva and sclera
Lacrimal apparatus
Cornea and Lens (use penlight)
Iris and pupil

33. Eyes: Objective Inspect pupils for PERRLA
Pupils Equal, Round, Reactive to Light, and Accommodation

34. Eye assessment Inspect ocular fundus using ophthalmoscope
To examine person (cont.)
Systematically inspect structures in ocular fundus
Optic disc
Retinal vessels
General background
Macula
Most prominent landmark is optic disc, located on nasal side of retina; explore these characteristics:
Color: creamy yellow-orange to pink
Shape: round or oval
Margins: distinct and sharply demarcated, although nasal edge may be slightly fuzzy
Cup-disc ratio: distinctness varies; when visible, physiologic cup is brighter yellow-white than rest of disc; width not more than one half disc diameter

35. The Ear
External ear:

36. Ears Sensory organs for hearing and maintaining equilibrium
Consist of 3 parts
External ear
Pinna or auricle
Auditory canal
Cartilage
Tympanic Membrane
Middle ear
Inner ear

37. The Middle ear The middle ear has 3 functions:
Conducts sound vibrations
Protects inner ear from loud sounds by reducing amplitude
Eustachian tube allows equalization of air pressure on each side of TM so that it does not rupture

38. Pathways of Hearing

39. Pathways of hearing
Normal pathway of hearing is air conduction (AC) described previously; it is the most efficient
Alternate route is by bone conduction (BC)
Bones of the skull vibrate and are transmitted directly to inner ear and to cranial nerve VIII

40. Hearing loss: Aging adults
In aging persons, cilia lining ear canal become coarse and stiff
May cause cerumen to accumulate and oxidize, which greatly reduces hearing
Impacted cerumen is a common but reversible cause of hearing loss in older people
Presbycusis: type of hearing loss that occurs with aging, even in people living in quiet environment

41. Hearing Loss
What does it sound like to become hard of hearing??

42. Ear assessment: Subjective
Earaches
Tinnitus
Infections
Discharge
Hearing loss
Environmental Factors
Vertigo
Self-care behaviors

43. Health Promotion: Ear care

44. Ear assessment: Objective
Equipment needed
Otoscope with bright light
Tuning forks in 512 and 1024 Hz
Inspect and palpate external ear
size and shape, skin condition, tenderness, and external auditory meatus

45. Otoscopic Examination

46. Ear assessment: Objective
Inspect the tympanic membrane
Color and characteristics
Position
Integrity of the membrane

47. Test hearing acuity
Whispered voice test
Tuning fork tests

48. Sample objective charting: Ear

49. The Nose What are the main functions of the nose? The nasal cavity
The FIRST segment of the respiratory system.
Warms, moistens, and filters inhaled air. It is the sensory organ for smell.

50. The Mouth
The mouth is the first segment of the digestive system and an airway for the respiratory system
Oral cavity: short passage bordered by lips, palate, cheeks, and tongue
Contains teeth and gums, tongue, and salivary glands
What is the function/importance of saliva?
Glands secrete saliva, the clear fluid that moistens and lubricates the food bolus, starts digestion, and cleans and protects the mucosa
Adults have 32 permanent teeth

51. The Mouth

52. Salivary Glands

53. Throat or Pharynx The area behind the mouth and nose Oropharynx
Tonsils
Nasopharynx
Pharyngeal tonsils (adenoids)
Tonsillar tissue enlarges during childhood until puberty
Posterior pharyngeal wall is seen behind these structures

54. Nose assessment: Subjective
Discharge
Frequent colds or upper respiratory infections
Sinus pain
Trauma
Epistaxis or nosebleeds
Allergies
Altered smell

55. Mouth &Throat assessment: Subjective
Sores or lesions, sore throat, bleeding gums, toothache
Hoarseness
Dysphagia
Altered taste
Smoking, alcohol consumption
Dentures and/or partials
Self-care

56. Nose, Mouth, & Throat: Objective assessment
Equipment needed:
Otoscope with short, wide-tipped nasal speculum
Penlight
Two tongue blades
Gloves
Inspect and palpate the nose

57. Inspect the nose

58. Objective assessment: Nose
Palpate the sinus areas
Using thumbs, press frontal sinuses by pressing up and under the eyebrows and over maxillary sinuses below cheekbones

59. Mouth assessment: Objective
Inspect the mouth
Begin with anterior structures and move posteriorly
Inspect lips for color, moisture, cracking, or lesions; retract lips and note inner surface
Teeth and gums
Tongue
Buccal mucosa
Palate
Why is it important to inspect the teeth and gums? What does poor dental hygiene tell us about a patient?

60. Throat assessment: Objective
Inspect the throat and look for the tonsils
Grading the tonsils.

61. Throat assessment: Objective
Depress the tongue to enlarge your view of the pharyngeal wall
May elicit the gag reflex
Inspect cranial nerve XII
Ask the patient to stick out their tongue
Hypoglossal nerve

62. Health Promotion: ENT Oral hygiene Smoking Chewing tobacco
Regular cleanings and checkups with a Dentist
Brush and floss twice/day
Smoking
Chewing tobacco
Decrease alcohol consumption
Have the students come up with these if time allows

63. Questions