Head, Face, Eyes, and Ears Assessment

• Health assessment focuses on the head, face, eyes, and ears.

COLDSPA Mnemonic

• COLDSPA aids in exploring symptoms by using Character, Onset, Location, Duration, Severity, Pattern, and Associated Factors.
• CHARACTER: Describe the sign or symptom (appearance, feeling, sound, smell, taste).
• ONSET: When did it begin?
• LOCATION: Where is it? Does it radiate? Does it occur anywhere else?
• DURATION: How long does it last? Does it recur?
• SEVERITY: How bad is it? How much does it bother you?
• PATTERN: What makes it better or worse?
• ASSOCIATED FACTORS: What other symptoms occur with it and how does it affect you?

Scalp and Face Inspection

• Assess scalp size, shape, and consistency.
• Normal: Head is symmetric, round, erect, and midline, varying with ethnicity.
• Abnormal: Extremely large or small scalp; asymmetry; bumps, soft spots, lumps, or lesions.
• Assess face symmetry.
• Normal: Symmetrical face with round, oval, elongated, or square appearance and no abnormal movements.
• Abnormal: Asymmetrical face with drooping, paralysis, weakness, or parotid gland enlargement.
• Clinical tip: Assess for other signs of stroke if drooping on one side of the face is observed.

Scalp, Face, and Neck Examination

• Observe facial features.
• Normal: Features vary.
• Abnormal: Distorted features like a mask-like face, tightened skin, sunken or swollen appearance, or moon-shaped face with red cheeks.
• Observe neck appearance.
• Normal: Symmetrical neck with head centered without bulging masses or swollen lymph nodes.
• Abnormal: Asymmetrical head position, masses, scars, swollen thyroid, or inflamed lymph nodes.

Abnormalities of the Head

• Acromegaly is characterized by enlargement of the feet, hands, and facial features, especially the nose and ears.
• Hypothyroidism/Myxedema is characterized by a dull, puffy face with edema around the eyes and dry, coarse, sparse hair.
• Hyperthyroidism is characterized by exophthalmos, which is bulging or protruding eyeballs.

Recognizing stroke symptoms

• Use FAST to recognize.
• (F)ace drooping
• (A)rm weakness
• (S)peech difficulty
• (T)ime to call

Eyes: Structure and Function

• External structures include eyelids, lacrimal apparatus, and extraocular muscles.
• Internal structures include the sclera, cornea, iris, lens, and retina.

Nursing Assessment: Collecting Subjective Data of Eyes

• Key areas include recent vision changes, spots, floaters, blind spots, halos, rings, and difficulty with night vision.
• Other data to collect includes double vision, blurred vision, eye pain, redness, swelling, or eye discharge.
• Determine the presence of excessive watering or tearing, history of prior surgery or trauma, and use of glasses or contacts.
• Investigate the date of last eye examination, use of safety glasses, exposure to chemicals, and use of supplements or medications, plus diet.

Testing Vision

• Distance vision: Use the Snellen chart with the client positioned 20 ft away.
• Normal: 20/20 vision in both eyes without hesitation, frowning, or squinting.
• Abnormal: Missing letters and myopia (impaired far vision).
• Near vision: Use newspaper at 35.6 cm from the client's head.
• Normal: Ability to read print at 35.6 cm without difficulty.
• Abnormal: Presbyopia (impaired near vision) tested by reading print closer or farther away than 35.6 cm
• Peripheral vision: Examiner report seeing object at same time as patient.
• Abnormal: Reduced peripheral vision.

Extraocular Muscle Function Testing

• Corneal Light Reflex: Assesses the parallel alignment of the eyes.
• Normal: Light reflections are noted at the same location on both eyes, indicating parallel alignment.
• Abnormal: Light reflections are noted in different areas on both eyes, indicating malalignment; strabismus (constant misalignment), tropia (specific type of misalignment), esotropia (inward turn of the eye), or exotropia (outward turn of the eye).
• Cover/Uncover Test: Tests for abnormal eye movement.
• Normal: The uncovered eye does not move when the opposite eye is covered or when the cover is removed.
• Abnormal: The uncovered eye moves to focus when the opposite eye is covered or uncovered, indicating misalignment. Phoria is misalignment when fusion reflex is blocked occurs.
• Position Test: Evaluates extraocular movements in six cardinal fields of gaze.
• Normal: Both eyes move smoothly and in a coordinated manner in all directions.
• Abnormal: Nystagmus (oscillating, shaking eye movements) or failure to follow the object with one or both eyes, indicating muscle weakness or cranial nerve dysfunction.

External Eye Structures Inspection

• Eyelids and Lashes.
• Normal: Skin on eyelids is without redness, swelling, or lesions; lid margins moist and pink; evenly spaced lashes curled outward; lids close easily.
• Abnormal: Crusting scales, absent or inward-curled lashes, edema, xanthelasma, itching, ulcerative lesions, asymmetry, ectropion (lower lids turn outward), entropion (lower lids turn inward), hordeolum (stye), blepharitis (waxy scales), or ptosis (drooping).
• Inspect bulbar conjunctiva and sclera.
• Normal: Symmetrical blinking at 15 blinks/min. Bulbar conjunctiva is clear, moist, smooth, and transparent with blood vessels; sclera is smooth and white.
• Abnormal: Asymmetrical/rapid blinking, discharge, crusting, foreign body present, conjunctiva redness, sclera petechiae or jaundice.
• Cornea and Lenses:
• Normal: Transparent, smooth, and moist.
• Abnormal: Lesions, opacities, irregular reflections, and rough/dry cornea.
• Iris and Pupils:
• Normal: Round and flat with uniform color, regular borders, and centered in the iris; equal in size (3-5mm).
• Abnormal: Irregular shape, fixed pupils, inconsistent color, or unequal size.
• Pupil Response:
• Normal: Pupils constrict when illuminated and the pupil opposite the illuminated one constricts simultaneously.
• Abnormal: Pupils fail to constrict, or monocular blindness can be detected.
• Check accommodation:
• Normal: Pupils converge and constrict as object moves in toward to nose.
• Lacrimal Apparatus:
• Normal: Puncta present on the nasal side of upper and lower lids, mucosa is pink, and no tenderness or discharge is noted.
• Abnormal: Markedly reddened and edematous puncta, blockage/inflammation, fluid/purulent discharge during palpation of the nasal-end

Opthalmic Examination of Internal Eye Structures

• Inspect red reflex through the pupil:
• Normal: Round, bright with a red-orange glow. Any opacities will appear as dark spots.
• Inspect optic disc, to evaluate: margins (blurred sharply or defined) of shape from the disc: slightly oval or round.
• Normal: Disc is 1.5mm, symmetrical and even. Palpate inner canthus.
• Abnormal :size or pallor, irregular shape, blurred margins or hypertension is present.
• Also inspect retinal vessels, retinal background, fovea (sharpest area of vision), macula (surrounds fovea), and anterior chamber.
• Assess for eye trauma. Foreign bodies, blood, swollen lids, hazy corneas, and pupil shape should all be observed.

Ear: Structure and Function Overview

• External ear: Includes the auricle or pinna and the external auditory canal.
• Middle ear: Contains auditory ossicles called malleus, incus, and stapes.
• Inner ear: Consists of the cochlea, vestibule, and semicircular canals.

Assessing Ears: Subjective Data

• History of ear infections or suspected hearing loss requires detailed data collection.
• Ask about recent changes in hearing, the types of sounds affected, ear drainage (amount, odor), and ear pain.
• Also ask about sore throat, sinus infection, teeth or gum problems, ringing/crackling, vertigo, and problems with balance.
• Inquire about infections, trauma, earaches, and treatments, including their success and satisfaction with them.
• Family history: If family has history of hearing loss in their family.
• Also inquire about noise exposure, swimming, impacts of hearing loss, and ear care routines.

Assessing Ears: Objective Data

• External Ear: Size, Shape, Position, Lesions and discolorations should be inspected.

• Normal :ears of equal size, aligned with corner of eye inside 10deg vertical range.

• Abnormal: Unequal size and positioning, nodules, edema, erythema.

• Palpate the external ear and mastoid process for tenderness, edema, and temperature.

• Normal: Non-tender process is wam and easily palpated.

• Abnormal: Painful, errythemic, palpable

• Auditory Canal and TM: Insert otoscope to visualize.

• Normal Appearance:

  • black/red/gray/brown cerumen
  • waxy, flaky, soft
  • no odorm
  • canal walls pink and tympanic membrane easy visible
  • TM pearly grey, translucent can show moment with swallowing.

• Abnormal Appearance: Impacted cerumen, discharge, lesions foreign body and inflamed ear. The TM should not be retracted or bulging.

• Perform Rinne test: compares hair and bone conduction. Strike tuning fork an place base on client process. Ask when no longer there. Move prongs to front of external meatus.

• Weber’s test: if client reports diminished or lust hearing in one ear, softlystick a tuning fork on person head or forehead.

• For Romberg, the client will std with feet together and arm the sides open and closed.

Abnormal External Ear Findings

• Otitis externa
• Otitis media
• Traumatic tympanic membrane
• Ear polyp
• Build-up of ear ceumen