HEENT Assessment and Migraine Headaches
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HEENT Assessment and Migraine Headaches

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Questions and Answers

What is a significant finding that may indicate cranial trauma?

  • Sensitivity to light
  • Unilateral weakness (correct)
  • Jaundiced sclera
  • Severe unilateral throbbing

    • Which of the following is NOT an expected finding during an acute migraine episode?

  • Nausea and vomiting
  • Facial drooping (correct)
  • Severe unilateral throbbing pain
  • Sensitivity to sound

    • What should be assessed to evaluate facial sensation related to the trigeminal nerve?

  • Pupil reaction to light
  • Cotton wisp on forehead, cheek, & chin (correct)
  • Uvula movement when saying 'ah'
  • Vision using a Snellen chart

    • Which visual impairment characteristic indicates legal blindness?

    <p>20/200 vision</p> Signup and view all the answers

    Which combination of cranial nerves is responsible for ocular movements and pupil response?

    <p>III, IV, and VI</p> Signup and view all the answers

    What symptom is typically associated with sensorineural hearing loss?

    <p>Tinnitus</p> Signup and view all the answers

    What does PERRLA stand for in pupil examination?

    <p>Pupils Equal, Round, Reactive to Light and Accommodation</p> Signup and view all the answers

    Which condition would likely prompt auscultation for a bruit?

    <p>Goiter noted on neck inspection</p> Signup and view all the answers

    What is a common environmental intervention to enhance safety for patients with visual impairments?

    <p>Avoiding trip hazards and using adequate lighting</p> Signup and view all the answers

    Which cranial nerve is primarily responsible for the sense of smell?

    <p>CN I: Olfactory</p> Signup and view all the answers

    What is a potential indicator of anaphylactic allergic reaction during a HEENT assessment?

    <p>Angioedema around the lips</p> Signup and view all the answers

    Which symptom is unlikely to be present during a migraine episode?

    <p>Facial drooping</p> Signup and view all the answers

    In assessing hearing loss, what condition is most likely related to excessive earwax buildup?

    <p>Conductive hearing loss</p> Signup and view all the answers

    Which cranial nerve is primarily responsible for the movement of the tongue?

    <p>Hypoglossal nerve</p> Signup and view all the answers

    What is the correct interpretation of a Snellen eye chart reading of 20/100?

    <p>The patient can see at 100 feet what a normal eye sees at 20 feet.</p> Signup and view all the answers

    Which condition involves rapid, involuntary eye movements and may indicate a neurological issue?

    <p>Nystagmus</p> Signup and view all the answers

    In an ear examination, which assessment finding is a common complication post head injury?

    <p>Ear bleeding</p> Signup and view all the answers

    Which of the following practices would not be recommended for managing visual impairments?

    <p>Minimizing screen time</p> Signup and view all the answers

    What cranial nerve is associated with the sense of hearing and balance?

    <p>Vestibulocochlear nerve</p> Signup and view all the answers

    What is the main purpose of assessing for jaundiced sclera during a HEENT examination?

    <p>To detect liver function issues</p> Signup and view all the answers

    Which cranial nerve is not involved in facial expressions or movement?

    <p>Olfactory (CN I)</p> Signup and view all the answers

    What characteristic of ear assessment indicates conductive hearing loss?

    <p>Cerumen buildup in the ear canal</p> Signup and view all the answers

    During a HEENT assessment, what would a finding of unilateral weakness most likely suggest?

    <p>Stroke symptoms</p> Signup and view all the answers

    Which symptom is a critical indicator to assess for during a sudden onset of cranial nerve dysfunction?

    <p>Sudden diplopia</p> Signup and view all the answers

    What might indicate an issue with the glossopharyngeal nerve during a HEENT examination?

    <p>Difficulty swallowing or gag reflex loss</p> Signup and view all the answers

    What is the significance of using a Snellen eye chart during a vision assessment?

    <p>To determine visual acuity</p> Signup and view all the answers

    In assessing the risk of an allergic reaction, what findings might correlate with angioedema?

    <p>Swelling around the eyes</p> Signup and view all the answers

    Why is it important to assess the alignment and symmetry of the nose during a HEENT examination?

    <p>To detect nasal fractures or asymmetry</p> Signup and view all the answers

    Which chronic condition might require preventive medication due to frequent episodes?

    <p>Migraine headaches</p> Signup and view all the answers

    Which cranial nerve is responsible for the sensation in the pharynx and larynx as well as parasympathetic processes such as digestion?

    <p>Vagus</p> Signup and view all the answers

    What characteristic symptom distinguishes nystagmus from other eye movement disorders?

    <p>Involuntary eye movement that is rapid and jerky</p> Signup and view all the answers

    In a patient experiencing severe unilateral throbbing headaches, which of the following symptoms would suggest that it is not merely a migraine?

    <p>Facial drooping</p> Signup and view all the answers

    What does a Snellen eye chart measure during a visual assessment?

    <p>Distance vision</p> Signup and view all the answers

    Which finding might be indicative of an acute issue when assessing ear health?

    <p>Sudden loss of hearing</p> Signup and view all the answers

    What is a primary assessment consideration for patients presenting with a goiter during a neck examination?

    <p>Auscultate for bruit</p> Signup and view all the answers

    Which of these findings is associated with chronic migraines and not typically observed in acute episodes?

    <p>Frequent episodes and lifestyle interference</p> Signup and view all the answers

    In assessing a patient’s hearing loss, what specific feature would most likely suggest a dysfunction of the vestibulocochlear nerve?

    <p>Presence of tinnitus</p> Signup and view all the answers

    Which cranial nerve is primarily evaluated using the ‘cotton wisp’ test to assess facial sensation?

    <p>Trigeminal</p> Signup and view all the answers

    What symptom is indicative of central cyanosis during a HEENT examination?

    <p>Purple/blue discoloration on the nose</p> Signup and view all the answers

    What does the presence of a bruit during a neck examination suggest?

    <p>Increased blood flow to a neck mass</p> Signup and view all the answers

    In what scenario would a pupil react abnormally during an examination?

    <p>As a result of a malfunctioning oculomotor nerve</p> Signup and view all the answers

    During a HEENT assessment, which finding is least likely to indicate a chronic condition?

    <p>Unilateral facial drooping</p> Signup and view all the answers

    Which of the following symptoms would NOT be characteristic of migraines?

    <p>Double vision</p> Signup and view all the answers

    When assessing for possible cranial nerve dysfunction, which observation might correlate with dysfunction of the facial nerve?

    <p>Inability to elevate eyebrows</p> Signup and view all the answers

    What might rapid jerky eye movements indicate during an eye examination?

    <p>Possible neurological dysfunction</p> Signup and view all the answers

    Which option best describes the significance of assessing a patient's buccal mucosa during a HEENT examination?

    <p>To evaluate potential anemia or discoloration</p> Signup and view all the answers

    What does a Snellen eye chart result of 20/50 indicate?

    <p>Vision impaired; can read at 20 feet what others can read at 50 feet</p> Signup and view all the answers

    Which cranial nerve, when assessed, would primarily evaluate face sensation and chewing function?

    <p>CN V - Trigeminal</p> Signup and view all the answers

    Which scenario during a HEENT assessment could indicate an acute need for medical intervention?

    <p>Sudden onset of diplopia</p> Signup and view all the answers

    Study Notes

    HEENT Assessment - Priority Findings

    • Facial asymmetry or signs of dysphagia may indicate stroke or other neurological issues
    • Unilateral weakness could be a sign of stroke
    • Cranial trauma or bleeding may indicate a serious injury
    • Angioedema (swelling around the lips) can be a sign of anaphylactic allergic reaction
    • Neck mass or goiter could indicate thyroid issues
    • Jaundiced sclera may indicate liver problems

    Migraine Headaches

    • Migraines should not cause neurological deficits, such as facial drooping
    • During an acute migraine episode, patients may experience severe unilateral throbbing pain, sensitivity to light and sound, nausea, and vomiting
    • Migraine headaches are often chronic and require preventative measures if frequent

    Cranial Nerves

    • Cranial nerve assessment is essential for neurological evaluation
    • CN I (Olfactory): Responsible for sense of smell
    • CN II (Optic): Responsible for vision
    • CN III (Oculomotor), CN IV (Trochlear), and CN VI (Abducens): These nerves control eye movements (up, down, medial, lateral) and pupil dilation/constriction
    • CN V (Trigeminal): Assess facial sensation using a "cotton wisp" on the forehead, cheek, and chin. Trigeminal neuralgia is pain associated with this nerve.
    • CN VII (Facial): Controls facial expressions and movements. Dysfunction can be associated with Bell’s Palsy
    • CN VIII (Acoustic/Vestibulocochlear): Responsible for hearing and balance
    • CN IX (Glossopharyngeal): Observe the uvula and soft palate rising when the patient says "ah"
    • CN X (Vagus): This nerve controls sensation in the pharynx, larynx, and parasympathetic processes (digestion)
    • CN XI (Spinal Accessory): Assess shoulder shrugging
    • CN XII (Hypoglossal): Observe tongue movements

    Head and Face

    • The skull should be normocephalic (normal size and shape), symmetrical, and nontender
    • The tops of the ears should align with the outer canthus of the eyes
    • Central cyanosis (purple/blue discoloration) on the nose, lips, or mucosa could indicate low oxygen levels
    • Assess for sinus tenderness in the maxillary (cheek below eyes) and frontal (forehead) sinuses

    Eyes

    • Assess the conjunctivae, sclera, iris, eyelids, eyelashes, and ocular movements
    • For any eye complaint, assess far vision using a Snellen eye chart
    • Snellen Eye Chart Interpretation:
      • The numerator indicates the distance from the chart (usually 20 feet)
      • The denominator indicates the distance at which a normal eye can see the same line
      • Normal vision: 20/20
      • Interpretation: The patient can read at 20 feet what an average person can read at [denominator] feet.
      • Example: 20/40 vision means the patient can read at 20 feet what a person with normal vision can read at 40 feet
      • 20/200 vision indicates legal blindness
    • Assess and document each eye separately and then bilaterally
    • Other vision assessments:
      • Ishihara chart: assesses for color blindness
      • Rosenbaum chart: assesses near vision (hold chart 14 inches away from the patient's eyes)
    • Environmental interventions to promote safety for visual impairments:
      • Remove trip hazards (small rugs, cords, clutter)
      • Encourage electronic devices that read or speak out loud
      • Advise consistent use of eyeglasses, adequate lighting, and a cane if necessary
      • Clean eyeglasses regularly
    • Nystagmus: Rapid jerky or tremor-like eye movement back and forth
    • Diplopia: Double vision (possible sign of head injury)
    • PERRLA: This acronym assesses CN III, IV, and VI and does not indicate vision (CN II):
      • Pupils
      • Equal (in size)
      • Round (and)
      • Reactive (to)
      • Light (and)
      • Accommodation: Pupils constrict when looking at a near object and dilate when looking at a far object

    Ears

    • Inspect and palpate the external ears
    • Hearing loss:
      • Conductive hearing loss: Caused by excessive cerumen buildup
      • Sensorineural hearing loss: Dysfunction of CN VIII (may be associated with tinnitus)
    • Nursing considerations for hearing impairments:
      • Assess the level of impairment, use of hearing aids, and patient preferences
      • Face the patient and speak slowly; do not shout
    • For complaints of acute hearing loss, assess for:
      • Use of hearing aids, exposure to loud noises, and tinnitus

    Nose

    • Assess septal alignment, symmetry, color, tenderness, and swelling of turbinates
    • Epistaxis (nosebleed) after a head injury could indicate ear bleeding

    Mouth

    • Observe the buccal mucosa (mucous membranes) - the best place to assess for discoloration in dark-skinned patients.

    Neck

    • Assess for masses or goiter (especially if the patient has difficulty swallowing)
    • If a goiter is present, auscultate for bruit (do not palpate)

    HEENT: Priority Findings

    • Asymmetry of the face or signs of dysphagia may indicate a serious condition, especially if accompanied by unilateral weakness.
    • Unilateral weakness or symptoms of stroke require immediate attention.
    • Cranial trauma/bleed is a critical finding that necessitates immediate intervention.
    • Angioedema, swelling around the lips, can be a sign of an anaphylactic allergic reaction and requires prompt management.
    • Neck mass/goiter should be investigated further, as they can indicate underlying medical issues.
    • Jaundiced sclera, yellowing of the whites of the eyes, suggests potential liver dysfunction.

    Migraine Headaches

    • Migraines should not cause signs of neurological dysfunction, such as facial drooping.
    • Expected findings during an acute migraine episode include severe unilateral throbbing pain, sensitivity to light and sound, and nausea or vomiting.
    • Many patients experience chronic migraines, making prevention a crucial aspect of management.
    • Assess the impact of migraines on daily life and functioning to determine the need for preventive medications.

    Cranial Nerves

    • Cranial nerves control various functions, including smell, vision, eye movements, facial sensation, chewing, facial expressions, hearing, balance, swallowing, speech, and tongue movements.
    • Assessing each cranial nerve function allows for identification of potential neurological impairments.

    Head and Face

    • The skull should be normocephalic, symmetrical, and nontender.
    • The tops of the ears should align with the outer canthus of the eyes.
    • Central cyanosis, a purple or blue discoloration on the nose, lips, or mucosa, indicates oxygen deficiency.
    • Assess for sinus tenderness, specifically in the maxillary (cheek below eyes) and frontal (forehead) sinuses.

    Eyes

    • Inspect the conjunctivae, sclera, iris, eyelids, eyelashes, and ocular movements.
    • Assess far vision using a Snellen eye chart for any eye complaint, as visual impairments can pose safety risks.
    • Snellen eye chart interpretation:
      • Numerator represents the distance from the chart.
      • Denominator indicates the distance at which a normal eye can see.
      • Normal vision is 20/20, meaning the patient can see at 20 feet what an average person can see at 20 feet.
      • 20/200 is considered legal blindness.
    • Assess and document vision for each eye separately and then bilaterally.
    • Other vision assessments include the Ishihara chart for color blindness and the Rosenbaum chart for near vision.
    • Environmental interventions to promote safety for patients with visual impairments include:
      • Avoiding trip hazards like small rugs, cords, and clutter on the ground.
      • Encouraging the use of electronics that read or speak out loud.
      • Consistent use of eyeglasses, adequate lighting, and a cane.
      • Cleaning eyeglasses and drying them with soft cloths.
    • Nystagmus, rapid jerky or tremor-like eye movement, may indicate neurological issues.
    • Diplopia, double vision, can be a sign of serious complications related to head injury. Assess for sudden onset.
    • PERRLA, Pupils Equal, Round, Reactive to Light and Accommodation, assesses cranial nerves III, IV, and VI. It does not indicate vision (cranial nerve II).

    Ears

    • Inspect and palpate the external ears.
    • Hearing loss can be conductive due to excessive cerumen buildup or sensorineural due to dysfunction of cranial nerve VIII.
    • Sensorineural hearing loss may be associated with tinnitus.

    Nursing Considerations for Hearing Impairments

    • First assess the level of impairment, use of hearing aids, and patient preferences.
    • Face the patient and speak slowly; avoid shouting.

    Nose

    • Assess septal alignment, symmetry, color, tenderness, and swelling of the turbinates.
    • Epistaxis (nosebleed) after head injury requires assessment for ear bleeding.

    Mouth

    • Inspect the buccal mucosa (mucous membranes) for discoloration, especially in dark-skinned patients.

    Neck

    • Assess for masses or goiter, which may indicate difficulty swallowing.
    • If goiter is noted, auscultate for a bruit (do not palpate).

    HEENT Assessment

    • Priority findings: Facial asymmetry, dysphagia, unilateral weakness, signs of stroke, cranial trauma/bleed, angioedema (swelling around lips), neck mass/goiter, and jaundiced sclera.
    • Migraine headaches: Should not cause neurological dysfunction, such as facial drooping.
      • Acute episode findings: Severe unilateral throbbing, sensitivity to light/sound, nausea/vomiting.
      • Chronic episodes: Patients often experience frequent episodes, preventive medications may be necessary to manage these.
    • Cranial Nerves: See chart below for a detailed breakdown of each cranial nerve.
    • Visual impairments: Can be significant safety concerns at home and while driving.
      • Snellen Eye Chart: Measures far vision, normal vision is 20/20.
        • Numerator: Distance from the chart.
        • Denominator: Distance a normal eye can see at.
        • Legal blindness: 20/200.
      • Other vision assessments: Ishihara chart (color blindness) and Rosenbaum chart (near vision).
    • Hearing loss:
      • Conductive hearing loss: Caused by excessive cerumen buildup.
      • Sensorineural hearing loss: Dysfunction of CN VIII, may be associated with tinnitus.
    • Assessment of the nose: Assess for septal alignment, symmetry, color, tenderness, and swelling of turbinates.
      • Epistaxis after a head injury: Assess for ear bleeding.
    • Mouth: Inspect the buccal mucosa (mucous membranes), this is the best place to assess discoloration in dark-skinned patients.
    • Neck: Inspect and palpate for masses or goiter.
      • Goiter: Auscultate for bruit (do not palpate).

    Cranial Nerves

    • CN I: Olfactory (Smell) - Sensory
    • CN II: Optic (Vision) - Sensory
    • CN III: Oculomotor (Eye movement & pupil dilation) - Motor
    • CN IV: Trochlear (Vertical eye movement) - Motor
    • CN V: Trigeminal (Facial sensation & chewing) - Both
    • CN VI: Abducens (Lateral eye movement) - Motor
    • CN VII: Facial (Facial expressions) - Both
    • CN VIII: Vestibulocochlear (Hearing) - Sensory
    • CN IX: Glossopharyngeal (Swallow/gag reflex) - Both
    • CN X: Vagus (Digestion & throat sensation) - Both
    • CN XI: Spinal Accessory (Shoulder movements) - Motor
    • CN XII: Hypoglossal (Tongue movements) - Motor

    Environment Interventions to Promote Safety for Visual Impairments

    • Avoid trip hazards (small rugs, cords, & clutter on the ground).
    • Encourage electronics that read or speak out loud.
    • Consistent use of eyeglasses, adequate lighting, and a cane.
    • Clean eyeglasses and dry them with soft cloths.

    Additional HEENT Assessment Items

    • Nystagmus: Rapid jerky or tremor-like eye movement back and forth.
    • Diplopia: Double vision, can indicate a serious complication related to a head injury, assess for sudden onset.
    • PERRLA: Evidence of CNs III, IV, and VI.
      • Assess for pupils:
        • Equal (in size)
        • Round (and)
        • Reactive (to)
        • Light (and)
        • Accommodation: Pupils constrict when looking at a near object and dilate when looking at a far object.
    • Ears: Inspect and palpate external ears.
    • Head and face: Skull should be normocephalic, symmetrical, and nontender.
      • Tops of ears should align with the outer canthus of the eyes.
      • Central cyanosis: Purple/blue discoloration on the nose, lips, or mucosa.
      • Sinus tenderness: Assess for tenderness of the maxillary (cheek below eyes) and frontal (forehead) sinuses.

    HEENT Assessment

    • Prioritize assessment for facial asymmetry, dysphagia signs, unilateral weakness, cranial trauma/bleeding, angioedema, neck masses/goiter, and jaundiced sclera.
    • Migraine headaches should not cause neuro dysfunction like facial drooping.
      • Acute migraine symptoms: severe unilateral throbbing, light/sound sensitivity, nausea/vomiting.
      • Chronic migraine: frequent episodes, preventative medication may be needed.
      • Assess daily function and life interference.
    • Cranial nerves are crucial to assess.
      • CN I (Olfactory): Sense of smell.
      • CN II (Optic): Vision.
      • CN III (Oculomotor), CN IV (Trochlear), & CN VI (Abducens): Ocular movements (up/down/medial/lateral) and pupil dilation/constriction.
      • CN V (Trigeminal): Facial sensation (test with "cotton wisp" on forehead, cheek, and chin). Dysfunction associated with trigeminal neuralgia/facial nerve pain.
      • CN VII (Facial): Facial expressions/movements. Dysfunction related to Bell's Palsy.
      • CN VIII (Acoustic/Vestibulocochlear): Hearing/balance.
      • CN IX (Glossopharyngeal): Uvula and soft palate rise when saying "ah."
      • CN X (Vagus): Sensation in pharynx, larynx, and parasympathetic processes/digestion.
      • CN XI (Spinal Accessory): Shoulder shrugging.
      • CN XII (Hypoglossal): Tongue movements.
    • Head and Face:
      • Skull should be normocephalic, symmetrical, and nontender.
      • Ears should align with outer canthus of eyes.
      • Central cyanosis: purple/blue discoloration on nose, lips, or mucosa.
      • Assess for sinus tenderness: maxillary (cheek below eyes) and frontal (forehead) sinuses.
    • Eyes:
      • Assess conjunctivae, sclera, iris, eyelids, eyelashes, and ocular movements.
      • For any eye complaint: assess far vision using a Snellen eye chart. Visual impairments pose safety risks.
      • Snellen Eye Chart interpretation:
        • Numerator: distance from chart (always 20 feet).
        • Denominator: distance at which a normal eye can see.
        • Normal vision: 20/20.
        • Example: 20/40 vision: The patient can read at 20 feet what an average person can read at 40 feet (decreased vision).
        • 20/200: Legal blindness.
      • Assess and document each eye separately and bilaterally.
      • Other vision assessments: Ishihara chart (color blindness) and Rosenbaum chart (near vision - hold 14 inches from the patient's eyes).
      • Environmental interventions for visual impairments:
        • Avoid trip hazards (small rugs, cords, clutter).
        • Encourage assistive technology (reading or speaking electronics).
        • Consistent use of eyeglasses, adequate lighting, and canes.
        • Clean eyeglasses with soft cloths.
      • Nystagmus: rapid jerky or tremor-like eye movement back and forth.
      • Diplopia (double vision): May indicate a serious complication related to head injury. Assess for sudden onset.
      • PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation):
        • Assesses CNs III, IV, VI (does NOT indicate vision/CN II).
        • Accommodation: pupils constrict when looking at a near object and dilate when looking at a far object.
    • Ears:
      • Inspect and palpate external ears.
      • Hearing loss:
        • Conductive hearing loss: caused by excessive cerumen buildup.
        • Sensorineural hearing loss: dysfunction of CN VIII, may be associated with tinnitus.
      • Nursing considerations for hearing impairments:
        • Assess level of impairment, hearing aid use, and patient preferences.
        • Face the patient and speak slowly, do not shout.
      • For acute hearing loss complaints: Assess for hearing aid use, exposure to loud noises, and tinnitus.
    • Nose:
      • Assess septal alignment, symmetry, color, tenderness, and swelling of turbinates.
      • Epistaxis (nosebleed) after head injury: Assess for ear bleeding.
    • Mouth:
      • Buccal mucosa (mucous membranes): Best place to assess for discoloration in dark-skinned patients.
    • Neck:
      • Assess for masses or goiter: Especially important if the patient has difficulty swallowing.
      • If goiter is noted: Auscultate for a bruit (do NOT palpate).

    Cranial Nerve Mnemonic

    • Oh Oh To Touch And Feel Very Good Veins Ah Heaven
    • Some Say Marry Money But My Brother Says Big Brains Matter More

    HEENT Assessment

    • Assess for facial asymmetry, dysphagia, unilateral weakness, signs of stroke, cranial trauma/bleed, angioedema, neck mass, or goiter.

    • Assess for jaundice of the sclera.

    Migraines

    • Migraines should not cause neuro dysfunction, such as facial drooping.

    • Expected findings in an acute migraine include:

      • Severe unilateral throbbing.
      • Sensitivity to light and sound.
      • Nausea/vomiting.

    • Patients often experience chronic episodes.

    • The goal for treatment is prevention, especially for frequent episodes.

    • Assess for interference with daily life and functioning.

    Cranial Nerves

    • CN I: Olfactory (smell): Sensory
    • CN II: Optic (vision): Sensory
    • CN III: Oculomotor (eye movement & pupil dilation): Motor
    • CN IV: Trochlear (vertical eye movement): Motor
    • CN V: Trigeminal (facial sensation and chewing): Both sensory and motor
      • Assess facial sensation using a "cotton wisp" to touch the forehead, cheek, and chin.
      • Dysfunction is associated with trigeminal neuralgia/facial nerve pain.
    • CN VI: Abducens (lateral eye movement): Motor
    • CN VII: Facial (facial expressions): Both sensory and motor
      • Dysfunction is related to Bell's Palsy.
    • CN VIII: Vestibulocochlear (hearing and balance): Sensory
    • CN IX: Glossopharyngeal (swallow/gag reflex): Both sensory and motor
    • CN X: Vagus (digestion and throat sensation): Both sensory and motor
      • Assess by observing the uvula & soft palate rising when the patient says "ah".
    • CN XI: Spinal Accessory (shoulder movements): Motor
    • CN XII: Hypoglossal (tongue movements): Motor

    Head and Face

    • The skull should be normocephalic, symmetrical, and nontender.

    • The tops of the ears should align with the outer canthus of the eyes.

    • Central cyanosis, a purple/blue discoloration of the nose, lips, or mucosa, should be noted.

    • Assess for sinus tenderness:

      • Maxillary (cheek below eyes).
      • Frontal (forehead).

    Eyes

    • Assess conjunctivae, sclera, iris, eyelids, eyelashes, and ocular movements.

    • For any eye complaint, assess far vision using a Snellen eye chart.

    • Snellen Eye Chart Interpretation:

      • Numerator: Distance from the eye chart.
      • Denominator: Distance at which a normal eye can see.
      • Normal vision: 20/20.
      • Example: 20/40 means "the patient can read at 20 feet what an average person can read at 40 feet" (decreased vision).
      • Legal blindness: 20/200.

    • Assess and document each eye separately and then bilaterally.

    Other Vision Assessments

    • Ishihara chart: Assesses for color blindness.

    • Rosenbaum chart: Assesses near vision.

      • Hold the chart 14 inches away from the patient's eyes.

    Environmental Interventions for Visual Impairments

    • Avoid trip hazards (rugs, cords, clutter).

    • Encourage electronics that read or speak out loud.

    • Consistent use of eyeglasses, adequate lighting, and a cane.

    • Clean eyeglasses and dry with soft cloths.

    Eye Movement Findings

    • Nystagmus: Rapid jerky or tremor-like eye movement back and forth.

    • Diplopia (double vision): May be a sign of a serious complication related to a head injury.

      • Assess for SUDDEN ONSET.

    PERRLA

    • PERRLA indicates functionality of CNs III, IV, and VI (does NOT indicate vision/CN II).

      • P: Pupils
      • E: Equal
      • R: Round
      • R: Reactive
      • L: Light
      • A: Accommodation

    • Accommodation: Pupils constrict when looking at a near object and dilate when looking at a far object.

    Ears

    • Inspect and palpate the external ears.

    • Hearing Loss:

      • Conductive hearing loss: Caused by excessive cerumen buildup.
      • Sensorineural hearing loss: Dysfunction of CN VIII.
        • May be associated with tinnitus.

    Nursing Considerations for Hearing Impairments

    • First, assess the level of impairment, use of hearing aids, and patient preferences.

    • Face the patient and speak slowly. Do not shout at the patient.

    Acute Hearing Loss

    • Assess for:
      • Hearing aid use.
      • Exposure to loud noises.
      • Tinnitus (ringing in the ears).

    Nose

    • Assess for septal alignment, symmetry, color, tenderness, and swelling of the turbinates.

    • Epistaxis (nosebleed) after head injury: Assess for ear bleeding.

    Mouth

    • Assess buccal mucosa (mucous membranes).
      • This is the best place to assess for discoloration in dark-skinned patients.

    Neck

    • Assess for masses or a goiter, especially if the patient has difficulty swallowing.

    • If a goiter is noted, auscultate for a bruit (do NOT palpate).

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    Description

    This quiz focuses on priority findings in HEENT assessment, including signs of stroke, cranial nerve evaluation, and symptoms of migraines. It covers critical conditions that can be identified through physical examinations and neurological assessments.

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