Nose, Mouth, Throat, and Neck Assessment

• These notes cover health assessment techniques for the nose, mouth, throat, and neck, including anatomy, assessment procedures, and common abnormalities.

Staff and Publication Details

• Chris Burghardt is the Publisher.
• Joan M. Robinson is the Clinical Director.
• Diane Labus is the Product Manager.
• Beverly Ann Tscheschlog is the Clinical Project Manager.
• Jaime Stockslager Buss is the Editor
• Karen Comerford is the Copy Editor.
• Joan Wendt is the Design Coordinator.
• Bot Roda is the illustrator.
• Beth J. Welsh is the Associate Manufacturing Manager.
• Karen J. Kirk, Jeri O'Shea, and Linda K. Ruhf are the Editorial Assistants.
• The clinical treatments are based on research, nursing, medical, and legal authorities.
• These procedures reflect currently accepted practice, but must be considered in light of the patient's condition.
• Authors and publisher disclaim responsibility for adverse effects, undetected errors, or misunderstanding of the text.
• © 2011 by Lippincott Williams & Wilkins.
• No part of this book may be reproduced without prior written permission, except for brief quotations, testing and evaluation materials.
• Printed in China
• Derived from American Gothic, 1930 by Grant Wood.

Contributors and Consultants

• Nancy Berger, RN, MSN, BC, CNE, Program Coordinator at Middlesex County College, Edison, N.J.
• Marsha L. Conroy, RN, BA, MSN, APN, Nurse Educator at Indiana Wesleyan University, Marion and Chamberlain College of Nursing, Columbus, Ohio.
• Roseanne Hanlon Rafter, RN, MSN, GCNS, BC, Director of Nursing Professional Practice at Chestnut Hill Hospital, Philadelphia, Pa.
• Dana Reeves, RN, MSN, Assistant Professor at University of Arkansas—Fort Smith.
• Denise Stefancyk, RN, BSN, CCRC, Clinical Specialist at University of Massachusetts Medical Center, Worcester.
• Allison J. Terry, RN, PhD, Director, Center for Nursing, Alabama Board of Nursing, Montgomery.
• Leigh Ann Trujillo, RN, BSN, Clinical Educator at St. James Hospital and Health Centers, Olympia Fields, Ill.
• Rita M. Wick, RN, BSN, Simulation Coordinator at Berkshire Health Systems, Pittsfield, Mass.
• Sharon E. Wing, RN, PhD(C), CNL, Associate Professor at Cleveland (Ohio) State University.
• Lisa Wolf, RN, MS, CMSRN, Clinical Educator at Mount Carmel West, Columbus, Ohio.

Fundamentals of Assessment

• Involves collecting objective and subjective data.
• Objective data are observed and verifiable.
• Subjective data are provided and verified only by the patient.
• Effective interview techniques include a quiet setting, clear language, silence, reflection, and open/closed-ended questions.

Components of Health History

• Biographical data includes name, address, date of birth, and next of kin information.
• Chief complaint describes the main reason for the patient's visit.
• History of present illness details the current health problem.
• Current medications lists all drugs, dosages, frequency, and last dose and include prescription, over-the-counter, herbal, and supplements.
• Allergies specifies drug, food, environmental, and blood reaction allergies.
• Medical history covers childhood illnesses, previous hospitalizations, and existing health problems.
• Family medical history includes health problems like arthritis, cancer, diabetes, heart disease, hypertension, and stroke.
• Psychosocial history includes coping strategies, feelings of safety, social history, religious and cultural observances, activities of daily living, diet and exercise, elimination patterns, sleep patterns, work and leisure activities, and use of safety measures.
• Health maintenance history includes colonoscopy, dental examination, eye examination, immunizations, and mammography dates.
• Review of systems covers all body structures to ensure no symptoms are missed, starting from head to toes.

Evaluating a Symptom

• Identify the symptom bothering the patient.
• Assess if the patient's condition indicates an emergency, such as sudden bloating along with sweating and light-headedness.
• Take a thorough history, especially noting GI disorders, and perform a physical examination.
• Evaluate findings for emergency signs like abdominal rigidity and abnormal bowel sounds.
• Thoroughly examine the patient, observing abdominal asymmetry, skin, bowel sounds, percussion, palpation, and abdominal girth and also measure abdominal girth.
• Consider possible causes based on findings, such as cancer, bladder distention, cirrhosis, heart failure, or gastric dilation.
• Develop a care plan, ensuring patient comfort, administering analgesics, and preparing for diagnostic tests.

Physical Assessment Tools

• Necessary tools include cotton balls, gloves, metric ruler, vision charts, ophthalmoscope, otoscope, penlight, percussion hammer, etc.
• Baseline data includes height, weight, and vital signs like temperature, pulse, and blood pressure.

Blood Pressure Measurement

• Position the patient with the upper arm at heart level.
• Apply the cuff 1 inch (2.5 cm) above the brachial pulse.
• Inflate the cuff to 30 mm Hg above the point where the pulse disappears.
• Place the stethoscope's bell over the brachial pulse.
• Release the valve slowly and note the reappearance of Korotkoff's sounds for systolic pressure and the last sound for diastolic pressure.

Interpreting Vital Signs

• Analyze vital signs simultaneously to identify potential problems, such as shock indicated by a rapid, thready pulse with low blood pressure.
• Recheck abnormal values to ensure accuracy.
• Consider age-related normal ranges and baseline values.

Physical Assessment Techniques

• Four techniques: inspection, palpation, percussion, and auscultation.
• Abdominal assessment sequence: inspection, auscultation, percussion, and palpation.
• Inspection involves using vision, smell, and hearing.
• Palpation uses different parts of the hands with varying pressure and wear gloves when palpating mucous membranes or areas in contact with body fluids.

Types of Palpation

• Light palpation is for surface abnormalities using finger pads with light touch.
• Deep palpation is for internal organs and masses, applying firm, deep pressure.

Percussion

• Percussion involves tapping fingers or hands to locate organ borders and determine organ shape and density.

Types of Percussion

• Direct percussion reveals tenderness by tapping directly on the body part.
• Indirect percussion elicits sounds by pressing a finger on the body part and tapping it with another finger.

Auscultation

• Auscultation involves listening for breath, heart, and bowel sounds using a stethoscope.
• Use the diaphragm for high-pitched sounds and the bell for low-pitched sounds.

Documentation

• Initial assessment findings should be accurately recorded on assessment forms.

Skin, Hair, and Nails: Anatomy

• Skin covers and protects internal structures; it consists of the epidermis and the dermis.
• Subcutaneous tissue lies beneath these layers.
• Epidermis is the outer layer made of squamous epithelial tissue.
• Dermis is the thick, deeper layer with connective tissue, blood vessels, lymphatic vessels, nerves, hair follicles, and sweat and sebaceous glands.
• Hair is formed from keratin in hair follicles.
• Nails are hard plates of keratin converted from epidermal cells.

Skin Assessment: Color

• Look for variations like bruising, cyanosis, pallor, and erythema. Check for uniformity and areas of hypo- or hyperpigmentation.
• In dark-skinned people, check conjunctivae, palms, soles, buccal mucosa, and tongue for color variations.

Skin Assessment: Moisture, Texture, and Turgor

• Skin should be relatively dry.
• Palpate the skin's texture, noting thickness and mobility.
• Assess skin turgor by gently squeezing the skin on the forearm or sternal area.

Skin Assessment: Temperature

• Palpate the skin bilaterally using the dorsal surface of the hands and fingers.

Assessment of Hair and Nails

• Hair should be evenly distributed; assess quantity, texture, and color.
• Nails should be pink or brown, smooth, and slightly curved or flat.

Skin Lesions

• Classify as primary (new) or secondary (change in a primary lesion). Determine if solid or fluid-filled.
• Include descriptions of symmetry, borders, color, configuration, diameter, and drainage.

Types of Skin Lesions

• Macule: A small, discolored spot.
• Papule: A solid, raised lesion less than 1 cm in diameter.
• Vesicle: A small, fluid-filled blister less than 1 cm
• Pustule: A small, pus-filled lesion.
• Wheal: A raised, reddish, itchy area lasting less than 24 hours.
• Ulcer: A crater-like lesion extending into the dermis.
• Bulla: A large, fluid-filled blister 1 cm or more in diameter.
• Nodule: A raised lesion detectable by touch, 1 cm or more in diameter.
• Cyst: A closed sac in or under the skin containing fluid or semi-solid material.
• Fissure: A painful, crack-like lesion extending at least into the dermis.

Benign vs. Cancerous Lesions

• Benign nevi are symmetrical with sharply defined borders and uniform color.
• Cancerous lesions exhibit asymmetry, irregular borders, varied colors, and a diameter greater than 6 mm.

ABCDEs of Malignant Melanoma

• A = Asymmetrical lesion.
• B = Border irregular.
• C = Color varies with shades of tan, brown, or black.
• D = Diameter greater than 6 mm.
• E = Elevated or enlarging lesion.

Common Skin Disorders

• Psoriasis: Chronic disease with epidermal thickening and scaly, red plaques.
• Contact dermatitis: Inflammatory disorder resulting from contact with an irritant, vesicles, bullae, and red macules.
• Urticaria (hives): Allergic reaction with pink, edematous papules or wheals.
• Herpes zoster: Group of vesicles along a nerve root, usually unilateral on the trunk.
• Scabies: Lesions caused by mites burrowing under the skin, appearing in a straight or zigzag line.
• Tinea corporis (ringworm): Round, red, scaly lesions with raised borders, accompanied by intense itching.

Pressure Ulcers

• Localized areas of skin breakdown due to prolonged pressure, leading to necrotic tissue.

Staging Pressure Ulcers

• Stage I: Intact skin that doesn't blanch with pressure.
• Stage II: Superficial partial-thickness wound with a red and pink wound bed.
• Stage III: Full-thickness wound with tissue loss and subcutaneous tissue visible.
• Stage IV: Full-thickness skin loss with exposed muscle, bone, and tendon.
• Unstageable: Full-thickness tissue loss with the base of the ulcer covered by slough and eschar.
• Suspected deep tissue injury: Maroon or purple intact skin or blood-filled blister.

Hair Abnormalities

• Alopecia: Diffuse or patchy hair loss.
• Hirsutism: Excessive hairiness in women.

Nail Abnormalities

• Clubbed fingers: Angle between the fingernail and skin increasing to 180 degrees or more.
• Splinter hemorrhages: Reddish-brown streaks under the nails.
• Muehrcke's lines: Longitudinal white lines indicating metabolic stress.

Eye Anatomy

• Eyes have extraocular and intraocular structures.
• Bony orbits protect the eyes.
• Eyelids, lashes, and lacrimal glands protect from injury.
• Intraocular structures include the cornea, sclera, choroid, ciliary body, iris, pupil, lens, retina, and optic nerve.

Ear Anatomy

• External ear collects sound.
• Middle ear conducts vibrations.
• Inner ear receives vibrations.

Eye Assessment: Distance Vision

• Use Snellen charts to measure visual acuity at 20 feet (6.1 m).
• Record vision as a fraction.

Eye Assessment: Near-Vision

• Use a Rosenbaum card 14 inches (35.6 cm) from the eyes.
• Record visual accommodation with and without corrective lenses.

Eye Assessment: Confrontation

• Test peripheral vision by bringing wiggling fingers into the patient’s visual field.

Eye Inspection

• Assess the position of the eyes and eyelids and check for redness, edema, inflammation, or lesions.
• Corneas should be clear and convex.
• Irises should be flat and the same size, color, and shape.

Eye Inspection: Conjunctivae and Sclerae

• Conjunctivae should be clear and shiny.
• Sclerae should be white or buff.

Eye Examination: Pupils

• Pupils should be equal in size, round, and reactive to light.

Assessing Eye Muscle Function

• Perform the corneal light reflex test and assess the six cardinal positions of gaze.

Examining Intraocular Structures

• Use an ophthalmoscope to observe internal structures and check the red reflex.

Retinal Structures

• Examine blood vessels, optic disk, retina, and macula with an ophthalmoscope.

Ear Assessment: External Observation

• Observe for position, symmetry, lesions, drainage, or redness.

Otoscopic Examination

• Straighten the ear canal, positioning the scope properly, and view the tympanic membrane and bony structures.

Hearing Acuity Tests

• Use Weber's test and the Rinne test with a tuning fork.

Eye Abnormalities

• Conjunctivitis: Hyperemia of the conjunctiva with discharge and tearing.
• Acute angle-closure glaucoma: Rapid onset of inflammation, severe eye pain, decreased vision, and pupil dilation.
• Periorbital edema: Swelling around the eyes.
• Ptosis: Drooping upper eyelid.
• Cataract: Clouding of the lens.
• Macular degeneration: Atrophy or deterioration of the macular disk.
• Decreased visual acuity is the inability to see clearly, commonly occurs with refractive errors.
• Diplopia, or double vision, occurs when the extraocular muscles are misaligned. Discharge may occur in one or both eyes and may be scant or copious.
• Eye Pain may signal an emergency and requires immediate attention.
• Types of vision loss include central vision loss, peripheral vision loss, or a blind spot in the middle of an area of normal vision (scotoma).
• Visual halos Increased intraocular pressure, which occurs in glaucoma, causes the patient to see halos and rainbows around bright lights.

Ear Abnormalities

• Earache usually results from disorders of the external and middle ear and are associated with infection, hearing loss, and otorrhea.
• Otitis media is the inflammation of the middle ear.
• Complications of otitis media consist of Otitis media with effusion (Characterized by fluid in the middle ear that may not cause symptoms, May be acute, subacute, or chronic.) and Perforation.
• Cholesteatoma which is an abnormal skin growth or epithelial cyst in middle ear that usually results from repeated ear infections.

Nose Anatomy

• Lower two-thirds made of cartilage, upper one-third of a bone.
• Filters, warms, and humidifies air.

Nose and Sinuses Assessment: Inspection

• Observe position, symmetry, and color. Check patency by occluding one nostril.
• Examine the nasal cavity with a nasal speculum or otoscope. Note the nasal septum, Nasal airway, Middle turbinate, Middle meatus, Inferior meatus, Inferior turbinate.

Nose and Sinuses Assessment: Palpation

• Palpate the nose and sinuses for pain, tenderness, swelling, and deformity.
• Check for swelling around the eyes, and palpate the sinuses for tenderness.

Mouth and Throat Assessment

• Inspect lips, gums, teeth, tongue, and oropharynx.
• Use a tongue blade and bright light. Check for lesions, ulcers, or edema and finally, assess the patient’s gag reflex by gently touching the back of the pharynx. Be sure to assess the gag reflex on the patients oropharynx using a cotton-tipped applicator or the tongue blade.

Neck Assessment

• Inspect for symmetry, scars, pulsations, and masses. Palpate lymph nodes for size, shape, mobility, consistency, temperature, and tenderness.
• Palpate the trachea and the thyroid gland. Use light pressure on the bell of the stethoscope, listen over the carotid arteries to check for turbulent blood flow.

Neck Masses: SPEND

• Swelling
• Pulsations
• Enlargement (of thyroid gland or lymph node)
• Neck masses
• Distention.

Nose Abnormalities - Symptom Synopsis

• Epistaxis: Refers to nosebleed caused by, Coagulation disorders, Trauma, Other hematologic disorders, Renal disorders, and Hypertension
• Flaring: Refers to nostril dilation that occurs during inspiration causes, Respiratory distress
• Stuffiness and discharge: Refers to obstruction of the nasal mucous membranes accompanied by secretions causes, Common cold, Sinusitis, Trauma, Allergies, Exposure to irritants, and Deviated septum

Mouth Abnormalities

• Herpes simplex (type 1)
• Angioedema
• Leukoplakia
• Candidiasis

Throat Abnormalities - Symptom Synopsis

• Dysphagia: Refers to difficulty swallowing causes, Esophageal disorders, Oropharyngeal, respiratory, neurologic, or collagen disorders and Certain toxins and treatments
• Throat pain (Commonly known as a sore throat): Refers to discomfort in any part of the pharynx causes, Upper or lower respiratory tract infections (URTI/LRTI), Allergic reactions, Chemical and physical reactions, Immunocompromised states and Other causes for example, connective tissue disease