Nursing Assessment Questions

• Assessing the head includes examining the head, face, neck, nose, mouth, and throat.
• Concentrate initially on the face, head, and nose's external features.
• A light source and tongue blade are required for visualizations for mouth and throat evaluations.
• The assessment includes palpating the lymph nodes in the head and neck, as well as the trachea and thyroid.
• The health evaluation should emphasize each system when gathering data that could affect health and spotting knowledge gaps that call for more education.

Head, Neck, and Lymph Considerations

• Headaches that are unusually frequent or severe
• Neck or face discomfort
• Problems twisting, bending, or stretching the neck
• Swellings or lumps in the head or neck that may or may not be painful
• A history of brain damage from trauma
• Participation in high-contact sports like football in the past

Nose, Mouth, and Throat Considerations

• Past dental care practices, including dental hygiene
• Allergies history
• Having trouble eating or swallowing anything
• Having issues with your teeth or gums
• A history of consuming medications or inhaling narcotics or fumes

Lifestyle Considerations

• When evaluating the region's risk variables, remember to inquire about lifestyle choices that could have an impact on this system's health.
• What choices do clients make right now that could affect the future health of their head, neck, nose, mouth, and throat?

Risk Factors for Head and Neck

• Not using safety gear, like seatbelts and helmets
• Taking drugs or alcohol

Risk Factors for Nose, Mouth, and Throat

• Using cigarettes, cigars, vapes, or chewing tobacco
• Lack of consistent dental care
• Poor nutrition
• Not engaging in proper hand washing and infection prevention practices

Preparation

• Tongue blades and cotton gauze can be used to move the tongue out of the way to see the throat better.
• It can be helpful to have a little cup of water on hand to rinse the mouth or test swallowing.
• Saliva exposure necessitates the use of gloves.
• A penlight or flashlight is required to see the mouth and throat.
• Also, for a more thorough examination and palpation of the head, have the patient take off any hats, wigs, or headgear.

Head Inspection and Palpation Points

• Head position
• Symmetry of shape and features
• Color changes, scars, lumps, and noticeable masses
• Symptoms of parasitic diseases (behind ears, nape of neck, eyebrows)
• Tender regions, lumps, and palpable masses
• Soft spots or indentations
• Fontanelles (sunken, bulging, soft, closed) in infants

Neck Inspection and Palpation Points

• Symmetry and trachea midline alignment
• Scars from earlier operations
• Any obvious lumps or swelling on the neck's front
• The thyroid (should be smooth, nonpalpable, and non-tender)
• Trachea's location (should be midline)

Lymph Node Inspection and Palpation Points

• Lymph nodes are tiny, flexible, oval-shaped structures found throughout the body.
• Vessels connect them to filter out foreign materials and transport immune cells.
• The neck has the most.
• Inspecting and palpating for enlarged lymph nodes is crucial because they could point to significant issues requiring additional examination.
• Palpable lymph nodes, when present, are typically less than 1 cm in diameter, soft, non-tender, and somewhat mobile.
• Most lymph nodes cannot be palpated in healthy individuals.

Nose Inspection Points

• Examining the symmetry and form of the nasal form as well as the nares, or nostril openings
• Variations in the size of the nares may indicate complete or partial nasal passage obstruction.
• Piercings raises the possibility of infection or harm.
• A light source is used to examine the inside of the nose for inflammation symptoms, septal deviation, and symmetry, any of which could affect how a nasogastric tube is placed.
• If there is drainage, be aware of its color, quantity, odor, and consistency.
• Have the patient close one nostril and breathe deeply on each side to check for patency.

Nose Assessment Points

• Symmetry, size, deviation signs, and shape
• Lesions, injuries, or piercings
• Symptoms of internal nose inflammation or perforation
• Drainage
• Patency on both sides

Mouth Assessment

• Check the lips for moisture, cracking, lesions and color.
• The mucous membranes need to be hydrated and pink.
• The tongue needs to be pink, wet, and move freely without any lesions.
• Notice any indications of erythema or decay when looking at the teeth and gums.

Throat Assessment

• The uvula should be undamaged and in the middle when looking back in the throat.
• The posterior pharynx needs to be hydrated and pink.
• Should be pink, moist, and devoid of any lesions in the buccal mucosa.
• Free of lesions, the soft and hard palates should range in color from yellow to pink.
• The tonsils need to be pink, wet, and devoid of exudate and lesions if they exist.

Oral Health Trends

• It is crucial to comprehend the difficulties many Americans encounter when accessing dental care when evaluating the mouth.
• People of all ages do not receive consistent dental care as a result of societal, financial, and geographic barriers to health.
• Questions should be asked about the patient's dental history.

Pediatric Considerations

• Milia may be present in newborns (small white cysts or bumps along the nose or nasal bridge).
• Birth trauma can cause newborns to have uneven head shapes.
• The joints between the bones of the skull and fontanels can be felt.
• A baby should be able to move their head from side to side at two weeks old.
• There shouldn't be any nasal flaring or constriction when breathing.
• Determining nasal patency is essential in newborns because they must breathe through their noses.
• Observe the pattern, state, location, number, and cleanliness of the teeth.

Geriatric Considerations

• Facial skin may appear wrinkled as a result of decreased suppleness.
• Arthritis may make it difficult to move in the neck.
• The nose can protrude out more due to fat loss.
• Though the color is consistent, the teeth may appear somewhat yellowed.
• The gums recede, making the teeth appear longer.
• Papillary atrophy makes the tongue appear smoother.

Abnormalities

• Thyroid gland issues, headaches, and head abnormalities.
• Nasal deformities, lip cracks or lesions, tooth loss, gingivitis, pharynx infection.

Health Education

• Lifestyle modifications can significantly affect the head, neck, nose, mouth, and throat.
• Education and preventative actions that can prevent or lessen injuries
  • Consistent dental care
  • Quitting smoking
  • Using safety equipment for sports and activities
  • Drug rehabilitation
  • Wearing seatbelts in automobiles

Application points

• In order to identify potential and actual health risks and offer interventions that promote health, assessments are carried out in a logical order using the clinical decision-making process and the nursing process.
• Utilize developmental, cultural, and lifestyle awareness to distinguish between normal and abnormal results

Social Considerations

• Iodine-fortified table salt has greatly decreased the incidence of goiter.
• Iodine was found to be necessary for proper thyroid function in the late 1800s.
• A lack of iodine can cause hypothyroidism and goiter.

Hypothyroidism Treatment

• The synthetic T4 hormone levothyroxine is the standard treatment for hypothyroidism.
• Treatment with levothyroxine will be lifelong.
• This therapy restores the depleted hormone levels and lessens the signs and symptoms of hypothyroidism.

Levothyroxine Considerations

• Thyroid-stimulating hormone (TSH) levels are regularly monitored when clients begin the medication.
• Once the proper dose has been determined, TSH will be checked annually.
• Levothyroxine should be taken 30 minutes before eating or taking any other medications, first thing in the morning on an empty stomach.
• Iron supplements or multivitamins containing iron, calcium supplements, biotin, and antacids containing magnesium, aluminum, or calcium are among the foods and supplements that impair the absorption of levothyroxine.

Eyes and Ears Assessment

• Analyze evaluation results to spot clues related to changes in eye and ear health.
• Put health education into practice by addressing genetic, cultural, lifestyle, and developmental hazards for eye and ear conditions.

Subjective Data

• Health habits and medical background, aid in addressing deficits and impacting choices.
• Nurses apply information from background to establish assessment emphasis and extent.

Eye Questions

• Inquire about vision problems (blurred vision, decreased acuity, blind spots), ocular conditions eye pain, discharge, or watering, redness or swelling, glaucoma, contacts or glasses, medications, smoking, vision loss, and date of last exam.

Ear Questions

• Inquire about tinnitus, vertigo, earaches and infections, hygiene habits, discharge, and noise exposure.

Objective Data

• Assess impact on ear and eye wellness by addressing lifestyle.

Ocular Risks

• Consider family disease history, advanced age, unprotected light exposure, untreated strabismus, intraocular pressure, and lifestyle choices.

Hearing Risks

• Consider age, genetic factors, noise exposure, cerumen buildup, and previous infections.

Ocular Inspection Tips

• When looking at the eyes, note eye placement in sockets, lid droopiness, drainage/moisture, tracking ability, and sclera/conjunctiva color.

Ear Inspection Tips

• Look to see is there size/shape symmetry, alignment on the head, devices, odors, skin condition, piercings, lesions ,and drainage.

Eye Tool Overview

• Inspect for whiteness with erythema or jaundice
• Palpate for moist pinkness with pale/erythematous conjunctiva

Eye Considerations

• Use PERRLA to check size/light response with pupil variation under 1 mm
• Pupil gauge measures normal eye range of 3-5 mm diameter (miosis is under 2 mm and mydriasis over 6 mm)
• Gaze uses H or wagon wheel method to watch eye movements, position, and presence of nystagmus.
• Snellen charts test visual acuity

Ear Exam Overview

• Otoscope is used to examine ear canal, membrane for inspection, palpation, visualization, testing.
• Inspection helps look for size, shape, symmetry, lesions, discharge.

Ear Palpation

• Look for tenderness in auricle, lobe, tragus and mastoid.
• Otoscope checks auditory canal, membrane, and ossicles.

Ear Inspection Points

• Confirm occlusion, color, integrity.
• Erythema or redness, discharge, and inflammation.
• To test acute hearing, perform various tests.

Hearing Acuity Exams

• To check ears with whisper test, have them occlude tragus.
• Whisper numbers from the ear 1-2 feet and check accuracy to confirm.
• Tuning fork tests can reveal sensorineural or conductive loss via Rinne and Weber tests.

Hearing Assessment Using Tuning Forks

• Rinne (AC:BC) test finds air conduction twice more than bone.
• Weber assessment confirms sound equally when placing the tuning fork center.
• Conductive losses mean louder and more painful hears, with sensorineural loss louder in unaffected ear.
• Age shapes vision by affecting health.

Infant Vision

• Conduct testing a few days after birth and well visits.

Vision Function

• Immature when born but develops in years. Peripheral function shows at birth. Then binocularity can fixate around 20 weeks.

Geriatric Vision

• Acuity may decrease with drooping and wrinkling. Lacrimal glands may lead to tear production.
• Issues include cataracts, glaucoma, macular degeneration, and retinopathy.

Ear Assessment

• During infant exams, use an otoscope while pulling pinna down to examine for ear tube and verify age milestones.
• Aging leads drooping and wrinkling, with stiffened cilia increasing oxidized cerumen impacting hearing.

Vision Abnormalities

• Dysfunction to muscle movements, abnormalities, pupil variances, field loss, and vascular issues.

Ear Abnormalities

• Lesions, issues and structure problems, which can impact loss with internal malfunctions.

Eye Health Safety

• Intervening early with monitoring is critical for those impacted.
• Protect through eyewear, sunlight, and age vision visits while monitoring function changes.
• Educate for protection around noises, clean with swabs, treat infections, avoid insertion and liquids.
• Intervention can also stop other impacts of isolation.

Nursing points

• Development should screen with education for health per client.
• Nurses can identify the impact with communication and documentation.

Important nursing assessment questions covering dental history, nasal patency in newborns, aging adult assessments, headache evaluation, thyroid gland enlargement, oral health, and head/neck examinations. These questions help identify potential health barriers and conditions requiring immediate attention.