Physical Assessment of Head and Face PDF

PHYSICAL ASSESSMENT Inspecting and Palpating the Head and Face Inspect and palpate the head for size and shape. The parts of the head and face should be in proportion to each other and symmetric. Although the shape of the normal skull varies considerably, generally the shape is gently curved with pr...

PHYSICAL ASSESSMENT Inspecting and Palpating the Head and Face Inspect and palpate the head for size and shape. The parts of the head and face should be in proportion to each other and symmetric. Although the shape of the normal skull varies considerably, generally the shape is gently curved with prominences at the frontal and parietal bones. Abnormal findings include lack of symmetry or unusual size or contour of the skull (either may be the result of trauma or diseases affecting the growth of bone) and tenderness. If the skull of a child or an adult appears disproportionately large or small, measure the circumference. Measuring head circumference is a normal part of infant assessment to the age of 2 years and should be conducted at each health-related visit. Inspect the face for color, symmetry, and distribution of facial hair. Edema of the face, especially around the eye (periorbital edema), and involuntary facial movements (e.g., tics, tremors) are abnormal findings. If abnormalities are noted, document the location, amount, duration, and timing. Inspecting the Eyes Assess the structures and functions of the eyes using a penlight and an eye chart. Inspection is the primary assessment technique used. Assessment includes the external eye structures, visual acuity, extraocular movements, and peripheral vision. Advanced health care providers usually perform assessment of the internal eye structures with an ophthalmoscope, which is an advanced assessment skill. Refer to a health assessment text for details. Inspecting External Eye Structures. Inspect the eyes, eyebrows, eyelids, eyelashes, lacrimal glands, pupils, and iris for position and alignment (Fig. 27-9). Asymmetry of position and alignment of the eyes may be caused by muscle weakness or a congenital abnormality. The eyebrows should be equally distributed; the eyelashes should curl outward. Inspect the eyelids for color, edema, and equal coverage of the eyeball. Abnormal findings include drooping of the upper lids (ptosis), which may be attributable to damage to the oculomotor nerve, myasthenia gravis, or a congenital disorder; inward turning of the lower lid and lashes (entropion); outward turning of the lower lid and lashes (ectropion); and redness or drainage (from infection of the lid margins, conjunctivae, or hair follicles). Inspect and palpate the lacrimal glands for edema and pain. The pupils are normally black, equal in size, round, and smooth. The pupils may be pale and cloudy if the patient has cataracts (loss of opacity of the lens). Injury to the eye, glaucoma, and certain medications may cause the pupil to dilate (mydriasis); certain drugs can cause constriction (miosis), and unequal pupils may result from central nervous system injury or illness. Assess the pupils for reaction to light and accommodation and for convergence (Guidelines for Nursing Care 27-2 on page 794). Decreased or absent pupillary response indicates blindness or serious brain damage. Inability of the eyes to accommodate or converge is abnormal. Assessing Visual Acuity, Extraocular Movements, and Peripheral Vision. Assess visual acuity with the Snellen chart. Have the patient stand 20 ft from the chart and ask the patient to read the smallest line of letters possible, first with both eyes and then with one eye at a time (with the opposite eye covered). Note whether the patient's vision is being tested with or without corrective lenses. Visual acuity is measured by using the standardized numbers listed on the side of the chart. The numerator is 20, representing the distance in feet the patient was from the test. The denominator represents the smallest line read accurately by the patient. Visual acuity is recorded as a fraction and is written as 20 over the smallest line read by the patient with no more than two inaccurate readings (such as "20/30--2 with glasses"). Thus, the larger the denominator, the poorer the patient's vision (Jensen, 2019). Use a Snellen picture chart or Snellen E-chart to test vision in patients who are unable to read English and in young children. The E-chart uses the capital letter E in varying sizes pointing in different directions. The patient points their fingers in the direction the legs of the E are pointing. Test near vision with a handheld vision screen with varying sizes of print. A Jaeger card can be used for this measurement. The patient holds the card 14 inches from the eyes. Ask the patient to read the smallest line of letters possible, with one eye at a time (with the opposite eye covered), and corrective lenses in place, if used. The results are recorded as a fraction and written as 14 over the smallest line read by the patient. A normal result is 14/14. Test extraocular movements by assessing the cardinal fields of vision for coordination and alignment. Normally both eyes move together, are coordinated, and are parallel. Tests for peripheral vision (or visual fields) are used to assess retinal function and optic nerve function. Full peripheral vision is normal. GuInspecting and Palpating the Ears Assess the external ear by inspection and palpation. Advanced health care providers usually perform assessment of the structures of the ear canal and tympanic membrane with an otoscope, which is an advanced assessment skill. Refer to a health assessment text for details. Inspecting and Palpating the External Ear. Inspect the external ear (Fig. 27-10) for shape, size, and lesions. The external surfaces of the ear should be smooth, and the shape and size of the ears should be symmetric and proportional to the head. Abnormal findings include unequal height and size, uneven color, and lesions. Inspect the visible portion of the ear canal. Note the presence of cerumen (wax), edema, discharge, or foreign bodies. Gently palpate the external ear for pain, edema, or presence of lesions. Pain when manipulating the pinna is a symptom of an infection of the external ear. Assessing Hearing and Sound Conduction. General hearing screening tests that are useful include self-report questionnaires and the whisper test. Self-report questionnaires can be administered in a verbal, written or computerized format and collect information related to patient reports of hearing ability and deficits, and associated impact on activities of daily living and quality of life. Screening of hearing using the whisper test is accomplished as follows: test hearing in one ear at a time by determining whether the patient can hear a whispered voice. Assess hearing acuity out of the patient's line of vision (to prevent lip reading), with the opposite ear covered. Determine whether the patient can hear a whispered sentence or group of numbers from a distance of 1 to 2 ft. Ask the patient to repeat what you said. Both screening tests can provide clues to identifying a need for further evaluation, such as an audiologic (hearing) evaluation by an audiologist (professional who provide prevention, identification, diagnosis and treatment of hearing, balance and oidelines for Nursing Care 27-3 describes how to assess extraocular movements and peripheral vision. Inspecting the Nose Assessment of the nose involves examining the external nose and the nares (Fig. 27-11A). Inspect the nose and inspect and palpate the sinuses with the patient sitting and their head slightly tilted back, if possible. Assess the nose for patency by occluding one nostril at a time and asking the patient to inhale and exhale through the nose. Inspect each anterior nares by tipping the patient's head back slightly and shining a light into the nares. Examine the mucous membranes for color and the presence of lesions, exudate, or growths. Normally, the nasal mucosa is moist and darker red than the oral mucosa. Abnormal findings include swelling of the mucosa, and bleeding or discharge (indicating allergies with inflammation or infection). Palpating the Sinuses The frontal and maxillary sinuses, located in the frontal and maxillary bones, respectively, are palpated for pain and edema. The frontal sinuses are palpated by gently pressing upward on the bony prominences located above each eye (Fig. 27-11A). The maxillary sinuses are palpated by gentle pressure on the bony prominences of the upper cheek (Fig. 27-11B). Normally, the sinuses are not painful when palpated. Pain may be a finding if the sinuses are infected or obstructed. Inspecting the Mouth and Pharynx The mouth and pharynx include the lips, tongue, teeth, gums, hard and soft palate, salivary gland, tonsillar pillars, and tonsils (Fig. 27-12). Equipment used to assess the mouth, pharynx, and neck includes a penlight, a tongue blade, a 4 × 4-inch gauze sponge, and gloves. Assess the mouth and pharynx by inspecting the lips, gums and teeth, tongue, under the tongue, and hard and soft palates. Have the patient sit with the head tilted backward, if possible, and the mouth opened wide. Use palpation if any abnormalities are noted during inspection. Wear gloves when assessing a patient's mouth and use 4 × 4-inch gauze to hold the tongue for palpation. The lips should be pink, moist, and smooth. The tongue and mucous membranes are normally pink, moist, and free of swelling or lesions. If the patient wears dentures, ask the patient to remove them for inspection of the gums and roof of the mouth. The gums should be pink and smooth. With the patient's tongue relaxed on the floor of the mouth, examine the mucous membrane of the oropharynx while depressing the base of the tongue with a tongue depressor. The uvula is normally centered and freely movable. The tonsils, if present, are small, pink, and symmetric in size. The teeth should be regular and free of cavities or have dental restoration. Abnormal findings include pallor, cyanosis, or redness and swelling of the mucous membranes; lesions of the mucosa and lips; swollen, red tonsils (indicating infection); swollen, red, and bleeding gums (from nutritional deficits, inflammation or infection, poorly fitted dentures, or poor oral hygiene); poorly aligned, missing, or carious teeth; a white coating on the tongue (from poor oral hygiene, irritation, or smoking); a fissured tongue (from dehydration); a bright-red tongue (seen in deficiencies of iron, vitamin B12, or niacin); or a black, hairy tongue (from antibiotic use). Inspecting and Palpating the Neck Assessments of the neck include the trachea, lymph nodes, and thyroid gland (Fig. 27-13). Assess the neck with the patient sitting and the neck slightly hyperextended, if possible. Ask the patient to tilt the head backward, forward, and side to side to assess range of motion (ROM). The neck should be symmetric, with smooth and controlled ROM. Also assess the neck for venous distention. No neck vein distention (indicating heart problems) should be visible. Palpation of the thyroid is an advanced assessment skill, usually performed by advanced health care providers. Refer to a health assessment text for details. Inspecting and Palpating the Trachea. Assess the position of the trachea in the neck. Inspect and palpate the trachea. The trachea should be midline and symmetrical. Inspecting the Thyroid Gland. Assess the thyroid gland with the neck slightly hyperextended. Observe the lower portion of the neck overlying the thyroid gland. Assess for symmetry and visible masses. Ask the patient to swallow. Observe the area while the patient swallows. Offer a glass of water, if necessary, to make it easier for the patient to swallow.