Unit 3 Health Assessment of HEENT & Mouth 2024 PDF

HEA 1032HEALTH ASSESSMENT PHYSICAL ASSESSMENT OF HEAD & FACE, EYES, EARS, NOSE, MOUTH AND THROAT PRESENTED BY: MRS. KERON JONES-FRASER, PHD CANDIDATE, MSCN, BSCN, CERT ED, RN  OBJECTIVES At the end of the session students should: Review briefly the anatomy an...

HEA 1032HEALTH ASSESSMENT PHYSICAL ASSESSMENT OF HEAD & FACE, EYES, EARS, NOSE, MOUTH AND THROAT PRESENTED BY: MRS. KERON JONES-FRASER, PHD CANDIDATE, MSCN, BSCN, CERT ED, RN  OBJECTIVES At the end of the session students should: Review briefly the anatomy and physiology of the HEENT Describe physical assessment of the head, face, eyes, ears, nose and mouth MOTIVATIONAL ACTIVITY GROUP ACTIVITY Prepare presentations to assess the body systems assigned. From the information gathered, also prepare a short song, poem or dub poetry to add creativity to your presentation. Time: 30 minutes Group 1 – head & face Group 2 – eye Group 3 – ear Group 4 – nose Group 6 – mouth & throat Group 7 – neck & regional Lymph nodes  ASSESSMENT OF THE HEAD Physical Assessment Inspect the head Size, shape, configuration Involuntary movement Palpate the head  ASSESSMENT OF THE FACE Inspect the face Symmetry Features Movement Expression Skin condition ASSESSMENT OF THE EYE  ASSESSMENT OF THE EYE External Structures Eyelids: inspect for ability to blink; position (ptosis); lesions (hordeolum- stye). Conjunctiva: palpebral (lid)- color (pink) or lesions. Sclera: color- white, not red or yellow Cornea: assess for opacity or scratch Pupil: inspect for size, shape, reaction to light and accommodation. PERRLA normally, both are black, round, equal in size and react to light and accommodation. Chart is used to measure size (1-10mm). GENERAL AREAS OF INQUIRY Vision difficulty History of ocular Pain problems Strabismus Glaucoma Redness, swelling Use of glasses/contact lens Watering, discharge Self care behaviours  ASSESSMENT OF THE EYE Test pupillary reaction to light: have client look at distant object (room should be dim); look for direct and consensual. Accommodation refers to pupillary change for near and distance (look far off then at finger. Eyes should converge and pupils contract). Extraocular Movement- evaluation of the movement of the eyes while the head remains still. –8 cardinal fields of gaze, which are controlled by three cranial nerves (CN 3 oculomotor, 4 trochlear, 6 abducens). Watch for nystagmus.  ASSESSMENT OF THE EYE Visual Fields: How much a person can see at the periphery. Visual Acuity: Degree to which a person can discern an image. Normal is 20/20. –Test wearing corrective lenses. –Using Snellen Chart, have client stand 20’ from chart (numerator is 20). Take three readings, right, left, both eyes. Record the smallest line person is can read. The denominator is the number next to the line on the chart that the person can read.  ASSESSMENT OF THE EYE Visual Acuity: 20/200 client can read only very large # which a person with normal vision could read at 200’. The larger the denominator, the worse the vision. Internal Structures: Requires use of an ophthalmoscope to visualize the fundus. ASSESSMENT OF THE EAR  ASSESSMENT OF THE EAR Tympanic membrane landmarks Handle and short process of the malleus Umbo Cone of light Pars flaccida and pars tensa ASSESSMENT OF THE EAR  ASSESSMENT OF THE EAR Auricle: Inspect for position (pinna level with corner of eye), compare each side; lesions. Canal- look for drainage. Tympanic membrane (eardrum) requires use of otoscope. Auditory acuity: gross hearing may be assessed by client’s response to voice. Test one ear at a time, covering the other. Start with a whisper. Use 2 syllable words such as “baseball.” A tuning fork may be used to perform tests such as Weber and Rinne. Perform the Rhomberg Test  ASSESSMENT OF THE NOSE & SINUSES External nose: inspect for any deviations in shape, size, color, flaring or discharge. Check for patency Check for sense of smell (olfactory nerve- CN I). Frontal/Maxillary sinuses- palpate for tenderness. ASSESSMENT OF THE MOUTH  ASSESSMENT OF THE MOUTH Physical Assessment: Mouth –Inspect: lips (color, consistency); teeth (number, color, condition, alignment); gums (color, consistency); buccal mucosa (color, consistency, Stenson’s ducts); tongue (color, moisture, size, texture); fasciculations (fine tremors) –Inspect: hard (anterior) and soft (posterior) palate, uvula, tonsils (color, size, presence of exudate or lesions), posterior pharyngeal wall (exudate, lesions), note odor ASSESSMENT OF THE MOUTH  ASSESSMENT OF THE MOUTH Physical Assessment: Tongue Check for midline protrusion; inspect ventral surface, frenulum, area under tongue; palpate lesions for induration (hardness); inspect Wharton’s ducts and sides of tongue; check tongue strength; check anterior tongue (taste)  NECK & REGIONAL LYMPH NODES  Head should be held erect and still  Note enlargement of glands and pulsation of veins  Muscles should be symmetrical  Note limitation of movement during active motion  Ask the client to: › Touch chin to the chest (flexion) look up at the ceiling (hyperextension) › Touch each ear to the shoulder on both sides (lateral bending) › Touch chin to shoulders both sides (rotation)  Test muscle strength by asking client to shrug shoulders and turn head from side to side against resistance  NECK & REGIONAL LYMPH NODES With the pads of the fingers palpate the nodes in a gentle circular motion Begin with the preauricular nodes and work your way down in a systemic manner Usually better to palpate with both hands to assess symmetry. If one hand is used for palpation, stabilize the head with the other For ease of accessing the deep cervical chain and supraclavicular nodes tip the head to the side to be examined and asking the client to hunch shoulders forward respectively NECK & REGIONAL LYMPH NODES  Lymph Nodes of head & neck:  If nodes are palpable, note size, consistency, 1. Preauricular mobility and 2. Postauricular tenderness. If 3. Occipital enlarged and tender 4. Tonsillar assess area from 5. Submandibular which they drain for 6. Submental the problem. 7. Superficial cervical 8. Posterior cervical 9. Deep cervical 10. Supraclavicular  NECK & REGIONAL LYMPH NODES EXAMINATION OF THE TRACHEA  Place index finger on trachea in the sternal notch and slip it off to each side. Space should be symmetric on both sides OR  Place index and ring finger on either end of the clavicle, bring second finger down trachea. It should fall in the middle of stationary fingers NECK & REGIONAL LYMPH NODES  NECK & REGIONAL LYMPH NODES EXAMINATION OF THE THYROID GLAND Can be done from behind or in front of the client USUALLY NOT PALPABLE!! Shine light tangentially across neck to highlight any possible swelling Ask client to sip on water offered and note movement of thyroid (should move upward)  NECK & REGIONAL LYMPH NODES POSTERIOR APPROACH  Ask client to sit upright and bend head slightly to the right  Stand behind the client  Use the fingers of the left hand to push trachea slightly to the right  Curve the fingers of your right hand between the trachea and the sternomastoid muscle. Retracting them slightly ask the client to swallow  The thyroid should move up as client swallows. Repeat procedure on the left side  NECK & REGIONAL LYMPH NODES ANTERIOR APPROACH  More awkward to perform  Ask client bend head forward and tip it slightly to the right  Use right thumb to displace trachea slightly to the right  Hook left thumb and fingers around the sternomastoid muscle. Feel for lobe enlargement as client swallows  Repeat for the other side  If enlarged check for consistency and nodules as well as symmetry  Auscultate for bruit  INFANTS & OLDER ADULTS  Infant’s skull is soft and head circumference should be larger than chest circumference  Note caput or cephalhaematoma  Note fontanelles (anterior should be approximately 2.5 cms and posterior 1 cm.)  To test muscle development in infants, cradle the head with hands and move it through ROM  INFANTS & OLDER ADULTS Lymph nodes are more easily palpated in children. They are usually mobile and nontender Thyroid gland may be palpable during pregnancy Senile tremors may be seen in the elderly as well as increased curvature of cervical spine  References Weber, J., & Kelley, J. 2018. Health assessment in nursing. Philadelphia: Lippincott, Williams & Wilkinson.