Head, Face, Neck, Nose, Mouth and Throat Assessment

**Week 4: Head, Face, Neck, Nose, Mouth, and Throat** The assessment of the head includes inspecting the head, face, neck, nose, mouth, and throat. The nurse will initially concentrate on the outside structures of the head, face, and nose. When assessing the mouth and throat, a light source and lik...

**Week 4: Head, Face, Neck, Nose, Mouth, and Throat** The assessment of the head includes inspecting the head, face, neck, nose, mouth, and throat. The nurse will initially concentrate on the outside structures of the head, face, and nose. When assessing the mouth and throat, a light source and likely a tongue blade will be needed to visualize the structures. Palpation of the lymph nodes in the head and neck, the trachea, and the thyroid is also included in the assessment. As you complete the head, face, neck, nose, mouth, and throat assessment activities, you will gain the knowledge and skills needed to​:​ Analyze health assessment findings to identify cues associated with alterations of head, face, neck, nose, mouth, and throat health.​ Utilize critical thinking to perform focused assessments based on subjective and objective data.​ Assess the head, face, neck, nose, mouth, and throat systems using inspection and palpation.​ Distinguish between normal and abnormal findings.​ Identify the impact of developmental and cultural influences on head, face, neck, nose, mouth, and throat assessment data.​​ Plan and implement health education addressing developmental, cultural, lifestyle, and genetic risk factors for head, face, neck, nose, mouth, and throat disease.​ **The Health History​** During the health history of the head, neck, nose, mouth, and throat, the nurse should focus on each system, asking for information that could impact health and identifying knowledge deficits requiring further health education. **Head, Neck, and Lymph​** - unusually frequent or severe headaches​​ - facial or neck pain​​ - difficulty turning, flexing, or extending the neck​​ - painful or painless lumps or masses in the head or neck​​ - history of traumatic brain injury​ - past athletic participation, including high-contact sports like football **Nose, Mouth, and Throat** - past oral care practices, including dental health​ - history of allergies​ - difficulty chewing or swallowing food​​ - difficulty with teeth or gums​​ - partially or completely blocked nares​ - history of snorting or inhaling drugs or vapors​ - past vaping or smoking cigarettes, pipes, or cigars​​ - family history of mouth cancer or genetic syndromes​ ​ - history of giving oral sex and any associated sexually transmitted infections​ **Lifestyle** When assessing for risk factors associated with the region, remember to ask about lifestyle practices that may impact the health of this system. What choices does the client make now that can impact the future health of their head, neck, nose, mouth, and throat? **Risk Factors for the Head and Neck** - not using safety equipment such as helmets and seat belts ​​ - alcohol or drug consumption **Risk Factors for the Nose, Mouth, and Throat** - cigarette, vape, cigar, or chewing tobacco use​ - lack of routine dental care​ - not practicing proper hand hygiene and infection prevention practices​ - poor nutritional intake **Preparing to Assess** Here are some tools that may be helpful when assessing the head, neck, nose, mouth, and throat. Tongue blades and cotton gauze can be used to move the tongue out of the way when visualizing the throat. A small cup of water can be helpful to rinse the mouth out or to test swallowing. Gloves are essential because of possible exposure to saliva. A penlight or flashlight is necessary to visualize the mouth and throat. Also, have the client remove all hats, wigs, or headpieces for better inspection and palpation of the head. **Inspecting and Palpating the Head​** When inspecting the head, it is important to note: ​ - posture of the head (erect or slumped, midline, stable, or bobbing) - symmetry of features and shape are normocephalic - obvious masses, lumps, scars, or color variations - signs of parasitic infestation (eyebrows, nape of neck, and hairline behind ears) When palpating the head, be sure to note: ​ - palpable masses, lumps, or tender areas - depressions or soft areas - the fontanelle in infants (soft, depressed or sunken, bulging, closed) **Inspecting and Palpating the Neck** The assessment of the neck should include the inspection and palpation of the neck structures, including the lymph nodes, trachea, and thyroid. **Inspect the neck for:** - symmetry and midline alignment of the trachea​​ - scars that might indicate prior surgeries​ - visible lumps or areas of protrusion or swelling over the anterior aspect of the neck​ **Palpate the neck for:** - thyroid (should be smooth, nonpalpable, and non-tender) - lumps or protrusions (note the size, density, ease of mobility, and overall shape)​ - location of the trachea (should be midline) **Inspecting and Palpating the Lymph Nodes** Lymph nodes are small, soft, oval-shaped structures located all over the body connected by vessels that work to filter foreign substances and carry immune cells. The largest number of lymph nodes in the body are found in the neck area. ​ It is important to inspect and palpate for enlarged lymph nodes because they can be a sign of serious problems that need to be evaluated further. Most lymph nodes are not palpable when someone is healthy. Occasionally, a palpable lymph node can be felt, is usually less than 1 cm, soft, non-tender, and slightly movable. **Inspecting the Nose** Assessing the nose includes inspecting the contour and symmetry of the nasal form, as well as the nostril openings (nares). Differences in nares size can suggest partial or complete blockage of the nasal passage. Note piercings, which can present an increased risk for infection or injury. Using a light source to view the inside of the nose, look for symmetry, septal deviation, signs of inflammation, or perforation, which could impact the insertion of a nasogastric tube. If drainage is present, note the color, odor, consistency, and amount. Have the client occlude one nare and breathe deeply once on each side to assess patency. **Assessing the nose includes:** - symmetry, size, shape, and signs of deviation of the external nose - lesions, piercings, or other injury - symmetry, signs of inflammation, or perforation of the internal nose - drainage - bilateral patency **Inspecting the Mouth and Throat​** Before assessing the mouth, ask the client about mouth pain and difficulty chewing, eating, or swallowing. Use a good light source, a tongue blade, and gloves to assess the mouth. Have the client open their mouth and stick out their tongue. **Mouth Assessment** The mouth assessment includes: ​ - Inspect the lips for color, moisture, cracking, or lesions​. - Mucus membranes should be pink and moist. - The tongue should move freely, be free of lesions, be pink, and moist​. - Teeth and gums are visualized, noting signs of decay or erythema. **Throat Assessment** Looking further back in the throat, assess the: ​ - The uvula should be intact and midline. - The posterior pharynx (back of the throat) should be pink and moist. - The buccal mucosa (inside of the cheeks) should be pink, moist, and free of lesions. - The soft and hard palates (roof of mouth) should be yellow to pink and free of lesions​. - The tonsils, if present, should be pink, moist, and free of exudate and lesions (note that tonsils are not always visible, especially in older adults). Note if they are enlarged or erythematous. **Oral Health in America​** When assessing the mouth, it is important to understand the challenges many Americans face accessing oral healthcare. Across the lifespan, people do not receive regular dental care due to social determinants of health, including social, financial, and geographic obstacles. When asking about the client's history regarding their mouth, questions should include: - Do they have a regular dentist? ​ - How often is routine dental care obtained? ​ - What are some of the reasons they have not seen a dentist? ​ - What dental care has been completed in the past? ​ - How often is oral care, including toothbrushing, performed? ​ - Do they use dental floss? **Developmental Changes** Developmental changes occur throughout the lifespan. Select each tab to view some special considerations at both ends of the lifespan to include during the assessment. **Infants and Children** The newborn may have milia (a common skin condition that causes small white bumps or cysts under the surface of the skin) across the nose or a nasal bridge that may be flat.​​ Newborns may have an asymmetrical head shape due to birth trauma. The sutures and fontanelles are palpable. ​​ The infant can turn the head side to side by 2 weeks​.​ There should be no nasal flaring or narrowing with breathing. Determining nasal patency in the immediate newborn period is essential because newborns are obligate nose breathers. Note the number of teeth and whether it is appropriate for the child\'s age. Also, note the pattern of eruption, position, condition, and hygiene. **The Aging Adult** Facial skin may appear wrinkled due to a lack of elasticity.​​ Range of motion (ROM) in the neck may be limited due to arthritis.​​ The nose may appear more prominent on the face from a loss of subcutaneous fat.​​ The teeth may look slightly yellowed, though the color is uniform.​​ The teeth may look longer as the gum margins recede. The tongue looks smoother as a result of papillary atrophy.​ **Disorders​** During the assessment of the head, neck, nose, mouth, and throat, a variety of abnormalities may be noted. Here are some possible abnormalities that may be seen. Abnormalities of the head and neck include: - headaches​​ - head deformities​​ - thyroid gland disorders​​ - fetal alcohol syndrome​​ - Down syndrome​​ - parotid gland enlargement​​ Abnormalities of the nose, mouth, and throat include:​ - nasal deformities​ - lip lesions or cracking​ - tooth decay, gingivitis, or tooth loss​​ - infection of the pharynx **Health Education** Lifestyle changes can have a significant impact on the head, neck, nose, mouth, and throat. Education and prevention practices that can reduce or eliminate injuries include​​: - use of appropriate safety equipment for sports and occupation​​ - use of seat belts in vehicles​​ - smoking cessation​​ - drug cessation​ - regular dental care **Introduction to Nursing Application: Head, Neck, Nose, Mouth, and Throat Assessment​** Assessment of the head and neck is completed in a logical sequence using the nursing process and clinical decision-making to identify actual and potential health risks and provide interventions that promote health.​​ As you complete the head and neck assessment application activities, you will gain the knowledge and skills needed to:​​ Utilize prior knowledge of theories and principles of nursing while implementing the nursing process​​. - Differentiate between abnormal and normal findings​​. - Recognize developmental, cultural, and lifestyle influences​​. - Utilize effective communication when performing a health assessment.​​ - Identify client education opportunities from the assessment process​​. - Demonstrate appropriate documentation​​.  **Social Determinants of Health and Hypothyroidism** In many ways, health is more about where you live than it is about physiology. In the late 1800s, it was discovered that iodine was essential for the health of the thyroid. A lack of iodine can lead to hypothyroidism and the production of a goiter. In some parts of the world, a goiter related to iodine deficiency is still common. In the United States, table salt is fortified with iodine, which significantly reduces the incidence of goiter. **Treatment** The standard treatment for hypothyroidism is the use of the synthetic T4 hormone levothyroxine. This treatment restores the depleted hormone levels and reverses the signs and symptoms of hypothyroidism. Treatment with levothyroxine will be lifelong.​ Determining the correct dosage may take some time. When clients first start on the medication, thyroid-stimulating hormone (TSH) levels will be monitored frequently. Once the correct dosage of medication is determined, TSH will be checked annually. Levothyroxine should be taken first thing in the morning on an empty stomach 30 minutes before any medication or food.​ There are certain foods and supplements that impair the absorption of levothyroxine, including: ​ - iron supplements or multivitamins containing iron​ - calcium supplements​ - biotin​ - antacids that contain aluminum, magnesium, or calcium and some other ulcer medications​ - some cholesterol-lowering drugs​ **Introduction to Eyes and Ears** As you complete the eye and ear assessment activities and assignments, you will gain the knowledge and skills needed to​​: - Analyze health assessment findings to identify cues associated with alterations in the eye and ear health​. - Utilize critical thinking to perform focused assessments based on subjective and objective data​. - Assess the eyes and ears using inspection and palpation​. - Distinguish between normal and abnormal findings​. - Identify the impact of developmental and cultural influences on eye and ear assessment data​​. - Plan and implement health education addressing developmental, cultural, lifestyle, and genetic risk factors for eye and ear diseases. **The Health History** The health history collects subjective data about the individual's medical history, lifestyle choices that may impact the health of both the eyes and ears, and knowledge deficits to address with health education.​ The nurse uses data collected from the health history to determine the focus and depth of assessment of each system. **Eyes** Ask about: - vision difficulty, including decreased acuity, blurring, and blind spots ​ - eye pain, burning, or itching ​ - strabismus or diplopia ​ - redness or swelling ​ - watering or discharge ​ - history of ocular problems ​ - glaucoma ​ - use of glasses or contact lenses ​ - medications, systemic or topical ​ - history of smoking​ - vision loss​ - date of last eye exam **Ears** Ask about​: - earaches and ear infections​ - discharge from the ears​ - hearing loss and environmental noise​ - tinnitus and vertigo​ - cleaning of the ears **Lifestyle** Interviewing the client regarding their lifestyle provides important data that will help the nurse assess the impact on eye and ear health. The information gathered during the interview will guide the nurse in providing the most relevant education and interventions. **Risk Factors** Risk factors for eye diseases and vision loss may include: - family history of eye disease - advancing age​ - untreated strabismus​ - frequent or unprotected ultraviolet light exposure​ - increased intraocular pressure (glaucoma)​ - lifestyle behaviors (e.g., smoking, alcohol use) ​ - chronic diseases such as hypertension, diabetes mellitus, and renal dysfunction Risk factors for hearing impairment may include: - genetic predisposition for hearing loss ​ - loud environments (e.g., high volume music, factory work, gun use)​ - chronic ear infections - cerumen buildup​ - advancing age **Inspection: Eyes and Ears​** The nurse should use a consistent approach when inspecting the eyes and ears. These questions serve as a guide. **Ask Yourself** When inspecting the eyes, ask yourself:​ - Are the eyes positioned appropriately within the socket without bulging?​ - Are the lids droopy?​ - Do the eyes follow or track your movements as you do your examination?​ - Does there appear to be enough moisture in the eye, or is there any drainage?​ - What is the color of the sclera (white) and conjunctiva (the pink area surrounding the eye)?​ When inspecting the ears, ask yourself:​ - Is the size and shape of the auricle symmetrical?​ - What is the ear position and alignment on the head? ​ - What is the skin condition (including color and any lumps or lesions)?​ - Are there any hearing devices, such as a hearing aid?​ - Is there any ear drainage or odor?​ - Does the client have any piercings, discs, or tattoos? **Eye Assessments: Inspection and Testing** Select each tab to learn more about the different eye assessments. **Inspection** The sclera (the area surrounding the iris) should be white. Erythema or jaundice could indicate other health issues. The conjunctiva, which is the mucus membranes on the inner portion of the eyelid, should be pink and moist. Pale conjunctiva could indicate anemia, and erythematous conjunctiva could indicate infection. **PERRLA** You will use the mnemonic PERRLA when completing the eye assessment. Pupils are generally the same size, but slight variations in size, up to 1 mm, may be normal. The pupils should be round and change in size when exposed to light or when focus changes to an object that is nearer or farther. ​ **Pupil Gauge** A pupil gauge measures the size of the pupil in millimeters. The normal pupil diameter is 3, 4, or 5 mm. Miosis is pupils smaller than 2 mm or pupils that do not dilate when light is removed. ​ Mydriasis is pupils that are 6 mm or larger or pupils that do not constrict when light is applied. **Fields of Gaze** Assessing the eye includes the ability to move the eyes through the six positions of gaze with the diagnostic positions test. The nurse can use the H method or the wagon wheel method for this assessment. While having the client move through the fields of gaze, the nurse will watch the client\'s eyes for nystagmus (a shakiness of the eyes), smooth and parallel movement through each position, and the ability to follow the movement fully. ​ The eyes can provide a great deal of information regarding the neurologic system. You will learn more about how to use the assessment of the eye to gain insight into the neurologic system in the neurological assessment modules. **Visual Acuity** Do you remember being in school and having to have an eye exam? They would make you put a spoon or other device over one eye and read letters of various sizes on a chart. The school nurse was assessing your vision acuity using a Snellen chart. Normal vision is 20/20, which means you can see objects clearly from 20 feet away. So, what does it mean if you have 20/30 vision? This means that you can see items clearly at 20 feet, which most people can see clearly at 30 feet. So, in essence, the higher the second number, the worse the vision. However, if you have 20/10 vision, you can see at 20 feet what most people see at 10 feet. The use of the ophthalmoscope is an advanced technique. **Inspection and Palpation: Ears** To examine the ears, the only tool needed is an otoscope, which is used to examine the ear canal and tympanic membrane (ear drum).​ Assessment of the ears includes inspection, palpation, use of the otoscope to visualize within the auditory canal, and testing. **Inspection** Start the ear assessment with inspection and look for:​ - symmetry ​ - general size and shape (malformations of the ear can indicate renal problems) ​ - redness or discharge from the ear​ - piercings, wounds, nodules, or lesions (the ears can be a commonly missed location of skin cancer, or nodules known as tophi may indicate renal impairment) **Palpation** Palpate both ears for tenderness in each of the following locations: ​ - auricle ​ - lobe ​ - tragus ​ - mastoid process **Otoscope** Looking into the ear canal with an otoscope will allow you to visualize the external auditory canal, cerumen (if any), the tympanic membrane, and two of the ossicles of the ear. Remember to pull the pinna up and back for adults and pull it down for children under the age of 3. ​ Assessment with the otoscope includes: ​ - presence of occlusion (cerumen buildup, bony growths, or foreign objects) ​ - color, integrity, and transparency of the tympanic membrane (expect pearly gray, translucent, and intact)​ - identify erythema (redness), discharge​, or other signs of inflammation **Auditory Acuity** If the client has current hearing loss, audiometric testing should be done. If not, then perform the whispered voice test and tuning fork tests. Select each tab to review information on these tests. The techniques are also described in your textbook. **Whispered Voice Test** The whispered voice test is used to detect high-tone loss. Stand about 2 feet behind the client. To test one ear at a time, instruct the client to place one finger on the tragus, pushing it in the auditory meatus to occlude sound. Move your head 1 to 2 feet from the person\'s ear. Slowly whisper three random numbers and letters, such as "3, S, L." Ask the client to repeat each number/letter correctly after you say it. A passing score is the correct repetition of 4 of 6 numbers/letters. **Tuning Fork Tests** Tuning fork tests can help the nurse identify if the client has conductive hearing loss or sensorineural hearing loss. The Rinne test assesses air conduction to bone conduction (AC:BC). Air conduction should be about twice as long as bone conduction of sound. A normal finding for the Rinne would be documented as AC\>BC at 2:1. An abnormal Rinne test would require additional testing to confirm. ​ The Weber test should demonstrate that sound is heard equally in both ears when a vibrating tuning fork is placed in the center of the top of the head. An abnormal test would demonstrate that the sound is louder in one ear. In conductive hearing loss, the sound would be louder in the "poorer" ear. With sensorineural hearing loss, the sound would be louder in the unaffected ear. **Developmental Influences: Eye** The health of the eyes is influenced by multiple factors, including the process of aging. Review the information for details about age-related eye health. **Infants and Children** The eyes should be examined within a few days after birth and at every well-child visit thereafter. The child\'s age determines the screening measures used. At birth, eye function is limited but matures fully during the early years. Peripheral vision is intact in the newborn infant. By 3--4 months of age, the infant establishes binocularity and can fixate on a single image with both eyes simultaneously. **The Aging Adult** Central acuity and peripheral vision may be diminished. Changes in eye structure can cause distinct facial changes in the aging person. Loss of skin elasticity causes wrinkling and drooping; fat tissue and muscle atrophy also have an impact. Lacrimal glands involute, causing decreased tear production and a feeling of dryness and burning. In older adults, the most common causes of decreased visual functioning are: - cataract formation - glaucoma - age-related macular degeneration - diabetic retinopathy **Developmental Influences: Ear** The health of the ears is influenced by multiple factors, including the process of aging. Review the information for details about age-related ear health. **Infants and Children** Examination of the external ear is similar to that described for the adult. Determine if ear tubes have been placed prior to the assessment. During the otoscope examination, remember that for ages less than 3, pull the pinna straight down; for children older than 3, pull the pinna up and back. Use developmental milestones located in your text to assess the hearing of the infant. **The Aging Adult** An aging adult may have pendulous earlobes with linear wrinkling because of the loss of elasticity of the pinna. The cilia lining of the ear canal becomes coarse and stiff, which may cause cerumen to accumulate and oxidize, which may greatly reduce hearing. **Abnormal Findings: Eyes and Ears** Though most assessments of the eyes and ears lead to normal findings, the nurse needs to understand and recognize abnormal findings. **Abnormal findings of the eye include**: - extraocular muscle dysfunction​ - external structure abnormalities​ - eyelid lesions​ - pupil abnormalities​ - visual field loss​ - vascular disorders​ - internal structure abnormalities **Abnormal findings of the ear include​:** - external structure abnormalities​ - hearing loss​ - ear lesions​ - internal structure abnormalities **Health Education** Data collected during the assessment of the eyes and ears provides information the nurse can use to help clients maintain or improve their health. Select each tab to learn more. **Health Education: Eye** Loss of eyesight can impact client independence, so quick and timely intervention is essential when changes are detected. Education of proper care and protection of the eyes includes but is not limited to​: - use of appropriate safety eyewear for sports and occupation - use of appropriate eyewear for sun exposure - annual eye visits to assess vision and age-related changes - reporting of changes to vision and eye function as soon as possible **Health Education: Ear** Noise-induced hearing loss is usually permanent and progresses with each exposure. Client education should include: - use of proper ear protection when working around loud noises - never put foreign objects in the ear - do not use cotton swabs to probe or clean the ear canals - do not put cotton balls or liquids into the ear unless prescribed by a provider - treat ear infections as soon as possible Hearing loss may be prevented by prompt treatment. When hearing loss is treated early, one may be able to prevent or delay problems. Impaired hearing may contribute to depression, social isolation, and loss of independence and has been associated with cognitive decline. **Introduction to Nursing Application: Eyes and Ears** As with all nursing care, assessment of the eyes and ears is completed in a logical sequence using the nursing process and clinical decision-making to identify actual and potential health risks and provide interventions that promote health.​ Development and lifestyle all contribute to eye and ear health and should be included in screening for disease, identifying priorities of care, and providing health education that promotes optimal health for each client.​ As you complete the eye and ear assessment application activities, you will gain the knowledge and skills needed to:​ - Utilize prior knowledge of theories and principles of nursing while implementing the nursing process​. - Demonstrate beginning assessment skills in performing a complete physical examination​. - Differentiate between abnormal and normal findings.​ - Recognize developmental, cultural, and lifestyle influences​. - Utilize effective communication when performing a health assessment​. - Identify client education opportunities from the assessment process​. - Demonstrate appropriate documentation​.