H&PA Exam 2 - HEENT Assessment

Head - Subjective Data:

• Are you experiencing headaches?

• Do you have any lumps or bumps on the face or scalp?

• Have you had any head trauma or injury?

Head - Inspect:

• Symmetry, unexpected movements such as twitching, swelling, growths or lesions.

• Neck including the trachea for symmetry.

Head - Palpate:

• Depressions or raised areas, lightly palpate the patient’s cheeks and nose asking “are you able to feel this?”

• Swollen lymph nodes, bumps or lesions.

Traumatic Brain Injury

• This occurs when an external force, such as a blow, jolt, or penetration, causes damage to the brain. It can result from incidents like falls, MVC, sports injuries or assaults.

• The injury can range from mild (slight concussion) to severe: potentially leading to long-term impairments such as memory loss, cognitive deficits, mood changes, or physical disabilities.

• The after effects depend on the severity of the injury and the area of the brain affected.

Coup:

Injury at the direct site of impact.

Contrecoup:

Opposite from the impact site occurs when the brain rebounds and strikes inside of the skull.

Eyes - Subjective Data:

• Do you have any vision difficulty (Decreased acuity, blurring or blind spots)? Pain?

• Redness/swelling? Watering? Discharge?

• History of ocular problems? Glaucoma? Use of glasses or contact lenses? Reading glasses Self-care behaviors?

Strabismus:

Disorder in which the eyes don’t look in exactly the same direction at the same time.

Diplopia:

Seeing two images of an object, also known as double vision.

Eyes - Inspect:

• Symmetry, the conjunctiva for swelling or drainage, the presence of eyelashes.

• Using a penlight evaluate the pupillary response using PERRLA, inspect for extra ocular movements.

PERRLA (P)

Pupils clear.

PERRLA (E)

Equal and between 1 to 5 mm in diameter.

PERRLA (R)

Round.

PERRLA (RL)

Reactive to light both directly and consensually when you direct light into one pupil and then the other.

PERRLA (A)

Accommodation of the pupils when they dilate to look at an object far away and then converge and constrict to focus on a near object.

Cataracts:

A cloudy, opaque area over the lens of one or both eyes.

Glaucoma:

Manifests itself with the initial loss of peripheral vision.

Diabetic retinopathy:

Manifests itself with a patient seeing spots, floaters and blurred vision.

Macular Degeneration:

Loss of central vision and can lead to eventual blindness.

Eyes - Palpate:

Lacrimal apparatus and assess for tenderness or drainage.

Eye Specific Test - Snellen or Rosenbaum Chart:

Visual Acuity

Eye Specific Test - Ishihara Test:

Color Blindness

Ears - Subjective Data:

• Do you have any difficulty hearing?

• Do you experience any ringing in your years?

• Do you have any pain in your ears?

• Have you noticed any liquid or drainage coming from your ears?

Ears - Inspect:

Outer ear for symmetry, redness or swelling, lesions or drainage.

Ears - Palpate:

Outer ear for pain/tenderness or warmth.

Function of the Outer Ear

• The external ear comprises the pinna (auricle), the external auditory canal, and the tympanic membrane (eardrum).

• The pinna collects sound waves, guiding them into the ear canal.

• The auditory canal carries sound to the eardrum, which vibrates when hit by sound waves. This vibration passes to the middle ear's bones, transmitting sound to the inner ear for processing.

• The external ear's role is to gather and funnel sound waves, enabling the initial steps of hearing.

Functions of the Middle Ear

• The main function of the middle ear is to carry sound waves from the outer ear to the inner ear, which contains the cochlea and where sound input can be communicated to the brain. Sound waves are funneled into the outer ear and strike the tympanic membrane, causing it to vibrate.

• Protects the inner ear by reducing the amplitude of loud sounds.

• The eustachian tube allows equalization of air pressure on each side of the tympanic membrane in order to prevent membrane rupture.

Functions of the Inner Ear

• The inner ear is the innermost part of your hearing system and home to your vestibular (balance) system.

• It contains the cochlea, which helps you hear, and the semicircular canals and otolith organs that help you balance.

Whisper test

Occlude one ear and test the other to see if the client can hear whispered sounds without seeing your mouth move. client can hear you whisper softly from 30 to 60 cm (1 to 2 ft) away.

Rinne test

Place a vibrating tuning fork firmly against the mastoid bone. Have the client state when they can no longer hear the sound.

Weber test

Place a vibrating tuning fork on top of the client’s head. Ask whether the client can hear the sound best in the right ear, the left ear, or both ears equally.

Acoustic neuroma:

A noncancerous tumor that can form on an important nerve involved in balance.

Benign paroxysmal positional vertigo (BPPV):

A vestibular (balance) disorder that happens when small fragments of your inner ear (otoconia) get trapped in your semicircular canal. This can make you feel like you’re moving when you aren’t, or have feelings of extreme dizziness or feeling like the room is spinning.

Hearing loss:

A common condition with many causes and types, including age-related hearing loss (presbycusis), noise-induced hearing loss (NIHL) and sudden sensorineural hearing loss (SSNHL).

Inner ear infection (otitis interna):

Any condition that causes inflammation in your inner ear. The most common types are labyrinthitis and vestibular neuritis. Infections can cause severe hearing loss and prolonged dizziness.

Ménière’s disease:

Chronic (long-lasting) inner ear condition that causes fluctuating problems with both hearing and balance.

Ototoxicity:

Damage to your inner ear that’s a side effect of taking certain medications.

Tinnitus:

Ringing in your ears that’s often related to hearing loss.

Nose - Subjective Data:

• Do you ever have pain, stuffiness, or fluid draining from your nose?

• Have you ever injured your nose?

• Do you have nosebleeds?

• Have you had a change in your senses of smell or taste?

• Do you use nasal sprays?

• Do you snore or have difficulty breathing through your nose?

Nose - Inspect:

Alignment and the nostrils for symmetry.

Nose - Palpate:

Frontal and maxillary sinuses for pain or tenderness.

Deviated septum:

Shifting of the nasal cavity wall.

Nasal polyps:

Soft growths on the lining of the nose or sinuses.

Epistaxis:

Nosebleeds

Rhinitis:

Inflammation of the nose and sinuses, sometimes caused by allergies.

Sinusitis:

Chronic inflammation of the sinuses.

Other Nasal Conditions:

• Smell and taste disorders

• Allergies

Palpation of Sinuses

When assessing a patient who is complaining of a possible sinus infection, the nurse will gently palpate the maxillary sinus area with their thumbs.

Throat - Subjective Data:

• Do you have any sores or lesions, sore throat, bleeding gums, toothache or hoarseness?

• Do you have Dysphagia ( difficulty swallowing)? Do you have altered taste?

• Do you smoke? What is your alcohol consumption?

• What are your self-care behaviors, dental care patterns, dentures or appliances?

Throat - Inspect:

Using a penlight assess the structures of the mouth and throat including the tonsils, uvula, tongue, teeth and buccal mucosa. The underside of the tongue is referred to as the sublingual mucosa.

Throat Issues

• Strep Throat

• Enlarged tonsils

• Strep Rash