HNN

Equipment for All Assessments

  • Penlight


Select assessments

  • Otoscope (for ears)

  • Snellen Chart (for vision screening)

  • Tape measure (for measuring skin findings)

  • stethoscope reflex hammer

  • tuning fork

  • tongue blade

  • ophthalmoscope

Health history

  • If they have a condition that is related to an assessment:

    • ask follow-up questions

      • when was the last episode

      • what did it look or feel like for you

      • do you know what your triggers are

      • what do you take for condition management

      • who manages your condition

      • when was the last time you saw your doctor

      • what is the severity

      • Past medical history

      • family history

      • medications

      • history of falls - recent and past (within 3 months)

      • dizziness

      • vision changes

      • difficulty hearing

      • difficulty swallowing

      • changes to taste and smell

      • (Report acute changes of patient to physician)

Techniques of Assessment

Head

  • Appearance

  • symmetry

  • shape

  • size

  • smile

  • frown

  • (I’m not going to know what to do for certain conditions, so CALL for a nurse or call light do not leave the patient alone)

  • acute change is sudden

Ears - inspection

  • symmetry

  • drainage

  • lesions

Eyes - inspection

  • Eyelid

  • conjunctiva

  • sclera

  • P-ER-RL-A

  • Pupils are EQUAL ROUND and Reactive to Light and Accommodation

    • Pupils (size between them; light does not need to be on for this)

    • jvorw

    • React to Light (come in to the side)

    • Accommodations (bring object slowly to nose; tests eye convergence)

  • EOM

    • 6 cardinal gazes (cat whiskers, return to the center of the whisker)

    • Follows commands without involuntary eye movements

    • Tests cranial nerve: 3,4, and 6

Nose - inspection

  • Symmetry

  • nasal patency

  • drainage

Mouth

  • Symmetry

  • lips

  • mucosa

  • teeth

  • sores

  • ulcers

  • edema

  • uvula rise and fall

  • speech pattern

Palpation

Head

  • Entire head

  • sinuses

  • TMJ

  • Sensation

Ears

  • Outer ear

  • tenderness

Screening tests - if applicable

  • Facial sensation


Neck

  • Inspection

    • symmetry

    • trachea

    • thyroid

    • JVD (jugular vein distention; occurs when fluid overload )

    • ROM of C-spine

    • shoulder shrug (tests cranial nerve 11)

  • Palpation

    • trachea

    • thyroid

    • lymph nodes

    • carotid artery

Lymph nodes assessment

  • expected

    • non-palpable

    • or

      • less than 1 cm

      • soft

      • moveable

      • non-tender

  • Unexpected

    • large

    • tender

    • fixed in place

    • hard

Neck auscultation

  • listen to carotid artery (bruits: narrowing in the area where blood flows, there should be no sound of blood flow)


Neuro

LOC

  • Alert

  • Lethargic (awakens to light stimulus)

  • obtunded (awakens to stronger stimulus but is confused)

  • stupor (does not awaken to stimulation but withdraws from pain)

  • comatose

Orientation

  • Person (does the patient know who they are)

  • Place (do they know where they are)

  • time (Do they know when it is)

  • situation (Do they know why they are here)

  • Document that oriented: X (whatever number of person, place, time, situation they have correct)

  • Cranial nerves

    • Olfactory