health assesment Comprehensive Clinical Assessment: Eyes, Head, Neck, and Skin Integrity

Pupil Assessment and Accommodation

• Definition of Accommodation: This is a diagnostic test where the patient's focus shifts from a distant point to a near point.

• Procedure for Accommodation:

  • Instruct the patient to look at a distant object.

  • Hold an object (like a penlight) approximately $12\,inches$ away from the patient's eyes.

  • Move the object forward toward the patient.

• Normal Responses during Accommodation:

  • Constriction: The pupils should become smaller as the object moves closer.

  • Convergence: The eyes should move inward toward the center to maintain focus on the near object.

External Inspection of the Eyes

• Initial Assessment Step: The first step in any physical assessment is always Inspection.

• Inspection Factors:

  • Cultural and Individual Variations: Note differences in the shape and size of the eyes.

  • Iris Color: Often linked to ethnicity (e.g., in Asian populations, irises are typically black or dark brown).

  • Sclera Color: The normal color is white. Variations or redness can indicate infection or irritation.

• Eyelid Abnormalities:

  • Blepharitis: Inflammation or the presence of nodules on the eyelids.

  • Sties: Often referred to generally as sties, there are two distinct types covered in the lecture.

  • Hordeolum: A painful, red infection of an oil gland in the eyelid. (Mnemonic provided: "Hordeolum hurts").

  • Chalazion: A slow-growing, typically painless lump or cyst on the eyelid. It may cause discomfort but is generally not painful to the touch.

• Eyelashes:

  • Inspect for presence and distribution.

  • Clinical Warning: Artificial eyelashes or falling lashes can pose a risk in clinical settings, such as falling into tracheostomy tubes or onto medical supplies.

Pupil Size and Reactive Testing

• Normal Pupil Size: Generally ranges around $3\,mm$ on the pupil scale.

• Age-Related Changes: As individuals age, pupils naturally tend to become smaller.

• Anisocoria: This refers to unequal pupil size. This is a critical observation for patients with:

  • Intracranial Pressure (ICP).

  • Stroke.

  • Example Scenario: One pupil may be measured at size $2$ while the other is size $8$.

• PERRLA/PERLOC Assessment:

  • P: Pupils.

  • E: Equal.

  • R: Round.

  • R: Reactive to.

  • L: Light.

  • A/C: Accommodation.

• Proper Lighting Technique:

  • Do not shine the light directly into the patient's center of vision immediately to avoid causing pain or glares, especially in those with macular degeneration.

  • Tell the patient to look straight forward.

  • Advance the light from the side and pause.

• Consensual Reaction: When shining light into one eye, observing the other eye to ensure it constricts simultaneously even though it is not receiving direct light.

• Abnormal Findings: Dilation of the pupils (especially significant in trauma or neurological events like stroke or increased ICP).

Neurological Testing: Cardinal Fields and Specialized Diagnostics

• Six Cardinal Fields of Gaze: Checks for Extraocular Movement (EOM).

  • Involves testing Cranial Nerves III (Oculomotor), IV (Trochlear), and VI (Abducens).

  • Method: Hold a target (penlight or finger) $12\,inches$ away. Ask the patient to follow it with their eyes only, keeping their head still. Move in an "H" or star pattern and pause slightly at each cardinal position.

• Hirschberg Test: Shining a light onto the eyes to observe the symmetry of the light reflection. If reflections are in different spots on each eye, it indicates malalignment.

• Snellen Test: Used to assess visual acuity.

• Amsler Grid: Used specifically for testing for Macular Degeneration. Patients with the condition will report that the straight lines on the grid appear wavy.

Head and Facial Assessment

• General Inspection: Check size, shape, and symmetry of the head.

• Hair Assessment: Note distribution, color, and consistency. Identify any infestations (e.g., lice/nits).

• Temporal Artery: Palpate between the top of the ear and the eye. Normal findings should be nontender and elastic.

• Cranial Nerve V (Trigeminal): Sensory test. Ask the patient to close their eyes and identify where they feel a light touch on their face (forehead, cheeks, chin).

• Cranial Nerve VII (Facial): Motor test. Observe symmetry while the patient performs the following actions:

  • Smiling.

  • Showing teeth.

  • Blowing out cheeks.

  • Raising eyebrows.

  • Closing eyes tightly.

• Pediatric Consideration (Fontanelles):

  • Anterior Fontanelle: The soft spot on top of an infant's head.

  • Dehydration Indicator: A depressed or sunken anterior fontanelle is a major sign of dehydration in infants.

Neck and Lymph Node Assessment

• Range of Motion (ROM):

  • Turn head left/right (Chin to shoulder).

  • Lateral flexion (Ear to shoulder).

  • Flexion (Chin to chest).

  • Extension (Chin to ceiling).

• Lymph Nodes:

  • Preauricular: Located in front of the ears.

  • Postauricular: Located behind the ears.

  • Normal Findings: Lymph nodes should ideally be non-palpable. If felt, they should not be swollen, tender, or hard.

• Trachea: Palpated at the sternal notch; must be midline.

• Thyroid Gland: Located using landmarks with index finger and thumb. Typically not palpable. If enlarged, auscultate using the bell of the stethoscope to check for bruits (blowing/swishing sounds).

• Carotid Arteries:

  • Palpation: Must be done one at a time. Bilateral (simultaneous) palpation may reduce cerebral blood flow.

  • Auscultation: Use the bell of the stethoscope. Have the patient hold their breath during the check to eliminate respiratory noise.

Pressure Injuries (Pressure Ulcers)

• Definition: Skin breakdown occurring over bony prominences when applied pressure exceeds capillary closure pressure for prolonged periods.

• Common Locations: Sacrum, heels, back of the head, and elbows.

• Risk Factors: Immobility, poor nutritional status, sensory dysfunction, decreased tissue perfusion, increased moisture, and advanced age.

• Staging of Pressure Injuries:

  • Stage I: Non-blanchable area of redness over a bony prominence.

  • Stage II: Partial-thickness skin loss involving the dermis. May appear as an intact or ruptured blister.

  • Stage III: Full-thickness skin loss involving subcutaneous tissue. Usually shows a deep crater.

  • Stage IV: Full-thickness skin loss with visible bone, muscle, tendons, or cartilage.

  • Deep Tissue Injury (DTI): Intact skin that is purple or maroon or a blood-filled blister.

  • Unstageable: Thickness is obscured by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black), preventing accurate staging until removed.

• Assessment Tools: The Braden Scale is used to predict a patient's risk.

• Nursing Interventions:

  • Turn patients in bed at least every $2\,hours$.

  • Reposition chair-bound patients every $30\,minutes$.

  • Keep the Head of Bed (HOB) at $30^{\circ}$.

  • Use specialty air mattresses and moisture-absorbing pads.

Questions & Discussion

• Question: What does it mean if a patient has "pinpoint pupils"?

• Response: This can indicate a drug overdose, specifically of Opiates (Fentanyl, Morphine) or alcohol. It can also be a side effect of certain SSRIs or antipsychotic medications.

• Question: How do we check for signs of life in an unresponsive patient?

• Response: Check for non-reactive, fully dilated pupils, observe for the rise and fall of the chest, and attempt to measure blood pressure.

• Question: What is the significance of the Braden Scale?

• Response: It is a standardized tool used by nurses to identify which patients require additional interventions to prevent skin breakdown.

• Question: Where do we find these lecture materials/videos?

• Response: They are located in the Week 1 module of the Canvas course materials.