Chapter 14-19: HEENT, Respiratory, and Cardiovascular Systems – Nursing Notes
Problem-Based Health History (P-BHH) and HEENT Focus
Purpose: Systematic approach to collect history and guide physical examination (HEENT: head, eyes, ears, nose, throat) with problem-based prompts.
OPQRSTU mnemonic to differentiate headache etiologies:
O: Onset
P: Provocation/Palliation
Q: Quality
R: Region/Radiation
S: Severity
T: Timing
U: Understand the patient’s perception/impact
Headache/Migraine: differentiate using OPQRSTU; meningitis suspected with severe headache plus fever and nuchal rigidity.
Comprehensive PHH components relevant to HEENT:
Headaches (current/past conditions) and conditions affecting HEENT.
Trauma, injuries, or surgeries to HEENT regions.
Medications and potential side effects.
Corrective devices (glasses, contacts, hearing aids, prosthetics).
Self-care activities/health promotion.
Changes in senses (sight, hearing, smell, taste, touch).
HEAD: Skull and Scalp; Inspection and Normal/Abnormal Findings
Skul/Head: Normocephalic; common abnormalities include: hydrocephaly, plagiocephaly, craniostenosis.
Inspection focuses on symmetry, deformities, and contour.
Posterior and anterior assessment aided by tilt/position to evaluate for goiters or thyroid issues later.
NECK: Muscle Function, Trachea, and CN XI
Muscles: trapezius and sternocleidomastoid musculature integrity; assess shoulder strength and head rotation against resistance.
CN XI (Accessory): motor function assessment.
Trachea: midline position to exclude deviation.
LYMPHATICS: Lymphatic System Overview and Nodes
Function: Major part of the immune system; lymph vessels transport clear fluid from tissues into the circulation; lymph nodes filter lymph and engulf pathogens, preventing harmful substances from entering circulation.
Drainage: All nodes drain into the deep cervical chain.
Lymph Nodes:
Inspection: look for gross swelling or deformities.
Palpation: circular motions; palpable nodes should be movable, small, soft, and non-tender in proximal areas.
Abnormal: enlarged, tender, movable or hard/immobile (fixed) which may suggest malignancy.
Lymphadenopathy: enlargement of lymph nodes.
THYROID GLAND: Inspect, Palpate, Auscultate
Goiter assessment: inspect with head tilted back; swallow to differentiate.
Palpation: posterior approach preferred; normal thyroid is often nonpalpable; check for nodules.
Auscultation: if enlarged or hyperplastic, listen for bruit (pulsing/noise indicating increased vascular flow).
Thyroid disorders: signs of hypo- and hyperthyroidism include:
Hypothyroidism: cold intolerance, weight gain, cool/dry skin, decreased vital signs, constipation, myxedema.
Hyperthyroidism: heat intolerance, weight loss, warm/velvety skin, increased vital signs, diarrhea, exophthalmos.
FACE: Symmetry, Sensation, and TMJ
Face: assess symmetry during movement (CN VII).
Sensation: cotton-wisp test (CN V).
Sinuses: inspect for locking, crepitus, decreased ROM, and pain as abnormal.
Temporomandibular Joint (TMJ): palpate and assess movement for tenderness or crepitus.
Older Adults: consider prolapsed submandibular salivary glands (soft and bilateral).
EYES: External Structures, Vision, and Tests
External Eye Examination: inspect eyelids (ptosis), sclera, conjunctiva, brows, lashes, and palpebral fissures.
VISION TESTS:
Visual Acuity (CN II): Snellen chart; understanding of refractive errors:
Hyperopia = farsightedness
Myopia = nearsightedness
Example: read at 20/30 means you can read at 20 ft what a normal eye can read at 30 ft. This can be expressed as VA = \frac{D{read}}{D{normal}} = \frac{20}{30} in this example.
Visual fields/Peripheral Vision: Confrontation test (CN II).
EXTRAOCULAR MUSCLES (EOMs):
6 cardinal gazes; normal parallel tracking without nystagmus.
Diagnostic positions test (CN III, IV, VI).
Pupil tests: Shine a light from the side; expect equal direct and consensual light reflex; cover test for ocular alignment; Corneal Light Reflex (Hirschberg test) for strabismus.
PUPILLARY RESPONSE: Pupils equal, round, reactive to light and accommodation; anisocoria = unequal pupils; CN II and III involved.
OPHTHALMOSCOPIC EXAM: Red reflex present bilaterally; optic disc location (nasal retina); color creamy yellow-orange to pink; margins distinct; retinal vessels observed.
EYE ABNORMALITIES AND CONDITIONS
Cataract: lens opacity due to aging; symptoms include blurred vision, night blindness; abnormal red reflex.
Age-Related Macular Degeneration (AMD): loss of central vision due to macular changes.
Diabetic Retinopathy: leading cause of blindness in the U.S.; acute onset of flashing lights, floaters; shadow/diminished vision in part of the visual field.
Retinal Detachment: abrupt visual field loss; see floaters and flashes.
Strabismus: abnormal ocular alignment due to extraocular muscle weakness.
Glaucoma: increased intraocular pressure (IOP) risking optic nerve damage.
EARS: External Ear, Tympanic Membrane, and Hearing
External Ear: assess size/shape/skin condition/texture; tenderness; redness/swelling; discharge; foreign bodies; impacted cerumen; inspect and palpate.
Tympanic Membrane (TM): Normal findings include shiny, translucent, pearl-gray color; junctional light reflex (“cone of light”); movable; intact.
Abnormal TM findings: red (otitis media), blue (blood in middle ear), dense white patches (scarring).
Hearing Acuity: CN VIII; screening tests include Whispered Voice Test; Tuning Fork/Audiometric testing (most accurate).
Hearing Loss Types:
Conductive: external or middle ear problems; treatable with medications or procedures; decreased hearing with visible exam findings.
Sensorineural: causes include presbycusis, CN VIII dysfunction due to brain lesion, ototoxic drugs; high-frequency tone loss, garbled words, reduced localization.
Common Conditions: Otitis Media (middle ear) with otalgia and TM changes; Otitis Externa (outer ear) with otalgia on manipulation; swimmer’s ear; Presbycusis (age-related sensorineural loss).
NOSE & SINUSES
External nose: inspect for symmetry and midline alignment; assess patency.
Sinuses: palpation of frontal and maxillary sinuses; transillumination may help identify sinus issues.
Nasal inspection: nasal speculum to inspect turbinates; turbinates should be pink; swelling may indicate allergic rhinitis.
Olfactory function: CN I test (smell).
Allergic Rhinitis vs Acute Rhinitis:
Allergic rhinitis: sneezing, congestion, clear drainage; turbinates enlarged and pale/pale-violet.
Acute rhinitis (common cold): clear then purulent drainage; turbinates dark red and swollen.
MOUTH AND ORAL CAVITY
Begin with anterior structures and move posteriorly: lips, teeth, gums, tongue, oral mucosa.
CN X (vagus) test: "ahhh"; midline rise of soft palate and uvula.
Gag reflex: CN IX and X.
Normal soft palate rise scales:
1+: just visible
2+: halfway to uvula
3+: touching uvula
4+: touching each other
Tonsils: pink with crypts/indentations.
Normal variations in mouth:
Torus Mandibularis: bony ridge on mandible
Torus Palatinus: bony ridge on hard palate (seen in 20-35% of Americans; more common in American Indians and Asians)
Bifid Uvula: in ~10% of some American Indian groups
Breath odor (halitosis): may indicate diabetic ketoacidosis (DKA), infection, or other systemic issues.
Common oral lesions:
Aphthous Ulcer (canker sore): round/oval ulcer with yellow/white center and red halo; up to 2 weeks; caused by Candida? (in text: may imply infection by Candida albicans for thrush).
Oral Candidiasis (thrush): nonadherent creamy-white plaques; painful.
Leukoplakia: precancerous; very adherent plaque.
Tonsillitis and Peritonsillar Abscess: S/S include odynophagia, fever, malaise, lymphadenopathy; exudate; petechiae on palate; Strep test if needed; Abcess complications include severe throat pain, swelling, difficulty swallowing/breathing.
Infants/Children: fontanels assessment; palpable lymph nodes; risk factors for OM; binocularity; daycare; smoking exposure; pacifier use.
Pregnancy considerations: gingivitis, rhinitis; temporary vision changes; thyroid palpability changes.
Other considerations:
Hyperpigmentation, sclera pigmentation, bluish sclera; bluish lips; line on gingival margin.
Older adults: mouth and dentition changes; risk for malignancies; xerostomia considerations.
OLDER ADULTS: Age-Related HEENT Changes
Nose appears more prominent; decreased sense of smell and taste.
Decreased salivary production; dental changes; recession of gums; sunken cheeks; smoother tongue with papillary atrophy.
Tongue protrusion; increased risk for oral malignancies.
Presbyopia and cataracts common with aging; changes in pupillary response and accommodation.
RESPIRATORY SYSTEM: Anatomy, History, and Exam Basics
Thoracic landmarks:
Sternal angle (Angle of Louis) = bifurcation of the trachea; costal angle normally 90°; vertebra prominens C7; intercostal spaces named for the rib above (e.g., 2nd ICS is below the 2nd rib).
Anterior landmarks: RUL to RML extent; LUL; RLL; LLL mapped by ICS levels (e.g., 4th-5th ICS for RML, etc.). Posterior landmarks span T3 to T10 for lower lobes.
Health history for respiratory assessment:
Allergies; medications; vaccines; smoking history; TB exposure (PPD) and years of exposure (PY = PPD × years).
Cough characteristics: dry, congested, barky, hacking; sputum color, consistency, odor, and amount.
Dyspnea: orthopnea, dyspnea on exertion; chest pain related to respiration.
Physical examination (RESPIRATORY): seated position preferred; general appearance; observe breathing effort; skin and nails; anterior and posterior thorax:
Inspect, palpate, percuss, auscultate.
Respiratory metrics: Eupnea; rate 12–20/min; depth; regular breathing pattern; unlabored effort.
Tachypnea, bradypnea, hyperventilation, hypoventilation, Cheyne-Stokes, apnea patterns with examples.
Palpation findings:
Symmetry; tenderness; crepitus (subcutaneous emphysema);
Tactile fremitus: use ulnar edge or base of fingers; say "99" or "blue moon"; fremitus strongest over bronchi; vibrations decrease toward the peripheral chest wall.
Percussion and resonance:
Percuss from apices to bases; normal resonance; dullness, hyper-resonance, and flatness patterns.
Auscultation:
Normal breath sounds:
Bronchial: high-pitched, loud, hollow; Inspiration < Expiration.
Bronchovesicular: moderate pitch; Inspiration = Expiration.
Vesicular: low-pitched, soft; Inspiration > Expiration.
Adventitious sounds:
Rhonchi: continuous, low-pitched; secretions in larger airways; may improve with cough.
Crackles (rales): discontinuous, high-pitched; alveolar fluid; pneumonia or edema.
Pleural friction rub: grating, low-pitched; pleuritis/pleurisy.
Wheeze: continuous, high-pitched; narrowed airways (asthma, COPD).
Stridor: high-pitched crowing; upper airway obstruction.
Voice sounds: auscultate for amplified transmitted sounds as needed (eg, egophony, bronchophony, whispered pectoriloquy).
Older adults considerations:
Calcified costal cartilage and stiffer lungs; weaker cough; kyphosis; shallower, faster breathing; reduced thoracic expansion.
RESPIRATORY PATHOPHYSIOLOGY AND COMMON DISORDERS
Atelectasis:
Small airway collapse due to hypo-inflation; signs include dyspnea, hypoxia, diminished breath sounds, decreased tactile fremitus, dullness over area; mediastinal shift possible with large areas affected.
Pneumonia:
Consolidation with pus/exudate; infectious or aspiration etiology; fever/chills, tachycardia, malaise; cough, pleuritic chest pain, dyspnea; purulent sputum; rales; increased breath and voice sounds; increased fremitus.
Focal or Multifocal Infiltrates: pneumonia patterns vary by location (Jarvis reference).
Asthma (Reactive Airway Disease): bronchoconstriction, mucus production, inflammation; triggers; cough, dyspnea, chest tightness; retractions; expiratory wheeze.
Chronic Obstructive Pulmonary Disease (COPD): chronic bronchitis and emphysema spectrum; barrel chest; chronic cough; hypoxemia; orthopnea; tachypnea with prolonged expiratory time; wheeze and crackles; respiratory acidosis; variable SpO2 around 88–92% is not unusual in some COPD patients.
Pleural Effusion: accumulation of fluid in pleural space; dyspnea; decreased chest wall movement; sharp pleuritic pain; decreased fremitus; dullness; decreased breath sounds.
Pneumothorax: air in pleural space; dyspnea; hyperresonance; decreased breath sounds on affected side; potential tracheal shift.
Pulmonary Tuberculosis (TB): contagious bacterial infection; fatigue, weight loss, low-grade fevers, night sweats; crackles at apices; dyspnea; chronic cough with hemoptysis.
Lung Cancer: high mortality; persistent cough, chest pain, fatigue, weight loss, hemoptysis, dyspnea; nail clubbing; possible dull percussion over large tumor.
Acute Respiratory Distress Syndrome (ARDS): post-trauma/shock; rapidly increasing pulmonary edema; restlessness, severe dyspnea, persistent hypoxemia; frothy sputum.
Pediatric considerations (RSV, Croup):
RSV: cold-like symptoms; bronchiolitis and pneumonia risk in infants.
Croup: swelling of trachea, larynx, bronchi; fever, dysphonia, stridor; barking cough; watch for drooling and cyanosis.
CARDIOVASCULAR SYSTEM: Anatomy and Hemodynamics
Cardiac anatomy and layers: Pericardium (fibrous sac), epicardium (outer), myocardium (muscular wall), endocardium (inner lining).
Chambers and Valves:
Right heart: tricuspid valve; right side.
Left heart: mitral (bicuspid) valve; left side.
Semilunar valves: pulmonic (right) and aortic (left).
Direction of blood flow:
SVC/IVC → Right Atrium (RA) → Tricuspid → Right Ventricle (RV) → Pulmonic Valve → Pulmonary Arteries → Lungs → Pulmonary Veins → Left Atrium (LA) → Mitral Valve → Left Ventricle (LV) → Aortic Valve → Aorta → Systemic Circulation.
Cardiac cycle: Systole vs Diastole
Systole: ventricular contraction; apex involved; SL valves open; AV valves close; S1 (“lub”).
Diastole: ventricular relaxation; AV valves open; SL valves close; S2 (“dub”).
Key landmarks for auscultation:
Aortic: 2nd ICS, right sternal border.
Pulmonic: 2nd ICS, left sternal border.
Erb’s Point: 3rd ICS, left sternal border.
Tricuspid: 4th ICS, left sternal border.
Mitral (apex): 5th ICS, left midclavicular line.
Apical impulse (PMI): usually at 4th–5th ICS, left MCL; may be visible/palpable if enlarged; thrill indicates abnormal flow.
Precordium examination: inspect symmetry, color, skin integrity; palpate, percuss, and auscultate pericardium; look for heaves/lifts and pulsations; auscultate for bruits in neck vessels.
Cardiac sounds and maneuvers:
Use bell for low-pitched murmurs; listen at apex with patient in left lateral position to detect S3/S4.
S3 (ventricular gallop): early diastole; may be normal in young, healthy individuals with high CO; pathologic in LV dilation/congestive HF.
S4 (atrial gallop): late diastole; related to stiff ventricles; usually pathologic, except physiological occurrences during high-output states.
Murmurs:
Definition: blowing or whooshing sounds due to turbulent flow across a valve or great vessel.
Timing: systole or diastole; location/valve area; intensity and presence of a thrill.
Posture effect: some murmurs disappear or become louder with position changes.
Murmurs can be innocent (functional) due to high flow states (pregnancy, fever, hyperthyroidism) or pathologic from valvular disease.
CARDIOVASCULAR RISK AND DISEASE PATHOPHYSIOLOGY
Hypertension (HTN): often called the "silent killer" due to asymptomatic progression; untreated HTN increases risk for MI, HF, stroke, kidney disease, PAD, retinopathy. (
30–40% prevalence concerns across populations; exact numbers not provided in slides but implied.)
Coronary Artery Disease (CAD) and Angina:
Cardiac chest pain radiating to jaw, back, arm; described as chest discomfort due to myocardial ischemia; stable angina <15 min relieved by rest/nitro; ACS is longer and more severe.
Myocardial Infarction (MI):
Ischemia lasting >20 minutes causing cellular death (infarction); S/S include heavy/ache CP radiating to jaw/arm; signs of poor perfusion (SOB, pallor, diaphoresis); troponin/ECG changes (ST elevations); prompt treatment essential to limit myocardial damage.
Pericarditis: inflammation of parietal and visceral pericardial layers, possibly viral or MI-related; friction rub; sharp chest pain worsened by deep breathing, lying flat; managed with anti-inflammatory therapies and treatment of underlying cause.
VASCULAR SYSTEM: Peripheral and Central Circulation
Peripheral Vascular Assessment:
Signs of arterial disease: claudication, pallor, paresthesia, paralysis, pulselessness, poikilothermia (coldness).
Ulcers: pale, deep, round, distal (toes/metatarsals); ABI measurement used for PAD assessment.
Ankle-Brachial Index (ABI): ABI = \frac{SBP{ankle}}{SBP{brachial}}; \quad ABI < 0.90 \rightarrow PAD.
Brachial, radial, and ulnar pulses palpated; femoral, popliteal, posterior tibial, dorsalis pedis pulses evaluated; capillary refill tests; hair distribution and skin changes.
Arterial bruits may indicate stenosis; carotid bruits correlate with cerebrovascular risk.
Venous System:
Venous insufficiency signs: edema, hemosiderin staining, venous stasis ulcers; risk of DVT and PE; Homan’s sign (calf pain with dorsiflexion) may indicate DVT but is not highly specific.
Varicose veins and dependent edema; temperature and pulses may remain normal in early venous disease.
Lymphatic considerations: edema related to lymphatic drainage issues; lymphedema characterized by heavy, non-pitting edema.
GERIATRIC CONSIDERATIONS IN HEENT, RESPIRATORY, AND CARDIOVASCULAR HEALTH
Aging-related changes:
Lungs: more rigid thorax, decreased chest wall compliance; lower reserve; pathology progresses with age.
Heart: A-P diameter increases; S2 quieter; S4/murmurs more common; pulses in lower extremities harder to palpate.
Skin and tissues: thinner, drier mucosa; reduced mucosal defense; dental and salivary gland changes; higher risk for oral lesions and infections.
Functional implications:
Slower healing, higher susceptibility to infections, and altered presentation of acute illnesses.
Importance of thorough hydration, nutrition, vaccination status, and assessment for polypharmacy.
CONNECTIONS AND PRACTICAL IMPLICATIONS
Integrative assessment: HEENT findings can influence systemic diagnoses (e.g., goiter influencing metabolic status, thyroid disease impacting cardiovascular risk, or HPV-related oral lesions indicating risk factors).
Diagnostic reasoning: combine history (OPQRSTU), targeted exam, and targeted tests (e.g., Snellen chart, Whisper Test, ABI, JVD, PMI, murmurs) to form differential diagnoses.
Ethical/practical considerations:
Respect patient autonomy and obtain informed consent for examinations that may be invasive or uncomfortable (e.g., palpation of neck nodes, use of instruments like otoscope or ophthalmoscope).
Be mindful of age-related vulnerabilities in older adults; ensure gentle technique and consider assistive devices for hearing/vision impairments.
KEY NUMERICAL REFERENCES AND SIMPLE FORMULAS
Snellen Visual Acuity example: 20/30\;\text{(read at 20 ft what normal eye reads at 30 ft)}
Ankle-Brachial Index (ABI): ABI = \frac{SBP{ankle}}{SBP{brachial}}; \, ABI < 0.90 \rightarrow PAD
Cardiac cycle terms (qualitative): Systole vs. Diastole with valve movements and heart sounds S1 (lubb) and S2 (dupp) timing relative to valve closures.
Normal EF range (left ventricular ejection fraction): EF = 50\%\text{ to }70\%
Normal thoracic landmarks and spaces (reference for auscultation locations):
Aortic area: 2nd ICS, right sternal border
Pulmonic area: 2nd ICS, left sternal border
Erb’s point: 3rd ICS, left sternal border
Tricuspid area: 4th ICS, left sternal border
Mitral area (apex): 5th ICS, left midclavicular line
CONNECTIONS TO FOUNDATIONAL PRINCIPLES
Anatomy and physiology: understanding the anatomy of HEENT, respiratory, and cardiovascular systems underpins interpretation of findings (e.g., valve locations, murmurs, airway sounds).
Pathophysiology: linking symptoms to mechanisms (e.g., inflammation in sinusitis, edema in heart failure, ischemia in MI).
Clinical reasoning: history-taking (OPQRSTU) guides physical exam focus and prioritization of differential diagnoses.
Public health and ethics: screening (BP, carotid bruits), vaccination history, and prevention (smoking cessation) have broad implications for patient safety and population health.
SUMMARY TAKEAWAYS
Use Problem-Based Health History to structure HEENT assessment and identify risk factors, past history, and current symptoms.
Mastery of anatomy and exam techniques (inspection, palpation, percussion, auscultation) across head, neck, eyes, ears, nose, throat, and chest.
Distinguish normal vs abnormal findings and recognize when to pursue further testing (e.g., audiometry for hearing loss, ABI for PAD, ophthalmoscopic exam for retinal pathology).
Remember key signs of common conditions: facial asymmetry (CN VII), optic disc and retinal changes (diabetic retinopathy, AMD), TM changes (otitis media/externa), lung sounds and adventitious sounds, murmurs and heart sounds, JVD in right-sided HF, and peripheral pulses.
Consider aging in assessments: changes in chest wall, heart sounds, vision/hearing, and skin/nails that affect exam technique and interpretation.