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U of R SCHOOL OF NURSING > CLASS 2 - HEENT > Flashcards

CLASS 2 - HEENT Flashcards

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1
Q

HEENT

A
  • Head
  • Ears
  • Eyes
  • Nose
  • Throat
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2
Q

HEENT ASSESSMENT FACTORS

A
  • Skull
  • Face
  • Neck
  • Thyroid
  • Regional lymphatics
  • Blood supply
  • Eyes and ears
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3
Q

SUBJECTIVE DATA ASSESSMENT

A
  • Past medical history
  • Family history
  • Health maintenance
  • Personal and social
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4
Q

COMMON/CONCERNING HEAD ASSESSMENT SYMPTOMS

A
  • Headache

- History of head injury

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5
Q

COMMON/CONCERNING EYE ASSESSMENT SYMPTOMS

A
  • Injury
  • Visual disturbances
  • Spots (scotomas)
  • Flashing lights
  • Use of corrective lenses
  • Pain
  • Redness
  • Excessive tearing
  • Double vision
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6
Q

COMMON/CONCERNING EAR ASSESSMENT SYMPTOMS

A
  • Ringing (tinnitus)
  • Hearing loss
  • Pain
  • Discharge
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7
Q

COMMON/CONCERNING NOSE ASSESSMENT SYMPTOMS

A
  • Drainage (rhinorrhea)
  • Congestion
  • Sneezing
  • Nose bleeds (epistaxis)
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8
Q

COMMON/CONCERNING OROPHARYNX ASSESSMENT SYMPTOMS

A
  • Soreness
  • Gum bleeding
  • Hoarseness
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9
Q

COMMON/CONCERNING NECK/THYROID ASSESSMENT SYMPTOMS

A
  • Lumps
  • Pain
  • Stiffness
  • Temperature intolerance
  • Excessive sweating
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10
Q

HEAD INJURY PREVENTION

A
  • Decrease head injuries (concussion identification, use of seat belts/helmets)
  • Reduce fall injures (playground safety, home safety)
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11
Q

ORAL HEALTH PREVENTION

A
  • Decrease dental caries and periodontal disease)
  • Increase detection of oral pharyngeal cancers
  • Decrease use of tobacco products that increase risk for oral cancer
  • Increase number of people receiving dental and oral care
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12
Q

HEAD INSPECTION ASSESSMENT

A
  • Symmetry
  • Hair distribution, quantity
  • Scalp: scaling, nevi (separate hair)
  • Skull: size and contour
  • Face: expression, contours
  • Skin: color, pigmentation, hair distribution, lesions
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13
Q

HEAD PALPATION ASSESSMENT

A
  • Hair texture
  • Skull: lumps, tenderness
  • Face: sinuses
  • Skin: texture, temperature
  • TMJ
  • Temporal arteries
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14
Q

NOSE/SINUSES INSPECTION ASSESSMENT

A
  • Anterior and interior surface: asymmetry or deformity
  • Inside of nose using otoscope: mucosa color, swelling bleeding, exudate, polyps
  • Inside of nose using otoscope: septum deviation, inflammation, perforation
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15
Q

NOSE/SINUSES PALPATION ASSESSMENT

A
  • Palpate frontal and maxillary sinus with circular motions for tenderness, inflammation, or pain
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16
Q

MOUTH/PARYNX INSPECTION ASSESSMENT FACTORS

A
  • Lips
  • Oral mucosa
  • Gums and teeth
  • Roof of mouth
  • Tongue and floor of mouth
  • Pharynx: soft palate, anterior and posterior pillars, uvula, tonsils, pharynx
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17
Q

LIP INSPECTION ASSESSMENT

A
  • Color
  • Moisture
  • Lumps
  • Ulcers
  • Cracking
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18
Q

ORAL MUCOSA INSPECTION ASSESSMENT

A
  • Color
  • Ulcers
  • Nodules
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19
Q

GUMS AND TEETH INSPECTION ASSESSMENT

A
  • Color
  • Presence/position of teeth
  • Color of gums
  • Bleeding gums
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20
Q

ROOF OF MOUTH INSPECTION ASSESSMENT

A
  • Color
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21
Q

TONGUE AND FLOOR OF MOUTH INSPECTION ASSESSMENT

A
  • Color
  • Texture
  • Ulcers
  • Nodules
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22
Q

PHARYNX INSPECTION ASSESSMENT

A
  • Color
  • Symmetry
  • Presence of exudate
  • Swelling
  • Ulceration
  • Tonsillar enlargement
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23
Q

TONSIL GRADING SCALE

A
  • +1: Tonsils are visible
  • +2: Tonsils are between the pillars and the uvula
  • +3: Tonsils are touching uvula
  • +4: One or both tonsils extend to the midline of the oropharynx
24
Q

NECK INSPECTION ASSESSMENT FACTORS

A
  • Symmetry
  • Masses
  • Scars
  • Enlarged lymph nodes
  • Position and alignment of trachea
  • Symmetry of thyroid gland
25
Q

NECK PALPATION ASSESSMENT FACTORS

A
  • Lymph nodes: pre auricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical chain, supraclavicular
  • Thyroid gland
26
Q

LYMPH NODE PALPATION ASSESSMENT

A
  • Gentle, circular motion using finger pads
  • Size
  • Shape
  • Delimitation
  • Mobility
  • Consistency
  • Tenderness
27
Q

PREAURICULAR LYMPH NODE ANATOMY

A
  • Front of the ear
28
Q

POSTERIOR AURICULAR LYMPH NODE ANATOMY

A
  • Superficial to the mastoid process
29
Q

OCCIPITAL LYMPH NODE ANATOMY

A
  • At the base of the skull
30
Q

TONSILLAR LYMPH NODE ANATOMY

A
  • Under the angle of the mandible
31
Q

SUBMANDIBULAR LYMPH NODE ANATOMY

A
  • Halfway between the angle and the tip of the mandible
32
Q

SUBMENTAL LYMPH NODE ANATOMY

A
  • Midline, behind the tip of the mandible
33
Q

SUPERFICIAL CERVICAL LYMPH NODE ANATOMY

A
  • Overlying the sternomastoid muscle
34
Q

POSTERIOR CERVICAL LYMPH NODE ANATOMY

A
  • In the posterior triangle along the edge of the trapezius muscle
35
Q

DEEP CERVICAL CHAIN LYMPH NODE ANATOMY

A
  • Deep under the sternomastoid muscle
36
Q

SUPRACLAVICULAR LYMPH NODE ANATOMY

A
  • Just above and behind the clavicle
37
Q

THYROID GLAND PALPATION ASSESSMENT

A
  • Posterior approach: stand behind patient and have them swallow
  • THYROID SHOULD NOT BE PALPABLE
  • Consistency
  • Masses
  • Tenderness
38
Q

EAR INSPECTION ASSESSMENT

A
  • Auricle & ear canal for lesions
  • Signs of infection
  • Tympanic membrane for landmarks, fluid
39
Q

EAR PALPATION ASSESSMENT

A
  • Auricle for tenderness with movement

- Mastoid bone behind ear

40
Q

EAR WHISPER ASSESSMENT

A
  • Palpate and move tragus slightly

- Two syllabus word whispered in other ear

41
Q

EAR AIR AND BONE CONDUCTION ASSESSMENT

A
  • Weber: strike sound, hold on head between ears (lateralization of sound? - conduction loss)
  • Rinee: comparing time of air vs. bone conduction
42
Q

T/F: Air conduction > bone conduction

A
  • True
43
Q

OTITIS MEDIA

A
  • Fluid or infection in the middle of the ear
44
Q

OTITIS EXTERNA

A
  • Fluid or infection on the outside of the ear
45
Q

STRABISMUS

A
  • One eye goes the opposite way (lazy eye)
46
Q

PTOSIS

A
  • Drooping eyelid that covers more than 50% of the eye
47
Q

SNELLEN EYE CHART ASSESSMENT

A
  • Person 20 feet from the chart (or 6 feet from card)
  • Cover one eye and read smallest line of letters possible
  • Example: 20/30 -1 with glasses
  • Person missed one letter (can only have 2 misses on a line)
  • Can read at 20 feet what normal eye can see from 30 feet away
48
Q

VISUAL FIELDS (CONFRONTATION) EYE ASSESSMENT

A
  • Tests patient’s peripheral vision
  • Stand in front of patient and look directly into provider eyes
  • Wiggle fingers in bowl-like pattern that covers all fields
49
Q

EXTRAOCULAR MOVEMENTS (EOM’S) EYE ASSESSMENT

A
  • Eyes coordinated by 6 muscles and 3 cranial nerves (III, IV, VI)
  • Patient look forward only moving eyes
  • “H” pattern
  • Look for eyes moving in parallel fashion and nystagmus (beats of the eye)
50
Q

CORNEAL LIGHT REFLEX EYE ASSESSMENT

A
  • Tests for alignment of eyes
  • Patient look forward and shine light 12” away
  • Reflection of light on corneas should be the same spot in each eye
51
Q

COVER/UNCOVER EYE ASSESSMENT

A
  • Assesses for weak muscles in eye
  • Straight ahead as one eye is covered
  • Uncovering the eye it should still be parallel to the other eye
52
Q

DIRECT AND CONSENSUAL EYE ASSESSMENT

A
  • Tests sensory paths controlled by cranial nerve III
  • Bright light to see pupil constriction (direct)
  • Shine light again on same eye and watch other eye (consensual)
53
Q

ACCOMMODATION EYE ASSESSMENT

A
  • Assessing muscles of the lens
  • Look at distant object (pupils dilate)
  • Shift gaze to your finger held 3 inches from their eyes (pupils constrict)
54
Q

PERRLA

A
  • Pupils Equal and Round, Reactive to Light and Accommodation
55
Q

RED REFLEX EYE ASSESSMENT

A
  • Test for reflection of light off the inner retina
  • Shine opthalamascope in eye and see red
  • If no red is seen, could mean retinal detachment

U of R SCHOOL OF NURSING (12 decks)

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