ENT Assessment Flashcards
General Approach
1. Greet the patient and explain the __________ that you will be using.
- Use a ______ room that will be free from interruptions.
- Ensure that the light in the room provides sufficient brightness to allow _____________ of the patient.
- Place the patient in an ___________ on the examination table. For clients who cannot tolerate the sitting position, gain access to the patient’s head so that it can be rotated from side to side for assessment.
- Visualize the __________ during the assessment process to allow adequate description of findings.
- Always compare _______________________
- Use a ____________ that is followed consistently each time the assessment is performed
(1) assessment techniques
(2) quiet
(3) adequate observation
(4) upright sitting position
(5) underlying structures
(6) right and left ears, sides of the nose, sinuses, mouth and throat.
(7) systematic approach
Physical assessment of the ear consists of
three parts:
1. _______________
2. _______________
3. _______________
(1) Auditory screening (CNVIII)
(2) Inspection and palpation of the external ear
(3) Otoscopic assessment
Equipment Needed for Eye Assessment
∙ Watch with a second hand for Romberg test
∙ Tuning fork
∙ Otoscope
EXTERNAL EAR STRUCTURES
Inspect the ________, _________, and _________. Note size, shape and position
auricle / tragus / lobule
External Ear Normal Findings:
• Ears are equal in size (1) ________ (4-10cm)
• (2) _________ aligns with the corner of the eye and within a 10-degree angle of the vertical position
• (3) _________ may be free, attached or soldered (tightly attached to adjacent skin with no apparent lobe)
• No (4) ________
• (5) ___________ is clinically insignificant
(1) bilaterally
(2) Auricle
(3) Earlobes
(4) lesions
(5) Darwin’s tubercle
ABNormal Findings:
• (1) ____________
• (2) ____________
• (3) ____________
• (4) ____________
(1) Tophi
(2) Frostbite
(3) Postauricular Cyst
(4) Malaligned or low-set ears
May be seen with genitourinary disorders or chromosomal defects.
Malaligned or low-set ears
EXTERNAL EAR STRUCTURES
- Palpate the _______ and ________.
auricle / mastoid process
EXTERNAL EAR STRUCTURES
Normal Findings:
• The auricle, tragus and mastoid process are _________.
not tender
EXTERNAL EAR STRUCTURES
ABNormal Findings:
▪ A painful auricle and tragus is associated with (1) ________ or a ________.
▪ Tenderness over the mastoid process suggests (2) __________.
▪ Tenderness behind the ear may occur with (3) __________.
(1) otitis externa / postauricular cyst
(2) mastoiditis
(3) otitis media
INTERNAL EAR STRUCTURES
∙ Inspect the __________. (use the otoscope)
external auditory canal
INTERNAL EAR STRUCTURES
o Normal Findings:
▪ A small amount of odourless (1) _________ is the only discharge normally present.
▪(2) ________ may be yellow, orange, red, brown, gray or black and soft, moist, dry, flaky or even hard.
(1) cerumen (ear wax)
(2) Cerumen
INTERNAL EAR STRUCTURES
o Abnormal Findings:
▪ Reddened, swollen canal – (1) ________
▪ (2) _______ (non-malignant nodular swellings)
▪ (3) _______
(1) otitis externa
(2) Exostoses
(3) Polyps
Perform Voice-Whisper Test
1. Instruct the patient to _____________.
2. Stand _______ behind the patient’s other ear and whisper a _________ word or phrase that is evenly accented.
3. Ask the patient to _______ the word or phrase.
4. Repeat the test with the other ear.
(1) occlude one ear with finger
(2) 2 feet / two-syllable
(3) repeat
Perform Voice-Whisper Test
o Normal Findings:
▪ The patient should be able to __________
repeat the words whispered from a distance of 2 feet.
Performed if the client reports diminished or lost hearing in one ear
Weber’s Test
Weber’s Test
1. Hold the handle of the tuning fork and strike the tines on the ________ to activate it.
2. Place the stem of the fork firmly against the _________.
3. Ask the patient if the sound is heard ________.
(1) ulnar border of the palm
(2) middle of the patient’s forehead, on top of the head at the midline.
(3) centrally or toward one side
Weber’s Test
o Normal Findings:
▪ Vibrations are heard (1) ________.
▪ No (2) ________ of sound to either ear.
(1) equally well in both ears
(2) lateralization
Weber’s Test
o ABNormal Findings:
▪ (1) ________ Hearing Loss
▪ (2) ________ Hearing Loss
(1) Conduction
(2) Sensoryneural
Rinne Test
1. Stand behind or to the side of the patient and strike the ________.
2. Place the stem of the tuning fork against the patient’s right mastoid process to test ________.
3. Instruct the patient to indicate if ________.
4. Ask the patient to tell you when the sound _______.
5. When the patient says that the sound stopped, move the tuning fork, with the tines facing forward, in front of the __________, and ask the patient if the sound is still heard. Note the length of time the patient hears the sound (___________)
6. Repeat the test on the left ear.
(1) tuning fork
(2) bone conduction
(3) sound is heard
(4) stops
(5) right auditory meatus / testing air conduction
Rinne Test
o Normal Findings:
▪ Air conduction sound is ________ than the bone conduction
normally longer
Rinne Test
o Abnormal Findings:
▪ (1) ________ (BC≥AC)
▪ (2) ________ (AC≥BC)
(1) Conductive
(2) Sensorineural
SCHWABACH TEST
1. Stand behind or to the side of the patient and strike the ________.
2. Place an activated tuning fork at the _____________ of the client. Instruct the patient to indicate if the sound is heard.
3. Ask the patient to tell you when the sound ______.
4. When the client no longer hears the sound, place the tuning fork on __________ and determine if you can still hear the sound.
5. Repeat the test on the left ear.
(1) turning fork
(2) tip of the mastoid process
(3) stops
(4) your mastoid process
Schwabach Test
o Normal Findings: ___________
The nurse and the patient cannot hear the tuning fork at the same time
Equal Schwabach
Schwabach Test
o Abnormal Findings:
▪ (1) _________ – Patient still hears tuning fork after the examiner have already stopped hearing it.
▪ (2) _________ – The examiner still hear the tuning fork after patient has already stopped hearing it.
▪ (3) _________ – are judged on the assumption that the examiner have normal hearing
(1) Prolonged Schwabach
(2) Shortened Schwabach
(3) Abnormal Schwabachs
• Tests the client’s equilibrium
• Ask the client to stand with feet together and arm at sides and eyes open and then with the eyes closed.
• This assessment is primarily done in Neurologic Assessment
Romberg Test
Romberg Test
Normal Findings:
▪ Client maintains position for _________ without swaying or with minimal swaying.
20 seconds
∙ Readiness for enhanced communication related to use of hearing aid.
Wellness Diagnoses
∙ Risk for injury related to hearing impairment
Risk Diagnoses
∙ Disturbed sensory perception: Auditory related to conductive or sensorineural
hearing loss.
Actual Diagnoses
ASSESSMENT OF THE MOUTH, NOSE, THROAT AND SINUSES
Equipment:
∙ __________
∙ __________
∙ __________
∙ __________
∙ __________
∙ __________
∙ Gloves
∙ 4x4 inch gauze
∙ Penlight
∙ Short, wide tipped speculum attached to the head of an otoscope
∙ Tongue depressor
∙ Nasal speculum
Inspection and Palpation:
∙ Inspect the lips. Observe _______ and ________
lip consistency / color
Inspection and Palpation of Lips:
Normal Findings
— Lips are ________
smooth and moist without lesions
