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NURS 2910 > HEENT Assessment > Flashcards

HEENT Assessment Flashcards

1
Q

What is HEENT

A

Head, Ears, Eyes, Nose, Throat

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2
Q

Subjective data for HEENT assessment

A
  • Present history
  • Past history
  • family history
  • lifestyle
  • health practices
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3
Q

Objective data for HEENT assessment

A
  • Inspect
  • Palpate
  • Auscultate
  • Percussion
  • mainly INSPECT AND PALPATE
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4
Q

Skull is made up of

A

two subsections
- cranium and facial bones

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5
Q

Cranium

A
  • houses and protects the brain and major sensory organs
  • consist of 8 BONES
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6
Q

Facial bones

A
  • Gives shape to the face
  • All immovable except the mandible
  • Consists of 14 BONES
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7
Q

Subjective data questions HEAD AND FACE

A
  • Do you have a history of headaches?
  • Have you ever had head injuries or loss of consciousness?
  • Do you have any jaw or facial pain?
  • Have you ever had a seizure?
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8
Q

Normal findings: HEAD

A
  • Skull rounded and symmetrical
  • Size of head is typical for family, proportional for body size, and age
  • Head is erect and midline
  • non-tender, smooth/normal contours, no lesions, scalp mobility
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9
Q

Abnormal findings: HEAD

A
  • Larger or smaller than expected size
  • Asymmetry of skull, not rounded
  • Masses, tenderness, abnormal contour/bumps
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10
Q

Normal Findings: FACE

A
  • symmetrical appearance and smooth movement of facial features
  • facial expression is appropriate for the situation
  • no visible lesions and normal hair distribution
  • non-tender
  • normal muscle tone
  • normal TMJ function
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11
Q

Abnormal Findings: FACE

A
  • Asymmetry of the face
  • lesions, lumps, abnormal hair distribution
  • the irregular or uneven movement of the jaw or popping/cracking
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12
Q

Pediatric variations: HEAD AND FACE

A
  • newborn head is misshapen
  • anterior fontanel> 9-18 mo
  • posterior fontanel> birth- 2mo
  • look for abnormal fontanel
  • cradle cap is common
  • potential flat spot on head
  • observe face when crying
  • hold head up> around 4mo
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13
Q

Subjective data questions: EYES

A
  • Have you noticed any changes in eyesight?
  • Do you wear glasses or contacts?
  • Have you ever had an eye injury?
  • Have you ever had eye surgery?
  • When was your last eye exam?
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14
Q

Eyelids

A

two movable structures made up of skin and muscle

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15
Q

Eyelashes

A

filter dust and dirt

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16
Q

Conjunctivia

A

the mucous membrane that covers eyelids, is peach and moist

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17
Q

Sclera

A

White outer coating of the eye

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18
Q

Iris

A

eye color

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19
Q

PERRLA

A

pupils equal, round and reactive to light, and accomodation

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20
Q

Extraocular muscles

A

the six muscles attached to the outer surface of the eyeball

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21
Q

rectus muscles

A

superior, inferior, lateral and medial

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22
Q

oblique muscles

A

superior and inferior

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23
Q

How many rectus muscles and oblique muscles control six different directions

A
  • 4 RECTUS
  • 2 OBLIQUE
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24
Q

Snellen Chart

A
  • based on age and literacy level
  • top number is distance in feet from chart
  • bottom number is distance at which a person with normal eyesight can read the same line
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25
Q

Expected/ normal findings: EYES

A

20/20 vision, 6-7 years or older

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26
Q

Abnormal: EYES

A

Small fraction: diminished distant vision, near sited
Larger fraction: diminished near vision, far sited

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27
Q

Visual acuity

A

Eye’s ability to detect the details of an image

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28
Q

What cranial nerves allow to tract movement

A

CN III, IV, VI

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29
Q

Peripheral vision

A

boundaries of the eye when the eye is in a fixed position

30
Q

Expected/abnormal: Peripheral vision

A

expected: no deficits
abnormal: strabismus, amblyopia> loss of peripheral vision

31
Q

Extraocular Movements(EOMs)

A
  • inspect for parallel alignment
  • 6 cardinal fields of gaze
  • test corneal lights reflex
32
Q

Inspect/ palpate: EYES

A
  • inspect general appearance, eyelids, eyelashes, conjunctiva, sclera, lacrimal ducts and glands, iris and pupils
  • palpate external structures
  • test distance, near, and color vision, peripheral vision, EOMs, and PERRLA
33
Q

Pediatric considerations: EYES

A
  • newborn: 20/100 or 20/400
  • not able to distinguish color well and other details
  • 3 mo: eyes should be aligned and movement coordinated
  • 5 yrs: 20/40 or 20/30
  • 7 yrs: 20/20
  • strabismus is normal until about 4-6 mo
34
Q

Older adult considerations: EYES

A
  • eyeball appearance can appear sunken in
  • lens of eyes begin to lose ability to accommodate to near objects
  • color vision declines
  • PERRLA reaction becomes slower
  • iris pigmentation causes iris to look brownish and pale
  • lower lid sags
  • conjunctiva may be pale or slight yellowish
35
Q

Accommodation

A

the eyes ability to focus on something as it comes closer to the eye

36
Q

Middle Ear

A
  • conducts sound waves to the inner ear
  • compromised of tympanic membrane, eustachin tube, and auditory osicles
36
Q

External Ear

A
  • collects and conveys sound waves to middle ear
  • protects middle ear
  • physically can see
37
Q

Inner ear

A
  • responsible for hearing and equilibrium
  • bony labyrinth> cochlea, vestibule, semicircular canals
38
Q

Subjective data questions: EARS

A
  • Do you have any hearing problems?
  • Have you had any changes in your hearing?
  • Do you have any ear damage?
  • Do you have any ear pain?
  • Do you have any balance problems?
  • Have you ever had ringing in your ear?
39
Q

Inspect/palpate: EARS

A
  • symmetry in size, note the appearance of piercings
  • pinna level with corner of eye
  • color and condition of the skin
  • drainage, lesions, tenderness
  • palpate external ear> condition of skin/color
  • tympanic membrane> grey/ pearly/ shiny
40
Q

Weber test: EAR

A
  • ALWAYS start with
  • hearing wand top of patients head
  • sound is the same in both ears(negative)
  • sound is louder in one ear(negative)
  • if test is positive move to rinne test
41
Q

Rinne Test: EAR

A
  • ONLY perform when weber test is positive
  • this test compares AC and BC, normal= AC 2x as long as BC
42
Q

Gross hearing (whispering test) assess

A
  • assess low tone hearing
43
Q

Romberg test assesses

A

BALANCE

44
Q

Pediatrics consideration: EAR

A
  • 20 week gestation fetus can hear
  • infants are more prone to ear infections
  • tubes are shorter, wider, horizontal
  • infant/toddler> gently pull down
  • older child> gently tug up
45
Q

Older Adult consideration: EAR

A
  • presbycusis
  • earwax increases
  • longer earlobes
  • coarse hair and dry skin
46
Q

Cerumen

A

Ear wax

47
Q

Subjective data questions: NOSE

A
  • Do you have nasal congestion?
  • Do you have history of sinus problem?
  • Do you have seasonal allergies?
  • Do you experience nose bleeds?
  • Have you ever broken your nose?
48
Q

The nose and sinuses are responsible for…..

A

smell

49
Q

vaporized molecules trigger what CN?

A

CN I

50
Q

Sinuses

A
  • Air filled cavities to decrease weight of the skull
  • 4 sinuses( frontal, ethmoid, sphnoid, maxillary)
  • lined with ciliated mucous membrane
  • Act as resonance chambers during speech
51
Q

inspect/palpate: NOSE

A
  • inspect external position, size, and shape
  • observe and palpate for discharge
  • inspect internal structures with otoscope or light
  • palpate external structures, frontal and maxillary sinuses
52
Q

Pediatric consideration: NOSE

A
  • infants 3-6 mo are nose breathers
53
Q

Older adult consideration: NOSE

A
  • the sense of smell diminishes
54
Q

Subjective data questions: THROAT/MOUTH/NECK

A
  • Do you have any problems with your teeth?
  • When was your last dental exam?
  • How often do you brush your teeth?
  • Do you have any sores or irritation in your mouth?
  • Do you smoke or chew tobacco?
55
Q

The neck is composed of…

A
  • muscles, ligaments, and cervical vertebrae
  • jugular veins are carotid artery
  • thyroid gland
  • CN XI
  • cervical vertebrae
56
Q

Lymph nodes size and shape may vary T or F

A

TRUE

57
Q

Lymph nodes in the neck are usually palpable T or F

A

FALSE

58
Q

Inspect/ palpate: NECK

A
  • check symmetry, ROM, and condition
  • condition of skin and cervical vertebrae
  • Is the neck erect and midline
  • look for lesions, lumps, bumps
    -check lymph nodes, trachea, and thyroid gland
59
Q

Palpating lymph nodes

A
  • note size, tenderness, consistency, mobility, and temperature
60
Q

Palpating the thyroid

A
  • stand behind, having client flex neck forward and to the left
  • thumbs at nape of neck
  • palpate cricoid cartilage below thyroid cartilage
  • push trachea slightly to left with right hand as palpate below cricoid
    -TYPICALLY NOT PALPABLE
61
Q

What color should nasal mucosa be?

A

PINK

62
Q

What color is the tympanic membrane

A

GREY & PEARLY

63
Q

When do babies typically begin to get their deciduous teeth

A

6 months

64
Q

Deciduous teeth are

A

baby teeth

65
Q

Subjective data questions: NECK

A
  • Any neck pain or stiffness?
  • Any neck masses or lumps?
  • Is there any history of thyroid disorders?
  • Do you have difficulty swallowing?
66
Q

Throat structure and function

A
  • behind mouth and nose
  • passageway for food and air
  • below the nasopharynx is the oropharynx
  • tonsil
67
Q

Mouth structure and function

A
  • structure includes lips, tongue, teeth, gums, uvula, hard and soft palate, salivary glands, and ducts
  • beginning of the digestive tract
  • airway for the respiratory tract
68
Q

inspect/palpate: MOUTH

A
  • inspect mouth externally> lip placement, color, condition
    -oral mucosa and gums> color, condition
  • buccal mucosa> color, condition
  • inspect teeth and tongue
  • inspect oropharynx> say ahh
  • palpate lower lip> note tenderness, lesions, mobility
  • palpate inside of cheek, tongue, and floor of mouth
69
Q

Mouth tests

A
  • test gag reflex, touch back of soft palate of tongue with depressor
70
Q

pediatric considerations: MOUTH

A
  • primary nose breathers
  • tonsils typically larger
  • deciduous teeth at about 6 months
  • permanent teeth about 6 years
71
Q

older adult considerations: MOUTH

A

NURS 2910 (16 decks)

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