HEENT assessment

Question 1

Preparation

Answer 1

• Gather equipment- pen light, alcohol pads, tongue depressors, gauze, otoscope, ophthalmoscope
• wash hands
• Introduction
• Gloves
• Privacy
• Explain procedure

Question 2

Head

Answer 2

• Subjective info: headaches, dizziness, head injuries/surgeries, jaw pain
• Notes shape and symmetry of head
• Hair texture and distribution
• Palpates scalp for tenderness or lesions
• Palpates TMJ- asking pt to open and close mouth

Question 3

Lymph nodes

Answer 3

• Palpates auricular (front and back of the ear)
• Occipital (base of the skull posteriorly)
• Submandibular and submental (jaw line under jaw)
• Cervical (along the neck-side and back)
• Supraclavicular and infraclavicular

Question 4

Face

Answer 4

• Symmetry and facial movement (ask pt to raise eyebrows and smile)
• Notes tics and involuntary movements

Question 5

Eyes

Answer 5

• Subjective data- Vision difficulties/diagnoses, eye pain, hx of injuries/infections, use of glasses or contacts
• Notes symmetry of eyes/irises/pupils
• Notes eyebrows and eyelashes are full
• Assesses the sclera and conductive for redness, pallor, jaundice
• Notes any swelling, discharge, excessive tearing, or dryness
• Notes the cornea is clear (no clouding)
• Corneal reflex test (shine light on bridge of nose-note if reflection is symmetric on both eyes)
• Check pupillary reaction to light, accommodation, PERRLA, CN-III
• Checks Extra ocular muscle integrity (uses 6 cardinal positions, notes presence or absence of nystagmus
• Cover/uncover test (watch for drift)
• Uses opthalmoscope appropriately, able to see red reflex, identify optic disc and describe blood vessels
• Use large Snellen chart appropriately

Question 6

Ears

Answer 6

• Subjective data: hearing loss/diagnosis, ear aches, hx of injuries/infections, use of aides
• Inspects and palpates pinna, notes symmetry, deformities, tenderness, discharge
• Otoscope, identifies and describes the tympanic membranes
• Performs Whisper voice test

Question 7

Nose

Answer 7

• Subjective data: Alterations in smell, pain, discharge, hx of trauma/nosebleeds
• Inspects for deviation, swelling, drainage
• Palpates nose for tenderness
• Palpates sinuses for tenderness (above eyes and under cheekbones)
• Checks for congestion (breathe through nostril one at a time)
• Otoscope- inspect nares, describes septum, tubinates, mucosa

Question 8

Mouth/Throat

Answer 8

• Subjective data: Mouth sores/lesions, dentures, sore throat/trouble swallowing, injuries/surgeries to mouth/throat area
• Inspects lips, teeth, and buccal mucosa (gums and inside cheeks) using penlight and tongue depressor
• Inspects tongue upper and dorsal surfaces and both sides using gauze
• Identifies hard and soft palate, pillars
• Inspects tonsils and grades
• Note uvula position/movement
• Notes presence of swelling/redness/drainage
• Checks gag reflex

Question 9

Neck/Thyroid

Answer 9

• Subjective data: Neck pain, thyroid issues, weight changes, fatigue, hair loss, issues with temp, mood swings
• Identifies thyroid location
• Palpate thyroid posteriorly

Question 10

Closing

Answer 10

• Make pt safe and comfortable (lower bed, side rails)
• Offer to answer questions
• Wash hands