Module 10 Flashcards
Subjective Factors for the Head,Face,Neck Health history
Headaches
Jaw Pain
Neck Pain
Dental Pain
Mouth Lesions
Sore Throat
Hoarseness
Epistaxis
Past Medical History Considerations for Face, head, and Neck exams?
History of headaches, head injury, or seizures
allergies
tonsillitis
surgeries
medications
cancer: BCC, squamous cell, melanomas
Chronic illnesses
STDS: HSV and HIV
Family Health History Considerations for Head, Face, and Neck Exams
Malignancy
Blood Disorders
Recent Infections
History of HA (Migraines)
Musculoskeletal issues
thyroid problems
rhinitis in family
Social History/Habits/Lifestyle Considerations for Head, Face, Neck Exams
Alcohol Use
Smoking
drug use
their job (ex: Welders getting metal flecks in eyes)
environmental exposures
coping strategies
HEENOT
Head Ears Eyes Nose Oral Throat
Oral includes gums, teeth, mucosa, palette, etc
Epistaxis
significant nose bleeding
BCC
basal cell carcinoma
v common on face due to sun exposure
What is a very important thing to ask about for HEENOT?
Any traumatic brain injuries that occurred (loss of cons, injury to face/neck, change in behavior, cognitive issues, risk factors)
Important characteristics of headaches to ask about?
Onset
Duration
Location
Character
Severity
Visual Prodromal Events (distortion of size, shape, location)
Pattern of Headaches
Associated Symptoms
Precipitating Factors
Efforts to treat
*COLDSPA essentially
Sinus headache
pain in sinus regions
Cluster Headache
pain clusters in one region
ex: in right eye
Tension Headache
pain in the frontal area of the head
Migraine
headache pain and sensitivity to light in one half of the head (or whole)
Treatments for headaches
- Medication:
(ex: Anticonvulsants
Anti arrhythmic
beta blockers
calcium channel blockers
oral contraceptives
serotonin antagonists or agonists
uptake inhibitors
antidepressants
nonsteroidal anti inflammatory drugs
narcotics
caffeine containing drugs
nonprescription drugs) - Alternative or Complementary Therapy (relaxation, acupuncture, magnesium (v helpful Mg))
Techniques for HEENOT Physical Exam
Inspection –> Palpation
Examine Exterior then Interior
Important Landmarks of the Head to Know
Frontal
Parietal
temporal
Occipital
Zygomatic
Lacrimal
Sphenoid
Maxilla/Mandible
Head Exam in Infants
measured at each well child visit up to age 3
importantly checking for size (cephalic): micro, macro, normo
Palpation of the Scalp involves looking at…
Texture and Distribution of Hair (distribution, alopecia, facial [hirsutism], color, infestation,)
Tenderness
Alopecia
hair loss
Hirsutism
excessive hair growth that is male like in women
Physical examination of the face involves…
inspection general survey:
asymmetry v symmetry: dropping and drooling
facial expressions
palpation of temporal artery for tenderness and make sure to auscultate it
edema
color, condition, cyanosis, jaundice of skin
lesions
TMJ - open and close jaw (mandibular joint dysfunction)
When we auscultate the temporal artery we should use what side of the stethoscope?
the bell
Sinuses
Frontal (Forehead), maxillary (cheekbone), Sphenoid (behind eye), Ethmoid (near nose)
Tran illuminate –> Palpate –> Percuss
Pain elicited on palpation or percussion may mean infection or congestion
important nose considerations in HEENOT
size (widens with age ion men)
shape
symmetry
drainage
internal mucosae
color differences
intactness
perforations of septum
nasal polyps (can occlude airway)
A unilateral drainage from the nose may indicate…
CSF leak
What sounds do we want to hear from the nose?
Smoothness, not rumbling or congestion
Epistaxis
Hemorrhage from the nose
may be a serious problem leading to airway compromise or significant blood loss
Most common site of epistaxis? Most dangerous site of epistaxis?
Anterior; Posterior (as seen in the back of the throat, and harder to treat)
Treatments for Epistaxis
Topical Vasoconstrictors
Packing of Nasal Cavity or Balloon Catheter
Nursing Care for Patients w/ Epistaxis
Assess Bleeding
Monitor Airway and Breathing
Get Vital Signs
Reduce their anxiety
Teach patient on avoiding nasal trauma, nose picking, nose blowing, air humidification
Put pressure on nose to stop bleeding, and if it does not stop in 15 minutes then seek medical attn
Important emphasis in HEENOT is on the mouth, what things are important to look at here?
Color (lesions and odor)
Lips (ulcers, color, moisture)
Teeth (28 to 32 present, color, condition, number, dentures should be removed for viewing by going to the side and breaking suction)
gums (bleeding, hyperplasia with Dilantin and calcium channel blockers)
tongue (color, texture, moisture, mobility)
Palate (intact, color)
Buccal mucosa
Tonsils (color, size, exudate, cobble stoning)
Poor Dentition and Pain in the mouth may impact …
nutritional health and vice versa!!
Tonsil Scale
0, +1, +2, +3, +4
+4 = kissing tonsils
When doing oral examination, make sure to do what with the tongue?
move it side to side to check for lesions
Leukoplakia
condition in which one or more white patches or spots (lesions) form inside the mouth
can eventually become oral cancer
Anatomy Parts of the Neck
Sternocleidomastoid
Trapezius
Trachea
Thyroid Gland
Salivary Gland (parotid, submandibular, sublingual)
Cervical Lymph Nodes (check all of them)
What to inspect during neck exam?
Evaluate ROM
Evaluate Sternocleidomastoid, scalene, trapezius (accessory resp muscles)
Check movement
Check lymph nodes for size, shape, consistency, definition, mobility, and tenderness
Torticollis
problem involving muscles of the neck that cause the head to tilt down or in another condition
congenital often in infants
Where are the parotid, sublingual, and submandibular glands?
Back of throat region, under the tongue, lower and inner jaw
Important Lymph Node Locations to Know
Preauricular
Posterior Auricular
Occipital
Submandibular
Submental
tonsillar
Superficial Cervical/Deep Cervical
Posterior Cervical Chain
Supraclavicular
(look at HEENOT side 37)
Techniques for Thyroid Examination
Inspect –> palpate –> auscultate
important considerations during thyroid exam
Masses
Scars
Lesions
Trauma
Atrophy/Hypertrophy
Exophthalmos
Goiters
Exophthalmos
Bulging Eyes
What occurs / is inspected with hypothyroidism
SKIN AND HAIR CHANGES:
thinning hair
myxedema
fingernails are thick
skin is dry
constipation
menorrhagia
warmth
weight gain
What occurs / is inspected with hyperthyroidism
SKIN AND HAIR CHANGES:
Fine Hairs
Thin breakable fingernails
bulging eyes
goiter and neck pain
increased bowel activity
amenorrhea
increasing weakness/neuro
Anterior Palpation Approach of The Thyroid Exam
Pads of fingers on one hand finds gland –> find cartilage and cricoid cartilage then move inferiorly to isthmus –> work laterally into gutter between trachea and sternocleido to feel one thyroid lobe for masses –> have patient swallow and see if thyroid moves superiorly –> feel for masses during swallowing and repeat on other side
Posterior Palpation Approach of the Thyroid Exam
Similar except done from behind on patient
Auscultation of the neck Exam / Thyroid Exam
Use Diaphragm thyroid
Use bell on carotids
Look for bruits, especially if the gland is enlarged
Bruits
blockages in arteries that disrupt the smooth swirling noise of blood
Risk Factors for oropharyngeal cancer
tobacco and heavy alcohol use
smoking and drinking together
HPV
exposure to sunlight (lip cancer only)
being male (2x as common)
> 55 y/o
fair skin
poor oral hygiene
poor diet and nutrition (low fruit/vegi)
chewing betel quid or gutka (S and SE Asia)
weak immune system
graft v host disease
genetic syndromes
lichen planus
Betel Quid and Gutka
Betel nuts and lime wrapped in betel leaves - Betel Quid
mixture of betel quid and tobacco - Gutka
Categories of Larynx Cancer
Supraglottic
Glottic
Subglottic
Supraglottic cancer
false vocal cords above vocal cords larynx cancer
Glottic Cancer
true vocal cord cancer / larynx cancer
Subglottic Cancer
Below vocal cords cancer (larynx cancer type)
Symptoms of Larynx Cancer
Hoarseness
Persistent Cough
Sore Throat or Pain, Burning in Throat
Lump in Neck
Later Symptoms: Dysphagia, Dyspnea, Unilateral nasal Obstruction, Persistent Hoarsness, Persistent Ulceration, foul Breath
Generalize Symptoms: Weight loss, debilitation, lymphadenopathy, radiation of pain to ear
The nursing process is …
systematic
patient centered
cyclic
interrelated
outcome oriented
Nursing Long Term Goal End terminology
ONGOING
Nursing Intervention End terminology
done, not done, partially done
Nursing Short Term Goal End terminology
met, not met, partially met
Hydrocephalus
extra fluid around the head, but not the brain
PERRLA
pupils, equal, round, reactive to light, accommodation
Eye Orbit
cushion of fat surrounding the eyeballs
eyelids do what?
prevent foreign objects from getting in
squinting for limiting light
lubrication
Conjunctiva
thin transparent membrane on lower eyelid
Lacrimal Gland
lubricating ducts of the eyes
can get blocked and cause dryness or excess drainage
Canthus
divot of the eye near the nose containing the caruncle
Suspensory Ligaments
support lens position posterior to iris
Iris
circular disk of muscle determinin color and pupil size
Optic Disc
on retina
cream color
on retina near medial nasal side of eye where the optic nerve enters
usually round and oval in shape
Eye Chamber
Anterior - between cornea and iris
Posterior - between iris and lens
Vitreous - behind lens to the retina
fluid (aqueous or vitreous fill these chambers to provide cleanliness and nourishment and maintain ocular pressure)
What can a yellow sclera indicate?
relationship to the digestive system - liver issue
Edema or Dehydration of the body may be apparent in what eye area?
periorbital area around the eye
Above the neck is indicative of …
the whole body interacting with one another
Subjective Data to collect during eye exam?
Vision difficulties
Acuity changes
blurriness
floaters
blind spots
halos
pain
acute primary angle (closed) - glaucoma
headaches
redness and swelling
discharge from allergies
PMH of surgery, cataracts, diabetes, or retinal issues
Glaucoma (last testing and FMH)
Macular Degeneration (last test and FMH)
cataract present in FMH
use of glasses/contacts (last eye exam, effectiveness, problems, use with make up)
Occupation (work environment, school, nutrition, exercise)
Medications (eye gtts/ointments, systemic or topical digoxin)
Floaters
visual abnormality common in people 40+ that is not necessarily concerning
Night Blindness is associated with
vitamin a deficiency
Diplopia
double vision from trauma, injury, or pressure
It may be a medical emergency if found to have ___ ___ ___ ___ ___
Acute Primary Angle (Closed) Glaucoma
Headaches DO relate to ___
vision
Glaucoma
high pressure in the eye taht affects the optic nerve
acute angle glauc can cause nausea, blurriness, lights, headaches, erythema of the eye
should be screened for as you get older
risks: age, FMH, thin cornea history, sus optic nerve, cupping size appearance, nearsightedness, eye surgeries, high BP, diabetes, corticosteroid use, cream use
*look up angle closure glaucoma for more info
Macular Degeneration
starting to lose central vision with macular process tending to be blurred and distorted
start screening at 65+ and sooner if at risk (age, smoking, female, FMH, race (caucasian), prolonged sun exposure, high fat/chol, HTN, already in one eye)
Cataracts
often preventable
cloudiness of clear lense
opacity and vision decrease
screening should be done with risks: age 30+, newborns, alcohol use, diabetes, lots of UV exposure, previous eye trauma, corticosteroid use, smoking
The leading cause of blindness is due to …
cataracts
If it is not considered a medical need, what will not be covered by insurance?
Eye Exams
Eye Exam Tools
Snellen chart
Jaegar Card
Occluder
Penlight
Opthalmoscope
Important Cranial Nerves for the Eye
2 3 4 6
Objective Data from eye Exam
General Appearance of Eye and Structures
thin or seborrhea eyebrows
eyelids and lashes - entropion v ectropion
conjunctiva and sclera - should be white not jaundice yellow
Entropion
where the inner eyelids turn toward the eye
Ectropion
where the inner eyelids turn outward from the eye
not necessarily needs treatment unlike entropion
Lacrimal Apparatus and the Eye Exam
inspect it for redness, swelling and tenderness
structures for tear production and excretion
above eye laterally and medially along the nose
Cornea and the Eye Exam
anterior outer layer that covers the pupil and iris
shine a light from the side and check for smoothness clarity and breaking
Iris and Pupil & the Eye Exam
iris should be flat, round, and even in color
Pupil should be checked for size shape and equality
reaction to light can glean info on the neurological
Brushfield Spots
white specks found in the iris that is a sign of down syndrome
PERRLA
Pupils Equal Round Reactive Light Accommodation
A in PERRLA
Accommodation
look at the pupil and notice constriction and dilation
this means the eye accommodates for distance and near vision (by bringing the finger close) and seeing if the pupils constrict and then dilate as you move your finger to a thing in the distance
Conjuntivitis
Pink eye / eye inflammation / conjunctiva inflammation
Pupillary Light Reflex / Response
Darken the room and have the patient look straight ahead –> bring a light to the side –> look for direct and consensual response which is normally 3-5 mm
Direct Constriction Response
pupil response to light entering the same eye
Consensual constriction Response
pupil response to light entering the opposite eye
How to check accommodation and convergence
Have the patient look at a distant object, and you should see pupils dilate with distance (D - DISTANCE)
Have patient look at object 3 inches from eyes, and pupils should constrict with closeness (C - CLOSENESS)
Snellen Chart
stand 20 ft away
leave correcting lenses or contacts on
cover one eye
read smallest line of print
Normal Snellen
20/20
num - distance from chart
denom - distance normal eye could read chart
Jaegar Card
Near vision check
hold card 14 in away
test eyes individually with glasses
can check for myopia and hyperopia
normal value is 14/14 in each eye
could use magazine if no card
over 40 should have this checked for presbyopia
Confrontation test
measure of peripheral vision
practitioner visual field must be normal too!!!
advance from periphery with finger slight behind the patient
should see from normal angle values
document normal as “visual fields intact”
Normal Values from Confrontation Test
50 degree periphery upward
90 degree periphery temporal
70 degree periphery downward
60 degree periphery nasal
Extraocular Muscle Function: Testing Cranial Nerves
Tests Cranial Nerves 3 4 and 6 for ability to move eye
Corneal Light Reflection
an extraocular muscle function test
assesses alignment of eyes by having patient look straight ahead and viewing reflections of light on the corneas
a normal reflection should be symmetric in both eyes but abnormal indicates doing a cover/uncover test
Cover / Uncover Test
Extraocular Muscle Function Test
patient looks straight ahead at a distant object and one eye is covered –> when uncovering the covered eye should not move and should also be looking in the same direction as the other eye –> repeat on other side
Cardinal Position of Gaze
Extraocular Muscle function te4st
patient keeps head still and follows finger or penlight with their eyes ONLY in 6 positions (done in a “H” Shape
Normal results should have tracking with both eyes symmetrically but lateral gaze or nystagmus is abnormal findings
Nystagmus
shaking movement of the eyes during cardinal position of gaze
could be due to MS, inner ear issues, or opioid/narcotic use
Cardinal position of gaze positions
1 2
3 H 4
5 6
- Inferior Oblique
- Superior Rectus
- Medial Rectus
- Lateral Rectus
- Superior Oblique
- Inferior Rectus
Tool used to look at eye internal and external structures?
Opthalmoscope
Red Reflex
hold ophthalmoscope 10-15 in from eye while using your same corresponding eye
we want to see a reddish/orange glow from the light being reflected back off the retina to the device
Black Red Reflex
cataract
blood
scarring
etc
White Red Reflex
leukocoria
Yellow / Orange Red Reflex
normal red reflex
Leukocoria
a retinal blastoma which is a malignant tumor in childhood
found with white red reflex
Macula
should be round red spot with the fovea centralis darker in the middle seen during ophthalmoscopy exam
Physiologic Cup / Optic Disc in Ophthalmoscope Exam
yellow halo of light with arteries and veins leading in and out from it
Special Considerations for Eye Exams in Infants and Children
Malformation
Term infants have 20/200 acuity while school age kids should have 20/20
Peripheral vision develops at birth and central vision develops later
red reflex important to check here, especially for leukocoria
Special Considerations for Eye Exams in Older Adults
70 years of age should expect Presbyopia (farsightedness from loss of lens elasticity)
visual disturbances begin when driving, night vision, and ambulating
older adults have smaller pupils
know their last eye exam for cataracts and vision loss
eye discomfort like dryness or burning
arcus senilis
Arcus Senilis
arching white around the iris
does not mean much but does begin to occur with age
Important Principles to keep in mind with eye exams?
Use Adequate Light (those over 60 need 2x as much light to do eye tasks as the average 20 y/o)
Use color (avoid monochrome colors because older people have trouble discriminating borders)
Population other than Elderly and Children to keep in mind during eye exams?
Pregnant women
How to care for patient eyes
Clean from inner to outer canthus with a wet warm cloth/cotton ball/ compress
use artificial tear solution or normal saline every 4 hours if blink reflex is absent - if ordered by physician
care for their eyeglasses, contacts, or artificial eyes as they are expensive
How to instill eye drops
1 wash hands
2 glove up
3 offer tissues
4 clean eye, eyelids, and eyelashes
- tilt their head back
- hold the dropper close but DONT touch the eye
- let the drop(s) fall in as prescribed in the conjunctival sac
- press LIGHTLY on inner canthus to decrease systemic effect
How to apply eye ointmentys
- Perform 11 rights for med administration
- wash hands
- wear gloves
- clean eye, eye lids, eye lashes
- tilt head back
- apply pressure downward to expose lower eye
- apply prescribed amount along the conjunctival sac
- close eyes gently
You must wait how long between instilling 2 different types of eye drops?
at least 5 minutes
Main function of the ears is …
hearing and equilibrium
Cranial Nerve that is stimulated by sound waves moving through the ext, mid, and inner ear?
CN VIII (which then passes the info to the temporal lobe for interpretation)
Equilibrium is maintained through the ___ of the inner ear
vestibule (sensory receptors here, and semicircular canals maintain static and dynamic equilibrium inside it) of the bony labyrinth
External Ear Structures
Auricle
Helix
External Ear Canal (Meatus)
modified sweat glands producing cerumen
Middle Ear Structures
Tympanic Membrane
Tympanic Cavity (air filled)
Eustachian tube
Auditory Ossicles (malleus, incus, stapes)
Inner Ear Structures
bony labyrinth
cochlea
spiral organ of corti
semicircular canals
vestibule
Conductive Hearing
conduction of sound through the external and middle ear
Sensorineural Hearing
transmission of sound from the inner ear
Which part of the inner ear is the sensory organ for hearing?
Spiral Organ of Corti in the inner cochlear duct
Subjective Information to Gather on Ear Assessments
Hearing difficulties
any balance issues
otalgia
otorrhea
head trauma
recent health problems
noise pollution, work, home
tinnitus
medications
PMH (immunizations, chronic illness, surgeries, childhood illness, allergies)
FMH (genetic disorders, cultural differences)
Ear Care (q tip use, wax amount)
Otorrhea
ear drainage
Otalgia
earachews
Tinnitus
ringing in the ears
Prebycusis
age related change in being able to hear different tones
Gird and MI may have ..
ear referred pain
Signs of Hearing Loss
Repeating statements
Straining
leaning forward
tilting their head
shouting ion conversation
raising volume
avoiding large groups
social isolation
Important Considerations for the Ear Examination in Children and Infants
Ear Placement
Hearing Tests done prior to Discharge
Infections
Important Considerations for the Ear Examination in Young and Middle Adutls
excessive or chronic noise exposure
Important Considerations for the Ear Examination in Older Adults
common issues like presbycusis
stiffening of cilia (and getting wiry) causing cerumen to accumulate
Important Objective Data of Ear Examination
Patient should be in a sitting position:
Inspection –> Palpation of External ear
Inspect: Size, shape, position, condition of skin, color, drainage, impacted cerumen
Palpate: tenderness, ear structures (tragus, mastoid process, helix)
Unilateral Bloody and Watery Ear Drainage is ..
Cerebrospinalfluid !!!
Purulent Ear Drainage may indicate …
otitis media (middle ear infection)
Use of the Otoscope Principles
use shortest and largest speculum you can
tilt the head to the opp shoulder
hold patients head
hold the otoscope with the handle up
view the external ear canal and assess the Tympanic membrane
use a cerumen scoop to clear the canal
assess mobility of TM by using the bulb to release air, and a normal TM should flutter and then return to rest (non-movement means an issue like infection or fluid)
NEVER irrigate the ear canal unless ..
the TM is intact
Grey, Pearly, Translucent, Slight concave, Cone Shaped Reflection TM?
Normal TM
Red or Bulging TM
potentially otitis media
Yellow TM
could be cerumen behind the TM
Blue or Darkish TM
potentially from some trauma, like perforation or scarring, so check landmarks like the cone of light that should appear
Pulling on the Auricle of the Ear in Adults v Children
The positions of the canals are different so for adults pull UP AND BACK but children grip[ DOWN AND BACK
Important things to view in otoscopic exam?
External ear canal: color, drainage, lesions
TM: color, position of landmarks, intactness, grey color, slightly concave, cone of light, position of bony landmarks, mobility (flat, bulging, retracted)
Cone of light and positioning
reflection of the TM by the otoscope
Right ear should have it at 5 o clock, left ear should have it at 7 o clock
Conductive Loss
occurs when there is a PHYSICAL OBSTRUCTION to the transmission of sound waves like cerumen, tumors, or ossicles scar tissue buildup
Sensorineural Loss
due to a DEFECT IN THE ORGAN OF CORTI, CN VIII, or the brain due to infections, surgery, DM (from vascular loss), meds, trauma, or CN VIII damage
Most profound hearing loss comes from
Mixed Conductive and Sensorineural Hearing Loss
Whisper Test (Voice Test)
Stand 1-2 feet behind and whisper having them cover one ear, and they should repeat
do again on other side saying something different
Watch test
hold ticking watch within 5 inches
cover other ear
often noted in elders
Weber Test
place tuning fork on top of patients head
normal = tone heard midline without lateralization (heard equally and bilaterally)
Issue with weber Test
cannot distinguish conductive or sensorineural hearing loss, but they will report lateralization to the poor ear in conductive loss, and lateralization to good ear in sensorineural loss
Lateralization (best hearing) to the poor ear in conductive loss is due to bone conduction with no air conduction making the perception as louder in the affected ear
Lateralization (best hearing) in the intact ear is because air condition is impaired in the worst ear (sensorineural hearing loss) meaning that there is a softer/quieter perception
Rinne Test
place vibrating tuning fork on mastoid process (BC) and count
have patient signal when the sound stops and then move to the front of the ear (AC)
length of time should be Air Conduction > Bone Conduction (2:1 ratio)
With conductive hearing loss, what happens to the Rinne test ratio…
the bone conduction is heard longer or equal to air conduction
How does Air v Bone Conduction work in Rinne Test
Conduction through bone but lack of ability to hear when the fork is conducting only air means that some issue or trauma has occurred to the vibrating parts of the outer/middle ear
Conduction heard through the air but not the bone means that the middle and outer ear are still working, so it must be a sensorineural issue
Romberg’s Test
Balance Test relating to the ears
have patient stand with feet together with eyes closed, and stand nearby and note their ability to maintain balance
a positive Romberg is if they move their feet apart to prevent falling which may indicate vestibular disorder
Administering Ear Drops
- Perform 11 rights for med administration
- wash hands
- glove up
- position patient with the affected ear toward you and unaffected ear down
- clean any drainage
- again check 11 rights
- stabilize dropper hand to avoid ear canal damage
- straighten ear canal and instill drops (angle INTO the ear canal, not directly onto TM)
- have patient remain for 5-10 minutes to allow meds to go into the ear canal
Caring for Patient Ears
Wash external ear with washcloth covered finger
DONT use Q tips
Perform hearing aid teaching and care if indicated
*WATCH HEENOT VIDEOS AGAIN FOR REVIEW BEFORE THE NEXT EXAM
REMINDER
