Comprehensive Head and Neck Assessment, Lecture notes of Health sciences

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GENERAL APPROACH

1. Greet the patient and explain the assessment techniques that you will be using.
2. Use a quiet room that will be free from interruptions.
3. Ensure that the light in the room provides sufficient brightness to allow adequate observation of the patient.
4. Place the patient in an upright sitting position 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.
5. Visualize the underlying structures during the assessment process to allow adequate description of findings.
6. Always compare right and left ears, sides of the nose, sinuses, mouth and throat.
7. Use a systematic approach that is followed consistently each time the assessment is performed ASSESSMENT OF THE EARS Physical assessment of the ear consists of three parts:
8. Auditory Screening (CNVIII: Auditory Nerve)
9. Inspection and palpation of the external ear
10. Otoscopic assessment Equipment Needed:  Watch with second hand for Romberg test  Tuning fork  Otoscope EXTERNAL EAR STRUCTURES Inspect the auricle, tragus and lobule. Note size, shape and position Normal Findings:  Ears are equal in size bilaterally (4-10cm)  (^) Auricle aligns with the corner of the eye and within a 10-degree angle of the vertical position  Earlobes may be free, attached or soldered (tightly attached to adjacent skin with no apparent lobe)  No lesions  Darwin’s tubercle is clinically insignificant Abnormal Findings:  (^) Tophi  Frostbite  Postauricular Cyst  (^) Malaligned or low-set ears may be seen with genitourinary disorders or chromosomal defects. Palpate the auricle and mastoid process Normal Findings:  The auricle, tragus and mastoid process are not tender. Abnormal Findings:  A painful auricle and tragus is associated with otitis externa or a postauricular cyst.  Tenderness over the mastoid process suggests mastoiditis.  Tenderness behind the ear may occur with otitis media. INTERNAL EAR STRUCTURES Inspect the external auditory canal (use the otoscope) Normal Findings:  (^) A small amount of odourless cerumen (ear wax) is the only discharge normally present.  Cerumen may be yellow, orange, red, brown, gray or black and soft, moist, dry, flaky or even hard. Abnormal Findings:  Foul smelling, sticky, yellow discharge – otitis externa or impacted foreign body.  Bloodym purulent discharge – otitis media with ruptured tymphanic membrane.  Blood or watery drainage – skull trauma

Observe the color and consistency of the ear canal walls and inspect the character of any nodules Normal Findings:  The canal walls should be pink and smooth and without nodules Abnormal Findings:  Reddened, swollen canal – otitis externa  Exostoses (non-malignant nodular swellings)  Polyps Inspect the tympanic membrane (eardrum). note the color, shape, consistency, and landmarks Normal Findings:  The tympanic membrane should appear pearly, gray, shiny, translucent with no bulging or retraction.  Slightly concave , smooth and intact Abnormal Findings:  Acute otitis media – red bulging eardrum and distorted, diminished or absent light reflex.  (^) Serous otitis media – yellowish, bulging membrane with bubbles behind  Bluish or dark re color-blood behind the eardrum from skull trauma.  White spots – scarring from infections  Perforated Tympanic Membrane HEARING AND EQUILIBRIUM TESTS Voice-Whisper Test

1. Instruct the patient to occlude one ear with finger.
2. Stand 2 feet behind the patient’s other ear and whisper a two-syllable word or phrase that is evenly accented.
3. Ask the patient to repeat the word or phrase.
4. Repeat the test with the other ear. Normal Findings:  The patient should be able to repeat the words whispered from a distance of 2 feet. Weber’s Test Perform if the client reports diminished or lost hearing in one ear
5. Hold the handle of the tuning fork and strike the tines on the ulnar border of the palm to activate it.
6. Place the stem of the fork firmly against the middle of the patient’s forehead, on top of the head at the midline.
7. Ask the patient if the sound is heard centrally or toward one side. Normal Findings:  Vibrations are heard equally well in both ears.  No lateralization of sound to either ear. Abnormal Findings:  Conduction Hearing Loss  Sensoryneural Hearing Loss Rinne Test
   1. Stand behind or to the side of the patient and strike the turning fork.
   2. Place the stem of the tuning fork against the patient’s right mastoid process to test bone conduction.
   3. Instruct the patient to indicate if sound is heard.
   4. Ask the patient to tell you when the sound stops.
   5. When the patient says that the sound stopped, move the tuning fork, with the tines facing forward, in front of the right auditory meatus, and ask the patient if the sound is still heard. Note the length of time the patient hears the sound (testing air conduction)
   6. Repeat the test on the left ear. Normal Findings:  Air conduction sound is normally longer than the bone conduction (AC>BC) Abnormal Findings:  Conductive (BC≥AC)  Sensorineural (AC≥BC) Romberg Test  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. Normal Findings:  (^) Client maintains position for 20 seconds without swaying or with minimal swaying. APPROPRIATE NURSING DIAGNOSES Wellness Diagnoses  Readiness for enhanced communication related to use of hearing aid. Risk Diagnoses  Risk for injury related to hearing impairment

Actual Diagnoses  Disturbed sensory perception: Auditory related to conductive or sensorineural hearing loss. Sample Objective Data:  Equal in size bilaterally  Auricles aligned with the corner of each eye within a 10-degree angle of vertical position  Skin smooth, no lumps, lesions, nodules  No discharge  Non-tender on palpation  Small amount of moist yellow cerumen in external canal.  Tympanic membrane pearly gray, shiny transparent, no bulging. ASSESSMENT OF THE MOUTH AND THROAT 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 lip consistency and color Normal Findings:  Lips are smooth and moist without lesions or swelling Abnormal Findings:  circumoral pallor  (^) cyanosis  redness  edema Inspect teeth and gums. Ask the client to open mouth. Note the number, color, condition, and alignment of the teeth Normal Findings:  32 teeth with smooth surfaces and edges, 28 if 4 molars are not yet erupted Put on gloves and retract the client’s lips and cheeks to check gums for color and consistency Normal Findings:  Gums are pink, moist and firm with tight margins to the tooth. No lesions or masses. Inspect the buccal mucosa Normal Findings:  Tissue is smooth and moist, without lesion. Inspect and palpate the tongue Normal Findings:  Tongue is pink, moist, moderate size with papillae present Assess the ventral surface of the tongue Normal Findings:  Smooth, shiny, pink or slightly pale with visible veins and no lesions. Inspect for Wharton’s ducts - openings from the submandibular salivary glands located on either side of the frenulum on the floor of the mouth Normal Findings:  Frenulum is midline  Wharton’s ducts are visible  (^) No swelling, redness or pain Observe the sides of the tongue Normal Findings:  No lesions, ulcers, or nodules Check the strength of the tongue Normal Findings:  With strong resistance Check the anterior tongue tongue’s ability to taste Normal Findings:  Can distinguish between sweet and salty Inspect the hard and soft palates and uvula Normal Findings:  Hard palate is pale and whitish with firm transverse rugae Abnormal Findings:  Carcinoma of the tongue  Leukoplakia  Hairy leukoplakia  Candida albicans infection  Smooth, reddish, shiny tongue without papillae due to vitamin B12 deficiency Note odor Normal Findings:  No unsusual or foul odor

Assess the uvula Normal Findings:  The uvula is fleshy, solid structure that hangs freely in the midline.  No redness, exudates.  Midline elevation of the uvula and symmetric elevation of the soft palate. Inspect the Tonsils Normal Findings:  May be present or absent  Pink and symmetric, no exudates, swelling or lesions Inspect the posterior pharyngeal wall Normal Findings:  Throat is normally pink without exudates or lesions. ASSESSMENT OF THE NOSE INSPECTION AND PALPATION Inspect and palpate the external nose. Note nasal color, shape, consistency and tenderness. Normal Findings:  Color is the same as the rest of the face.  Smooth and symmetric  No tenderness Check patency of air flow through nostrils. Normal Findings:  Able to sniff through each nostril while other is occluded Inspect the internal nose Normal Findings:  Nasal mucosa is dark pink, moist and free of exudates.  (^) Nasal septum intact, free of ulcers or perforations Abnormal Findings:  Nasal Polyps  Perforated nasal septum ASSESSMENT OF THE SINUSES PALPATION Palpate the sinuses Normal Findings:  Frontal and maxillary sinuses are non-tender to palpation and no crepitus is evident. Percuss the Sinuses Normal Findings:  Not tender Transilluminate the sinuses Normal Findings:  A red glow transilluminates the frontal sinuses, indicating normal air-filled sinus.  A red glow transilluminates the frontal sinuses, indicating normal air-filled sinus. SAMPLE DOCUMENTATION OF OBJECTIVE DATA  Lips pink, smooth and moist without lesions  Buccal mucosa, pink, moist and without exudates.  Parotid ducts visible with no redness or swelling  (^) Moist bubbles are seen near ducts  32 white to yellowish teeth present  Gums pink without redness or swelling frenulum in the midline with visible veins present  Midline and symmetric elevation of the uvula and soft palate with phonation.  Nose somewhat large but smooth and symmetric ASSESSMENT OF THE MOUTH, NOSE, THROAT, AND SINUSES Appropriate Nursing Diagnoses Wellness Diagnoses  Readiness of enhanced effective managemtn of the teeth and gums Risk Diagnoses  Risk for aspiration related to decreased or absent gag reflex Actual Diagnoses  Ineffective health maintenance related to poor oral hygiene