This document provides instructions for performing a physical assessment of the head, eyes, ears, nose, and throat (HEENT). The assessment is meant to obtain baseline health data, identify any abnormalities, establish nursing diagnoses, and plan care. The assessment involves inspecting and palpating various areas of the head and eyes while observing for normal and abnormal findings. Key areas examined include the skull, facial features, eyes, pupils, extraocular muscles, ears, nose, and throat.
This document provides instructions for performing a physical assessment of the head, eyes, ears, nose, and throat (HEENT). The assessment is meant to obtain baseline health data, identify any abnormalities, establish nursing diagnoses, and plan care. The assessment involves inspecting and palpating various areas of the head and eyes while observing for normal and abnormal findings. Key areas examined include the skull, facial features, eyes, pupils, extraocular muscles, ears, nose, and throat.
This document provides instructions for performing a physical assessment of the head, eyes, ears, nose, and throat (HEENT). The assessment is meant to obtain baseline health data, identify any abnormalities, establish nursing diagnoses, and plan care. The assessment involves inspecting and palpating various areas of the head and eyes while observing for normal and abnormal findings. Key areas examined include the skull, facial features, eyes, pupils, extraocular muscles, ears, nose, and throat.
This document provides instructions for performing a physical assessment of the head, eyes, ears, nose, and throat (HEENT). The assessment is meant to obtain baseline health data, identify any abnormalities, establish nursing diagnoses, and plan care. The assessment involves inspecting and palpating various areas of the head and eyes while observing for normal and abnormal findings. Key areas examined include the skull, facial features, eyes, pupils, extraocular muscles, ears, nose, and throat.
Purpose: To obtain baseline data of the client’s functional abilities To assess the general health status of the client To obtain data that will enable the nurse to establish nursing diagnoses and plan client care
Equipments / Materials: Pen Light Cotton swabs Snellen Chart Watch w/ second hand Tuning Fork Examination Gloves
PROCEDURE NORMAL ABNORMAL ACTUAL
Assessment: 1. Identify the client. 2. Explain the procedure and discuss how she or he can cooperate. Planning: 3. Perform hand hygiene. 4. Provide privacy. 5. Position the client comfortably allowing for easy access to the body part being assessed. Implementation: HEAD Skull and Face 6. Inspect the skull for the size, Lack of symmetry; shape and symmetry. Rounded (norm cephalic) Increased skull size with and symmetric, with more prominent nose frontal, parietal, and and forehead; occipital prominences). Longer mandible (may Smooth skull contour. indicate excessive growth hormone or increased bone thickness). 7. Palpate for modules, masses Sebaceous cysts; and depressions. Absence of nodules or masses. Local deformities from trauma.
8. Inspect the facial features, Increased facial hair;
symmetry of facial Smooth, uniform Thinning of eyebrows; movements. (Ask the client to consistency; Asymmetric features; elevate the eyebrows, frown, Symmetric or slightly Drooping of lower eyelid or lower the eyebrows, close the eyes tightly, puff the asymmetric facial and mouth; Involuntary cheeks, and smile and show features. facial movements like the teeth.) tics or tremors. 9. Inspect the eyes for edema Exophthalmos, and hollowness. myxedema facies; moon Absence of edema. face , periorbital edema, enopthalmos (Sunken eye).
EYES Eyebrows 10. Inspect for the evenness of Hair evenly distributed; Loss of hair; scaling and hair distribution and skin intact; Eyebrows flakiness of skin; alignment / symmetry, skin symmetrically aligned; quality and movement. Unequal alignment and equal movement. movement of eyebrows;
Eye Lashes 11. Inspect for the evenness of Equally distributed; Turned inward. hair distribution and direction Curled slightly outward. of curl. Eye lids 12. Inspect for the surface Skin intact; no discharge; Redness, swelling, characteristics, position in no discoloration; Lids flaking, crusting, relation to the cornea, ability close symmetrically; plaques, discharge, to blink and frequency of Approximately 15-20 nodules, lesions; Lids blinking. involuntary blinks/ min.; close asymmetrically, bilateral blinking; incompletely, or painfully; When lids open, no visible sclera above Rapid, monocular, corneas, and upper and absent, or infrequent lower borders of cornea blinking; Ptosis, are slightly covered. ectropion, entropion; rim of sclera visible between lid and iris.
13. Inspect the bulbar conjunctiva Transparent; Capillaries Jaundice, Pallor,
(lying over the sclera) for sometimes evident; Erythema, and presence color, texture and presence of Sclera appears white of lesions or nodules. lesions. (yellowish in dark- skinned clients).
14. Inspect the palpebral Shiny, smooth and pink Extremely pale (possible conjunctiva (lining the eye or red. anemia); Extremely red lids) for color, texture and (inflammation); Nodules presence of lesions by or other lesions. everting the eyelids. 15. Evert the upper eyelids, if a problem is suspected. 16. Inspect and palpate the No edema or tenderness Swelling or tenderness lacrimal gland over lacrimal gland. over lacrimal glands. 17. Inspect and palpate lacrimal No edema or tearing. Evidenced of increased sac and nasolacrimal duct. tearing; Regurgitation of fluid on palpation of lacrimal sac. Cornea 18. Inspect the cornea for the Transparent, shiny and Opaque; surface not clarity and texture. smooth; details of the smooth (may be the iris are visible; result of trauma or abrasion); In older people, a thin, grayish white ring Arcus senilis in clients around the margin, under age 40 is called arcus senilis, abnormal. maybe evident.
19. Perform corneal sensitivity to Client blinks when the One or both eyelids fail test the function of the 5th cornea is touched, to respond. (Trigeminal) Cranial Nerve. indicating that the (Use a wisp cotton and brush trigeminal nerve is against the lower or lateral cornea to evaluate the intact. corneal reflex). 20. Inspect the anterior chamber No shadows of light on Cloudy; Crescent- for transparency and depth. iris; Depth of about shaped shadows on far 3mm. side of iris; Shallow chamber.
Pupils 21. Inspect pupils for the color, Black in color; Equal in Cloudiness, Mydriasis shape symmetry of size. size; 3-7 mm diameter; (dilation of the pupil), Round, smooth border, Myosis (constriction of iris flat and round. pupils) , Anisocoria; Bulging of iris toward cornea.
22. Assess each pupil for light Illuminated pupil Neither pupil constricts; reaction and accommodation. constricts (direct (Shine light into pupil for 1 Unequal responses; response). Non- second with opposite eye illuminated pupil Absent responses. covered. Observe for pupil restriction and dilation. constricts (consensual Repeated on opposite.) response).
Sclera 23. Inspect for the color and White, without Discoloration; yellow clarity exudates, lesions, or (jaundice) or blue foreign bodies. (osteogenesis imperfecta). Iris 24. Inspect for the color and Entire iris is illuminated. Narrow angle of anterior shape chamber. Extraocular Muscles 25. Assess six ocular movements to Both eyes coordinated, Eye movements not determine alignment and move in unison, with coordinated or parallel; coordination. (Hold a pen at a distance from the parallel alignment. One or both eyes fail to client and ask to keep head still and follow a penlight in follow the pen with the eyes only. specific directions, such Move the pen towards the right and left eye, then towards the ceiling and as strabismus (cross-eye floor. Repeat on the other side.) or squint. 26. Perform eye cover test. Uncovered eye does not Uncovered eye move to (Repeat previous procedure but move from fixed point focus on fixed point, with one eye covered. Repeat on when the other eye is indicating it is not well the other side.) aligned before other was covered. covered; it is shifting from Newly uncovered eye, if lateral to central gaze. well aligned, does not Newly uncovered eye move when index card is moves to focus on fixed removed. point, indicating it was not well aligned when covered.
Visual Acuity 27. Test for near vision. Able to read newsprint Difficult reading (Ask client to read newsprint.) at a distance of 36 cm newsprint unless due to (14 in). aging process.
28. Test for distant vision. 20/20 vision on Snellen Denominator of 40 or
(Position the patient 20 feet in chart. Client can read the more on Snellen chart front of the Snellen eye chart.) letters/objects in 20 ft with corrective lenses. which a normal sighted The higher the deno- person can read at 20 ft. minator, the poorer the vision.
Visual Fields 29. Assess Peripheral visual fields. When looking straight Visual fields smaller than ahead, client can see normal (possible objects in the periphery. glaucoma);
One half visions in one
or both eyes (indicates nerve damage).
EARS Auricles 30. Inspect for color, symmetry of Color same as facial skin;Bluish color of earlobes size and position. (eg. Cyanosis); Pallor (eg. Symmetric position. Line Frostbite); Excessive drawn from lateral angle redness (inflammation of the eye to point or fever) ; where top part of auricle joins head is horizontal. Low-set ears associated with congenital anomaly, such as Down syndrome).
31. Palpate for the texture, Mobile, firm, and not Lesions (eg. Cyst); Flaky, elasticity and areas of tender; scaly skin; tenderness. (Pull the auricle upward and Pinna recoils after it is Tenderness when moved backward (>3 y.o.); downward folded. or pressed (may indicate and backward (<3 y.o.). inflammation or Pull the pinna forward (it should infection of external be recoil. Push in on the tragus ear). and apply pressure to mastois process). Ear Canal
32. Inspect cerumen, skin lesions, Distal third contains hair Redness and discharge; pus and blood. (Use a follicles and glands; Dry Scaling; Excessive penlight.) cerumen, grayish-tan cerumen obstructing color; or sticky, wet canal. cerumen in various shades of brown.
Hearing Acuity Tests
33. Assess client’s response to Normal voice tones Normal voice tones not normal voice tones audible. audible (eg. Requests nurse to repeat words or statement, leans toward the speaker, turn the head, cups the ears, or speaks in loud tone of voice).
34. Assess client’s response to Able to repeat Unable to repeat 50% of
whispered voice. nonconsecutive numbers whispered. (Stand 30 to 60 cm (1-2 ft) from numbers. the client in a position where the client cannot read your lips. Ask the client to occlude one ear by putting a finger in it.) 35. Perform the watch tick Able to hear ticking in Unable to hear ticking in test. both ears. one or both ears. (Place ticking watch 2 to 3 cm (1- 2 in) from the unoccluded ear.)
36. Perform the Weber’s Test to Sound is heard in both Sound is heard well in assess bone conduction by ears or is localized at the impaired ear, indicating placing the activated tuning center of the head a bone-conductive fork on the client’s skull. (Weber negative). hearing loss (eg. Due to obstruction), or sound is heard well in ear without a problem, indicating a sensorineural disturbance.
37. Perform the Rinne’s Test to Air-conducted (AC) Bone conduction time is compare air conduction to hearing is greater than equal to or longer than bone conduction by placing bone-conducted (BC) the air conduction time, the ringing tuning fork at the hearing, that is, AC>BC that is, BC>AC or BC=AC mastoid process until no sound is heard and then place (positive Rinne). (negative Rinne; the prongs of the tuning fork indicates a conductive in front of the client’s ear hearing loss). canal. NOSE External Nose 38. Inspect external nose for any Symmetric and straight; Asymmetric; Discharge deviations in shape, size or from nares; Localized color and flaring or discharge No discharge or flaring; areas of redness or from the nares. Uniform color. presence of skin lesions.
39. Inspect the nasal cavities for Mucosa pink ; Clear, Mucosa red, edematous; redness, swelling, growths watery discharge; No Abnormal discharge (eg. and discharge using penlight. lesions. Purulent); Presence of lesions (eg. Polyps).
40. Inspect the nasal septum Nasal septum intact and Septum deviated. between the nasal chambers in midline. noting its position.
41. Test patency of both nasal The examiner can hear The examiner can not cavities. (Assess the patency or feel air passing out of hear or feel air passing of the nares by asking the the unobstructed naris. out of the unobstructed person to occlude one ala nasi naris. while breathing through the other. 42. Palpate for any tenderness, No tenderness. Tenderness on masses and displacements of palpation. bone and cartilage. No lesions. (Palpate up on the frontal sinuses Presence of lesion. from under the bony brows, avoiding pressure on the eyes. Press upon the maxillary sinuses.) Sinuses 43. Locate / palpate / identify Not tender. Tenderness in one or sinuses and note for any more sinuses. tenderness. Evaluation: 44. Evaluate if findings from the To provide proper physical assessment is within nursing care. normal limits. Documentation: 45. Document and report To obtain baseline data. significant findings.
