2/10/2020

Primary function is to
protect the brain.

Head and Neck

Assessment
Erlyn Laurence T. Cajes, RN,MAN, USRN

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Framework for the face and

Head and Neck provide attachment for
Assessment muscles that move the head
Includes: and control facial
- Skull and Face expressions and chewing.
- Ears, Eyes, Nose, Sinuses
- Mouth, Throat, Neck

2 5

Review of Anatomy Review of Anatomy

and Physiology and Physiology
Head Neck
- Composed of 2 major groups of - Composed of:
bones • Hyoid bone
- Cranium (8 bones) joined by 4 • Several major blood vessels
sutures
• Larynx
- Facial Bones (14 bones)
• Trachea
• Thyroid gland

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Review of Anatomy Headache

and Physiology • one of the most common
Neck symptoms in clinical
- Composed of: practice
• Muscles • three most important
• Cervical Vertebrae attributes of headache:
• Blood Vessels • severity, chronologic pattern,
and its associated symptoms
• Midline Structures
• Thyroid Gland • Generally classified as:
• Primary
• Secondary
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Review of Anatomy Headache

and Physiology • one of the most common
Lymph Nodes symptoms in clinical
- Preauricular - Submental practice
- Postauricular - Superficial cervical • three most important
attributes of headache:
- Tonsillar - Posterior cervical
• severity, chronologic pattern,
- Occipital - Deep cervical and its associated symptoms
- Submandibular - Supraclavicular • Generally classified as:
• Primary
• Secondary
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Common Concerns on Headache: Collecting Subjective Data

Head and Neck • Elicit a full description of every headache
• Headache / Migraine
and its seven attributes
• Is it unilateral or bilateral?
• Head Injury • Severe with sudden onset, like a
• Neck Injury
thunderclap?
• Steady or throbbing? Continuous or
• Muscle Pain intermittent?
• Swollen lymph nodes or • Is there an aura?
neck lumps • Look for important signs (“red flags”) that
• Enlarged thyroid gland warn of headaches needing prompt
investigation.
• Hoarseness
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Traumatic
Brain
Injury
(TBI)

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Traumatic Brain Injury

Common Concerns on Neck
• blow to the head or a piercing head injury that
interferes with the function of the brain • Muscle Pain
• Can be mild or severe • Swollen lymph nodes or
neck lumps
• Enlarged thyroid gland
• Hoarseness

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Traumatic Brain Injury Swollen Lymph Nodes

• Mild injury • Indicates an ongoing inflammatory response
• a brief change in mental status or consciousness
• Severe Injury
• an extended period of unconsciousness or amnesia
after the injury

Leading causes of TBI:

• Falls (35.2%)
• Motor vehicle or traffic accidents (17.3%)
• Being struck by or against solid surfaces (16.5%)
• Assaults (10%)
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Findings: Normal
Thyroid Enlargement
• Inspection
• Suggestive of goiter • Rounded (normocephalic and symmetric, with frontal, parietal, and
occipital prominences) Head size and shape vary, especially in accord
with ethnicity and body size.
• No facial edema, lesions, and involuntary movements
• Neck is symmetric, with head centered and without bulging masses.
• The thyroid cartilage, cricoid cartilage move upward symmetrically as the
client swallows.
• C7 (vertebrae prominens) is usually visible and palpable.
• Normally neck movement should be smooth and controlled with 45-
degree flexion, 55-degree extension, 40-degree lateral abduction, and
70-degree rotation.
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Collecting Objective Data Findings: Normal

• Prepare the Client: • Palpation
• Identify and verify the client • The head is normally hard and smooth, without lesions.
• Instruct the client to remove wigs, hat, hair • The temporal artery is elastic and not tender.
ornaments, pins, rubber bands, jewelry, and head or • Normally there is no swelling, tenderness, or crepitation with
neck scarves.
movement. Mouth opens and closes fully (3 to 6 cm between upper
• Prepare the Environment and Equipment and lower teeth). Lower jaw moves laterally 1 to 2 cm in each
• Ensure client’s privacy direction.
• Organize equipment: • Trachea and thyroid landmarks are positioned midline.
• Gloves • Thyroid gland is usually not palpable.
• Examination Gown (as needed)
• Glandular thyroid tissue may be felt rising underneath your fingers.
• Small cup with water (optional)
Lobes should feel smooth, rubbery, and free of nodules.
• Position the Client
• Sitting Position 20 23

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Physical Assessment Techniques Findings: Normal

• Inspection • Auscultation
• Skull size and shape • No bruits are auscultated.
• Symmetry of skull, facial features and facial movements
• Eyes (for edema and hollowness)
• Neck features and movement
Bruit
- also called vascular murmur
• Palpation
- the abnormal sound generated by turbulent flow of
• Skull consistency
• Temporal Artery, Temporomandibular Joint
blood in an artery due to either an area of partial
• Trachea, Thyroid obstruction or a localized high rate of blood flow
• Neck Lymph Nodes through an unobstructed artery.
• Auscultation
• Thyroid 21 24

21 24

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Findings: Abnormal (Facial Swelling) Findings: Abnormal

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25 28

Findings: Abnormal (Facial Swelling) Findings: Abnormal

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Anatomy of the
Eye:
External Eye
Structures

Findings: Abnormal

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Anatomy of the Eye:

Vision
Internal Eye
Structures • Visual Fields
• refers to what a person
sees with one eye.
• The visual field of each
eye can be divided into
four quadrants:
• upper temporal
• lower temporal
• upper nasal
• lower nasal

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Eye Muscles Vision

• Visual Perception
• Intrinsic Eye Muscles  Extrinsic Eye Muscles • occurs as light rays strike
• Ciliary Muscle  Inferior Oblique the retina, where they are
• Innervated by CN III
 Inferior Rectus transformed into nerve
• Constricts ciliary body, relaxes tension
on lens for eye accommodation  Superior Rectus impulses, conducted to
the brain through the
• Sphincter Pupillae  Medial Rectus
optic nerve, and
• Innervated by CN III  Lateral Rectus interpreted.
• Constricts pupil
 Superior Oblique
• Dilator Pupillae
• Innervated by sympathetic nerves
• Dilates Pupils
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Vision

• Visual Acuity
• The degree of
detail the eye can
discern in an
image

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Visual Reflexes Common eye concerns

• Accommodation • Hyperopia
• the ability of the eye to change its focus from distant to near • Farsightedness
objects (and vice versa). This process is achieved by the lens
changing its shape.
• Myopia
• nearsightedness
• Convergence
• Presbyopia
• the simultaneous inward movement of both eyes toward
each other, usually in an effort to maintain single binocular • loss of elasticity of the lens and thus loss of ability to see close objects
vision when viewing an object. • Often associated with aging
• Astigmatism
• uneven curvature of the cornea that prevents horizontal and vertical
rays from focusing on the retina 40
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Visual Reflexes Common eye concerns

• Pupillary Reflexes • Strabismus (Tropia)
• Constriction of pupils following exposure • Cross-eye
to light • Malalignment of one or
both eyes
• Direct - constriction occurs in the eye
• Can be detected by:
exposed to the light • Cardinal Fields of Gaze
• Consensual - constriction occurs in the Test
opposite eye as the other eye is exposed • Hirschberg Test
to the light • Cover Test

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Common Eye Concerns Common eye concerns

• Changes in vision:
• Hyperopia • Visual Disturbances • Scotoma
• Presbyopia • Scotomas • An area of partial
• Double vision or diplopia alteration in the field of
• Myopia vision consisting of
• Astigmatism • Macular Degeneration partially diminished or
• Strabismus • Glaucoma entirely degenerated
• Cataracts visual acuity that is
• Conjunctivitis
• Photophobia surrounded by a normal
• Lesions field of vision
• Hordeolum (Sty)
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Common eye concerns Common eye concerns

• Diplopia
• Double vision • Cataracts
• Simultaneous perception of • clouding of the usually clear
two images of a single object lens of the eye, causing a
that may be displaced person to see as though
horizontally, vertically or looking through a frosty or
diagonally or rotationally in foggy window
relation to each other
• Can be
• Monocular
• Binocular
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Common eye concerns Common eye concerns

• Photophobia
• Macular Degeneration • not a morbid fear or phobia,
• Deterioration of the macula but an experience of
caused by deterioration of the discomfort or pain to the eyes
retina and can severely impair due to light exposure or by
vision presence of actual physical
• Often age-related sensitivity of the eyes
• No cure

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Collecting
Common eye concerns Subjective Data
• The nurse should begin
• Glaucoma
the inquiry about the
• group of eye conditions that
damage the optic nerve caused
eyes with a broad, open-
by increased intraocular ended question such as:
pressure (IOP) • “Have you noticed any
• Can be changes with your eyes?”
• Dry (close-angle) • “Is your vision as good
• Wet (open-angle) now as previously?”

45
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Collecting Objective Data Physical Assessment Techniques

• Prepare the Client:
• Identify and verify the client • Evaluate:
• Explain the procedure to the client • Visual Fields
• Prepare the Environment and Equipment • Confrontation Visual Field Test
• Ensure client’s privacy • Amsler Grid
• Organize equipment: • Perimetry (Static automated, Kinetic, Frequency doubling)
• Gloves (if lesions and discharges are noted) • Extraocular Muscle Strength and Eye Movement
Penlight
• Cardinal Fields of Gaze Test (or Extraocular Muscle
•
• Millimeter Ruler
• Snellen Chart Test/Positions Test)
• Opaque Card • Corneal Light Reflex Test (or Hirschberg Test)
• Ophthalmoscope • Cover Test (or Cover-Uncover Test)
• Position the Client
• Sitting Position
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Physical Assessment Techniques

Ophthalmoscope • Evaluate:
• Aka Funduscope • Visual Acuity
• An instrument that allows a • Near Visual acuity: use Rosenbaum pocket chart or
health professional to see the Jaeger eye chart
internal structures of the eye • Distant Visual acuity: use Snellen chart or E-chart
• Test is called as
• Color Vision
Opthalmoscopy or
Funduscopy • Ishihara Color Test
• Snellen Chart

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Physical Assessment Techniques

• Inspection
• Eyebrows and eyelashes (hair characteristics, symmetry)
• Eyelids (skin characteristics, ability to blink, ability to close and
open completely, presence of lesions)
• Bulbar and palpebral conjunctiva, sclera (color, discharge, lesions)
• Cornea (clarity, sensitivity, arcus)
• Pupils (size, shape, response to light and accommodation)
• Palpation
• Eyelids (nodules and other lesions)
• Lacrimal glands (swelling and discharge)
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Findings: Abnormal
• Inspection (Eyelids)
• Incomplete closure or opening of eyelids
• Redness, swelling, flaking, crusting, plaques, discharge,
nodules, lesions
• Ptosis
• Blepharospasm
• Ectropion
• Entropion

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Physical Assessment Techniques Findings: Abnormal

• Opthalmoscopic Examination: • Inspection (Bulbar and Palpebral
Conjunctiva and sclera)
• Retinal color and lesions
• Jaundiced sclera
• Characteristics of blood
• Excessively pale sclera
vessels
• Reddened sclera
• Disc characteristics
• Lesions or nodules
• Macula characteristics
• Conjunctivitis
• Depth of anterior chamber
• Pterygium: pinkish, triangular
tissue growth on the cornea of the
• Done using the eye
opthalmoscope or
• Pinguecula: benign growth in the
funduscope 56 conjunctiva 59

56 59

Findings: Abnormal Findings: Abnormal

• Inspection (Eyelashes and Eyebrows) • Inspection (Cornea) • Palpation (Eyelids)
• Asymmetry • Cataracts • Hordeolum (Sty)
• Unequal hair distribution • Keratoconus • Palpation (Lacrimal glands)
• Loss of hair, change in eyelash and eyebrow color • Arcus Juvenilis • Dacryocytitis
• Unequal alignment and movement of eyebrows • Inspection (Pupils)
• Trichiasis: inward growth of eyelashes • Miosis
• Mydriasis
• Anisocoria

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Other Concerns on Eyes

Ears
• Phoria Organ for
• misalignment of the eyes hearing and
that only appears when balance
binocular viewing is
broken and the two eyes Innervated by
are no longer looking at CN VIII
the same object
• Often appears when the
person is tired
• Detected by: Cover Test
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Other Concerns on Eyes Hearing

• Nystagmus • Hearing, or auditory

• Rapid involuntary perception, is the ability to
movement of the eyes perceive sounds by detecting
which can suggest vibrations, changes in the
neurologic problem pressure of the surrounding
• Detected by: Extraocular medium through time,
muscle test through an organ such as the
ear.

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Other Concerns on Eyes Balance

• Macropthalmia: big eyes (size of eyeballs)
• Micropthalmia: small eyes (size of eyeballs)
• Proptosis/Exopthalmus: bulging of one or both eyes • The sense of balance or
• Anopthalmia: No eyes equilibrioception is one of
• Amblyopia (Lazy Eye): partial or complete loss of vision due to conditions the physiological senses that
affecting normal eye development helps prevent humans and
• Anopia/Anopsia: defect or loss of vision in a particular area of visual field animals from falling over
• Nyctalopia: night blindness when standing or moving.
• Opthalmalgia: eye pain
• Epiphora: watery eyes
• Keratoconjunctivitis sicca: dry eyes
• Xeropthalmia: dry eyes with inflammation associated with Vitamin A deficiency
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Ear Anatomy Pathway of Hearing

2 phases:
• Conductive 7
Phase 5

• Sensorineural 2
4
6

Phase
3
1

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Sound Waves and Hearing

• Frequency
• the number of sound waves per second, determines the pitch of the
sound
• Measurec in Hertz (Hz)
• Normal: 250 through 8000 Hz
• Intensity
• Loudness of a sound, determined by the size of the sound waves
• Measured in decibels (dB)
• Normal: 0 – 130 dB
• Conversation : around 60 dB
68 • Generally considered loud: 80 dB and above 71

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Common Concerns on Ears

• Hearing Loss
• Tinnitus
• Ear ache
• Ear discharges
• Dizziness, Vertigo

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Conductive Hearing Loss

• Signs and Symptoms:
• Diminished ability to • Easier time hearing out of one
perceive sounds ear than the other
• Can be: • Pain in one or both ears
• Sensation of pressure in one or
• Conductive both ears
• Sensorineural • Difficulty or frustration with
• Mixed hearing loss telephone conversations
• A foul odor coming from the ear
Hearing Loss canal
• A feeling that one's own voice
sounds louder or different 76

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Sensorineural Hearing Mixed Hearing Loss

Loss
• Most common type of hearing loss
• result of damage to the inner ear, the auditory
nerve, or the hearing center in the brain
• Permanent, may be gradual or sudden
• Signs and symptoms:
• Speech of others may seem slurred or mumbled,
or, a feeling of you can hear but not understand
• Difficulty hearing women's or children's voices
and other high-pitched sounds
• Certain speech sounds are difficult to hear
during conversations (e.g. the "s" or "th" sound)
• Most common: Presbycusis
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• combination of conductive and sensorineural hearing loss.
• There may be a problem in the outer or middle ear and in the inner ear or
auditory nerve.
• It can happen after a head injury, long-term infection, or because of a
disorder that runs in the family.
Hyperacusis
• rare hearing disorder that causes sounds which would otherwise seem
normal to most people to sound unbearably loud.
• People who suffer from hyperacusis may even find normal environmental
sounds to be too loud.
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Conductive Hearing Loss Common ear concerns

• result of interrupted transmission of sound • Tinnitus
waves through the outer and middle ear • subjective perception of a high-pitched ringing or buzzing sound in one
structures or both ears. It occurs in certain disorders of the ear.
• Possible causes: • Ear ache (otalgia)
• Stenosis of ear canal • a common symptom of ear disorders, particularly ear infections
• Wax impaction or Foreign body
obstruction • Ear discharge (otorrhea)
• Otitis Externa • Drainage from the ear is abnormal. Purulent drainage indicates
• Microtia infection; drainage that is clear or contains cerebral spinal fluid or blood
• Ruptured tympanic membrane indicates trauma.
• Tympanosclerosis • Ear infection
• Otosclerosis • Otitis Externa
• Ossicular chain discontinuity
• tumors 75
• Otitis Media 78

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Collecting Objective Data

• Prepare the Client:
• Identify and verify the client
• Explain the procedure t the client

Dizziness • Prepare the Environment and Equipment

• Ensure client’s privacy
• Organize equipment:
• Gloves (if lesions and discharges are noted)
• nonspecific term used by patients encompassing several • Watch with a second hand for Romberg test
disorders that clinicians must carefully sort out. • Tuning fork (512 or 1024 Hz)
• Otoscope
• A detailed history usually identifies the primary etiology • Position the Client
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• Sitting Position
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• Vertigo—a feeling of spinning or whirling

when you are not actually moving; some
causes include peripheral vestibular
dysfunction, cerebral brainstem lesion,
atherosclerosis
• Presyncope—a near faint from “feeling faint

Otoscope
or lightheaded”; causes include orthostatic
hypotension, especially from medication,
arrhythmias, and vasovagal attacks (∼5%)
• Disequilibrium—unsteadiness or imbalance flashlight-type viewer
when walking due to spatial disorientation, used to visualize the
especially in older patients, causes include eardrum and external
fear of walking, visual loss, weakness from ear canal.
musculoskeletal problems, and peripheral
neuropathy (up to 15%) 80
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Collecting
Subjective Data
• Be especially alert for signs
that suggest problems with
the ear. Ask yourself these
questions:
• Is the person guarding her
or his ear? If the patient is
a child, is she or he
tugging or rubbing the
ear?
• Is the patient attentive and
responding appropriately?
• Is the patient speaking
loudly? 81 84

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Physical Assessment Techniques

• Inspection
• External Ear (Color, shape, size, symmetry, position,
discharges)
• Tympanic Membrane (color, gloss, movement)
• Palpation
• External Ear (Elasticity, tenderness, lesions)
1 2 3 4

• Hearing Acuity Tests

• Whisper test
• Tuning Fork Tests
• Weber’s Test
• Rinne Test 85 88

85 88

Findings: Abnormal
• Inspection (External Ears)
• Creased ear lobe: Associated with
heart conditions.
• Ear pits or sinuses usually located
anterior to the tragus: Associated
with internal ear anomalies.
• Low-set ears or ears rotated
posteriorly, > 15 degrees:
Associated with mental
retardation.
• Tophi
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86 89

Findings: Abnormal Findings: Abnormal

• Inspection (External Ears) • Inspection (External ear canal)
• Microtia: Small ears, <4 cm vertical height in adults. Seen in • Obstructed ear canal: may be due to impacted cerumen or
some genetic disorders. foreign object.
• Macrotia: Large ears: >10 cm vertical height in adults. • Otitis externa: redenned ear canal with exudate and may be
• Anotia: no ear edematous
• Exotosis: abnormal bone growth (Surfer’s ear)

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Findings: Abnormal
• Inspection (Tympanic Membrane)
• Acute Otitis media: Red, bulging eardrum and distorted,
• diminished, or absent light reflex
• Serous otitis media: Yellowish, bulging membrane with bubbles
• Hemotympanum: Bluish or dark red color due blood behind
the eardrum from skull trauma
• Tympanosclerosis: White spots—scarring from infection
• Perforations—trauma from infection

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Findings: Abnormal
• Palpation (External Ear)
• Tenderness
• Lesion

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Findings: Abnormal
Assessing the Ears: Internal Structures
• Hearing Tests
Procedure • Whisper Test
• Perform pneumatic • Test for high-frequency hearing
• Using an otoscope with bulb
otoscopy insufflators, observe the position • Failed to repeat 3 words out of 6
of the tympanic membrane when • Inability to perceive high frequency sounds
Rationale the bulb is inflated and again • Weber’s Test
 Evaluate the mobility of when the air is released • Test for lateralization
the tympanic • Sound is heard better in impaired ear (conductive hearing Loss)
membrane
• Sound is heard better in ear without a problem = Weber Positive
(possibly sensorineural hearing loss)
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Findings: Abnormal
Diagnostics tests for ears
• Hearing Tests
• Rinne Test • Electronystagmography
• Bone conduction time is equal to or longer than the air • diagnostic test to record
conduction time, i.e., BC > AC or BC = AC (negative Rinne = involuntary movements of
conductive hearing loss) the eye caused by a
condition known as
nystagmus. It can also be
• Tuning fork tests do not provide the examiner with an exact used to diagnose the cause
percentage of hearing loss. Therefore, the client should be of vertigo, dizziness or
referred to a hearing specialist for more accurate testing if a balance dysfunction by
testing the vestibular
problem is suspected. system
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Findings: Abnormal
• Test of Balance NOSE
• Romberg’s Test
• Positive Romberg: cannot maintain foot stance; moves the feet • The body's primary
apart to maintain stance organ of smell and also
If client cannot maintain balance with the eyes shut, client may functions as part of
have sensory ataxia (lack of coordination of the voluntary the body's respiratory
muscles)
If balance cannot be maintained whether the eyes are open or
system
shut, client may have cerebellar ataxia • Innervated by CN I –
Olfactory Nerve
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Diagnostics tests for ears

• Audiometric Screening
 Sense of smell
• determine a subject's hearing
levels with the help of an  Occurs in response to
audiometer, but may also air borne molecules
measure ability to discriminate called odorants
between different sound
intensities, recognize pitch, or  Olfactory neurons –
distinguish speech from sensory neuron for
background noise smelling located in the
99
olfactory epithelium

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Anatomy Of The Nose Paranasal Sinuses

Frontal Sinuses

Ethmoid Sinuses
Sphenoid Sinuses

Maxillary Sinuses

elc| elc|
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Anatomy Of The Nose Common Concerns on

Nose and Sinuses
• Rhinorrhea
• Nasal Congestion /
Obstruction
• Epistaxis
• Sinusitis
• Pain

elc|
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104 107

Paranasal Common concerns on Nose and Sinuses:

Sinuses • Rhinorrhea
• “runny nose”
• a group of four paired air- • a condition where the nasal cavity is filled with a significant amount
filled spaces that surround of mucus fluid
the nasal cavity • common symptom of allergies (hay fever) or certain viral infections,
such as the common cold
• They function to reduce the
weight of the skull, to • Coryza
produce mucus, and to • common colds
influence voice quality by • acute inflammation of the mucous membrane of the nasal cavities
acting as resonating • Epistaxis
chambers. • nosebleed
• acute hemorrhage from the nostril, nasal cavity, or nasopharynx 108
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Common concerns on Nose and Sinuses: Physical Assessment Techniques

• Sinusitis • Inspection
• inflammation or swelling of the tissue lining the sinuses • External Nose (shape, size, color, and patency of nares.)
• most important clinical signs for sinusitis in adults include a • Nasal mucosa and nasal septum (color, alignment, discharge,
maxillary toothache, purulent nasal secretion, poor response swelling and perforation)
to decongestants, abnormal transillumination, and patient
report of colored nasal secretions. • Palpation
• External Nose (Tenderness, displacement of cartilage and
• Rhinitis bone, and masses)
• common colds, coryza
• Frontal and maxillary sinuses (swelling and tenderness)
• acute inflammation of the mucous membrane of the nasal
cavities • Percussion
• Rhinosinusitis • Frontal and maxillary sinuses (tenderness)
• inflammation of the sinuses and nasal cavity 109
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109 112

Collecting Subjective Data Physical Assessment Techniques

The purpose of the nursing health history of the nose and sinus is to detect
changes in the patient’s breathing, sense of smell, nose, and sinuses. • Transillumination
The opening questions are: • a technique of sample
illumination by transmission
• “How is your breathing?” of light through the organ or
• “Have you noticed any changes with your nose or sinuses? body cavity
• Uses a transilluminator or
penlight
• may be performed if sinus
tenderness is present or
infection is suspected

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Collecting Objective Data

• Prepare the Client:
• Identify and verify the client
• Explain the procedure to the client
• Prepare the Environment and Equipment
• Ensure client’s privacy
• Organize equipment:
• Gloves (if lesions and discharges are noted)
• Nasal speculum
• Otoscope
• Penlight
• Position the Client
• Sitting Position
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PERFORMING SINUS Transillumination: Findings

TRANSILLUMINATION • Bilateral findings may vary because the frontal sinuses
develop differently.
• To transilluminate the maxillary
sinuses: • The sinuses may show differing degrees of illumination,
• Darken the room and place opaque (no transillumination), dull (reduced
the light source lateral to the transillumination), or a glow (expected transillumination).
nose, just beneath the medial • An opaque response may indicate that either the sinus is
aspect of the eye. filled with secretions or it never developed.
• Look through the patient’s • Asymmetry of transillumination is a significant finding.
open mouth for illumination
of the hard palate.
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115 118

Performing Sinus FINDINGS: ABNORMAL

Transillumination
To transilluminate the
frontal sinuses:
• Darken the room and
place the light source
against the medial
aspect of each
supraorbital rim
• Look for a dim red glow
just above the eyebrow.
• Inspection (External Nose)
• Saddle Nose: characterized
by a loss of height of the
nose, because of the
collapse of the bridge
• associated with nasal
trauma, congenital syphilis,
relapsing polychondritis,
granulomatosis with
polyangiitis, cocaine abuse,
and leprosy, among other
conditions

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116 119

Findings: Abnormal
• Inspection (External Nose)
• Hump Nose: also referred to as a
nose bump or dorsal hump,
describes a raised hump on the
bridge of the nose.
• Nose humps can be small “bumps”
that rise and fall, or larger humps
that encompass most of the bridge.
• Nose humps can be composed of
cartilage, bone, or combination of
the two.
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117 120

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Findings: Abnormal Findings: Abnormal

• Inspection (External Nose) • Inspection (nasal mucosa and
• Crooked Nose: nose that septum)
doesn't follow a straight, • Septal deviation: condition in
vertical line down the which the nasal septum is
center of your face. significantly off center, or crooked,
• The degree of making breathing difficult
crookedness may be very • May result to a s-,c- or i- shaped
subtle or more dramatic, crooked nose
depending on the cause.
• may be C-, I-, or S-shaped

121 124

121 124

Findings: Abnormal Findings: Abnormal

• Inspection (External Nose)
• Arhinia: no nose
• congenital nasal atresia
• congenital partial or complete
absence of the nose at birth. It
is an extremely rare condition,
with few reported cases in the
history of modern medicine
• Treatment: Surgery
• Inspection (nasal mucosa and
septum)
• Septal perforation: a medical
condition in which the nasal
septum, the bony/cartilaginous
wall dividing the nasal cavities,
develops a hole or fissure

122 125

122 125

Findings: Abnormal Findings: Abnormal

• Inspection (nasal mucosa and • Palpation (External Nose)
septum) • Nasal tenderness on palpation accompanies a local
• Nasal Polyps: soft, painless, infection.
noncancerous growths on the lining • Air movement is restricted in one or both nares
of the nasal passages or sinuses.
• They hang down like teardrops or
• Palpation (Sinuses)
grapes. • Sinusitis
• They result from chronic inflammation • Tenderness upon
and are associated with asthma, palpation
recurring infection, allergies, drug
sensitivity or certain immune
disorders 123 126

123 126

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Review of Anatomy

127 130

127 130

Findings: Abnormal
• Percussion (Sinuses)
• Sinusitis Mouth
• Tenderness upon
percussion – Oral cavity the houses:
• Crepitus: crackling
- Lips
sound
• suggestive of - Teeth - Cuts food into pieces
subcutaneous orbital – Cheeks - Mastication
emphysema.
– Tongue - Swallowing
– Salivary glands
128

128 131

Other abnormal findings:

•Hyposmia Teeth
• Aka: Microsmia – 32 teeth in normal adult
• reduced ability to smell and to detect odors. – Incisors, canine, premolars, molars, wisdom

•Hyperosmia – 20 primary teeth (baby teeth)

– Each tooth has crown, cusp, neck, root
• heightened and hypersensitive sense of smell – Center of tooth is pulp cavity
•Anosmia – Enamel is hard covering protects against
• Inability to smell or detect odors
abrasions
– Cavities are breakdown of enamel by acids
from bacteria
129

129 132

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Pharynx
– From the mouth, food passes posteriorly into
the oropharynx and then the
laryngopharynx, both common passageways
for food, fluids, and air.
– The nasopharynx has no digestive role.

133 136

Common Concerns on
Mouth and Throat
Salivary Glands
- includes submandibular, sublingual, • Toothache
parotid glands • Tooth decay
- produce saliva which contains enzymes • Bleeding gums
to breakdown carbohydrates into • Sore throat
glucose • Hoarseness of voice
- cleans mouth • Tonsilitis
- dissolve and moisten food
137

134 137

Common concerns on Mouth and Throat:

Saliva
- watery and usually somewhat frothy
substance produced in the mouth
- 98% water, but it contains many important
substances, including electrolytes, mucus,
antibacterial compounds and various
enzymes
- Usually acidic
• Toothache
• odontalgia
• Occurs due to irritation of the dental nerve root
• Dental (tooth) infection, decay, injury, or loss of a tooth are the most
common causes.
• Tooth decay
• Dental caries or dental cavities
• the softening of your tooth enamel and refers to the damage of the
structure of the tooth caused by acids that are created when plaque
bacteria break down sugar in your mouth
• Bleeding gums
• Early symptom of gum infection (Gingivitis)
• Gingivitis: inflammation of the gums, or gingiva. It commonly occurs
because a film of plaque, or bacteria, accumulates on the teeth 138

135 138

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Common concerns on Mouth and Throat: Physical Assessment Techniques

• Sore Throat • Inspection
• pain, scratchiness or irritation of the throat that often worsens when • Lips (shape, size, color, contour and symmetry)
you swallow. • Teeth (occlusion, caries, missing teeth, surface abnormalities)
• Often accompanied by dysphagia and odynophagia • Tongue and gums (color, lesion, symmetry, and swelling)
• Hoarseness of Voice • Palate, uvula, oral and buccal mucosa, and tonsils (color, lesion,
• Dysphonia symmetry, and swelling)
• an abnormal change in voice, that's often experienced in conjunction • Palpation
with a dry or scratchy throat mouth
• most common cause: acute laryngitis (inflammation of the vocal cords) • Lips (edema, lesions and tenderness)
caused most often by an upper respiratory tract infection (usually viral), • Tongue, gums and buccal mucosa (lesion and tenderness)
and less commonly from overuse or misuse of the voice (such as from • Assess
yelling or singing)
• Function of CN XII
• Tonsillitis
• Gag Reflex (CN IX and X)
• Inflammation of the tonsils
139
142

139 142

Collecting Subjective Data Findings: Abnormal

The purpose of the nursing health history of the mouth and throat is to detect • Inspection (Lips)
changes in skin integrity, speech, or swallowing; infection; or illness. • Chapped lips: dry, flaky lips
The opening questions are:
• Cyanosis: bluish discoloration of lips due to hypoxia
• Have you noticed any changes in your mouth or throat?
• Lip deviation/asymmetry: may be associated with CN VII
• Have you had any difficulty eating? Swallowing? damage or Bell’s Palsy
• Lesions
• Herpes simplex (cold sore): herpes simplex virus (HSV) produces
recurrent and painful vesicular eruptions of the lips and
surrounding skin, contagious
• Cheliosis/chelitis: painful inflammation and cracking of the
corners of the mouth
140 • Swelling of lips: as seen on allergic reactions or in angioedema 143

140 143

Collecting Objective Data

• Prepare the Client:
• Identify and verify the client
• Explain the procedure to the client
• Prepare the Environment and Equipment
• Ensure client’s privacy
• Organize equipment:
• Gloves, surgical face mask
• Tongue depressor
• 2x2 gauze pads
• Penlight
• Food sample to taste (i.e salt, sugar, coffee)
• Position the Client
• Sitting Position
141 144

141 144

24
 2/10/2020

Findings: Abnormal
• Inspection (Teeth)
• Missing Tooth and impacted tooth
• Plaques: a white to yellow film that adheres to the enamel
surface of teeth; it consists of bacteria, molecules of saliva, and
remnants of epithelial cells and leukocytes
• Tartar (dental calculus): visible, hard deposit of plaque and
dead bacteria that forms at the gum lines which can damage
the teeth, usually yellow to brown or black in color
• Sordes: accumulated of foul matter (food, microorganisms, and
epithelial elements) on the teeth and gums
145 148

145 148

Findings: Abnormal Findings: Abnormal

• Inspection (Teeth) • Inspection (Gums)
• Malocclusion: misalignment or incorrect relation between the • Gingivitis
teeth and dental arches when the jaw closes • Receeding gums
• Class I: bite is normal but the upper teeth slightly overlap the • Gingival hyperplasia
lower teeth • Periodontits (periodontal disease / pyorrhea): infections of the
• Class II: aka retrognathism or overbite, occurs when the upper structures around the teeth which includes the gums,
jaw and teeth severely overlap the bottom jaw and teeth periodontal ligament and alveolar bone
• Class III: aka prognathism or underbite, occurs when the lower
jaw protrudes causing the lower jaw and teeth to overlap the
upper jaw and teeth

146 149

146 149

Findings: Abnormal
• Inspection (Tongue)
• Glossitis: inflammation of the tongue
• Ankyglossia: “tongue tied” short lingual frenulum
• Hypoglossia: short tongue
• Macroglossia: abnormally large tongue
• Aglossia: congenital condition of having no tongue
• Fasciculations: indicative of a neurological disorder
• Fissured: deep grooves in the dorsum of the tongue
• Deviated tongue: may indicate damage to CN XII

147

147 150

25
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Findings: Abnormal
• Inspection (Oral mucosa: Palata, uvula)
• Exotosis: abnormal bone growths
• Torus: an exotosis that grows either on the palate or (torus
palatinus) or mandible (torus mandibularis)
• Stomatitis: sore or inflammation in the mouth
• Canker sores: aka aphthous ulcers, ulcerations in the oral
mucosa, not contagious
• Cold sores (herpes stomatitis): occurs at lip area, contagious
• Leukoplakia: thick, white or grayish patches on the oral mucosa
(can also occur in gums and tongue) may be due to dental
irritation, poor dental fitting and smoking
151 154

151 154

Findings: Abnormal
• Inspection (tonsils)
• Tonsillitis: inflammation of the tonsils

152 155

152 155

Findings: Abnormal
• Inspection (Oral mucosa: Palata, uvula)
• Ashen grey mucosa: associated with hypoxia for dark-skinned
patients
• Jaundiced mucosa: associated with liver disease
• Pharyngitis: a bright red throat with white or yellow exudate
• Candidiasis: thick white plaques on the hard palate and tongue
153
Other concerns on Mouth and Throat:
• Aguesia: inability to taste
• Bad Breath
• Halitosis: foul-smelling breath
• Fruity Acetone breath: associated with Diabetic Ketoacidosis (DKA)
• Ammonia breath: associated with Kidney disease
• Suflur odor breath: associated with end-stage liver disease
• Fecal odor breath: obstruction in Lower GIT
• Parotitis: inflammation of the parotid glands (mumps)
156

153 156

26