Bulacan State University

City of Malolos, Bulacan

COLLEGE OF NURSING

NCM 101-A : HEALTH ASSESSMENT

Nursing Assessment of Physical Systems:

EENT – Eyes, Ears, Nose and Throat

THE EYES

I. Anatomy of the Eye (Structures and Functions)

A. External and Accessory Structures
1. Eyelids, eyelashes
2. Meibomian glands – sebaceous glands which produce oily secretions lubricating the eye
3. Ciliary glands – modified sweat glands of the eyes
4. Lacrimal glands – continually release dilute salt solution (tears) onto the anterior surface
of the eyeball
5. Extrinsic eye muscles
Name Action
Lateral Rectus Moves eye laterally
Medial Rectus Moves eye medially
Superior rectus Elevates eye
Inferior rectus Depresses eye
Inferior oblique Elevates eye and turns it laterally
Superior oblique Depresses eye and turns it laterally

B. Internal Structures
1. Eyeball – hollow sphere composed of 3 tunics and filled with fluids called humors that
help maintain its shape and intraocular pressure

a. Tunics of the Eyeball

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 i. Sclera
➢ “White of the Eye”
➢ Thick, white, outermost coat of the eyeball
➢ Cornea – central crystal clear portion of the sclera through which light
enters the eye
ii. Choroid
➢ A blood-rich middle coat of the eyeball
➢ Ciliary body – structure that attaches the lens
➢ Iris – it regulates the amount of light entering the eyes
iii. Retina
➢ Innermost sensory tunic of the eye
➢ Rods – photoreceptors which allow us to see gray tones and peripheral
vision
➢ Cones – photoreceptors that allow us to see the world in color and
houses fovea centralis for visual acuity
b. Lens – a biconvex structure that focuses light onto the retina; divides the eye into
two segments/chambers, namely anterior segment and posterior segment
respectively
i. Aqueous humor – watery fluid of the anterior segment produced by the choroid
ii. Vitreous humor – gel-like substance that fills the posterior segment of the eyes
➢ Both humors functions to maintain intraocular pressure or pressure
within the eyeball
➢ Canal of Schlemn – venous structure that reabsorbs aqueous humor

II. Assessing the Eye

A. Inspection of the Periorbital Area
✓ Discoloration
✓ Orbital (or periorbital) Edema (black eye)
✓ Gross deformity – requiring immediate referral
✓ Lacerations

B. Inspection of the Globe

✓ General Appearance:
o How does it sit within the orbit relative to
uninvolved side?
o Displaced:
• Medially, Inferiorly
• Posteriorly (Enophthalmos)
• Anteriorly (Exophthalmos)
C. Inspection of the Eyelid
✓ Swelling
✓ Ecchymosis
✓ Lacerations
✓ Stye – infection of a ciliary gland (form of sweat gland on the eyelid) or sebaceous gland
(oil-secreting)
D. Inspection of the Cornea
✓ Crystal clear
✓ Discoloration
✓ Hyphema – collection of blood within anterior
chamber of eye
E. Inspection of the Conjunctivae
✓ Appearance should be transparent (covers sclera)

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 ✓ Two types – bulbar and
palpebral conjunctivae
✓ Subconjunctival Hematoma
– leakage of the superficial
blood vessels beneath the
sclera
✓ Examination
✓ Inferior portion – gently
pull down on the eyelid,
patient looks up
✓ Upper portion – gently lift
upper eyelid, patient looks
down
F. Inspection of the Sclera
✓ Any abnormalities?
✓ Appearance of black object – may be inner tissue of eye bulging through a
wound
G. Inspection of the Iris
✓ Iritis – inflammation of iris
H. Inspection of the Pupils
✓ Normally equal in size and
shape
✓ Anisocoria – unequal pupil sizes
• Benign congenital
condition
• Secondary to Brain
Trauma
✓ Teardrop pupil - Serious underlying pathology (corneal laceration, ruptured
globe)
I. Special Consideration on Assessing
✓ Do NOT palpate globe except for superficial bony structures and soft tissue such
as:
• Orbital Margin (circumference of orbital rim)
• Frontal bone
• Nasal Bone
• Zygomatic bone
J. Vision Assessment
✓ Performed on one eye then with both eyes using a Snellen Chart

✓ Prescribed glasses/contacts worn during assessment

✓ Emmetropia - 20/20 Vision or Ability to read the letters on the 20 ft line of an
eye chart when standing 20 ft from the chart
✓ Note: The higher the denominator, the poorer the vision
✓ Common Abnormal Findings:

RHEALEEN C. VIRAY-VICEDO, RN, MAN

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 • Diplopia
• Blurred vision or Presbyopia (“Old vision”)
• Myopia (nearsightedness) or Hyperopia (farsightedness)
• Astigmatism
o Images are blurry
o Results from light focusing as lines, not points, on the retina
because of unequal curvatures of the cornea or lens
K. Pupil Reaction to Light
✓ Penlight - shine light into pupil for 1 second from the periphery
with opposite eye covered

✓ Observe for pupil restriction and dilation

✓ Repeated on opposite eye
✓ Positive Test suggests:
• Pupil unresponsive to light
• Pupil sluggish compared to opposite side
• Indicative of mechanical or neurological deficit of iris (e.g. Head Injury)
L. Neurological Testing
✓ Cranial Nerve II – Optic
• Vision Assessment → Snellen’s Chart
✓ Cranial Nerve III – Oculomotor
Assessment:
• Pupil reaction to light
• Elevation of upper eyelid
• Eye adduction and downward rolling
✓ Cranial Nerve IV – Trochlear
Assessment:
• Upward eye rolling
✓ Cranial Nerve VI – Abducens
Assessment:
• Lateral eye movement
M. Best Assessment Finding for the Eyes – PERRLA
✓ Pupils Equally Responsive and Reactive to Light and Accommodation

RHEALEEN C. VIRAY-VICEDO, RN, MAN

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THE EARS

I. Anatomy of the Ear(s)

A. Outer (External) Ear

1. Pinna / Auricle
2. External Auditory Canal
3. Ceruminous glands – secretes a waxy yellow substance called earwax or cerumen
4. Tympanic membrane (Eardrum) – separates the outer from the middle ear and is
continually vibrates with sound waves
B. Middle ear / Tympanic Cavity
1. Auditory tube / Eustachian tubeOssicles (3 smallest bones):
a. Hammer (malleus)
b. Anvil (incus)
c. Stirrup(stapes)
➢ These three transmit the vibratory motion of the eardrum to the fluids of
the inner ear
C. Inner (Internal) Ear
- Maze of bony chambers called osseous or bony labyrinth
- 3 Subdivisions:
a. Cochlea – it houses hair cells (hearing receptors) for the sense of hearing
b. Vestibule – essential to the sense of static equilibrium
c. Semicircular canals – essential to the sense of dynamic equilibrium
II. Hearing
A. Types of Sound Transmission
1. Conductive Hearing – transmission of sound waves from external ear through
the middle ear
2. Sensorineural or Perceptive Hearing - transmission of sound waves in the
internal ear
III. Assessing Ear Structures and Hearing
A. Inspection of the External Ear
✓ Inspection and direct palpation for symmetry, deformities, tenderness, lesions,
discharges
✓ Equipment – tuning forks or otoscope and/or audiometry (for MD use)
✓ In severe cases, may find sebaceous cyst and tophi on the pinna
B. Assessing Hearing
1. Gross Auditory Acuity
a. Whispered Voice Test

RHEALEEN C. VIRAY-VICEDO, RN, MAN

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 ✓ Assess client’s response to whispered voice
✓ Stand 30 to 60 cm (1-2 ft) from 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.
✓ Whisper some nonconsecutive numbers and
have the client tell you what was heard.
Increase the loudness of the whisper until the
client can identify at least 50% of the
numbers. Repeat with the other ear.
b. Watch Tick Test
✓ Place ticking watch 2 to 3 cm (1-2 in) from the
unoccluded ear
c. Weber’s Test
✓ A tuning fork, set in motion by grasping it
firmly by its stem and tapping it on the
examiner’s hand, is placed on the patient’s
head.
d. Rinne’s Test
✓ The examiner shifts the stem of a vibrating tuning fork between two
positions: 2 inches from the opening of the ear canal (for air
conduction) and against the mastoid bone (for bone conduction).
Patient is asked to indicate which tone is louder or when the tone is
no longer audible.

** The Rinne and Weber tests help distinguish between a conductive hearing loss and sensorineural
hearing loss

C. Hearing Loss or Presbycusis (in the elderly)

 Types
1. Conductive Hearing Loss – ineffective transmission of sound impulses through the
external auditory canal, eardrum, and/or the middle ear
2. Sensorineural Hearing Loss – it results from the damage of the inner ear structures or
acoustic nerve
3. Mixed – both conductive and sensorineural deafness

RHEALEEN C. VIRAY-VICEDO, RN, MAN

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Instructor I
THE MOUTH & THROAT

➢ Mouth and throat comprise the first part of the digestive system and aiding in speech. Cranial
Nerves V (trigeminal), VII (facial), IX (glossopharyngeal) and XII (hypoglossal) assist with some of
these functions.
➢ Nose and sinuses (paranasal sinuses) constitute the first part of respiratory functions. Receptors
of cranial nerve I (olfactory) are also located in the nose.

I. Anatomy of the Mouth (or Oral Cavity)

➢ A mucous membrane-lined cavity where food first enter; also called oral cavity
➢ Hard palate – forms the anterior roof of the mouth
➢ Soft palate – forms the posterior roof of the mouth
➢ Uvula – a fleshy fingerlike projection of the soft palate, which extends downward
from its posterior edge
➢ Tongue – occupies floor of the mouth
➢ Lingual frenulum – secures the tongue to the floor of the mouth and limits its
posterior movement
A. Pharynx
➢ It serves as a passageway for food and air
➢ Subdivided into three portion: nasopharynx, oropharynx and laryngopharynx
➢ Auditory tubes, which drain the middle ear, open into the nasopharynx
Tonsils – found also in the pharynx; the pharyngeal tonsils (adenoid), palatine tonsils, and
lingual tonsils
B. Salivary glands
➢ 3 pairs:
a. Parotid glands
b. Submandibular glands
c. Sublingual glands
➢ Saliva – product of the salivary glands
C. Teeth
➢ For mastication or chewing of food
➢ Deciduous teeth – baby or milk teeth; begin to erupt around 6mos in a baby and has a full
set (20 teeth) at the age of 2years.
➢ Permanent teeth – usually erupted by the end of adolescence
➢ Wisdom teeth – the third molars; emerge later between the ages of 17 and 25
➢ Classification according to shape and function:
a. Incisors – chisel-shaped; for cutting
b. Canines – fanglike; for tearing or piercing
c. Premolars – broad crowns; for grinding
d. Molars - broad crowns; for grinding
➢ Two major regions:
a. Crown
b. Root

RHEALEEN C. VIRAY-VICEDO, RN, MAN

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Instructor I
II. Assessing the Mouth, Pharynx and Tongue
✓ Inspect the outer lips for symmetry of contour, color, and texture
✓ Inspect and palpate the inner lips, buccal mucosa and oropharynx for color, moisture,
texture, and the presence of lesions
✓ Inspect teeth and gums (which can be done while examining the inner lips and buccal
mucosa)
✓ Inspect the dentures (Ask client to remove complete or partial dentures; Inspect their
condition, noting broken or worn areas)
✓ Inspect the surface of the tongue for position,
movement, color, and texture
✓ Palpate the tongue and floor of the mouth for any
nodule, lumps, or exoriated areas.
✓ Inspect salivary duct openings for any swelling or
redness
✓ Inspect the hard and soft palate for color, shape,
texture, and the presence of bony prominences
✓ Inspect the uvula for position and mobility while
examining the palates
✓ Inspect the tonsils for color, discharge, and size
✓ Elicit gag reflex (using tongue depressor)

III. Common Mouth Disorders

o Gingivitis
o Glossitis
o Stomatitis
o Parotitis
IV. Grading System to Describe Tonsillitis
o Grade 1 – The tonsils are behind the tonsillar
pillars (Normal)
o Grade 2 – between the pillars and the uvula
o Grade 3 – tonsils touch the uvula
o Grade 4 – one or both tonsils extend to the
midline of the oropharynx

RHEALEEN C. VIRAY-VICEDO, RN, MAN

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Instructor I
THE NOSE and SINUSES (particularly Paranasal Sinuses)

I. Anatomy of the Nose and Paranasal Sinuses

A. Nose
B. Paranasal sinuses
➢ They lighten the skull, and
they act as resonance
chambers for speech
➢ Classifications:
1. Frontal
2. Sphenoid
3. Ethmoid
4. Maxillary bones

II. Assessing Nose and Sinuses Structures and their Functions

A. Equipment – flashlight, nasal speculum, penlight or an otoscope with nasal attachment
B. Methods – Inspection and palpation of the external nose, and appearance and patency of
the nasal cavities
✓ Inspect the external nose for any deviations in shape, size, or color and flaring or discharge
from the nares.
✓ Inspect nasal cavities.
✓ Lightly palpate the external nose to determine
any areas of tenderness, masses, and
displacements
✓ Determine patency of both nasal cavities. Ask
the client to close the mouth, exert pressure on
one nares, and breathe through the opposite
nares. Repeat on the opposite nares.
✓ Gently palpate facial sinuses then
transillumination as necessary with a penlight.

RHEALEEN C. VIRAY-VICEDO, RN, MAN

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