Lesson: Head and Neck: Lecture MUSCLES AND CERVICAL VERTEBRAE

These 2 muscles allow movement and provide support

THE HEAD
to the head and neck:
Divided into 2 subsections:
1) Cranium
1. Sternomastoid (Sternocleidomastoid) muscle
2) Face
➔ Rotates and flexes the head
2. Trapezius muscle
CRANIUM
➔ Extends the head and moves shoulders
● Houses and protects the brain and major
sensory organs.
● 11TH CRANIAL NERVE
➔ responsible for muscle movements
● Consists or 8 bones:
➔ Eg. shrugging
○ Frontal (1)
○ Parietal (2)
● These 2 major muscles form a triangle that
○ Temporal (2)
provides an important landmark for assessments
○ Occipital (1)
○ Ethmoid (1)
● Anterior triangle is located under the mandible,
○ Sphenoid (1)
anterior to the sternomastoid.
● Cranial bones are joined by sutures:
○ Sagittal
● Posterior triangle located between trapezius and
○ Coronal
sternomastoid muscle
○ Squamosal
○ Lambdoid
● Cervical vertebrae (C1 to C7) located to the
posterior neck and support the cranium.
FACE
● Consists of 14 bones:
● Vertebra Prominens is at C7
○ Maxilla (2)
○ Easily palpated when neck is flexed.
○ Zygomatic cheek (2)
○ Inferior conchae (2)
BLOOD VESSELS
○ Nasal (2)
These are located bilaterally, parallel, and anterior to the
○ Lacrimal (2)
sternomastoid muscles:
○ Palatine (2)
● Internal jugular
○ Vomer (1)
● Carotid arteries
○ Mandible (1)
● All are immovable except mandible.
External jugular vein - lies diagonally over these 2.
● Temporal Artery - major artery b/w eye and ear
● Parotid glands -
** Do not compress carotid artery bilaterally during
● Submandibular glands
assessment; can reduce blood supply to the brain.

THYROID GLAND
THE NECK
● Largest endocrine gland in the body
Composed of:
● Consists of 2 lateral lobes.
● Muscles
● Surrounded by several structure like the
● Ligaments
Trachea.
● Cervical vertebrae
■ thru which air enters the lungs
■ Composed of C-shaped hyaline
Contained are:
cartilage ring
● Hyoid bone
○ FIRST UPPER TRACHEAL RING is
● Several Major blood vessels
called “Cricoid Cartilage”
● Larynx
● Trachea
○ Thyroid cartilage = Adam’s apple
● Thyroid gland
located above cricoid cartilage.
 ○ Hyoid bone, which is attached to the
hormone fluctuations
tongue, is above thyroid cartilage; below (Moloney & Johnson,
mandible. 2011).

Other vascular
LYMPH NODES OF HEAD AND NECK headaches may be
● Filter lymphs to remove bacteria and tumor cells. caused by fever or high
blood pressure (“cluster
● Common head and neck lymph nodes:
headaches”).
○ Preauricular
○ Postauricular Muscle contraction
○ Tonsillar headaches may be
○ Occipital caused by tightening of
○ Submandibular facial and neck
○ Submental muscles.
○ Superficial cervical Traction and inflammatory
○ Posterior cervical headaches may be
○ Deep cervical warning signs of other
○ Supraclavicular illnesses such as stroke,
sinus or gum infections,
*head shape may vary, but does not have clinical and meningitis
significance.
A sudden, severe
headache with no known
cause may be a sign of
Lesson: Head and Neck: Physical Assessment impending stroke

SUBJECTIVE DATA / HISTORY TAKING Facial Pain Trigeminal neuralgia (tic

HISTORY OF PRESENT HEALTH
CONCERN
Neck Pain Neck pain may
accompany muscular
problems or cervical
spinal cord problems.
Stress and tension may
increase neck pain.
Sudden head and neck
pain seen with elevated
temperature and neck
stiffness may be a sign of
meningeal
inflammation.
Headaches The most common types
of headaches are related
to vascular (e.g.,
migraine), muscle
contraction (tension),
traction, or inflammatory
causes.
Eighteen percent of
women have migraine
headaches provoked by
douloureux) is
manifested by sharp,
shooting, piercing facial
pains that last from
seconds to minutes. Pain
occurs over the divisions
of the fifth trigeminal
cranial nerve (the
ophthalmic, maxillary, and
mandibular areas).
Difficulty moving the Tension in muscles,
head and neck vertebral joint
dysfunction, and other
disorders of the head and
neck may limit mobility
and affect activities of
daily functioning.
Lumps or lesions on Lumps and lesions that
head or neck that do do not heal or disappear
not heal or disappear may indicate cancer.
A goiter (an enlarged
thyroid gland) may
appear as a large
swelling at the base of
the neck that the client
may notice when shaving
or putting on cosmetics.
The client with a goiter
 may also have a: The risk of
- tight feeling in the hypothyroidism
throat increases with increased
- Cough, radiation doses
- Hoarseness
- Difficulty
swallowing
- Or a hoarse voice FAMILY HISTORY

(Mayo Clinic, 2011). Headaches (due to Some prescription and

medications) nonprescription
Dizziness, Sudden trouble seeing in medicines may cause
lightheadedness, one or both eyes or headaches as follows:
spinning sensation, sudden trouble walking, ● Oral
blurred vision, or loss dizziness, or loss of contraceptives
of consciousness balance or coordination ● Blood-thinning
may be a sign of an medicines, such
impending stroke as warfarin,
(American Stroke heparin, or
Association, 2011). aspirin
● Caffeine (or
Change in the texture of Alterations in thyroid caffeine
your skin, hair, or nails function are manifested withdrawal)
in many ways. ● Heart and blood
Changes in your energy pressure
level, sleep habits, or medicines, such
emotional stability as nitroglycerin
● Antihistamines
Palpitations and
decongestants
Weakness or numbness Sudden weakness or ● Corticosteroids,
in face, arms, or legs or numbness in the face, such as
on either side of the arms, or legs—especially prednisone
body on one side of the ● Ergotamine
body—may indicate an (Cafergot)
impending stroke therapy
(American Stroke ● Hormone therapy,
Association, 2011). such as estrogen
or progestin
● Medicines to
prevent organ
PAST HEALTH HISTORY transplant
rejection
Previous head or neck Previous head and neck ● Certain types of
problems (trauma, trauma may cause chemotherapy
injury, falls); Type of chronic pain and ● Overuse of
treatment; Results limitation of movement. fat-soluble
This may affect vitamins, such as
functioning. vitamin A and
vitamin D
Radiation therapy for a Radiation therapy has ● Radiation therapy
problem in been linked to the
neck region development of thyroid History of head or neck Genetic predisposition is
cancer. cancer in your family a risk factor for head and
neck cancers.
Radiation to the neck
area may also cause History of migraine Migraine headaches
esophageal strictures, headaches in your commonly have a familial
leading to difficulty with family association.
swallowing.
 LIFESTYLE AND HEALTH PRACTICES
Smoke or chew tabacco Tobacco use increases
the risk of head and neck
cancer.
Symptoms of Head and
neck cancer include: a
lump or sore that does
not heal, a sore throat
that does not go away,
and trouble swallowing
(National Cancer Institute
[NCI] at the National
Institutes of Health [NIH],
2012).
Alcohol or recreational Alcohol use is also a risk
drugs factor for head and neck
cancers (NCI, 2012).
Headaches can be
precipitated by the use of
alcohol.
Wearing a helmet when Failure to use safety
riding a horse, bicycle, precautions increases the
motorcycle, or other risk for head and neck
open sports vehicle injury
Hard hat for hazardous
occupation
Recreational activity Contact or aggressive
sports may increase the
risk for a head or neck
injury
Typical posture when Poor posture or body
relaxing, during sleep, alignment can lead to or
and when working exacerbate head and
neck discomfort.
Problems with your Head and neck pain may
head or neck: interfere with
interfered with your relationships or prevent
relationships with others clients from completing
or the role you occupy at their usual activities of
home or at work daily living.
OBJECTIVE DATA
Inspection and Palpation
HEAD & FACE
Size, shape, and
configuration NORMAL:
- Head size and shape
vary, especially in accord
with ethnicity.
- Symmetric, round, erect,
and in midline and
appropriately related to
body size
(Normocephalic)
- No lesions are visible.
ABNORMAL:
- Microcephaly =
abnormally small head
- Acromegaly = skull
and facial bones are
larger and thicker
- Paget’s disease of the
bone = Acorn-shaped,
enlarged skull bones
Inspect for involuntary NORMAL:
movement
- Head should be held still
and upright
ABNORMAL:
- Neurologic disorders
may cause a horizontal
jerking movement
- involuntary nodding
movement may be seen
in patients with aortic
insufficiency
- Head tilted to one side
may indicate unilateral
vision or hearing
deficiency or shortening
of the sternomastoid
muscle
Palpate the head. Note NORMAL:
consistency
- The head is normally
hard and smooth,
without lesions.
 ABNORMAL:
- Lesions or lumps on the
head may indicate recent
trauma or a sign of
cancer.
Inspect the face: NORMAL:
Symmetry, features,
movement, expression, - Face is symmetric with
and skin condition a round, oval, elongated,
or square appearance.
- No abnormal
movements noted.
ABNORMAL:
- Asymmetry in front of
the earlobes occurs with
parotid gland
enlargement from an
abscess or tumor.
- Unusual or asymmetric
orofacial movements may
be from an organic
disease or neurologic
problem, which should
be referred for medical
follow-up
- Drooping, weakness, or
paralysis on one side of
the face may result from
a stroke
- Drooping, weakness, or
paralysis on one side of
the face may also result
from a neurologic
condition known as Bell’s
palsy
- Nephrotic syndrome
- A “mask-like” face
marks Parkinson’s
disease;
- A “sunken” face with
depressed eyes and
hollow cheeks is typical of
cachexia (emaciation or
wasting); and a pale,
swollen face
OLDER ADULT
CONSIDERATION:
- Facial wrinkles are
prominent because
subcutaneous fat
decreases with age. In
addition, the lower face
may shrink and the mouth
may be drawn inward as
a result of resorption of
mandibular bone, also an
age-related process
Palpate the temporal NORMAL:
artery
- The temporal
artery is elastic
and not tender
ABNORMAL:
- Temporal artery is hard,
thick, and tender with
inflammation, as seen
with temporal arteritis
(inflammation of the
temporal arteries that
may lead to blindness).
OLDER ADULT
CONSIDERATION:
- The strength of the
pulsation of the temporal
artery may be decreased
in the older client.
Palpate the NORMAL:
temporomandibular
joint (TMJ). - No swelling, tenderness,
or crepitation with
movement
- Mouth opens and closes
fully (3 to 6 cm between
upper and lower teeth).
Lower jaw moves laterally
1 to 2 cm in each
direction.
ABNORMAL:
- Limited range of motion,
swelling, tenderness, or
crepitation may indicate
TMJ syndrome.
 NECK - Neck movement is
smooth and controlled
Inspect the neck. NORMAL: with 45-degree flexion,
Observe the client’s 55-degree extension,
slightly extended neck for - symmetric, with head 40-degree lateral
position, symmetry, and centered and without abduction, and
lumps or masses. bulging masses. 70-degree rotation.

ABNORMAL: ABNORMAL:

- Swelling, enlarged - Stiffness, rigidity, and

masses or nodules may limited mobility of the
indicate an enlarged neck due to possible
thyroid gland, muscle spasms,
inflammation of lymph inflammation, or cervical
nodes, or a tumor. arthritis

- A stiff neck is often a

Observe the movement NORMAL: late symptom seen in
of the thyroid cartilage, meningitis
thyroid gland - The thyroid cartilage,
cricoid cartilage move OLDER ADULT
upward symmetrically as CONSIDERATION:
the client swallows.
- Older clients usually
ABNORMAL: have somewhat
decreased flexion,
- Asymmetric movement extension, lateral
or generalized bending, and rotation of
enlargement of the the neck. This is usually
thyroid gland due to arthritis.

Inspect the cervical NORMAL: Shoulder movement NORMAL:

vertebrae: Ask the client and facial expression
to flex the neck (chin to - C7 (vertebrae - Equal strength
chest). prominens) is usually
visible and palpable. ABNORMAL:

ABNORMAL: - Unequal strength

- Prominence or swellings
other than the C7 Trachea NORMAL:
vertebrae
- Trachea is midline.
OLDER ADULT
CONSIDERATION: ABNORMAL:

- In older clients, cervical - The trachea may be

curvature may increase pulled to the affected side
because of kyphosis of in cases of large
the spine. Moreover, fat atelectasis, fibrosis or
may accumulate around pleural adhesions.
the cervical vertebrae
- The trachea is pushed
(especially in women).
to the unaffected side in
This is sometimes called
cases of a tumor,
a “dowager’s hump.”
enlarged thyroid lobe,
pneumothorax, or with an
Inspect range of motion NORMAL: aortic aneurysm.
Thyroid Gland: NORMAL:
- Hyoid bone - Landmarks are
(arch-shaped bone; positioned midline.
located high in anterior
neck). - Unless the client is
extremely thin with a long
- Thyroid cartilage neck, the thyroid gland is
(under the hyoid usually not palpable
bone;also known as the
“Adam’s apple.”) - Glandular thyroid tissue
may be felt rising
- Cricoid cartilage underneath the fingers.
(smaller upper tracheal
- Lobes feel smooth,
ring under the thyroid
rubbery, and free of
cartilage).
nodules.
ABNORMAL:
- Landmarks deviate from
midline or are obscured
because of masses or
abnormal growths.
- Hyperthyroidism,
Graves’ disease, or an
endemic goiter: diffuse
enlargement
- Thyroiditis: An
enlarged, tender gland
- Coarse tissue or
irregular consistency may
indicate an inflammatory
process.
OLDER ADULT
CONSIDERATION:
- The older client’s thyroid
may feel more nodular or
irregular because of
fibrotic changes that
occur with aging;
- The thyroid may also be
felt lower in the neck
because of agerelated
structural changes.
Auscultation
: only if you find an enlarged thyroid gland
during inspection or palpation
NECK
Enlarged Thyroid gland NORMAL:
- No bruits are
auscultated.
ABNORMAL:
- A soft, blowing,
swishing sound
auscultated over the
thyroid lobes
- Often heard in
hyperthyroidism because
of an increase in blood
flow through the thyroid
arteries.
Inspection and Palpation
LYMPH NODES OF THE HEAD AND NECK
Preauricular nodes NORMAL:
Postauricular nodes
Occipital nodes - No swelling or
enlargement and no
tenderness.
<1cm
ABNORMAL:
- Enlarged nodes
Tonsilar nodes NORMAL:
- No swelling, no
tenderness, no hardness
is present.
<1cm
ABNORMAL:
- Swelling, tenderness,
hardness, immobility
Submandibular nodes NORMAL: tenderness

- No enlargement or
tenderness is present. Supraclavicular nodes NORMAL:

<1cm - No enlargement or
tenderness is present.
ABNORMAL:
- <1cm
- Enlargement and
tenderness ABNORMAL:

- Enlarged, hard,
Submental nodes NORMAL: nontender node,
particularly on the left
- No enlargement or side, may indicate a
tenderness is present. metastasis from a
malignancy in the
<1cm abdomen or thorax.
ABNORMAL:

- Enlargement and
tenderness OTHER ABNORMAL FINDINGS

Sinus Headache C: Deep, constant, throbbing

Superficial cervical NORMAL: pain; pressure-like pain in one
nodes specific area of face or head
- No enlargement or (e.g., behind eyes); face
tenderness is present. tender to the touch
<1cm O: Occurs with or after a cold
or acute sinusitis or acute
ABNORMAL:
febrile illness with purulent
- Enlargement and discharge from nose.
tenderness
L: May occur in one area of
face or along eyebrow ridge
Posterior cervical NORMAL: and below the cheek bone.
nodes
- No enlargement or
tenderness is present.

<1cm

ABNORMAL:

- Enlargement and
tenderness

Deep cervical chain NORMAL:

nodes
- No enlargement or
tenderness is present.

<1cm

ABNORMAL:
D: Lasts until associated
- Enlargement and condition is improved.
 S: May be moderately severe;
not debilitating.
P: Pain worse with sudden
movements of the head,
bending forward, lying down;
in the morning (due to mucus
collecting and draining all
night); or with sudden
temperature changes (going
from warm room to cold).
A: sinusitis, such as nasal
drainage and congestion,
fever, and foul-smelling
breath.
Cluster Headache C: Stabbing pain; may be
accompanied by tearing,
eyelid drooping, reddened
eye, or runny nose
O: Has a sudden onset; may
be precipitated by ingesting
alcohol
L: Localized in the eye and
orbit and radiating to the facial
and temporal regions.
Migraine Headache
D: Typically occurs in the late
evening or night.
S: Intense
P: Movement or walking back
and forth may relieve the
discomfort.
A: Occur more in young
males.
Tension Headache C: Dull, tight, diffuse
O: No prodromal stage; may
occur with stress, anxiety, or
depression.
L: Usually located in the
frontal, temporal, or occipital
region.
D: Lasts days, months, or
years
S: Aching
P: Symptomatic relief may be
obtained by local heat,
massage, analgesics,
antidepressants, and muscle
relaxants.
A: Affect women more often
than men.
C: Accompanied by nausea,
vomiting, and sensitivity to
noise or light
O: May have prodromal stage
(visual disturbances, vertigo,
tinnitus, numbness or tingling
of fingers or toes); may be
precipitated by emotional
disturbances, anxiety, or
ingestion of alcohol, cheese,
chocolate, or other foods and
substances to which client is
sensitive.
L: Located around eyes,
temples, cheeks, or forehead;
may affect only one side of the
 face. organs finish growing

Often due to a noncancerous

(benign) tumor of the pituitary
gland, and is also seen in
Paget’s disease

Cushing’s Present with a moon-shaped

Syndrome face with reddened cheeks
and increased facial hair

Scleroderma Tightened-hard face with

thinning facial skin

Hyperthyroidism Exophthalmos is seen

D: Lasts up to 3 days Bell’s Palsy Usually begins suddenly and

reaches a peak within 48
S: Throbbing, severe hours

P: Rest may bring relief Symptoms may include

A: Occur more often in women
Tumor-related C: Aching, steady; neurologic
Headache and mental symptoms as well
as nausea and vomiting may
develop
twitching, weakness,
paralysis, drooping eyelid or
corner of the mouth, drooling,
dry eye, dry mouth, decreased
ability to taste, eye tearing,
facial distortion.

O: No prodromal stage; may

be aggravated by coughing,
sneezing, or sudden
movements of the head

L: Varies with location of

tumor

D: Commonly occurs in the

morning and lasts for several
hours.

S: Variable in intensity

P: Usually subsides later in

the day

A:

Acromegaly Enlargement of the facial

features (nose, ears) and the
hands and feet.

Caused by increased
production of growth hormone
after the skeleton and other
Lesson: Breast and Lympathic: Lecture

Structure and Function

● The breasts are paired mammary glands that lie

over the muscles of the anterior chest wall,
anterior to the pectoralis major and serratus
anterior muscles.
● Depending on their size and shape, the breasts
extend vertically from the second to the sixth
rib and horizontally from the sternum to the
midaxillary line.
● The male and female breasts are similar until
puberty, when female breast tissue enlarges in
response to the hormones estrogen and
progesterone, which are released from the
ovaries.
● The female breast is an accessory
reproductive organ with two functions:
➔ To produce and store milk that provides
nourishment for newborns.
➔ To aid in sexual stimulation.
● The male breasts have no functional
capability.
● For purposes of describing the location of
assessment findings, the breasts are divided
into four quadrants by drawing horizontal and
vertical imaginary lines that intersect at the
nipple.
➔ Upper inner, upper outer, lower inner,
and lower outer quadrants.
➔ The upper outer quadrant, which
extends into the axillary area, is referred
to as the tail of Spence. Most breast
tumors occur in this quadrant.
● Lymph nodes are present in both male and
female breasts.
➔ These structures drain lymph from the
breasts to filter out microorganisms and
return water and protein to the blood.

External Breast Anatomy

● The skin of the breasts is smooth and varies in

color depending on the client’s skin tone.
● The nipple, which is located in the center of the
breast, contains the tiny openings of the
lactiferous ducts through which milk passes.
● The areola surrounds the nipple (generally 1-
to 2-cm radius) and contains elevated
sebaceous glands (Montgomery glands) that
secrete a protective lipid substance during
lactation.
 ● Hair follicles commonly appear around the
areola.
● Smooth muscle fibers in the areola cause the
nipple to become more erectile during
stimulation.
● The nipple and areola typically have darker
pigment than the surrounding breast.
➔ Their color ranges from dark pink to
dark brown, depending on the person’s
skin color.
➔ The amount of pigmentation increases
with pregnancy, then decreases after
lactation. It does not, however, entirely
return to its original coloration.
● During embryonic development, a milk line or
ridge extends from each axilla to the groin area.
● It gradually atrophies and disappears as the
person grows and develops.
● However, in some clients, supernumerary
nipples or other breast tissue may appear along
this “milk line”.
Internal Breast Anatomy
● Female breasts consist of three types of tissue:
glandular, fibrous, and fatty (adipose).
● Glandular tissue - constitutes the functional
part of the breast, allowing for milk production.
➔ Glandular tissue is arranged in 15 to 20
lobes that radiate in a circular fashion
from the nipple.
➔ Each lobe contains several lobules in
which the secreting alveoli (acini cells)
are embedded in grape-like clusters.
● Mammary ducts from the alveoli converge into
a single lactiferous duct that leaves each lobe
and conveys milk to the nipple.
● The slight enlargement in each duct before it
reaches the nipple is called the lactiferous
sinus.
➔ The milk can be stored in the lactiferous
sinus (or ampullae) until stimulated to be
released from the nipple.
● The fibrous tissue - provides support for the
glandular tissue largely by way of bands called
Cooper ligaments (suspensory ligaments).
➔ These ligaments run from the skin
through the breast and attach to the
deep fascia of the muscles of the
anterior chest wall.
➔ Fatty tissue is the third component of
the breast.
➔ The glandular tissue is embedded in the
fatty tissue.
➔ This subcutaneous and retromammary
fat provides most of the substance to
the breast, determining the size and
shape of the breasts.
➔ The functional capability of the breast
is not related to size but rather to the
glandular tissue present.
● The amount of glandular, fibrous, and fatty
tissue varies according to various factors
including the client’s age, body build, nutritional
status, hormonal cycle, and whether she is
pregnant or lactating.
Lymph Nodes
● The major axillary lymph nodes consist of the
anterior (pectoral), posterior (subscapular),
lateral (brachial), and central (midaxillary)
nodes.
➔ The anterior nodes drain the anterior
chest wall and breasts.
➔ The posterior chest wall and part of the
arms are drained by the posterior
nodes.
➔ The lateral nodes drain most of the
arms.
➔ The central nodes receive drainage
from the anterior, posterior, and lateral
lymph nodes.
➔ A small proportion of the lymph also
flows into the infraclavicular or
supraclavicular lymph nodes or
deeper into nodes within the chest or
abdomen.
Biological (Genetic) and Cultural Behavior Variations
● Both males and females have superficial veins
forming a network over the entire chest, known
as the mammary plexus.
➔ These veins have either a longitudinal
or transverse pattern, radiating either
laterally toward the axillae
(longitudinal) or radiating downward
and laterally in a fan shape.
Abnormal Findings in the Breast
1. Peau D’Orange
- Resulting from edema, an orange peel
appearance of the breast is associated
with cancer.
2. Paget Disease with Invasive Intraductal Lesson: Breast and Lympathic: Physical
Carcinoma Assessment
- Redness and flaking of the nipple may
be seen early in Paget disease and then SUBJECTIVE DATA / HISTORY TAKING
disappear.
- However, further assessment is needed HISTORY OF PRESENT HEALTH CONCERN
because this does not mean the disease
is gone.
Lumps or - Conditions where
- Tingling, itching, increased sensitivity,
swelling of lumps may be
burning, discharge, and pain in the
breast present:
nipple are late signs of Paget disease. It
● Benign breast
may occur in both breasts, but is rare. conditions
3. Nipple Inversion from Breast Cancer (fibrocystic
- Nipple inversion may suggest breast
malignancy. disease) –
4. Retracted Breast Tissue premenstrual
- Retracted breast tissue suggests breast
malignancy. lumpiness
5. Mastitis and soreness
- Reddened, painful area on breast warm that subside
to palpation. after mens
- Skin, nipple, and areola retraction. ● Fibroadenom
6. Mastectomy as
- Radical mastectomy ● Malignant
❖ The surgeon removes all the tumors
underarm lymph nodes plus the
entire chest muscle. - Lump should be
- Modified radical mastectomy assessed further.
❖ The surgeon removes some
- Should be referred to
physician.
underarm lymph nodes but
leaves the chest muscles intact.
Lumps or - Breast tissue +
7. Cancerous Tumors swelling in axillary lymph nodes
- These are irregular, firm, hard, not underarms may be enlarged w/
defined masses that may be fixed or inflammation,
mobile. fibroadenomas,
- They are not usually tender and usually infections, breast
occur after age 50. cancer
8. Fibroadenomas
- These lesions are lobular, ovoid, or [Fibroadenomas – painless,
round. They are firm, well defined, unilateral,
seldom tender, and usually singular and benign/non-cancerous,
mobile. non-fluid/solid lump]
- They occur more commonly between
puberty and menopause. Redness and - Indicates
9. Benign Breast Disease warmth of breast inflammation
- Also called fibrocystic breast disease,
Dimpling or - May indicate breast
benign breast disease is marked by
nipple retraction cancer
round, elastic, defined, tender, and
mobile cysts. Change is size - Recent increase in
- The condition is most common from age and firmness of size of one breast:
30 to menopause, after which it breast ● Inflammation
decreases. ● Pregnancy
 ● Lactation ; or diuretics
● Abnormal - Spontaneous,
growth unilateral, bloody,
guaiac-positive :
[Older Clients: NORMAL: refer for evaluation
❖ ↓ breast size and - + if client is male or
firmness = ↓ >40 or mass is
estrogen levels palpable
❖ ↓ glandular tissue = ↑
fatty tissue
*well-fitted bra can reduce
breast discomfort r/t sagging PERSONAL HEALTH HISTORY
breasts]

Pain and - Common in Prior breast - History of breast

tenderness in fibrocystic breasts disease, surgery, cancer = ↑ risk for
breast (before, during biopsy, implants, recurrence of cancer
*COLDSPA mens; taking oral trauma - Surgeries: may alter
contraceptives) the appearance of
breasts
- Late sign for breast - Silicone implants:
cancer cause breast
problems
Symptoms for fibrocystic - Trauma like sports,
breast: accidents, physical
● Breast pain / abuse: cause breast
tenderness tissue changes
● Lumps / thickening
areas Menstruation / - Increases risk for
● Lumps fluctuate in menarche breast cancer:
size ● Early menses
● Green / dark brown (before 12
non-bloody nipple yrs old)
discharge ● Delayed
● Changes in both menopause
breasts (after 52
years old)
Nipple discharge - Blood / blood-tinged:
refer for eval Given birth to - Increased risk for
- Clear, benign children breast cancer:
discharge: ● Who never
- may be have given
manually birth
expressed ● Who had first
from a breast child after 30
that is years old
frequently
stimulated First and last day - Determines the right
- Medications of menstrual / optimal time for
like cycle breast examination
contraceptive - Factors reduced
s, right after mens:
phenothiazin ● Hormone-rela
es, steroids, ted swelling
digitalis, ● Breast
 tenderness Caffeine intake, - Caffeine:
● Generalized milk, frequency aggravates
(kalat) fibrocystic breast
lumpiness condition
- One-quarter cup of
milk daily: ↑ risk of
breast cancer by
FAMILY HISTORY 30%
- One-third cup of
milk daily: ↑ risk of
Family history of - History of breast
breast cancer by
breast cancer cancer in family = ↑
70-80%
and who risk of breast cancer
- Hereditary breast Exercise - Vigorous exercise
cancer: 5-10% engagement w/ proper breat
cases only support: ↓ breast
tissue elasticity
**well-fitting, supportive bra
reduces discomfort during
exercise
LIFESTYLE AND HEALTH PRACTICES
Psychologic - Condition of breast
factors (thoughts, significantly
High blood - Some can cause physical influence how she
pressure breast engorgment appearance, feels about herself
medications in women fears) - May threaten
(contraceptives, - Hormones and women’ self body
hormones, contraceptives: ↑ image and feelings
antipsychotic risk of breast cancer of self-worth
agents, - Haloperidol - Men may be
sedatives, (antipsychotic drug): embarrassed to
medicines) + can cause have enlarged
opioid galactorrhea breasts
medications [persistent milk
secretion whether or Self-examination - (+) breast implants:
[opioid not breastfeeding] of breasts should check
medications: pain and lactation regularly, look and
medications] - Medroxyprogestero feeling of the
ne injections: can breasts
cause galactorrhea - Women who still
menstruate: check
monthly after a
Work area – - Increases breast week from
exposure to cancer risk menstruation
radiation, - Older clients and
benzene or others who no
asbestos longer menstruate
and continues BSE:
Daily diet - High-fat diet = ↑ risk check monthly, pick
of breast cancer date that is easily
remembered (e.g.
Alcohol and - 2 drinks per day and birthday)
tobacco tobacco use = ↑ risk
consumption of breast cancer **men can also develop
breast cancer; this is often
 overlooked d’orange
● From edema
caused by
blocked
OBJECTIVE DATA lymphatic
drainage
inspection, palpation ● Metastatic
breast disease
FEMALE BREASTS
—INSPECTION Superficial venous NORMAL:
pattern (veins)
Size and symmetry NORMAL: - Radiating veins either:

-Somewhat round ● Horizontally /

(depends on fatty toward axilla /
tissue) transverse
● Vertically with a
-Pendulous lateral flare /
longitudinal
-1 breast may normally
be larger than the other - More prominent veins
during pregnancy
[Older clients: more
pendulous, less firm, **pattern varies in
saggy breasts] cultural groups but are
normal; predominant:
ABNORMAL: transverse

- Recent increase in ABNORMAL:

size of one breast
● Inflammation; or - Prominent venous
● Abnormal pattern
growth ● Increased
circulation due
Color and texture NORMAL: to malignancy
- Varying color
- Asymmetric venous
depending on skin tone
pattern
- Smooth
● May be due to
- (-) edema
malignancy
- Visible linear stretch Areolas NORMAL:
marks:
● After pregnancy - Dark pink to dark
● Weight gain brown (depends on
● Weight loss skin tone)
- Round, varies in size
ABNORMAL: - (+) small Montgomery
glands
- Redness
● Breast - Dry areola: normal for
Inflammation pregnant/breastfeeding
mom
- Pigskin-like or
Orange-peel, Peau ABNORMAL:
 - (+) dimpling/retraction
- Peau d’orange skin ● Malignant tumor
● Carcinoma w/ fibrous
strands
- Red, scaly, crust attached to
areas breast tissue
● Paget disease and fascia of
muscles
Nipples NORMAL:
**fibrous tissue
- Nearly equal clumps/two lumps b/w
bilaterally in size the retraction
- Same location
- Everted ; can be
inverted / flat
- Supernumerary
nipples along —PALPATION
embryonic milk kline
- (-) Discharge Texture & elasticity NORMAL:
*3 fingerpads
**Bilateral inverted - Smooth
nipple - normal for
young ladies - Firm

- Elastic tissue (in

[Inverted nipple for nulliparous women)
first-time mothers:
stimulate by 1) - Often fuller & may be
massage, 2) arouse by tender (after
husband] menstruation)
[Older client: smaller, [Nulliparous women -
flatter nipples, less those who did not give
erectile on stimulation] birth yet]
ABNORMAL: [older client: more
granular,
- Recently inverted inframammary ridge is
nipple easily palpated]
● Malignancy
ABNORMAL:
- Spontaneous
discharge (when it - Thickening of tissues
comes out on its own) ● Malignant tumor
● Refer to
cytologic study **Dense breasts =
& eval amount of fibrous &
glandular tissue VS
Retraction, dimpling NORMAL:
fatty tissue
- Raise hands - Symmetrical breast;
- No dimpling, **Denser breasts =
- Hands on hip
retraction increased risk of breast
- Hand on hand
cancer
- Leaning
forward ABNORMAL:
Tenderness & NORMAL:
temperature - During ● 1-5 cm
menstruation/hormonal ● Round, oval
cycle: generalized ● Mobile, firm
increase in nodularity & ● Solid, elastic,
tenderness nontender
● Single/multiple
- Normal body temp. benign in
one/both
ABNORMAL:
Milk cysts
- Painful, tender ● Can turn to
breasts (right before abscess
menstruation) ● Occurs in
● Fibrocystic breastfeeding/re
breasts cent birth

- Pain From injury

● Malignant tumor ● Blood collection
drainage as lump

- Heat (in nulliparous Lipomas

women/not lactating) ● Collection of
● Inflammation fatty tissue

Masses NORMAL: Intraductal papilloma

● Small growth in
- (-) masses milk duct (near
areola)
- Firm inframammary
● Harmless
transverse ridge is
● 35-50 yrs old
normal (lower base of
breast) Nipples & Areola NORMAL:
[Nodular or glandular - Can erect
breast tissue: ropy,
lumpy, bumpy, textured - Areola can pucker
fibrocystic breast]
- Milk discharge during
[Benign breast disease: pregnancy/lactation
bilateral, multiple,
regular, rubbery, mobile - Clear discharge on
nodules] some women

ABNORMAL: ABNORMAL:

- Upper outer quadrant Other possible causes

● where most of nipple discharges:
malignant ● Endocrine
masses/tumors disorders
are found ● Birth control
pills
- Hard, immobile, fixed ● Menstrual cycle
irregular margins hormone
changes
Fibroadenomas ● Breast
 conditions ● Discrete,
(fibrocystic nontender
breasts, ● Movable nodes
infection,
abscess, During menstruation:
trauma) - Palpable lymph nodes
● Medications - enlarged/swollen
(sedatives, breasts
antidepressant,
antipsychotics, ABNORMAL:
high BP drugs,
opioids) - (+) redness,
● Herbal inflammation
supplements ● Infection of
● Benign/maligna sweat gland
nt tumors
- Dark, velvety color
Mastectomy or NORMAL: (acanthosis nigricans)
lumpectomy ● Malignancy
- Scar: whitish
- (-): - Enlarged/ >1cm
● swelling, nodes
● redness, ● Infection of
● lesions, hand/arm
● lumps,
● tenderness, - Large, fixed to skin
● inflammation ● Malignancy
ABNORMAL:

- (+) redness,
inflammation MALE BREASTS
● Infection
—INSPECTION, PALPATION
- Lesions, lumps,
tenderness Breasts NORMAL:
● Refer for eval Areolas
Nipples - (-):
Axillae ● swelling,
● nodule,
THE AXILLA ● ulceration

ABNORMAL:
—INSPECTION, PALPATION
- Soft, fatty
Axilla NORMAL: enlargement
● Obesity
- (-):
● rash, - Smooth, firm,
● infection, movable disc of
● swelling, glandular tissue
● inflammation ● Gynecomastia -
● palpable nodes; abnormal
or enlargement of
● 1-2 small/ <1cm male breast
 - Irregularly shaped,
hard nodules
● Breast cancer
Lesson: Abdominal System (p. 1238-1347)
Structure and Function
● The abdomen is bordered superiorly by the
coastal margins, inferiorly by the symphysis
pubis and inguinal canals, and laterally by
the flanks.
● It has four abdominal quadrants divided by an
imaginary vertical line (midline) extending from
the tip of the sternum (xiphoid) through the
umbilicus to the symphysis pubis. (A line from
the bottom of the chest to the belly button,
and another line across the belly button).
○ RUQ: Ascending and transverse colon,
duodenum, gallbladder, hepatic flexure
of the colon, liver, head of the pancreas,
pylorus, right adrenal gland, right kidney,
right ureter.
○ RLQ: Appendix, ascending colon,
cecum, lower pole of the right kidney,
right ovary and tube, right ureter, right
spermatic cord.
○ LUQ: Left adrenal gland, the upper pole
of the left kidney, left ureter, body, and
tail of the pancreas, spleen, splenic
flexure of colon, stomach, transverse
descending colon.
○ LLQ: Lower pole of the left kidney, left
ovary and tube, left ureter, left spermatic
cord, descending and ascending colon.
● The nine abdomen regions are:
● The epigastric, umbilical, and hypogastric
(suprapubic) are commonly used to describe
abdominal findings.
● The contents of the abdomen are enclosed
externally by the abdominal wall muscles, it
has three layers extending from the back,
around the flanks, and to the front.
○ External oblique (outermost)
○ Internal abdominal oblique (middle)
○ Transverse abdominis (innermost)
● These protect the internal organs and allow
normal compression during functional
activities: coughing, urination, defecation,
childbirth, and sneezing.
● Rectus abdominis is the vertical muscle of the
anterior abdominal wall enclosed by the
connective tissues from the three muscles.
● The muscles in the abdomen have strong fibers
and connective tissues called aponeuroses,
spread out in a plywood-like pattern, giving
strength to the abdominal wall.
● These fibers and aponeuroses come together
in the middle of the abdomen and form a
white line called the linea alba, which goes
from the bottom of the chest to the pelvic bone.
● The parietal peritoneum lines the abdominal
cavity while the visceral peritoneum acts as
the protective covering of the inner abdominal
organs.
 ● The abdominal cavity has different body systems
referred to as the abdominal viscera and has
two types:
○ Solid viscera - organs that constantly
maintain their shape.
○ Ex. liver, pancreas, spleen, adrenal
glands, kidneys, ovaries, and uterus.
○ Hollow viscera - structures that change
shape depending on their contents.
○ Ex. stomach, gallbladder, small
intestine, colon and bladder.
Solid Viscera
● Liver, is the largest solid organ in the body
but has a soft consistency and functions as an
accessory digestive organ, it could serve as a
glucose storage, urea synthesis, bile formation,
and more.
○ Located below the diaphragm in the
RUQ, it has four lobes that fill most of
the RUQ and extend to the left
midclavicular line.
○ In many individuals, the liver can be
felt just below the right costal margin
and may be palpated there.
● The pancreas, located behind the stomach
deep in the upper abdomen functions as an
endocrine gland and an accessory organ of
digestion.
○ Normally not palpable.
○ Extends across the abdomen from the
RUQ to the LUQ.
● Spleen, a soft and flat structure, functions
primarily to filter the blood of cellular debris,
digest MOs, and return the breakdown
products to the liver.
○ Located above the left kidney just below
the diaphragm at the level of the 9th,
10th, and 11th ribs, posterior to the left
midaxillary line, posterior and lateral to
the stomach, and is 7cm wide.
○ Normally not palpable, but in some
healthy clients the lower tip is
palpable below the left costal margin.
● Kidneys, glandular, bean-shaped organs,
10x5x2.5 cm a posterior organ and functions as
filtration and elimination of metabolic waste
products and as endocrine glands; also plays a
role in BP control, maintenance of water, salt,
and electrolyte balance.
○ T12 to L3 vertebrae.
○ Protected by the posterior rib cage (tops
of both kidneys).
○ Tenderness is best assessed at the
costovertebral angle.
○ RK - positioned slightly lower because
of the liver’s position; in some thin
clients, the bottom can be palpated
anteriorly.
● Pregnant uterus, may be palpated above the
level of the symphysis pubis in the midline.
● Ovaries, located in the RLQ and LLQ, normally
palpated only during a bimanual examination
of the internal genitalia.
Hollow Viscera
● Abdominal cavity begins with the stomach. It is
a distensible, flask-like organ located in the
LUQ just below the diaphragm and between the
liver and spleen.
● Stomach is not usually palpable. Its main
function is to store, churn, and digest food.
● The gallbladder, a muscular sac approximately
10 cm long, functions primarily to concentrate
and store the bile needed to digest fat. It is
located near the posterior surface of the liver
lateral to the MCL. It is not normally palpated
because it is difficult to distinguish between
the gallbladder and the liver.
● The small intestine is actually the longest
portion of the digestive tract (approximately 7.0
 m long) but is named for its small diameter ● The aorta branches into the right and left iliac
(approximately 2.5 cm). Two major functions of arteries just below the umbilicus. Pulsations of
the small intestine are digestion and the right and left iliac arteries may be felt in the
absorption of nutrients through millions of RLQ and LLQ.
mucosal projections lining its walls. The small
intestine, which lies coiled in all four quadrants
of the abdomen, is not normally palpated.
● The colon, or large intestine, has a wider
diameter than the small intestine (approximately
6.0 cm) and is approximately 1.4 m long. It
originates in the RLQ, where it attaches to the
small intestine at the ileocecal valve. The colon
is composed of three major sections:
ascending, transverse, and descending.
○ The ascending colon extends up along
the right side of the abdomen. At the
junction of the liver in the RUQ, it flexes
at a right angle and becomes the
transverse colon.
○ The transverse colon runs across the
upper abdomen. In the LUQ near the Lesson: Abdominal System - RLE
spleen, the colon forms another right
angle, then extends downward along the SUBJECTIVE DATA
left side of the abdomen as the
descending colon. At this point, it curves HISTORY OF PRESENT HEALTH CONCERN
in toward the midline to form the sigmoid
colon in the LLQ. QUESTION RATIONALE
○ The sigmoid colon is often felt as a
Abdominal Pain
firm structure on palpation, whereas
the cecum and ascending colon may Are you experiencing Affected by chemical
feel softer. abdominal pain? If the or mechanical factors
○ The transverse and descending colon client answers such as inflammation,
may also be felt on palpation. yes, use COLDSPA to infection, distention,
● The colon functions primarily to secrete large further explore this stretching, pressure,
symptom: obstruction, or
amounts of alkaline mucus to lubricate the
trauma.
intestine and neutralize acids formed by the
intestinal bacteria. Water is also absorbed Character: Describe the The quality or
through the large intestine, leaving waste pain (dull, aching, character of the pain
products to be eliminated in stool. burning, gnawing, may suggest its origin
● The urinary bladder, a distensible muscular sac pressure, colicky, sharp,
located behind the pubic bone in the midline knifelike, stabbing,
throbbing,
of the abdomen, functions as a temporary variable).
receptacle for urine. A bladder filled with urine
may be palpated in the abdomen above the Onset: When did (does) The onset of pain is a
symphysis pubis. the pain begin? diagnostic clue to its
origin.
Vascular Structures ● Excessive gas
after ingesting
● The abdominal organs are supplied with certain foods.
arterial blood by the abdominal aorta and its ● A burning
major branches. Pulsations of the aorta are sensation in the
esophagus may
frequently visible and palpable midline in the
occur with gastric
upper abdomen. acid reflux after
 eating.
Pain related to gastric
ulcers may occur
when the stomach is
empty.
Location: Point to the Location helps to
area where you have this determine the pain
pain. Does it source and whether it
radiate or spread to other is primary or referred.
areas? Where is the pain
located? Although abdominal
Does it move or has it pain can arise from
changed from the original the skin and
location? abdominal wall
muscles
● also originate
from abdominal
organs, including
the stomach,
small intestine,
colon, liver,
gallbladder,
spleen, and
pancreas.
● Dull or burning
pain located
between the
breasts and
umbilicus may
occur with peptic
ulcers.
● May also be felt
in the lower
lungs, kidneys,
uterus, or
ovaries.
● Pancreatic
inflammation may
be felt in the
back. This is
called “referred
pain” because the
pain is not felt at
its source.
Duration: How long does May be intermittent or
the pain last? prolonged, and varies
with different causes of
the pain.
Severity: How bad is the Perception of pain of the
pain on a scale of 1-10, client that provides data
with 10 being the worst? on their response and
tolerance to pain and
sensitivity to pain.
Patterns: When does the
pain occur?
What seems to bring on
the pain (precipitating
factors), make it worse
(exacerbating factors) or
make it better (alleviating
factors)?
Associated factors/How it
affects the client: Is the
pain associated with any
other symptoms?
Associated signs and
symptoms may
provide diagnostic
evidence to support or
rule out a particular
origin of pain. For
example, epigastric
pain accompanied by
tarry stools suggests
a gastric or duodenal
ulcer. Abdominal pain
with cramping,
diarrhea, nausea,
vomiting, weight loss,
and lack of energy is
Older adults have
diminished sensitivity to
pain, assess them
carefully for acute
abdominal conditions.
Timing and the
relationship of particular
events may be a clue to
the origin
of pain.
Various factors can
precipitate or
exacerbate abdominal
pain.
Ex. alcohol
ingestion with
pancreatitis or supine
position with
gastroesophageal
reflux disease
(GERD).
● Lifestyle and
stress factors
may be
implicated in
certain digestive
disorders, such
as peptic ulcer
disease.
● Alleviating
factors, such as
using antacids or
histamine
blockers, may be
a clue to the
origin.
Associated signs and
symptoms may provide
diagnostic
evidence to support or
rule out a particular
origin of pain.
● Ex. epigastric
pain
accompanied by
tarry stools
suggests a
gastric or
duodenal ulcer.
● Abdominal pain
with cramping,
diarrhea, nausea,
vomiting, weight
loss, and lack of
energy is often
often seen in Crohn's seen in Crohn's
disease. disease. symptoms with
indigestion, such as
nausea, vomiting,
Indigestion diarrhea, or constipation?
Do you experience Indigestion (pyrosis),
indigestion? Describe often described as
how this feels. heartburn, may be an
indication of acute or
chronic gastric disorders.
When did you first The main symptom of
experience this? When GERD in adults is
does this usually begin? frequent heartburn,
which is acid
indigestion, a burning
type of pain in the lower
part of the mid-chest,
behind the breast
bone, and in the
mid-abdomen.
Some
adults have GERD
without heartburn but
instead may have a
dry cough, asthma
symptoms, or trouble
MECHANISMS AND SOURCES OF ABDOMINAL PAIN
swallowing (Cleveland
Clinic, 2019).
TYPES OF PAIN
Point to where you Take time to
usually feel indigestion. determine the client’s
exact symptoms
because many clients
call indigestion
gassiness, belching,
bloating, and nausea.
How long does the
indigestion last? How
often does it recur?
Describe the severity of
this feeling on a scale of
1-10 (10 being the worst).
Does the indigestion
cause you to quit any of
your daily activities?
What activities can you
not do when you have
indigestion?
Does anything in Certain factors (e.g.,
particular seem to cause food, drinks, alcohol,
or aggravate the medications, stress)
indigestion have you are known to increase
noticed that this gastric secretion and
sensation occurs after acidity and cause or
you eat certain foods? aggravate indigestion.
Do you have other Indigestion
accompanied by
these factors
indicates more than
local irritation and
needs further
investigation.
Ex. nausea and
vomiting are often
seen with diseases of
the gastrointestinal
(GI) tract, in the first
trimester of
pregnancy, or as an
adverse effect of
medications. Vomiting
with blood
(hematemesis) is
seen with esophageal
varices or duodenal
ulcers. Diarrhea may
be seen with food
intolerances,
infections, and
irritable bowel.
● Abdominal pain may be formally described as
visceral, parietal, or referred.
● Visceral pain occurs when hollow abdominal
organs—such as the intestines—become
distended or contract forcefully, or when the
capsules of solid organs such as the liver and
spleen are stretched. Poorly defined or localized
and intermittently timed, this type of pain is often
characterized as dull, aching, burning, cramping,
or colicky.
● Parietal pain occurs when the parietal
peritoneum becomes inflamed, as in
appendicitis or peritonitis. This type of pain
tends to localize more to the source and is
characterized as a more severe and steady
pain.
● Referred pain occurs at distant sites that are
innervated at approximately the same levels as
the disrupted abdominal organ. This type of pain
travels, or refers, from the primary site and
becomes highly localized at the distant site.
 ● Splenic abscess
● Splenic rupture
● Renal colic
● Renal tumor
● Ureteral colic
● Vascular liver tumor
● Variable
● Stomach cancer

Physical Assessment for Abdomen

CHARACTER OF ABDOMINAL PAIN AND
IMPLICATIONS – Inspection, Auscultation, Percussion, Palpation

Dull, Aching Common abnormal findings include:

● Appendicitis ● Abdominal edema, or swelling, signifying ascites

● Acute hepatitis ● Abdominal masses, signifying abnormal growths
● Biliary colic or constipation
● Cholecystitis ● Unusual pulsations such as those seen with an
● Cystitis aneurysm of the abdominal aorta
● Dyspepsia ● Pain associated with appendicitis
● Glomerulonephritis
● Incarcerated or strangulated hernia Observe the coloration of Normal findings:
● Irritable bowel syndrome the skin. ● Abdominal skin
● Hepatocellular cancer may be paler
● Pancreatitis than the general
skin tone
● Pancreatic cancer
● Perforated gastric or duodenal ulcer Abnormal findings:
● Peritonitis ● Purple
● Peptic ulcer disease discoloration at
● Prostatitis the flanks (Grey
Turner sign)
Burning, Gnawing ● The yellow hue of
jaundice may be
● Dyspepsia more apparent on
● Peptic ulcer disease the abdomen.
● Cramping (“crampy”) ● Pale, taut skin
may be seen with
● Acute mechanical obstruction
ascites.
● Appendicitis ● Redness may
● Colitis indicate
● Diverticulitis inflammation.
● Gastroesophageal reflux disease (GERD) ● Bruises or areas
of local
Pressure discoloration are
also abnormal.
● Benign prostatic hypertrophy
● Prostate cancer Note the vascularity of Normal Findings:
the abdominal skin. ● Scattered fine
● Prostatitis
veins may be
● Urinary retention visible.
For older adults:
Colicky ● Dilated superficial
capillaries without
● Colon cancer a pattern may be
seen in older
Sharp, Knifelike clients. They are

Note any striae (stretch
marks) due to past
stretching of the reticular
skin layers due to fast or
prolonged stretching.
Assess for lesions and
rashes.
more visible in Abnormal Findings:
sunlight. ● Changes in
Abnormal Findings: moles including
● Dilated veins may size, color, and
be seen with border symmetry.
cirrhosis of the ● Bleeding moles
liver, obstruction or petechiae
of the inferior (reddish or purple
vena cava, portal lesions)
hypertension, or
ascites. Inspect the umbilicus. Normal Findings:
For older adults: Note the color of the ● Umbilical skin
● Dilated surface umbilical area. tones are similar
arterioles and to surrounding
capillaries with a abdominal skin
central star tones or even
(spider angioma) pinkish.
may be seen with Abnormal Findings:
liver disease or ● Cullen’s sign: A
portal bluish or purple
hypertension. discoloration
around the
Normal Findings: umbilicus
● New striae are (periumbilical
pink or bluish in ecchymosis)
color; ● Grey Turner sign:
● Old striae are bluish or purplish
silvery, white, discoloration on
linear, and the abdominal
uneven stretch flanks.
marks from past
pregnancies or Observe umbilical Normal Findings:
weight gain. location. ● Observe umbilical
Abnormal Findings: location.
● Dark bluish-pink Abnormal Findings:
striae are ● A deviated
associated with umbilicus may be
Cushing caused by
syndrome. pressure from a
● Striae may also mass, enlarged
be caused by organs, hernia,
ascites, which fluid, or scar
stretches the tissue.
skin.
● Nonhealing Assess contour of Normal Findings:
wounds, redness, umbilicus. ● It is recessed
inflammation. (inverted) or
● Deep, irregular protruding no
scars may result more than 0.5 cm
from burns. and is round or
conical.
Normal Findings: Abnormal Findings:
● Abdomen is free ● An everted
of lesions or umbilicus is seen
rashes. with abdominal
● Flat or raised distention
brown moles, ● An enlarged,
however, are everted umbilicus
normal and may suggests
be apparent. umbilical hernia.
Inspect abdominal Normal Findings: appears as a
contour. Sitting at the ● Abdomen is flat, bulge between a
client’s side, look across rounded, or vertical midline
the abdomen at a level scaphoid (usually separation of the
slightly higher than the seen in thin abdominis rectus
client’s abdomen (Fig. 23- adults; muscles.
9). Inspect the area ● Abdomen should ● An incisional
between the lower ribs be evenly hernia may occur
and pubic bone. Measure rounded. when a defect
abdominal girth as Abnormal Findings: develops in the
indicated in Assessment ● A generalized abdominal
Guide 23-2. protuberant or muscles because
distended of a surgical
abdomen incision.
● Distention below ● A mass within the
the umbilicus abdominal wall is
may be due to a more prominent
full bladder, when the head is
uterine raised, whereas a
enlargement, or mass below the
an ovarian tumor abdominal wall is
or cyst. obscured.
● Distention of the
upper abdomen Inspect abdominal Normal Findings:
may be seen with movement when the ● Abdominal
masses of the client breathes respiratory
pancreas or (respiratory movement may
gastric dilation. movements). be seen,
Clinical Tip: especially in male
● The major causes clients.
of abdominal Abnormal Findings:
distention are ● Diminished
sometimes abdominal
referred to as the respiration or
“6 Fs”: Fat, feces, change to
fetus, fibroids, thoracic breathing
flatulence, and in male clients
fluid may reflect
peritoneal
Assess abdominal Normal Findings: irritation.
symmetry. Look at the ● Abdomen is
abdomen as the client symmetric. Observe aortic Normal Findings:
lies in a relaxed supine Abnormal Findings: pulsations. ● A slight pulsation
position. ● of the abdominal
aorta, which is
visible in the
Further assessment. To Normal Findings: epigastrium,
further assess the ● Abdomen does extends full
abdomen for herniation or not bulge when length in thin
diastasis recti or to the client raises people.
differentiate a mass within head. Abnormal Findings:
the abdominal wall from Abnormal Findings: ● Vigorous, wide,
one below it, ask the ● A hernia exaggerated
client to raise the head. (protrusion of the pulsations may
bowel through the be seen with
abdominal wall) is abdominal aortic
seen as a bulge aneurysm.
in the abdominal
wall. Observe for peristaltic Normal Findings:
● Diastasis recti waves. ● Peristaltic waves
 are not seen, bowel sounds
although they indicate
may be visible in diminished bowel
very thin people motility.
as slight ripples ● Common causes
on the abdominal include paralytic
wall. ileus following
Abnormal Findings: abdominal
● Peristaltic waves surgery,
are increased inflammation of
and progress in a the peritoneum,
ripple-like fashion or late bowel
from the LUQ to obstruction. May
the RLQ with also occur in
intestinal pneumonia.
obstruction
(especially small Clinical Tip: Clinical Tip
intestine). Bowel sounds may Normal Findings:
● Abdominal be more active over the ● Bowel sounds
distention ileocecal valve in the resume gradually
typically is RLQ. depending on the
present with type of surgery.
intestinal wall ● Stomach
obstruction. emptying takes
24–48 hours to
Auscultate for bowel Normal Findings: resume; and the
sounds. ● A series of colon requires 3–
intermittent, soft 5 days to recover
clicks and gurgles propulsive
are heard at a activity.
rate of 5– Abnormal Findings:
30/minute. ● Decreased or
Hyperactive absent bowel
bowel sounds sounds signify
referred to as the absence of
“borborygmus” bowel motility
may also be
heard. These are Confirm bowel sounds in Abnormal Findings:
the loud, each quadrant. Listen for ● Absent bowel
prolonged up to 5 minutes (minimum sounds may be
gurgles of 1 minute per quadrant) associated with
characteristic of to confirm the absence of peritonitis or
one’s “stomach bowel sounds. paralytic ileus.
growling.” ● High-pitched
Abnormal Findings: Clinical Tip: tinkling and
● “Hyperactive” Bowel sounds rushes of
bowel sounds, normally occur every 5– high-pitched
including rushing, 15 seconds. An easy sounds with
tinkling, and way to remember is to abdominal
high-pitched equate one bowel sound cramping usually
tones, may to one breath sound. indicate
indicate abnormal obstruction.
rapid motility in Note the intensity, pitch,
conditions like and frequency of the Clinical Tip:
early bowel sounds. ● The increasing
obstruction, pitch of bowel
gastroenteritis, sounds is most
diarrhea, or diagnostic of
laxative use. obstruction
● “Hypoactive” because it
 signifies intestinal stethoscope. rare. If heard,
distention. they have a
highpitched,
Auscultate for vascular Normal Findings: rough, grating
sounds. ● Bruits are not sound produced
Use the bell of the normally heard when the large
stethoscopse to listen for over above surface area of
bruits, a low-picthed, abdominal aorta the liver or spleen
murmur-like sound. or renal, iliac or rubs the
femoral arteries. peritoneum. They
Also, bruits may are heard in
be normal in association with
some clients respiration.
depending on ● Heard over the
differentiating lower right costal
factors. area is
Abnormal Findings: associated with
● A bruit with both hepatic abscess
systolic and or metastases.
diastolic ● A rub heard at
components the anterior
occurs when axillary line in the
blood flow in an lower left costal
artery is turbulent area is
or obstructed. It associated with
may indicate splenic infarction,
aneurysm or abscess,
renal artery infection, or
stenosis. tumor.

Clinical Tip: Normal Findings: Percuss for tone. Normal Findings:

Auscultating for vascular ● Lightly and systematically ● Generalized
sounds is especially Abnormal Findings: percuss al quadrants. tympany
important if the client has ● An ultrasound or predominates
hypertension or if you an angiogram is over the
suspect arterial artery needed to be abdomen
insufficiency to the legs. more accurate. because of air in
the stomach and
Listen for venous hum. Normal Findings: intestines.
Use the bell of the ● Not normally ● Dullness may
stethoscope. to listen for heard over the also be elicited
a venous hum in the epigastric and over a
epigastric and umbilical umbilical areas. nonevacuated
areas. Abnormal Findings: descending
● Are rare, however colon.
an accentuated Abnormal Findings:
venous hum ● Accentuated
heard in the tympany or
epigastric or hyperresonance
umbilical areas is heard over a
suggests gaseous
cirrhosis of the distended
liver. abdomen.
● Enlarged area of
Auscultate for a friction Normal Findings: dullness is heard
rub over the liver and ● No friction rub over an enlarged
spleen. over liver or liver or spleen.
Listen over the right and spleen is present. ● Abnormal
left lower rib cage with Abnormal Findings: dullness is heard
the diaphragm of the ● Friction rubs are over a distended
 bladder, large the client to exhale after
masses or percussing.
ascites.
● If it’s ascites, To assess the upper Normal Findings:
perform the boarder, percuss over the ● Is located
shifting dull ness upper right chest at the between the left
and fluid wave MCL and percuss fifth and seventh
tests. downward, noting the intercostal
change from lung spaces.
Percuss the span of Normal Findings: resonance to liver Abnormal Findings:
height of the liver by ● The lower border dullness. ● May be difficult to
determining its lower and of liver dullness is estimate if
upper borders. located at the Mark this point: obscured by
costal margin to It’s the upper border of pleural fluid of
1–2 cm below. liver dullness lung
Abnormal Findings: consolidation.
● If it cannot be
found, keep in Measure the distance Normal Findings:
mind that the between two marks: the ● 6-12 cm, greater
lower border of span of the liver. in men and taller
liver dullness may clients, less in
be difficult to shorter clients.
estimate when Abnormal Findings:
obscured by ● Hepatomegaly, a
intestinal gas. liver span that
exceeds normal
limits is
chaarcteristic of
liver tumors,
cirrhosis,
abscess, and
vascular
enlargement.
● Atrophy is
indicated by a
decreased span.
● Liver in lower
position than
normal may be
caused by
emphysema.
● A higher position
may be caused
by an abdominal
mass, ascites or
paralyzed
diaphragm.
● A liver in a lower
To assess the lower RLQ Normal Findings: or higher position
at the MCL and percuss ● On deep should have a
upward. Note the change inspiration, the normal span.
from tympany to dullness. lower of the
border dullnes Repeat percussion of the Normal Findings:
Mark this point: It’s the may descend liver at the midsternal line ● Normal liver span
lower border of liver from 1 to 4 cm (MSL). is 4-8 cm.
dullnes. To assess the below the costal
descent of the liver, ask margin. Abnormal Findings:
the client tot ake a deep Abnormal Findings: ● Enlarged liver
breath hold; then repeat ● may be roughly
the procedure. Remind estimated, not

Scratch test, a technique
that can be used to
ascertain the location and
size of the liver and
spleen. It can be useful if
the abdomen is tense
(rigid or guarded),
distended, obese, or too
tender to palpate.
Percuss the spleen.
Perform blunt percussion
on the liver and the
kidneys.
Perform light palpation.
accurately, when nontender and
more intense soft. There is no
sounds outline a guarding.
liver span or
borders outside Abnormal Findings:
the normal range. ● Involuntary reflex
guarding, a
Normal Findings: serious and
● Normal liver span reflects peritoneal
is at the MSL and irritation. Usually
is 4-8 cm. seen on the side
because of nerve
Abnormal Findings: tract patterns.
● Enlarged liver Right sided
may be roughly guarding may be
estimated, not due to
accurately, when cholecystitis.
more intense
sounds outline a Deeply palpate all Normal Findings:
liver span or quadrants to delineate ● Normal (mild)
borders outside abdominal organs and tenderness is
the normal range. detect subtle masses. possible over the
xiphoid, aorta,
Normal Findings: cecum, sigmoid
● An oval area of colon, and
dullness approx. ovaries.
7 cm wide near
the left tenth rib Abnormal FIndings:
and slightly ● Severe
posterior to the tenderness or
MAL. pain may be
related to trauma,
Abnormal Findings: peritonitis,
● Splenomegaly, infection, tumors,
characterized by or enlarged
an area of diseased organs.
dullness greater
than 7 cm wide. Palpate for masses. Normal Findings:
The enlargement No palpable masses are
may result from present.
traumatic injury,
portal Abnormal Findings:
hypertension, and ● A mass detected
mononucleosis. in any quadrant
may be due to a
Normal Findings: tumor, cyst,
● Normally, no abscess,
tenderness is enlarged organ,
elicited. aneurysm, or
adhesions.
Abnormal Findings:
● Tenderness Palpate the umbilicus and Normal Findings:
elicited over the surrounding area for ● Umbilicus and
liver may be swelling, bulges or surrounding area
associated with masses. are free of
inflammation or swellings, bulges
infection. or masses.
Normal Findings: Abnormal Findings:
● Abdomen is ● A soft center of
 the umbilicus can cancer, late
be a sign of cirrhosis, or
herniation. syphilis.
● Palpation of a ● Tenderness may
hard nodule in or be from vascular
around the engorgement
umbilicus may (e.g., congestive
indicate heart failure),
metastatic nodes acute hepatitis, or
from an occult GI abscess.
cancer. ● A liver more than
1–3 cm below the
Palpate the aorta. Normal Findings: costal margin is
● Approx. 2.5-3.0 considered
cm wide with a enlarged (unless
moderately displaced by the
strong and diaphragm).
regular pulse.
Possible mild
tenderness may
be elicited. Palpate the spleen. Normal Findings:
● The spleen is
Abnormal Findings: seldom palpable
● A wide, bounding at the left costal
pulse may be felt margin.
with an ● Rarely, the tip is
abdominal aortic palpable in the
aneurysm. presence of a
● A prominent low, flat
laterally pulsating diaphragm (e.g.,
mass above the chronic
umbilicus with an obstructive lung
accompanying disease) or with
audible bruit, deep
suggests an diaphragmatic
aortic aneurysm. descent on
inspiration. ‘
Palpate the liver. Palpate Normal Findings: ● If the edge of the
bimanually. ● The liver is spleen can be
usually not palpated, it
palpable, should be soft
although it may and nontender.
be felt in some
thin clients. Abnormal Findings:
● If the lower edge ● A palpable spleen
is felt, it should suggests
be firm, smooth, enlargement (up
and even. Mild to 3x the normal
tenderness may size), which may
be normal. result from
infections,
trauma,
Abnormal Findings: mononucleosis,
● A hard, firm liver chronic blood
may indicate disorders, and
cancer. cancers
● Nodularity may ● The splenic notch
occur with may be felt,
tumors, which is an
metastatic indication of
 splenic Test for Ascites
enlargement.
● Splenic
enlargement may
not always be Test for Appendicitis/Peritoneal Irritation
pathologic.
● It feels firm with a Assess for rebound Normal Findings:
sharp edge when tenderness. ● No rebound
it is enlarged from tenderness is
chronic disease. present.
● Fells soft with a
rounded edge Abnormal Findings:
when it’s ● Rebound
enlarged from an tenderness is
infection present when the
client perceives
Palpate the kidneys. Normal Findings: sharp stabbing
● Kidneys are pain as the
usually not examiner
palpable. releases pressure
● Sometimes, the from the
lower pole of the abdomen,
RK may be suggests
palpable by the peritoneal
capture method, irritation.
it should feel firm,
smooth and Test for referred rebound Normal Findings:
rounded tenderness. Palpate ● No rebound pain
● The kidney may deeply in the LLQ and is elicited.
or may not be quickly release pressure.
slightly tender. Abnormal Findings:
● Pain in the RLQ
Abnormal Findings: during pressure
● Enlarged kidney in the LLQ is a +
may be due to a Rovsing sign,
cyst, tumor, or suggests acute
hydronephrosis, appendicitis.
can be
differentiated Assess for psoas sign. Normal Findings:
from ● No abdominal
splenomegaly by pain is present.
its smooth edge.
Abnormal Findings:
Palpate the urinary Normal Findings: Pain in the RLQ (psoas
bladder. ● Empty urinary sign) associated with the
bladder is neither irritation of the iliopsoas
palpable nor muscle due to
tender. appendicitis.

Abnormal Findings: Assess for obturator sign. Normal Findings:

● Distended ● No abdominal
bladder is pain is present.
palpated as a
smooth, round, Abnormal Findings:
and somewhat ● Pain in the RLQ
firm mass indicates irritation
extending as far of the obturator
as the umbilicus. muscle because
● Validated by dull of appendicitis.
percussion tones.
 ● Cause: Acute appendicitis
Perform hypersensitivity Normal Findings:
test. ● The client feels
Blumberg sign
no pain and no
exaggerated
- Abdominal pain or tenderness experienced
sensation.
when examiner tests for rebound tenderness by
Abnormal Findings: palpating deeply at 90 degrees into the
● Pain or abdomen halfway between the umbilicus and
exaggerated the anterior iliac crest (McBurney point)
sensation felt in ● Cause: Peritoneal irritation
the RLQ is a +
skin Abnormal Findings of Abdominal Distention
hypersensitivity
test and may PREGNANCY (NORMAL FINDING)
indicate
appendicitis. Pregnancy is included here so that the examiner may
differentiate it from abnormal findings.
Test for Cholecystitis
● It causes a generalized protuberant abdomen,
Assess RUQ pain or Normal Findings:
tenderness, which may ● No increase in protuberant umbilicus, a fetal heartbeat that can
signal cholecystitis pain is present. be heard on auscultation, percussible tympany
(inflammation of the over the intestines, and dullness over the uterus.
gallbladder). Press your
fingertips under the liver Abnormal Findings:
border at the right costal ● Accentuated
margin and ask the client sharp pain that
to inhale deeply. causes the client
to hold their
breath
(inspiratory
arrest)

Abdominal Signs

Psoas sign
FAT
- Pain in RLQ when leg is hyperextended
● Cause: Irritation of the iliopsoas muscle due to ● Obesity accounts for most uniformly protuberant
appendicitis (an inflamed appendix) abdomens. The abdominal wall is thick, and
tympany is the percussion tone elicited. The
Obturator sign
umbilicus usually appears sunken.
- Pain in the RLQ when hip and knee are flexed
FECES
and leg is rotated internally and externally
● Cause: Irritation of the obturator muscle due to Hard stools in the colon appear as a localized distention.
appendicitis or a perforated appendix Percussion over the area discloses dullness.
Murphy sign

- Pain elicited when pressure is applied under the

liver border at the right costal margin and client
inhales deeply
● Cause: Inflammation of the gallbladder

Rovsing sign

- Pain in the RLQ during pressure in the LLQ

 ❖ Medial canthus
- Contains puncta, 2 small
openings that allow drainage of
tears into the lacrimal system
- Contains caruncle, a small
fleshy mass that contains
sebaceous glands.
❖ Palpebral fissure
- White space between open
eyelids

*No sclera should be seen above or below the limbus

(the point where the sclera meets the cornea).

● Eyelashes
- Projections of stiff hair curving outward
along the margins of the eyelids that
filter dust & dirt from air entering the
eye.
● Conjunctiva
- Thin, transparent, continuous
membrane that is divided into 2
c
portions: a palpebral and a bulbar
portion.
❖ Palpebral conjunctiva
Lesson: Eyes and Ears: Lecture - Lines the inside of the eyelids.
❖ Bulbar conjunctiva
Eyes - Covers most of the anterior
eye, merging with the cornea at
- Transmits visual stimuli to the brain for the limbus.
interpretation.
- Functions as the organ of vision.

EXTERNAL STRUCTURES OF THE EYE

● Eyelids (upper & lower)

- 2 movable structures composed of
skin & 2 types of muscle: striated &
smooth.
- Protects the eye from foreign bodies.
- Limits the amount of light entering the
eye.
- Serve to distribute tears that lubricate
the surface of the eye.
- Join at 2 points: lateral (outer) canthus
& medial (inner) canthus.
❖ Upper eyelids
- Larger, more mobile
- Contains tarsal plates made up
of connective tissue. ● Lacrimal apparatus
- These places contain the - Consists of glands & ducts that
meibomian glands, which lubricate the eye.
secrete oily substances that ● Lacrimal gland
lubricate eyelids.
 - Located in the upper outer corner of
the orbital cavity just above the eye,
produce tears.
- As the lid blinks, tears wash across the
eye & then drain into the puncta, which
are visible on the upper & lower lids at
the inner canthus. Tears empty into
the lacrimal canals & are then
channeled into the nasolacrimal sac
through the nasolacrimal duct. They
drain into the nasal meatus.
● Extraocular muscles
- Six muscles attached to the outer
surface of each eyeball.
- Control 6 different directions of eye
movement.
- 4 rectus muscles (superior, inferior,
lateral, medial)
- 2 oblique muscles (superior, inferior)
- 3 cranial nerves: oculomotor (III),
trochlear (IV), and abducens (VI)
INTERNAL STRUCTURES OF THE EYE
● Eyeball
- Located in the eye orbit, a round, bony
hollow formed by several different bones
of the skull.
- Composed of 3 coats or layers: sclera &
cornea (external layer), iris & ciliary
body (middle layer), retina (innermost
layer)
❖ Sclera (E)
- Dense, protective, white
covering that physically
supports the internal structures
of the eye.
- Continuous anteriorly with the
transparent cornea.
❖ Cornea (E)
- Permits entrance of light, which
passes through the lens to the
retina.
- Well supplied with nerve
endings, making it responsive to
pain and touch
❖ Iris (M)
- Circular disc of muscle
containing pigments that
determine eye color.
- Muscles in the iris adjust to
control the pupil’s size, which
controls the amount of light
entering the eye.
- The muscle fibers of the iris also
decrease the size of the pupil
to accommodate for near vision
and dilate the pupil when far
vision is needed.
➔ Pupil
- The central aperture of the
iris.
➔ Lens
- Biconvex, transparent,
avascular, encapsulated
structure located
immediately posterior to the
iris.
- Suspensory ligaments
attached to the ciliary body
support the position of the
lens.
➔ Choroid layer
- Contains vascularity
necessary to provide
nourishment to the inner
aspect of the eye and
 prevents light from reflecting
internally.
- Anteriorly, it is continuous
with the ciliary body and
the iris.
❖ Retina (I)
- Innermost layer
- Extends only to the ciliary body
anteriorly.
- Receives visual stimuli and sends it to
the brain.
- Consists of numerous layers of nerve
cells, including the cells commonly
called rods and cones. These
specialized nerve cells are often
referred to as “photoreceptors”
because they are responsive to light.
The rods are highly sensitive to light,
regulate black-and-white vision, and
function in dim light. The cones
function in bright light and are
sensitive to color.
➔ Optic disc
- Cream-colored, circular area
located on the retina toward the
medial or nasal side of the eye.
- Optic nerve enters the eyeball.
- Seen with the use of an
ophthalmoscope and is normally
round or oval in shape, with
distinct margins.
- A smaller circular area that
appears slightly depressed is
referred to as the physiologic
cup.
➔ Retina Vessels
- Can be readily viewed with the aid
of an ophthalmoscope.
- Four sets of arterioles & venules
travel through the optic disc,
bifurcate, and extend to the
periphery of the fundus.
- Venules are dark red and grow
progressively narrower as they
extend out to the peripheral areas.
- Arterioles carry oxygenated
blood and appear brighter red
and narrower than the veins. The
general background, or fundus,
varies in color, depending on skin
color.
- A retinal depression known as the
fovea centralis.
- The fovea centralis and macular
area are highly concentrated with
cones and form the area of highest
visual resolution and color vision.
- Contains several chambers that
maintain structure, protect against
injury, and transmit light rays.
❖ Anterior chamber
- Located between the cornea
and the iris.
❖ Posterior chamber
- Area a between the iris and the
lens.
❖ Vitreous chamber
- Located in the area behind the
lens to retina.
- Largest of the chambers
- Filled with vitreous humor
(gelatinous).
❖ Aqueous humor
- Inside the chambers
- Clear liquid substance produced
by the ciliary body.
- Helps cleanse & nourish the cornea
& lens as well as maintain
intraocular pressure.
● Eye orbit
- In the orbit, a cushion of fat surrounds
the eye.
- The bony orbit & fat cushion protects
the eyeball.
Visual Fields & Visual Pathways
● Visual fields
- What a person sees with one eye.
- Can be divided into 4 quadrants: upper
& lower temporal, upper & lower nasal.
- Humans have binocular vision (2 eyed
vision)
 ● Visual perception
- Occurs as light rays strike the retina,
where they are transformed into nerve
impulses, conducted to the brain
through the optic nerve, and interpreted.
Visual Reflexes
● Pupillary light reflex
- Cause pupils to constrict immediately
when exposed to bright light.
- This can be seen as a direct reflex, in
which constriction occurs in the eye
exposed to the light,
- Indirect or consensual reflex, in which
exposure to light in one eye results in
constriction of the pupil in the
opposite eye.
● Accommodation
- Functional reflex allowing the eyes to
focus on near objects.
Ears
- Sense organ of hearing and equilibrium.
- Consists of three distinct parts: the external
ear, the middle ear, and the inner ear.
- Tympanic membrane separates the external
ear from the middle ear.
External Ear
- Composed of the auricle, or pinna, and the
external auditory canal.
● Auricle (pinna)
- Portion of external ear visible without
any tools.
- Composed of thin plate of yellow elastic
cartilage covered by tight-fitting skin and
is shaped with hollows, furrows, and
ridges that form an irregular funnel to
conduct sound waves into the external
auditory canal.
● External Auditory Canal
- S-shaped in adults.
- The outer part of the canal curves up
and back; the inner part of the canal
curves down and forward.
❖ Cerumen
- Secreted by the modified
sweat glands in external ear
canal.
- Wax-like substance that keeps
the tympanic membrane soft.
- Has bacteriostatic properties.
- Sticky consistency serves as a
defense against foreign bodies.
Middle Ear
- Also called tympanic cavity
- Small, air-filled chamber in the temporal bone.
- Separated from the external ear by the
tympanic membrane (eardrum) and from the
inner ear by a bony partition containing two
openings, the round and oval windows.
● Tympanic membrane
- Also called Eardrum.
- Has translucent, pearly gray
appearance and serves as a partition
stretched across the inner end of the
auditory canal, separating it from the
middle ear.
- Concave & located at the end of the
auditory canal in a tilted position such
that the top of the membrane is closer to
the auditory meatus than the bottom.
❖ Handle and short process of the
malleus
- the nearest auditory ossicle that
can be seen through the translucent
membrane.
❖ Umbo
- the base of the malleus, also
serving as a center point
landmark.
❖ Cone of light
- the reflection of the otoscope light
seen as a cone due to the concave
nature of the membrane.
❖ Pars flaccida
- the top portion of the membrane
that appears to be less taut than
the bottom portion.
❖ Pars tensa
- the bottom of the membrane that
appears to be taut.
❖ The middle ear contains three
auditory ossicles
- the malleus, the incus, and the
stapes
Inner Ear
- Also called labyrinth
 - Fluid-filled & made up of the bony labyrinth SUBJECTIVE DATA / HISTORY TAKING
and an inner membranous labyrinth.
- The bony labyrinth has three parts: the
HISTORY OF PRESENT HEALTH CONCERN
cochlea, the vestibule, and the semicircular
canals. Visual difficulties or ● Sudden changes
❖ Inner cochlear duct changes are associated with
- Contains the spiral organ of Corti, acute problems
which is the sensory organ for (head trauma or >
hearing. intracranial
pressure.
● Gradual changes
may be related to
❖ Sensory receptors
aging, diabetes,
- Located in the vestibule & the
hypertension,
membranous semicircular canals,
neurologic
sense position & head movements disorders
to help maintain both static and
dynamic equilibrium. Spots or floaters ● Common among
❖ Nerve fibers client with myopia
- Form the vestibular nerve, or in clients age 40.
which connects with the
cochlear nerve to form cranial Blind spots ● Blind spot
nerve VIII (acoustic or (scotoma) is
vestibulocochlear nerve). surrounded by
either normal or
Hearing slightly diminished
peripheral vision.
● Conductive hearing ● Maybe from
- Transmission of sound waves through glaucoma.
the external and middle ear. ● Intermittent blind
● Perceptive or sensorineural hearing spots may be
- Transmission of sound waves in the associated with
inner ear. vascular spasms
● Bone Conduction (ophthalmic
- Transmission of sound waves in the migraine )
bones of the skull. ● Consistent blind
spots may indicate
retinal detachment.

Halos or rings around ● Associated with

lights narrow-angle
glaucoma.

Trouble seeing at ● Night blindness is

night associated with
optic atrophy,
glaucoma &
vitamin A
deficiency

Eye pain or itching, ● Burning or itching

pain with bright lights pain is usually
associated with
Eyes: Physical Assessment allergies or
superficial
 irritation. effects of drugs
● Throbbing, are often
stabbing, deep, unrecognized or
aching pain overlooked. Some
suggests s a medications
foreign body in the reported to have
eye or changes ocular side effects
within the eye. include alpha-1
blockers, some
Redness or swelling ● Usually associated antiarrhythmics,
with inflammatory anticholinergics, &
response caused other medications.
by allergy foreign
body, or bacterial / Last eye examination ● All clients at risk
viral infection. for eye problems
should be
Excessive watering or ● Caused by examined annually
tearing (epiphora) exposure to or as
irritants / recommended by
obstruction of their primary care
lacrimal provider. A
apparatus. thorough eye
● Unilateral examination is
epiphora is recommended for
associated with healthy clients
foreign body / without risk factors
obstruction. every 2 years, for
● Bilateral epiphora ages 18 through
is associated with 64; annually for
exposure to those aged 65 and
irritants (makeups, older (American
facial cleansers). Optometric
Association [AOA],
Eye discharge ● Discharge other 2020).
than tears from one
or both eyes Tested for glaucoma ● Younger than 40 &
suggests a has no glaucoma
bacterial or viral should be
infection. examined every
5-10 years.

PERSONAL HEALTH HISTORY Prescription or ● Clients who do not

corrective glasses wear the prescribed
Eye surgery ● May alter the corrective lenses
appearance of eye are susceptible to
and the results of eye strain.
future ● Improper cleaning
examinations. or prolonged
wearing of contact
Past treatments ● Client may not be lenses can lead to
(medications, surgery, satisfied with past infection and
laser, corrective lenses) treatments for corneal damage.
vision problems.

Types of medications ● Ocular side

 FAMILY HISTORY has been found to
be strongly
History of eye ● Many eye disorders associated with eye
problems or vision have familial diseases, doubling
loss tendencies. the chance of
● Estimated that forming cataracts
nearly 22 million and causing a
will have macular threefold risk of
degeneration developing AMD.
worldwide by the
year 2050.
OBJECTIVE DATA
LIFESTYLE AND HEALTH PRACTICES
Distant visual acuity Normal:
Exposure to ● Injuries or diseases 20/20 with or without
conditions or may be related to corrective lenses
substances in exposure in the
workplace or home workplace or home. Deviation:
(chemicals, fumes, ● These problems Myopia (impaired far
smoke, dust, flying can be minimized vision) is present when
sparks) or avoided the second number in
altogether with the test result is larger
hazard than the first (20/40).
identification and
Near visual acuity Normal:
implementation of
14/14 with ot without
safety measures.
corrective lenses
Wears sunglasses ● Exposure to
during exposure to ultraviolet Deviation:
sun radiation puts the Presbyopia (impaired
client at risk for the near vision) is
development of indicated when client
cataracts. moves the chart away
from eyes to focus on
Vision loss ● Vision problems print.
may interfere with
the client’s ability Visual fields for gross Normal:
to perform usual peripheral vision Client should see
activities of daily examiner’s finger at the
living. same time the
examiner sees it.
Visual aids ● It is important to Inferior: 70 degrees
(magnifying glasses, assist the client to Superior: 50 degrees
audiotapes, CDs, access and use Temporal: 90 degrees
special glasses) assistive and Nasal: 60 degrees
adaptive visual
devices to improve Deviation:
one’s activities of Delayed or absent
daily living. perception of
examiner’s finger.
Typical diet ● Well-balanced diet
is essential.
Corneal light reflex Normal:
Smoking ● Tobacco smoking Reflection of light on
 Inspect & Palpate
the corneas should be
in the exact same spot
on each eye. Eyelids & Eyelash Normal:
Upper lid margin is
Deviation: between the upper
Asymmetric position of margin of iris & pupil.
the light reflex indicates
deviated alignment of Lower lid margin rests
the eyes. This may be on lower border of iris.
due to muscle
weakness or paralysis. Palpebral fissures may
be horizontal.
Cover test Normal:
Uncovered eye should Upper & lower lids
remain fixed straight close easily & meet
ahead. The covered completely.
eye should remain
fixed straight ahead Lower lid is upright, (-)
after being uncovered inward or outward

Deviation: Eyelashes are evenly

The uncovered eye will distributed, curved
move to establish focus outward
when the opposite eye
is covered. Skin (-) redness,
swelling, lesions.
Phoria is a term used
to describe Deviation:
misalignment that
occurs only when Ptosis or
fusion reflex is blocked. blepharoptosis,
drooping of upper lid
Strabismus is constant
malalignment of the Failure of lids to close
eyes. can cause corneal
damage.
Tropia is a specific
type of misalignment: Entropion, inverted
esotropia is an inward lower lid.
turn of the eye.
Ectropion, everted
Exotropia is an lower eyelid
outward turn of the eye.
Hordeolum (stye), a
Cardinal fields of Normal: hair follicle infection,
gaze Eye movement should causes local redness,
be smooth and swelling, and pain.
symmetric throughout
all six directions. Position & alignment Normal:
of eyeball Symmetrically aligned
Deviation: in sockets without
Failure of eyes to protruding or sinking.
follow movement
symmetrically in any Deviation:
or all directions.
 is turned slightly toward
Exophthalmos, the eye.
protrusion of the
eyeballs accompanied Deviation:
by retracted eyelid Redness or swelling
margins. (charac of may caused by
Graces disease) blockage, infection, or
inflammatory condition.
Bulbar & conjunctiva Normal:
Bulbar conjunctiva is Lacrimal apparatus Normal:
clear, moist, smooth, No drainage should be
and transparent, with noted from the puncta
visible tiny blood when palpating the
vessels. nasolacrimal duct.
Sclera is smooth and
white, with no lesions, Deviation:
foreign bodies, or Expressed drainage
exudates. from the puncta on
palpation occurs with
Darker-skinned clients duct blockage.
may have sclera with
yellow or pigmented Cornea & Lens Normal:
freckles. Cornea is transparent,
with (-) opacities. The
Yellowish nodules on oblique view shows a
the bulbar conjunctiva smooth and overall
are common in older moist surface; the lens
clients and appear first is free of opacities.
on the medial side of
the iris and then on the Deviation:
lateral side. Areas of roughness or
dryness on the cornea
Deviation: are often associated
with injury or allergic
Conjunctivitis, pink responses. Opacities of
eye, generalized the lens are seen with
redness of the cataracts.
conjunctiva
Iris & pupil Normal:
Palpebral conjunctiva Normal: Iris is typically round,
Lower and upper flat, and evenly
palpebral conjunctivae colored. Brown is the
are clear and free of most common iris color,
swelling or lesions. but green, hazel, or
blue may also be seen.
Deviation:
Cyanosis of the lower Pupil, round with a
lid suggests a heart or regular border, is
lung disorder. centered in the iris.
Pupils are normally
Lacrimal apparatus Normal: equal in size (3–5 mm).
(-) swelling/redness
Puncta is visible Deviation:
without Irregularly shaped
swelling/redness, and irises.
Pupillary reaction to Normal: Ringing, roaring, ● Ringing (tinnitus),
light Bilateral constriction of crackling excessive earwax
pupils to light. build up, > BP
● 60 years old &
Normal consensual above are at risk of
pupillary response is tinnitus
constriction.
Vertigo ● True spinning
Deviation: motion may be
Monocular blindness associated with
can be detected when inner ear problem.
directed to blind eye. ● Subjective
vertigo, clients feel
Pupils do not react at that they are
all to direct and spinning around.
consensual pupillary ● Objective vertigo,
testing. client feel that the
room is spinning
Pupil accommodation Normal: around them.
Pupils constrict &
converge when
focusing on near
object.
PERSONAL HEALTH HISTORY
Deviation:
(-) constriction, (-) Ear problems ● History of repeated
convergence (infections, trauma, infections can affect
earaches) the tympanic
membrane and
hearing.
Ears: Physical Assessment
Past treatments ● Client may be
SUBJECTIVE DATA / HISTORY TAKING (medication, surgery, dissatisfied with
hearing aids) past treatments.
HISTORY OF PRESENT HEALTH CONCERN

Changes in hearing ● Sudden decrease

in ability to hear in
one ear may be FAMILY HISTORY
associated with
History of hearing ● Age-related hearing
otitis media,
loss loss tends to run in
earwax (cerumen)
families.
impaction, or
● Otosclerosis
foreign-body
(fusion of the
obstruction.
ossicles in the
Ear drainage ● Drainage middle ear over
(otorrhea) usually time) obstructs
indicates infection. transmission of
● Purulent, bloody sound waves from
drainage suggests the tympanic
an infection of the membrane to the
external ear inner ear, reducing
(external otitis). hearing ability.
 LIFESTYLE & HEALTH PRACTICES enlargement of the
external ear.
Last hearing ● Annual hearing
examination evaluations are Move pinna, press Normal:
recommended for tragus, palpate Auricle, tragus, mastoid
clients who are mastoid process process are firm &
exposed to loud nontender
noises for long
periods. No pain upon palpation
& moving
Cleaning of ears ● Earwax is a natural,
self-cleaning agent Deviation:
that should not be Painful auricle or tragus
regularly removed (otitis externa or
unless its causing a postauricular cyst)
problem.
● Mineral oil, baby oil, Tenderness over
glycerin, or mastoid process
commercial drops suggests mastoiditis
may be placed in
ear to moisten Tenderness behind ear
earwax. may occur with otitis
media
Inspect & Palpate
External auditory Normal:
canal Small amount of
Auricle, tragus, lobule Normal: odorless cerumen
Equal in size (4-10 cm)
Auricle aligns with Cerumen may be
corner of each eye & yellow orange, red,
within a 10 degree brown, gray, black
angle
Earlobes may be free, Soft, moist, dry, flaky,
attached, or soldered hard
(-) lesions, lumps, or
deformities Canal walls are pink,
Skin is smooth, (-) smooth
lumps, lesions, nodules
Consistent color Deviation:
Foul-smelling, sticky,
Deviation: bloody, watery,
Smaller than 4 cm or swelling, redness
larger than 10 cm
Malaligned / low-set Tympanic membrane Normal:
ears (eardrums) Pearly, gray, shiny,
translucent
Microtia is a congenital
deformity in which the (-) bulging/retraction
external ear and
sometimes the ear Cone-shaped reflection
canal are not fully of otoscope
developed.
flutter when bulb is
Macrotia is a inflated
congenital excessive
 Deviation: AC sound is normally
heard longer than BC
Acute otitis media, sound
red, bulging eardrum
and distorted, Deviation:
diminished, or absent BC > AC (bone
light reflex conduction is heard
longer than air
Serous otitis media, conduction)
yellowish, bulging
membrane with Romberg test Normal:
bubbles behind Client maintains
position for 20
Bluish or dark red color, seconds without
white spots, swaying or with
perforations, prominent minimal swaying.
landmarks
Deviation:
Whisper test Normal: Client moves feet
Able to correctly apart to prevent falls or
repeat the starts to fall from loss
two-syllable word as of balance. This may
whispered. indicate a vestibular
disorder.
Deviation:
Unable to repeat the
two-syllable word
after two tries Lesson: Mouth, Nose, and Throat: Physical
indicates hearing loss Assessment
and requires follow-up
testing by an HISTORY TAKING
audiologist
HISTORY OF PRESENT HEALTH CONCERN
Weber test Normal:
Vibrations are heard
Nose and Sinuses
equally well in both
ears. No lateralization
Pain over Sinuses - Acute sinusitis
of sound to either ear.
(cavities around nasal symptoms:
passages) - Pain, tenderness,
Deviation:
swelling, and pressure
- Around eyes,
With conductive
cheeks, nose, or
hearing loss, the client
forehead
reports lateralization of
- Result from sinus
sound to the poor
infection
ear—that is, the client
“hears” the sound in
- Chronic sinusitis:
the poor ear.
- Persistent
inflammation and
With sensorineural
swelling
hearing loss, the client
- Symptoms last 12+
reports lateralization of
weeks even with
sound to the good ear.
treatment
Rinne test Normal:
Nosebleeds Causes of Epistaxis discharge: clear, fluid leak.
(Nosebleeds): watery, - Yellow mucous
mucous, bloody, red drainage is typical of a
- Local Causes: tinged. cold, rhinitis, or a
- Trauma sinus infection.
- Mucosal irritation - Most upper
- Septal abnormality respiratory illnesses
- Inflammatory are viral.
diseases
- Tumors Ability to breathe - Difficulty breathing
through both of through both nostrils
- Systemic Causes: nostrils may suggest sinus may
- Blood dyscrasias indicate sinus
- Arteriosclerosis Stuffy nose at congestion,
- Hereditary times during the day obstruction, deviated
hemorrhagic or night septum
telangiectasia - Nasal congestion can
disrupt daily activities
- Idiopathic Causes and sleep

Common Local Change in ability to - Decreased ability to

Causes: smell or taste smell may result from
various factors:
- Local trauma (most - Lesions of the
common) optic nerve (I) or facial
- Facial trauma nerve (VII)
- Foreign bodies - Head injuries
- Nasal or sinus - Upper respiratory
infections tract infections
- Prolonged inhalation - Conditions
of dry air affecting nasal
passages (nasal
Associations and polyps, sinusitis)
Risk Factors - Disorders related
(Nguyen, 2018): to aging or neurologic
- Allergic rhinitis illnesses (e.g.,
- Chronic sinusitis Parkinson's,
- Hypertension Alzheimer's)
- Hematologic
malignancy - Additional causes
- Coagulopathy include:
- Hereditary - Aging
hemorrhagic - Hormonal
telangiectasia disturbances (including
- Association with menopause)
older age and colder - Dental problems
weather - Exposure to
certain chemicals
Frequent Drainage - Thin, watery, clear (pesticides, solvents)
from Nose nasal drainage - Many medications
(Continuous or (rhinorrhea) suggests (especially certain
Intermittent) chronic allergy or, in a antibiotics and
client with a past head antihistamines)
Describe the injury, a cerebrospinal - Radiation
treatment for head and
 neck cancers Palliative/relieving a lump,
factors: What thickening,
- Changes in taste aggravates these rough, crusty, or
and smell perception lesions or makes them eroded areas.
can be linked to a go away? What
zinc deficiency. over-the-counter - Action Required:
remedies and past - Immediate
- Olfactory prescriptions have referral for
dysfunction has been you used? further
associated with evaluation if
increased mortality in Associated Factors: warning signs of
older adults. Do you have any cancer are
other symptoms with present.
these lesions such
as stress, pain,
bleeding? Describe.
Mouth

Mouth Sores and - COLDSPA Redness, Swelling, - Early gum disease

Lesions Exploration for Bleeding, or Pain in (gingivitis): Red,
Symptoms: Gums or Mouth swollen gums that
If there are any, explore - Helps bleed easily
the symptoms using determine if - Advanced gum
COLDSPA lesions are disease (periodontitis):
related to Recession of gums and
Characteristics: medications, tooth loss
Describe the size and stress, infection, - Dental pain may be
texture of the lesions. trauma, or caused by dental
malignancy. caries, abscesses, or
Onset: When did they - Lesions sensitive teeth
first occur? Do you lasting > 2
notice these more weeks require
when you are under further
stress or taking certain exploration and
medications? Did referral. Thoat
they occur after any
injury to your mouth? - Painful, Recurrent Difficulty Swallowing - Dysphagia (difficulty
Mouth Ulcers: or swallowing) or
Locations: Describe - Associated Painful Swallowing Odynophagia (painful
exactly where these with aphthous swallowing) can result
lesions are located in stomatitis from issues like
your mouth. (canker sores) pharynx, esophageal
and herpes tumors, or narrowing of
Duration: How long simplex (cold the esophagus.
have you had these sores).
lesions? Have you ever - Causes of narrowing
had these before, - Warning Signs of include postradiation,
and if so, did they go Cancer: Gastroesophageal
away? - Mouth or Reflux Disease
tongue sores (GERD), anxiety, poorly
Severity: Do these that don't heal. fitting dentures, and
lesions keep you from - Persistent neuromuscular
eating, talking, or red or white disorders.
swallowing? patches.
- Presence of - Dysphagia raises the
 risk of aspiration, and
those affected may
need to consult a
speech therapist.
- Late signs of oral
cancer may include
difficulty chewing,
swallowing, or moving
the tongue or jaws.
- Malocclusion
(misalignment of teeth)
can also lead to
difficulties in chewing
or swallowing.
Sore Throat - Sore throat: pain,
itchiness, or irritation of
the throat, may include
hoarseness.
- Common causes:
viral infections (flu,
colds, measles,
chickenpox, whooping
cough, croup,
infectious
mononucleosis),
bacterial infections
(Streptococcus, HIV).
- Additional causes:
allergies (pollens,
molds, pet dander,
dust), irritation from dry
heat, chronic stuffy
nose, pollutants, and
voice straining.
- Reflux: stomach
acids coming up into
the throat.
- Tumors: throat,
tongue, larynx; may
cause pain radiating to
the ear and difficulty
swallowing.
- Tonsillitis.
- Persistent sore throat
without healing may
indicate throat cancer.
Hoarseness - Hoarseness linked
to:
- Upper respiratory
infections
- Allergies
- Hypothyroidism
- Voice overuse
- Smoking or inhaling
irritants
- Larynx cancer
- If hoarseness
persists for 2+ weeks,
refer for further
evaluation.
PERSONAL HEALTH HISTORY
Oral, Sinus, or Nasal - Current symptoms
Surgery might connect to prior
issues or surgery.
History of Sinus - Clients prone to sinus
Infection infections may
experience recurring
issues.
- Excessive use of
nasal sprays can lead
to nasal irritation.
- Nosebleeds may
result from overuse of
nasal sprays.
- Rebound swelling can
occur due to prolonged
nasal spray use.
Diagnosed with - Seasonal rhinitis:
Seasonal Pollens
Environmental
Allergies (e.g., hay - Year-round rhinitis:
fever), Dust
Drug Allergies, Food
Allergies, or Insect
Allergies
 interested in quitting cheek cancer.
Describe the timing of this habit? - Smoking a pipe
the increases the risk of lip
allergies (e.g., spring, cancer.
summer) - Clients looking to quit
tobacco use can
Symptoms (e.g., benefit from a referral
sinus problems, to a smoking cessation
runny program.
nose, or watery eyes).
Do you drink alcohol? - Alcohol
overconsumption (>21
Treatments or - Prioritize How much and standard drinks per
Medications for understanding past how often? week)
Conditions that Affect remedies for client
the Mouth, Throat, or - Increases risk for oral
Nose to control Pain - Identify effective cancer
in treatments previously
the Mouth, Nose, used Do you grind your - Teeth grinding
Throat, or Sinuses teeth? (bruxism) can indicate
(e.g., - Note ineffective stress or minor
saline spray or use of remedies to avoid misalignment.
over-the-counter
nasal irrigations, - Enhance treatment - It may lead to
nasal sprays, throat strategy based on past temporomandibular
spray, ibuprofen) experiences joint (TMJ) issues and
pain.

Care routine for teeth - Brush teeth twice

or daily with a soft-bristle
dentures. toothbrush and fluoride
FAMILY HISTORY toothpaste
How often do you
brush and use dental - Floss between teeth
History of Nose, - Genetic risk for floss? once a day
Sinus, Mouth, or mouth, throat, nose,
Throat Cancer in your and sinus cancers When was your last - Maintain a healthy
Family exists dental examination? diet

- Higher risk for - Visit the dentist

individuals with genetic regularly
syndromes like Fanconi
anemia or dyskeratosis If the client wears - Follow orthodontist's
congenita braces: How do you cleaning routine for
care for your braces? braces to prevent
LIFESTYLE AND HEALTH PRACTICES staining and cavities.
Do you avoid any
specific types of - Avoid crunchy, sticky,
Do you smoke or use - Smoking cigarettes, foods? and chewy foods with
smokeless pipes, or cigars, as well braces to prevent
tobacco? as using smokeless damage to both braces
tobacco, raises the risk and teeth.
If so, how much? of oral cancer.
- Chewing tobacco is If the client wears - Poorly fitting
Are you specifically linked to dentures: How do dentures can cause:
your - Difficulty in eating Applied gloves and Normal
dentures fit? - Hesitation in inspected the inner - Uniform pink
speaking lips and buccal color; dark for
- Mouth sores or mucosa for color,
dark-skinned
leukoplakia (thick moisture, texture, and
white patches) the presence of client
- Leukoplakia is a lesions. - Soft, moist,
precancerous condition smooth
texture,
Do you brush your - Prevent halitosis glistening, and
tongue? (bad breath)
elastic texture
- Clean the tongue (drier for
elders)
- Remove bacteria on
posterior tongue Deviations
- Pallor
How often are you in - Sun exposure is the
- White patches
the sun? Do you main risk for lip cancer.
use lip sunscreen (leukoplakia)
products? - Excessive
dryness
Describe your usual - Poor nutrition raises - Mucosal cyst
dietary intake for a risk oral cancers and ulcerations
day.
- Presence of
nodules or
masses
PHYSICAL ASSESSMENT FOR MOUTH,
Inspected the teeth Normal
THROAT, AND NOSE
and gums while - 32 adult
examining the inner permanent
MOUTH AND Normal lips and buccal
teeth
THROAT - Uniform pink mucosa.
color; dark for - Smooth, white,
dark-skinned shiny tooth
Inspected the outer client enamel
lips for symmetry of - Soft, moist, - Pink gums
contour, color, and smooth texture - Moist firm
texture. Asked the - Ability to purse texture to
lips
client to purse the gums
lips as if to whistle. Deviations - No retraction of
- Pallor; cyanosis gums
- Blisters;
generalized or Deviations
localized - Missing teeth
swelling; crusty
- Brown or black
or scally, dry
lips discoloration of
- Inability to enamel
purse lips - Excessively
- Tenderness red gums
during pursing
of lips
 - Bleeding, textures
tenderness,
swelling Deviations
- Discoloration
Inspected the surface Normal (jaundice or
of the tongue for - Tongue is in the pallor)
position, color, and central position - Palates the
texture and tongue - Pink color + same color
movement. brown Irritations
pigmentation on - Bony growths
some borders in (exostoses)
dark-skinned from the hard
clients palate, jaw,
- Smooth with no gums, along the
lesions inside of the jaw
- Raised papillae
Inspected the uvula Normal
(taste buds)
for position and - Positioned in
- Moves freely;
mobility while midline of the
no tenderness
examining the soft palate
- Smooth tongue
palates.
based with
Deviations
prominent veins
- Deviation to one
side from tumor
Deviations
or trauma
- Tongue is
- Immobility
deviated from
(probable
the center
damage of the
- Excessive
5th and 10th
trembling
Cranial nerve)
Smooth red
tongue
Inspected the Normal
- Dry, furry
oropharynx for color - Pink and
tongue
and texture. smooth
- White coating
Inspected one side at posterior wall
- Areas of
a time to avoid
tenderness
eliciting the gag Deviations
- Nodes,
reflex. - Reddened or
ulcerations and
edematous
discolorations
- Presence of
- Restricted
lesions,
mobility
plaques, or
- Swelling
drainage
- Ulcerations
swelling; Inspected the tonsils Normal
nodules for color, discharge, - Pink and
and size. smooth
Inspected the hard Normal
- No discharge
and soft palate for - Light pink,
- Normal size
color, shape, texture, smooth soft
(Grade 1:
and the presence of palate
behind the
bony prominences. - Lighter pink,
tonsillar pillars
smooth hard
palate, w/
Deviations
irregular
- Inflamed
 - Presence of cavities using a - Nasal mucosa
discharge flashlight or a nasal is pink
- Grade 2, 3, 4 speculum. - No lesions
tonsils (between
the pillars and
the uvula; Deviations
touches the - Nasal mucosa
uvula; extends is red
to the - Presence of
oropharynx lesions
NOSE AND SINUSES Observed for the Normal
Normal presence of redness, - Clear watery
Inspected the - Symmetric and swelling, growths,
external nose for straight discharge
and Discharge.
deviations in shape, - No discharge or - No lesion/s
size, or color and flaring
flaring or discharge - Uniform color Deviations
from the nares. - Abnormal
Deviations discharge
- Asymmetric
- Presence of
- Discharge from
lesions
nares
- Localized
Inspected the nasal Normal
areas of septum between the - Nasal septum
redness or nasal chambers. is intact and in
presence of
midline
skin lesions
Deviations
Lightly palpated the Normal
external nose to - Septum
- Not tender
determine any areas deviated to the
- No lesions
of tenderness, right or to the
Deviations
masses, and left
displacements of - Tenderness on
bone and cartilage. palpation
Palpated the Normal
- Presence of maxillary and frontal - No pain or
lesions sinuses for tenderness
tenderness.
Determined patency Normal
of both nasal cavities. Deviations
- Air moves
- Presence of
freely as the
pain or
client breathes
tenderness in
through the
one or more
nares
sinuses
Deviations
- Air movement
is restricted in
one or both
nares

Inspected the nasal Normal