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I.

ASSESSMENT OF HEAD AND NECK Equipments: gloves, small cup of water HEAD AND NECK ASSESSMENT PROCEDURE INSPECTION AND PALPATION 1. Inspect the head for size, shape, and configuration 2. Inspect for involuntary movement NORMAL FINDINGS Head size and shape vary, especially in accord with ethnicity. The head is symmetric, round, erect, and in midline. Head should be held still and upright ABNORMAL FINDINGS

3. Palpate the head for consistency 4. Inspect the face for symmetry, features, movement, expression, and skin condition

5. Palpate the temporal artery

6. Palpate the temporomandibular joint

The skull and facial bones are larger and thicker in acromegaly, which occurs when there is an increased production of growth hormone. Tremors associated with neurologic disorders may cause a horizontal jerking movement. An involuntary nodding movement may be seen in patients with aortic insufficency The head is normally hard and smooth Lesions or lumps on the head and without lesions may indicate recent trauma or cancer The face is symmetric with a round, Asymmetry in front of the earlobes oval, elongated or aquare occurs with parotid gland appearance. No abnormal movement enlargement from an abscess or noted. tumor. Drooping of one side of the face may result from a stroke or Bells In older clients facial wrinkles are Palsy. prominent The temporal artery is elastic and not Hard, thick and tender as seen with tender temporal aretritis (inflammation of the temporal arteries that leads to The streght may be decrease in older blindness) clients Normally there is no swelling, Limited range of motion, swelling, tenderness or crepitus. Mouth opens tenderness, or crepitation may and closes fully (3 to 6 cm between indicate TMJ syndrome. upper and lower teeth) lower jaw moves laterally 1 to 2 cm in each direction. Neck is symmetric with head centered and without bulging masses. Swelling, enlarged masses, or nodules may indicate an enlarged thyroi8d

NECK 1. Inspect the neck

2. Inspect movement of the neck structures. Ask the client to swallow a small sip of water 3. Inspect the cervical vertebrae. (chin to chest, ear to shoulder, twist left tor right, and backward

The thyroid cartilage, cricoids cartilage, and thyroid gland move upward symmetry as the client swallows. C7 (vertebrae prominens) is usually visible and palpable. In older clients, cervical curvature may increase because of Kyphosis of the spine. Moreover, fat may accumulate around the cervical vertebrae especially in women called Dowagers hump Normally neck movement should be smooth and controlled with 45 degree flexion, 55 degree extension, 40 degree lateral abduction, and 70 degree rotation. Older clients usually have decreased flexion due to arthritis. Trachea is midline

gland. Asymmetric movement or generalized enlargement of the thyroid gland is considered abnormal. Prominece or swellings other than the C7 vertebrae may be abnormal.

4. Inspect range of motion

Muscle spasms, inflammation, or cervical arthritis may cause stiffness, rigidity, and limited mobility of the neck, which may affect daily functioning.

5. Palpate the trachea _place your finger in the sterna notch 6. Palpate the thyroid gland 7. Auscultate the thyroid only if you find an enlarged thyroid gland during inspection or palpation LYMPH NODES OF THE HEAD AND NECK 1. Palpate the preauricular nodes (in front of the ears), postauricular nodes (behind the ears), occipital nodes (at the posterior base of the skull) 2. Palpate the tonsillar nodes at

Landmarks are positioned midline No bruits are auscultated

The trachea may be pulled to one side in cases of a tumor, thyroid gland enlargement, aortic aneurysm, pneumothorax, atelectasis, or fibrosis. Landmarks deviate from midline or are obscured because of masses or abnormal growths. A soft, blowing, swishing sound auscultated over the thyroid bones is often heard in hyperthyroidism

There is no swelling or enlargement and no tenderness

Enlarged nodes are abnormal

NO swelling, no tenderness, no

Swelling, tenderness, hardness,

the angle of the mandible on the anterior edge of the sternomastoid muscle 3. Palpate the submandibular nodes located on the medial border of the mandible 4. Palpate the submental nodes 5. Palpate the superficial cervical nodes in the area superficial to the sternomastoid muscle 6. Palpate the posterior cervical nodes in the area posterior to the sternomastoid and anterior to the trapezius in the posterior triangle 7. Palpate the deep cervical chain nodes deeply within and around the sternomastoid muscle 8. Palpate the supraclavicular nodes by hooking your fingers over the clavicles and feeling deeply betweenthe clavicles and sternomastoid muscle

hardness is present No enlargement or tenderness is present No enlargement or tenderness is present No enlargement or tenderness is present No enlargement or tenderness is present

immobility are abnormal Enlargement and tenderness are abnormal Enlargement and tenderness are abnormal Enlargement and tenderness are abnormal Enlargement and tenderness are abnormal

No enlargement or tenderness is present No enlargement or tenderness is present

Enlargement and tenderness are abnormal An enlarged, hard nontender node, particularly on the left side, may indicate a metastasis from a malignancy in the abdomen or thorax.

II. EYE ASSESSMENT ASSESSMENT PROCEDURE Evaluating Vision 1. Test distant visual acuity NORMAL FINDINGS Normal distant visual acuity is 20/20 with or without corrective lenses. This means the client can distinguish what the person with normal vision can distinguish from 20 feet away. ABNORMAL FINDINGS Myopia (impaired FAR vision) is present when the second number in the test result is larger than the first (20/40). The higher the second number, the poorer the vision. A client is legally blind when vision in the better eye with corrective lenses is

2. Test near visual acuity

Normal near visual acuity is 14/14 (with or without corrective lenses). This means the client can read what the normal eye can read from a distance of 14 inches. With normal peripheral vision, the client should see the examiners finger at the same time the examiner sees it. Normal degrees are approximately as follows. Inferior: 70 Superior 50 Temporal 90 Nasal: 60 The reflection of the light on the corneas should be in the exact same spot on each eye, which indicates parallel alignment The uncovered eye should remain fixed straight ahead. The covered eye should remain fixed straight ahead after being uncovered.

3. Test visual fields for gross peripheral vision

20/200 or less. Presbyopia (impaired NEAR vision) is indicated when the client moves the chart away from the eyes to focus on the print. It is caused by accommodation. Common for clients over 40. A delayed perception of the examiners finger indicates reduced peripheral vision.

4. Perform corneal light reflex test

5. Perform cover test

6. Perform the positions test assesses eye muscle strength and cranial nerve function

Eye movement should be smooth and symmetric throughout all six directions.

Assymetric position of the light reflex indicates deviated alignment of the eyes. This may be due to muscle weakness or paralysis The uncovered eye will move to establish focus when the opposite eye is covered. When the covered eye is uncovered, movement to reestablish focus occurs PHORIA is a term used to describe misalignment that occurs only when fusion reflex is blocked STRABISMUS is constant malalignment of the eyes TROPIA is a specific type of misalignment : esotropia is an inward turn of the eye, and exotropia is an outward turn of the eye. Failure of eyes to follow movement symmetrically in any or all directions indicates a weakness in one or more extraocular muscles or dysfunction of the cranial nerve Nystagmus, an oscillating (shaking)

7. Inspect the eyelids and eyelashes a. Note width and positions of palpebral fissures b. Assess ability of eyelids to close c. Note the posirion of the eyelids in comparison with the eyeballs, observe for redness, swelling, discharge or lesions

The upper lid margin should be between the upper margin of the iris and the upper margin of the pupil. The upper and lower lids close easily and meet completely when closed The lower eyelid is upright with no inward or outward turning. Eyelashes are evenly distributed and curve outward along the lid margins. Xanthelasma, raised yellow plaques located most often near the inner canthus, normal with increasing age Skin on both eyelids is without redness, swelling, or lesions.

movement of the ye may be associated with an inner ear disorder, multiple sclerosis. Ptosis, (drooping of the eyelid) attributed to oculomotor nerve damage, MG, weakened muscle Failure of lids to close completely puts client at risk for corneal damage An inverted lower lid is a condition called an ENTROPION, which may cause pain and injure the cornea as the eyelash brushes against the conjunctiva and cornea. ECTROPION, an inverted lower eyelid, results in exposure and drying of the conjunctiva, interfere with normal tear drainage. Redness and crusting along the lid margins suggest seborrhea or blepharitis, an infection caused by Staphylococcus Aureus. Protrusion of the eyeballs accompanied by retracted eyelid margins is termed exophthalmos and is characteristics of Graves disease. Sunken may be seen with dehydration or chronic wasting. Generalized redness of the conjunctiva suggests conjunctivitis Areas of dryness are associated with allergies or trauma. Episcleritis is a local, noninfectious inflammation of the sclera

8. Observe the position and alignment of the eyeball in the eye socket

Eyeball are symmetrically aligned in sockets without protruding or sinking.

9. Inspect the bulbar conjunctiva and sclera

Bulbar conjunctiva is clear, moist, and smooth. Underlying structures are clearly visible. Sclera is white. Yellowish nodules on the nulbar conjunctiva are called PINGUECULA. These harmless nodules are common in older clients and appear first on the medial side of the iris and then on the lateral side

10.Inspect the palpebral conjunctiva

Dark skinned clients may have sclera with yellow or pigmented freckles. The lower and upper palpebral conjunctivae are clear and free of swelling or lesions. Palpebral conjunctiva is free of swelling, foreign bodies, or trauma. No swelling or redness should appear over areas of the lacrimal gland.

Cyanosis of the lower lid suggests a heart or lung disorder. A foreign body or lesion may cause irritation, burning, pain and/or swelling of the upper eyelid. Swelling of the lacrimal gland may be visible in the lateral aspect of the upper eyelid. Caused by blockage, infection, or an inflammatory condition. Areas of roughness or dryness on the cornea are often associated with injury or allergic responses. Opacities of the lens are seen with cataracts.

11.Inspect the lacrimal apparatus

12.Inspect the cornea and lens

The cornea is transparent with no opacities. The oblique view shows a smooth and overall moist surface: the lens is free of opacities. ARCUS SENILIS , a normal condition in older clients, appears as a white are arc around the limbus. The condition has no effect on vision The iris is tipically round, flat and evenly colored. The pupil, round with a regular border, is centered in the iris. Pupils are normally equal in size (3 to 50. An inequality in pupil less than 0.5 mm occurs in 20% of clients. The normal direct papillary response is constriction. The normal papillary response is constriction of the pupils and convergence of the eyes when focusing on a near object

13.Inspect the iris and pupils

Irregularly shaped irises, miosis, mydriasis, and anisocoria are abnormal findings. Unequal pupil size is anisocoria Monocular blindness can be detected when light directed to the blind eye results in no response in either pupil. Pupils do not constrict; eyes do not converge.

14.Test papillary reaction to light 15.Test accommodation of pupils

16.Use ophthalmoscope (to check the internal eye structures,. EAR ASSESSMENT

ASSESSMENT PROCEDURE 1. Inspect the auricle, tragus and lobule

NORMAL FINDINGS Ears are equal in size bilaterally normally 4 to 10 cm, the auricle aligns with the corner of each eye and within a 10 degree angle of the vertical position. The skin is smooth with no lesions, lumps or nodules. Color is same with facial color. No discharge should be present. In elderly normal elongated with linear wrinkles

ABNORMAL FINDINGS Mal aligned or low set ears may be seen with genitourinary disorders or chromosomal defects. Enlarged preacular and postauricular lymph nodes-infection. Tophi (nontender, hard, cream colored nodules on the helix or antihelix containing uric crystals- gout Blocked sebaceous glands postauricular cysts Redness, swelling, scaling, or itching otitis externa

2. Palpate the auricle and mastoid process

Normally the auricle, tragus, and mastoid process are not tender

Pale blue ear color - frosbite A painful auricle or tragus is associated with otitis externa or post auricular cyst Tenderness over the mastoid process suggests mastoid ties

3. Inspect the external auditory canal

A small amount of odorless cerumen is the only discharge present

Foul smelling, sticky, yellow discharge otitis externa or impacted foreign body. Bloody, purulent discharge otitis media with ruptured tympanic membrane. Blood or watery drainage (CSF)- skull trauma.

The canal walls should be pink and smooth and without nodules.

Impacted cerumen blocking the view of the external ear canal conductive hearing loss.

4. Inspect the tympanic membrane

It should be pearly, gray, shiny, and translucent with no bulging or retraction. Slightly concave, smooth and intact. Elderly eardrum may appear cloudy.

Reddened, swollen canals, exostoses (non malignant nodular swellings) Red, bulging eardrum and distorted, diminished or absent light reflex acute otitis media Yellowish, bulging membrane with bubbles behind serous otitis media Bluish or dark red colored blood behind the eardrum from skull trauma. White spots scarring from infections

HEARING AND EQUILIBRIUM TEST 5. Perform Webers test if the client reports diminished or lost hearing in one ear -this test helps to evaluate the conduction of sound waves through bone to help distinguish between conductive hearing loss (sound waves transmitted by the external ear) and sensorineural hearing (sound waves transmitted by the inner ear.

Vibrations are heard equally well in both ears. No lateralization of sound to either ear.

(strike a tuning fork softly with the back of your hand and place it in the center of the clients head or forehead. Centering is an important part. Ask whether the client hears the sound better in one ear or the same in both ears) With sensorineural hearing loss, the clients report lateralization of the good ear. This is because of limited perception of the sound due to nerve damage in the bad ear, making sound seem louder in the unaffected ear. Air conduction sound is normally heard longer than bone conduction sound (AC>BC)

Conductive hearing loss- the client reports lateralization of sound to the poor ear-that is, the client hears the sounds in the poor ear. The poor ear is distracted by background noise, conducted air, which the poor ear has trouble. Thus the poor ear receives most of the sound conducted by bone vibration

6. Perform the Rinne test The Rinne test compares AIR and BONE conduction sounds. Strike a tuning fork and place the base of the fork on the clients mastoid process. Ask the client to tell you when the sound is no longer heard. Move the prongs of the tuning fork to the front of the external auditory canal. Ask the client to

With conductive hearing loss, bone conduction sound is heard longer than or equally as long as air conduction sound (BC=>AC). With sensorineural hearing loss, air conduction sound is heard longer than bone conduction sound (AC>BC) if anything is heard at all.

tell you if the sound is audible after the fork is moved. 7. Perform the Romberg test

Client maintains positions for 20 seconds without swaying or with minimal swaying.

Client moves feet apart to prevent fall from loss of balance. This may indicate a vestibular disorder.

MOUTH, THROAT, NOSE, AND SINUS ASSESSMENT ASSESSMENT PROCEDURE MOUTH 1. Inspect the lips. Observe lip consistency and color NORMAL FINDINGS Lips are smooth and moist without lesions or swelling. Pink lips are normal in light skinned clients as are bluish or freckeled lips in some dark skinned clients. ABNORMAL FINDINGS Pallor around the lips (circumoral pallor) is seen in anemia and shock. Bluish(cyanotic) lips may result from cold or hypoxia. Reddish lips are seen in clients with ketoacidosis, carbon monoxide poisoning, and COPD with polycythemia. Swelling of lips is common in local or systemic allergic reaction. Yellow or brownish caused by smoke, drinking large quantities of coffee or tea, or have an excessive intake of fluoride. Tooth decay may appear as brown dots or cover more extensive areas of chewing surfaces. Missing teeth can affect chewing as well as self image. A chalky white area in the tooth surface is a cavity that will turn darker with time. White spots may result from antibiotic therapy. Receding gums are abnormal in younger clients; in elderly clients, the teeth may appear longer because of age related gingival recession, which is common. Red, swollen gums that bleed easily are seen in gingivitis, scurvy (vitamin

2. Inspect the teeth and gums. Ask the client to open the mouth. Note the number, color, condition, and alignment of the teeth.

Thrity two pearly whitish teeth with smooth surfaces and edges. Upper molars should rest directly on the lower molars and the front upper incisions should override the lower incisors. Normally 28 teeth if the four wisdom teeth do not appear. No repaired or decayed areas; no missing teeth or appliances.

Gums are pink, moist, and firm with tight margins to the tooth. No lesions or masses.

C) and leukemia. Receding red gums with loss of teeth are seen in periodontitis. Enlarged reddened gums (hyperplasia) that may cover some of the normally exposed teeth may be seen in pregnancy, puberty, leukemia, and use of some medications, such as phenytoin. A bluish black or grey white line along the gum line is seen in lead poisoning. Leukoplakia may bee seen in chronic irritation. It is a precancerous lesion, and the client should be reffered for evaluation. Whitish, curdlike patches that scrape off over reddened mucosa and bleed easily indicate thrush (candida albicans) infection. Kopliks spots (tiny whitish spots that lie over reddned mucosa) are an early sign of the measles. Deep longitudinal fissures seen in dehydration. Black tongueindicative of Bismuth (Peptobismol) toxicity: Black, hairy tongue; a smooth, reddish, shiny tongue without papillae indicative of niacin or Vitamin B12 defficiencies, certain anemia and antineoplastic therapy. The tongues ventral surface is smooth, shiny, pink or slightly pale with visible veins and no lesions. Older clinets may have varicose veins on the ventral surface of the tongue. Leukoplakia, persistent lesions, ulcers or nodules may indicate cancer and should be referred. Induration increases the likelihood of cancer. The area underneath the tongue is the most common site of oral cancer.

3. Inspect the buccal mucosa Use a penlight and tongue depressor to retract the lips and cheeks to check color consistency. Also note Stensons ducts (parotid ducts) located on the buccal mucosa across from the second upper molars.

Pink in light skinned clients; tissue pigmentation typically increases in dark skinned clients. In both, tissue is smooth and moist without lesions. Stensons ducts are visible with flow of saliva and with no redness, swelling, pain, or moistness in area.

4. Inspect and palpate the tongue. Ask client to stick out the tongue. Inspect for color, moisture, size and texture. Observe for fasciculations (fine tremors) and check for midline protrusion)

Tongue should be pink, moist, a moderate size with papillae present). No lesions are present

5. Assess the ventral surface of the tongue. Ask the client to touch the tongue to the roof of mouth, and use a penlight to inspect ventral surface of tongue, frenulum, and the area under the tongue. Check also

for short Frenulum that limits tongue motion (the origin of tongue-tied) 6. Inspect the Whartons ducts

7. Observe the sides of tongue 8. Check the strength of tongue 9. Check the anterior tongues ability to taste 10.Inspect the hard (anterior) and soft (posterior) palates and uvula 11.Note odor 12.Assess the uvula 13.Inspect the tonsils 14.Inspect the posterior pharyngeal wall NOSE 15.Inspect and palpate the external nose 16.Check patency of air flow through the nostrils 17.Inspect the internal nose SINUSES 18.Palpate the sinuses 19.Percuss the sinuses 20.Transilluminate the sinuses

The frenulum is midline: whartons ducts are visible with salivary flow or moistness in the area. The client has no swelling, redness, or pain. No lesions, ulcers, or nodules are apparent.

Lesions, ulcers, nodules, hypertrophied duct openings on either side Canker sores may be seen