Advanced Health assessment of HEEN

By
Serkalem Belay

Department of Adult Health Nursing School of Nursing and Midwifery

College of Medicine and Health Sciences Wollo University

12/28/2022 By Serkalem Beyene 1

 Presentation outline
• Introduction
• Equipment needed
• Techniques for HEENT assessment
• Preparation and positioning patient
• Head, Eye,Ear,Nose and Tongue assessment
• Reference
• Aknowlegemet

12/28/2022 By Serkalem Beyene 2

 Introduction

Step by Step Assessment

• Perform hand hygiene.
• Check room for contact precautions.
• Introduce yourself to the patient.
• Confirm patient ID using
• Explain the process to the patient.
• Assemble equipment prior to starting the exam.
• Be organized and systematic in your assessment.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure patient’s privacy and dignity.
• Apply principles of asepsis and safety.
12/28/2022 By Serkalem Beyene 3
 Equpiment

• The physical assessment includes an audioscope,

examination light, laryngeal mirror, nasal speculum,
otoscope, ophthalmoscope, penlight, percussion
hammer, sphygmomanometer, stethoscope,
thermometer, Tongue Depressors and tuning fork

12/28/2022 By Serkalem Beyene 4

 cont
• The assessment of the HEENT systems will include examinations of

the head, eyes, ears, nose, and throat/neck.  assessment includes

• symmetry, and color; hair distribution to scalp, eyebrows, and

eyelashes; hydration status of the mucus membranes to the nose

and mouth;

• the number and condition of teeth, palate structure and uvula

placement and color of lips and buccal membrane.

• Included in the assessment are the XII cranial nerves.

12/28/2022 By Serkalem Beyene 5

 Techniques of assess HEENT?

• The examination of the HEENT systems will be

completed by inspecting and palpating the head,
eyes, ears, nose, throat/neck, lymph nodes, and
testing the cranial nerves that innervate the
function of each organ/structure of HEENT.

12/28/2022 By Serkalem Beyene 6

Patient Preparation and positioning
• The HEENT exam is usually performed in the seated
position, but may be
done semi-recumbent in the hospital.
• Cranial nerves may be assessed at the time of the
head & neck
examination, or
• as part of the neurologic exam
12/28/2022 By Serkalem Beyene 7
 The Head assessment
• Because abnormalities covered by the hair are
easily missed, ask if the patient has noticed
anything wrong with the scalp or hair.
• Inspect the size and shape of the head and the
scalp
• Inspect for symmetry, masses, and signs of trauma

12/28/2022 By Serkalem Beyene 8

 cont
• The Hair: Note its quantity, distribution, texture,
and pattern of loss, if any.
• Fine hair in hyperthyroidism; coarse hair in
hypothyroidism. Tiny white ovoid granules that
adhere to hairs may be nits, or eggs of lice.
• The Scalp: Part the hair in several places and look
for scaliness, lumps, nevi, or other lesions
12/28/2022 By Serkalem Beyene 9
 cont
• The Skull: Observe the general size and contour
of the skull.
• Note any deformities, depressions, lumps, or
tenderness.
• Familiarize yourself with the irregularities in a
normal skull, such as those near the suture
lines between the parietal and occipital bones.
• Enlarged skull in hydrocephalus, Paget’s disease
of bone. Tenderness after trauma
12/28/2022 By Serkalem Beyene 10
 The Eyes assessment

Visual Acuity:
• To test the acuity of central vision use a Snellen eye
chart, if possible, and light it well.
• Position the patient 20 feet from the chart.

• Myopia is impaired far vision.

• Presbyopia is the impaired near vision, found in

middle-aged and older people.
12/28/2022 By Serkalem Beyene 11
 Snellen chart

12/28/2022 By Serkalem Beyene 12

 cont
• The normal Snellen chart is printed with eleven lines of block
letters
• The first line consists of one very large letter E, H, or N.
• Subsequent rows have increasing numbers of letters that
decrease in size.
• A person taking the test covers one eye from 6 metres or 20
feet away, and reads aloud the letters of each row, beginning
at the top.
• The smallest row that can be read accurately indicates the
visual acuity in that specific eye.
• The symbols on an acuity chart are formally known as "
optotypes".
12/28/2022 By Serkalem Beyene 13
 cont
• The Face: Note the patient’s facial expression
and contours.
• Observe for asymmetry, involuntary
movements, edema, and masses.
• The Skin: Observe the skin, noting its color,
pigmentation, texture, thickness, hair
distribution, and any lesions
• Acne in many adolescents.
• Hirsutism(excessive facial hair) in some women
12/28/2022 By Serkalem Beyene 14
 Visual Fields by Confrontation

• Normally, a person sees both sets of fingers at

the same time. If so, fields are usually normal
• Field defects that are all or partly temporal
include homonymous hemianopsia.

12/28/2022 By Serkalem Beyene 15

 cont
• If you find a defect, try to establish its
boundaries.
• Test one eye at a time.
• If you suspect a temporal defect in the left
visual field

12/28/2022 By Serkalem Beyene 16

 Position and Alignment of the Eyes

• Stand in front of the patient and survey the eyes

for position and alignment with each other.
• If one or both eyes seem to protrude, assess
inward or outward deviation of the eyes;
abnormal protrusion in Graves’ disease or ocular
tumors

12/28/2022 By Serkalem Beyene 17

 cont
• Eyebrows: Inspect the eyebrows, noting their
quantity and distribution and any scaliness of
the underlying skin.
• Eyelids: Note the position of the lids in relation
to the eyeballs.
• Lacrimal Apparatus. Briefly inspect the regions
of the lacrimal gland and lacrimal sac for
swelling, excessive tearing or dryness-
obstruction

12/28/2022 By Serkalem Beyene 18

 Conjunctiva and Sclera
• Ask the patient to look up as you depress both
lower lids with your thumbs, exposing the
sclera and conjunctiva.
• Inspect the sclera and palpebral conjunctiva for
color, and note the vascular pattern against the
white scleral background.
• Look for any nodules
or swelling.

12/28/2022 By Serkalem Beyene 19

 Cornea and Lens
• With oblique lighting, inspect the cornea of
each eye for opacities and note any opacities
in the lens that may be visible through the
pupil.

12/28/2022 By Serkalem Beyene 20

 Iris
• At the same time, inspect each iris.
• Shining directly from the temporal side, look
for a crescentic shadow on the medial side of
the iris
• This narrow angle increases the risk of acute
narrow-angle glaucoma
• A sudden increase in intraocular pressure
when drainage of the aqueous humor is
blocked.

12/28/2022 By Serkalem Beyene 21

 Pupils

• Inspect the size, shape, and symmetry of the pupils.

If the pupils are large (>5 mm), , small (<3mm)
• Miosis refers to constriction of the pupils, mydriasis
to dilation.
• Compare benign anisocoria with Horner’s syndrome,
oculomotor nerve paralysis, and tonic pupil.

12/28/2022 By Serkalem Beyene 22

 Ophthalmoscopic Examination
• Darken the room. Switch on the
ophthalmoscope light and turn the lens disc
until you see the large round beam of white
light.
• Shine the light on the back of your hand to
check the type of light, its desired brightness,
and the electrical charge of the
ophthalmoscope.

12/28/2022 By Serkalem Beyene 23

Some example of Abnormalities of the eye

12/28/2022 By Serkalem Beyene 24

 cont

12/28/2022 By Serkalem Beyene 25

 The Ear assessment
• The Auricle: Inspect each auricle and
surrounding tissues for deformities, lumps, or
skin lesions.
 If ear pain, discharge, or inflammation is
present, move the auricle up and down, press
the tragus, and press firmly just behind the ear.

12/28/2022 By Serkalem Beyene 26

 cont
• Movement of the auricle and tragus (the “tug
test”) is painful in acute otitis externa
(inflammation of the ear canal),
• But not in otitis media (inflammation of the middle
ear).
• Tenderness behind the ear may be present in otitis
media
12/28/2022 By Serkalem Beyene 27
 Ear Canal and Drum
• To see the ear canal and drum, use an otoscope
with the largest ear speculum that the canal will
accommodate.
• Position the patient’s head to see through the
instrument.
• To straighten the ear canal, grasp the auricle
firmly but gently and pull it upward, backward,
and slightly away from the head.

12/28/2022 By Serkalem Beyene 28

 cont
• Insert the speculum gently into the ear canal,
directing it somewhat down and forward and
through the hairs

12/28/2022 By Serkalem Beyene 29

 cont
• Non-tender nodular swellings covered by
normal skin deep in the ear canals suggest
exostoses.
• These are non-malignant overgrowths, which
may obscure the drum

12/28/2022 By Serkalem Beyene 30

 cont
• Inspect the ear canal, noting any discharge,
foreign bodies, redness of the skin, or swelling.
• Cerumen, which varies in color and consistency
from yellow and flaky to brown and sticky or
even to dark and hard, may wholly or partly
obscure your view

12/28/2022 By Serkalem Beyene 31

 cont

• Inspect the eardrum, noting its color and

contour.
• The cone of light—usually easy to see—helps
to orient you.

12/28/2022 By Serkalem Beyene 32

 Auditory Acuity
• To estimate hearing, test one ear at a time.
• Ask the patient to occlude one ear with a finger
• When auditory acuity on the two sides is
different, move your finger rapidly, but gently, in
the occluded canal.
• The noise so produced will help to prevent the
occluded ear from doing the work of the ear you
wish to test.

12/28/2022 By Serkalem Beyene 33

 Test for lateralization (Weber test).

• If hearing is diminished, try to distinguish between

conductive and sensorineural hearing loss.
• Place the base of the lightly vibrating tuning fork
firmly on top of the patient’s head
• Ask where the patient hears it: on one or both
sides.

12/28/2022 By Serkalem Beyene 34

 cont
• Normally the sound is heard in the midline or
equally in both ears. If nothing is heard, try
again, pressing the fork more firmly on the
head

12/28/2022 By Serkalem Beyene 35

 Air and Bone Conduction(Rinne test).
• Place the base of a lightly vibrating tuning fork
on the mastoid bone, behind the ear and level
with the canal.
• When the patient can no longer hear the
sound, quickly place the fork close to the ear
canal and ascertain whether the sound can be
heard again.
12/28/2022 By Serkalem Beyene 36
 cont

• Here the “U” of the fork should face forward,

thus maximizing its sound for the patient.
Normally the sound is heard longer through air
than through bone (AC > BC).

12/28/2022 By Serkalem Beyene 37

 cont
• In conductive hearing loss, sound is heard
through bone as long as or longer than it is
through air (BC = AC or BC > AC).
• In sensorineural hearing loss, sound is heard
longer through air (AC > BC).

12/28/2022 By Serkalem Beyene 38

 The Nose assessment
• Inspect the anterior and inferior surfaces of the
nose.
• Gentle pressure on the tip of the nose with your
thumb usually widens the nostrils and, with the
aid of a penlight or otoscope light,
• you can get a partial view of each nasal vestibule.
• If the tip is tender, be particularly gentle and
manipulate the nose as little as possible.
• Note any asymmetry or deformity of the nose.

12/28/2022 By Serkalem Beyene 39

 cont

• Test for nasal obstruction, if indicated, by

pressing on each nasal in turn and asking the
patient to breathe in.
• Inspect the inside of the nose with an
otoscope and the largest ear speculum
available.
• Tilt the patient’s head back a bit and insert the
speculum gently into the vestibule of each
nostril,

12/28/2022 By Serkalem Beyene 40

 cont
• avoiding contact with the sensitive nasal
septum. Hold the otoscope handle to one side
to avoid the patient’s chin and improve your
mobility.
• By directing the speculum posteriorly, then
upward in small steps, try to see the inferior
and middle turbinates, the nasal septum, and
the narrow nasal passage between them.
• Some asymmetry of the two sides is normal

12/28/2022 By Serkalem Beyene 41

 cont
Observe:
• The nasal mucosa that covers the septum and
turbinates.
• Note its color and any swelling, bleeding, or
exudate.
• If exudate is present, note its character: clear,
mucopurulent, or purulent.
• The nasal mucosa is normally somewhat
redder than the oral mucosa.

12/28/2022 By Serkalem Beyene 42

 cont
• The nasal septum: Note any deviation,
inflammation, or perforation of the septum.
epistaxis (nosebleed).
• Any abnormalities such as ulcers or polyps.
Make it a habit to place all nasal and ear specula
outside your instrument case after use.
• Palpate for sinus tenderness. Press up on the
frontal sinuses from under the bony brows,
avoiding pressure on the eyes.
• Then press up on the maxillary sinuses.
12/28/2022 By Serkalem Beyene 43
 The Tongue assessment
• The Mouth and Pharynx: If the patient wears
dentures, offer a paper towel and ask the
patient to remove them so that you can see
the mucosa underneath.
• If you detect any suspicious ulcers or nodules,
put on a glove and palpate any lesions, noting
especially any thickening or infiltration of the
tissues that might suggest malignancy.

12/28/2022 By Serkalem Beyene 44

 cont
• Inspect the following: The Lips. Observe their
color and moisture, and note any lumps, ulcers,
cracking.
• The Oral Mucosa. Look into the patient’s
mouth and, with a good light and the help of a
tongue blade, inspect the oral mucosa for
color, ulcers, white patches, and nodules.
• Irritation from sucking or chewing may cause
or intensify it

12/28/2022 By Serkalem Beyene 45

 cont
• The Gums and Teeth: Note the color of the
gums, normally pink. Patchy brownness may be
present, especially but not exclusively in black
people. Inspect the gum margins and the
interdental papillae for swelling or ulceration.
• Inspect the teeth. Are any of them missing,
discolored, misshapen, or abnormally
positioned? You can check for looseness with
your gloved thumb and index finger

12/28/2022 By Serkalem Beyene 46

 cont

• The Roof of the Mouth: Inspect the color and

architecture of the hard palate.
• The Tongue and the Floor of the Mouth. Ask the
patient to put out his or her tongue. Inspect it
for symmetry—a test of the hypoglossal nerve
(Cranial Nerve XII). Note the color and texture
of the dorsum of the tongue

12/28/2022 By Serkalem Beyene 47

 cont

• The Pharynx: ask the patient to say “ah” or yawn.

This action may let you see the pharynx well. If
not, press a tongue blade firmly down upon the
midpoint of the arched tongue—far enough back
to get good visualization of the pharynx but not
so far that you cause gagging.

12/28/2022 By Serkalem Beyene 48

 cont

• Simultaneously, ask for an “ah” or a yawn.

Note the rise of the soft palate—a test of
Cranial Nerve X (the vagal nerve
• In Cranial Nerve X paralysis, the soft palate
fails to rise and the uvula deviates to the
opposite side

12/28/2022 By Serkalem Beyene 49

 cont

• Inspect the soft palate, anterior and posterior

pillars, uvula, tonsils, and pharynx. Note their
color and symmetry and look for exudate,
swelling, ulceration, or tonsillar enlargement.

12/28/2022 By Serkalem Beyene 50

 cont
Inspect the neck: noting its symmetry and any
masses or scars.
• Look for enlargement of the parotid or
submandibular glands, and note any visible
lymph nodes. Lymph Nodes.
• Palpate the lymph nodes: Using the pads of
your index and middle fingers, move the skin
over the underlying tissues in each area.

12/28/2022 By Serkalem Beyene 51

 cont
The Trachea and the Thyroid Gland:
• Inspect the trachea for any deviation from its usual
midline position.
• Then feel for any deviation. Place your finger along one
side of the trachea and note the space between it and the
sternomastoid.
• Compare it with the other side.
• The spaces should be symmetric
12/28/2022 By Serkalem Beyene 52
 cont
Inspect the neck for the thyroid gland
• Tip the patient’s head back a bit. Using tangential
lighting directed downward from the tip of the
patient’s chin, inspect the region below the cricoid
cartilage for the gland.
• The lower, shadowed border of each thyroid gland
shown here is outlined by arrows

12/28/2022 By Serkalem Beyene 53

 Reference
• BATES’ GUIDE TO PHYSICAL EXAMINATION
AND HISTORY TAKING
• Physical diagnosis lecture notes for health
science students by Gashaw Messele 200s

12/28/2022 By Serkalem Beyene 54

 Acknowledgment
• For WU Adult health Department
• For Dr. Kumer
• For all my classmates

12/28/2022 By Serkalem Beyene 55