Heent Assessment Assignment PDF

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HEENT - Assessement/Exam...

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Name:__________________________________

Date:_________________

HEENT Assessment Submit to both Module 5 and Module 6 dropbox NUR2180 Physical Assessment

Patient _______________________________________ Age_________ Gender _________ Reason for Visit _______________________________________________________________

1. Health History (No or Yes, Explain) a. Any unusually frequent or severe headache? b. Any head injury c. Experienced any dizziness? d. Any neck pain e. Any nausea or vomiting? f. Any lumps or swelling in the head or neck? g. Any surgery on head or neck? h. Any difficulty seeing or blurring? i. Any eye pain? j. Any history of crossed eyes? k. Any redness, swelling, watering or tearing? l. Any injury or surgery or disease to eyes? m. Wear glasses or contact lenses? Last vision check? n. Any earache or ear pain? o. Frequent ear infection? p. Any discharge from the ears? Excess cerumen? q. Any hearing loss, exposure to loud noises? r. Any tinnitus or vertigo? s. Any nasal discharge? t. Frequent or severe colds? u. Any sinus pain or sinusitis? v. Any trauma or injury to the nose? w. Any nosebleed? How often? x. Any allergies? Or hay fever? y. Any change in sense of smell? z. Any sores in the mouth or tongue? Sore throat? aa. Any bleeding gums? Any toothache? bb. Any hoarseness or voice change? cc. Any difficulty swallowing? dd. Any change in sense or taste? ee. Do you smoke? How much?

Name:__________________________________

Date:_________________

ff. Drink alcohol? How many times per week? gg. Tell me about your dental care. hh. Use of nasal sprays? Eye medications? Ear medications? 2. Physical Examination (Refer to your textbook for normal/abnormal findings) A. Head, Face and Neck 1. General Size, Symmetry and Contour________________________________ 2. Deformities, lumps, lesions, tenderness_______________________________ 3. Temporomandibular joint__________________________________________ 4. Facial Expression and Symmetry____________________________________ 5. Neck Symmetry_________________________________________________ 6. Range of Motion active? __________________________________________ 7. Palpable enlargement of thyroid? Bruit?______________________________ 8. Palpate 10 lymph node locations, Size and Shape? Tenderness? _____________________________________________________ B. Eyes 1. 2. 3. 4.

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Visual Acuity (Snellen Chart)_______________________________________ Visual Fields (Confrontation Test)___________________________________ Extraocular muscle function (Corneal Light Reflex)_____________________ External eye structure:____________________________________________ i. (general, eyebrows and lashes, eyeballs, conjunctiva and sclarea) 5. Anterior eyeball:_________________________________________________ i. (cornea, iris, pupil size, accommodation) Ears 1. External ear size, shape, skin condition, tenderness______________________ 2. External canal, drainage or excess cerumen ___________________________ 3. Whispered voice test (R)____________________(L)____________________ Nose 1. Symmetry, deformity, inflammation__________________________________ 2. Color of nasal mucosa_____________________________________________ 3. Discharge______________________________________________________ 4. Septal deviation, bleeding or perforation______________________________ 5. Frontal and Maxillary sinuses_______________________________________ Mouth 1. Lips___________________________________________________________ 2. Teeth and Gums_________________________________________________ 3. Buccal mucosa__________________________________________________ 4. Palate and uvula_________________________________________________ 5. Tonsils (grade)__________________________________________________ 6. Tongue________________________________________________________ Throat 1. Pharyngeal wall__________________________________________________

Name:__________________________________

Date:_________________

2. Breath odor_____________________________________________________

Subjective Data: (list)

Objective Data (list)

Assessment: (written narrative)

2 Actual or Potential Risks:

Adapted from: Jarvis, C . (2020). Physical examination and health assessment (8th ed.)Study Guide. St. Louis, MO: Elsevier.

Name:__________________________________

Date:_________________...