PRNU 113 lecture 4 - Sarah Pinard Rogers PDF

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Sarah Pinard Rogers...

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PRNU 113 Lecture 4: Assessing Head, Neck, Eyes, Ears, Mouth, Throat, Nose and Sinuses Assessing head and neck -

Health history o Presenting problem o COLDSPA o Other symptoms o Past health history o Chronic infections o Family history o Lifestyle/health practices

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Presenting problem o Eyes: vision problems, discharge o Ears: change in hearing, discharge o Mouth: pain, lesions o Throat: pain, difficulty swallowing o Nose: discharge, pain, breathing issues

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Questions: subjective data o Remember that your questions will vary depending on the chief complaint or presenting problem

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Head assessment o Cranium: houses and protects brain and sensory organs: 8 bones o Facial bones: give shape to the face: 14 bones all immovable except for mandible at TMJ o Artery: amplitude/regularity

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Cranium o Frontal o Parietal (2) o Temporal (2) o Occipital

o Ethmoid o Sphenoid -

Face o Maxilla (2) o Zygomatic (2) o Inferior conchae (2) o Nasal (2) o Lacrimal (2) o Palatine (2) o Vomer o Mandible

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TMJ: temporomandibular joint o Have patient open mouth wide o Have patient move side to side o Shouldn’t be any swelling, tenderness, or crepitus with palpation

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Head assessment o Head inspection – symmetric, round, erect, midline, no lesions, still o Palpate head – hard and smooth o Inspect face – symmetric (smile/stick tongue out), shape, no twitching o Palpate TMJ and temporal artery

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Neck assessment o Muscles: 

Sternomastoid: rotates and flexes head

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Trapezius: extends head/moves shoulders

o 11th cranial nerve: CN XI: spinal accessory  -

Turning against resistance, shrugging shoulders

Cervical vertebrae o 7 cervical vertebrae support the head o C7: bony prominence when neck flexed o “3, 4, 5 keeps the diaphragm alive”

o Less than (C1-C2) = quadriplegia -

Blood vessels of the neck o Observation of internal jugular veins and carotid arteries

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Thyroid assessment

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Masses of the neck

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Neck assessment o Inspect neck – symmetric, head centered, no masses o Inspect movement of neck – swallow o Inspect cervical vertebrae – flex chin forward o Inspect range motion – flexion, extension, abduction, rotation o Palpate trachea – midline 

Deviated could signal pneumothorax or hemothorax

o Palpate thyroid – more advanced practice (auscultate if enlarged – bruit?) -

Lymph nodes o Assess for tenderness and enlargement o Note location

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Lymph node location o Pre auricular – front of ear o Post auricular – back of ear o Occipital – base of skull o Tonsillar – angle of mandible o Submandibular – medial border of mandible o Submental – tip of mandible o Superficial cervical – superficial to mastoid muscle o Posterior cervical – from mastoid part of temporal bone to clavicle o Deep cervical – near internal jugular vein o Supraclavicular - between clavicle and sternomastoid muscles

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Traumatic brain injury (TBI) o Bump, blow, jolt, penetrating injury o 2.8 million ED visits, hospitalizations or deaths in US in 2013

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Eyes assessment o External structures 

Eyebrows – symmetrical

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Eyelids and eyelashes – symmetrical, turnings, color, swelling, lesions, or discharge

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Eyeball aligned in eyesocket?

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Bulbar conjunctiva/sclera – color/lesions

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Conjunctiva – lower/upper

o Inspect lacrimal apparatus o Palpate lacrimal apparatus o Inspect cornea and lens o Inspect iris and pupil -

Visual acuity

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Eye assessment – cardinal fields of vision o Tests: CN III: oculomotor; CN IV: trochlear; CN VI: abducens o With patient looking at you, position finger 10-12 inches from nose o Ask the patient to keep head still and follow your finger with eyes

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Extraocular muscles

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Eye assessment o Corneal light reflex (Hirschberg’s test) 

Ask patient to look straight ahead

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Shine light at bridge of nose about 12-15 inches away

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Light should be symmetrical in both corneas

o Cover-uncover test

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Cover one of the patient’s eyes with a card or paper

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Observe uncovered eye for movement

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Remove paper and watch for eye movement

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Repeat with the other eye

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If uncovered eye moves to focus, it’s considered the weaker eye

Eye assessment – PERRLA

o Pupils equal/round 

Pupils should always be round

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If pupils unequal, it could indicate that there is intercranial pressure

o Reactive to light (constrict) 

Fixed – brain injury, drugs

o Consensual response to light 

When light is flashed into one eye, both pupils should constrict

o Accommodation – pupils constrict, and eyes converge 

Look at pen while brining it closer to nose, pupils should constrict when close and dilate when pen is moved further away

o Pupils dilate when focused on distant objects o Pupils constrict when focusing on close objects -

Pupil gauge (mm) o 1 mm = pinpoint o 10 = brain herniation o 3-4 = normal

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Pupil constriction – what does it mean? o Miosis – pinpoint, typically from narcotic drugs (codeine, fentanyl, hydrocodone, oxycodone, morphine, heroin) or brain damage

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Consensual reflex o Light is shown into one pupil and both constrict

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Accommodation – converging

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Vision o Visual fields (visual fields test) – peripheral vision o 4 fields of vision: upper temporal, upper nasal, lower temporal, lower nasal

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Cataracts o Protein accumulating in lens of eye o Greyish color

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Common eye problems o Glaucoma

o Macular degeneration o Cataracts -

Internal eye – red reflex (reflection of light from retina) o Using the ophthalmascope o Set diopter at 0 o Stand 10-15 inches away (on right side) o Shine light toward patient’s pupil

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Ear assessment o Inspect and palpate external ear o Otoscopic exam – internal ear o Assess hearing 

Whisper test

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Weber test 

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Rinne test 

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Tuning fork

Determines issues with bone conduction vs air conduction

Romberg test (balance test) 

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Structures of the ear

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Otoscopic exam

Patient stands up, closes their eyes and shouldn’t lose balance

o Position the otoscopic speculum not more than 0.5 inches into the ear o Examine the ear for pain first o Make sure the speculum is an appropriate size o For the adult, the pinna is pulled up and back to straighten the ear canal o Should be pearly grey -

Internal structures of ear o Tympanic membrane 

Normal eardrum

o Middle ear o Anatomical sites – middle ear

o Otitis media – middle ear infection o Otitis externa – infection of ear canal -

Hearing loss o CN VIII: acoustic or vestibulocochlear o Conductive hearing loss – mechanical problems…reversible o Sensorineural hearing loss – disease, injury…non-reversible

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Mouth and pharynx/throat

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Salivary glands

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Mouth assessment o Wear gloves and have penlight/tongue depressor available o Inspect the lips o Inspect teeth and gums o Inspect buccal mucosa o Inspect and palpate tongue o Assess dorsal/ventral surface of tongue o Observe sides of tongue o Check strength of tongue o Inspect hard and soft palate o Inspect uvula – heave patient say “aahh” o Note odor o Inspect tonsils and posterior pharyngeal wall

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Ventral part of tongue

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Tonsil inspection – 4 grades

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Nose and sinuses

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Nose assessment o Check patency of nostrils o Inspect external nose structure – deviations/lesions o Inspect internal nose structure 

Otoscope, penlight and/or nasal speculum

o Unilateral clear, watery nasal discharge after head trauma – CSF

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Nasal discharge o Bacterial infection: thick or purulent green-yellow, malodorous discharge o A foul-smelling discharge: a foreign body or chronic sinusitis o Profuse watery discharge: allergies o Blood discharge: neoplasm, trauma, forceful sneezing, or an opportunistic infection such as a fungal disease o Epistaxis: secondary to trauma, chronic sinusitis, malignancy, bleeding disorder, cocaine abuse, pregnancy, mono

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Sinus assessment o Palpate the sinuses – tenderness? o Percuss the sinuses – tenderness? o Transillumination of sinuses – red glow present?...