06 EENT Assessment

7/27/2019 06 EENT Assessment

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EENT assessment

Joy N. Bautista, RN, MPH, DRDM, MAN


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Corrective lenses for distance or for reading? Blurred vision, blind spots, floaters, double vision,

discharge, or unusual sensitivity to light? Trouble seeing at night? Eye injury or eye surgery? Lazy eye? Allergies?

Last eye examination? Complaints of eye pain or headaches? Squint to see objects at a distance? Hold objects close to his eyes to see them?

Health History:EYES


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Family History hypertension, diabetes, stroke, multiple sclerosis, syphilis, or HIV

glaucoma, cataracts, vision loss, or retinitis. Medication History

Digoxin overdose can cause a patient to see yellow halos aroundbright light

Occupation Exposure to chemicals, fumes, flying debris, or infectious agents Wear eye protection

Smoking Smoking increases the risk of vascular disease, which can lead to

blindness and can damage vision.

Health History:GENERAL EYE HEALTH


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Delivered vaginally or by cesarean birth?

If delivered vaginally, mother have a vaginal infectionat the time? (Inform the parents that infection such aschlamydia, gonorrhea, genital herpes, orcandidiasiscan cause eye problems in infant.)

Erythromycin ointment instilled in his eyes at birth? Passed the normal developmental milestones?

Know how to hold and care for sharp objects such asscissors?

Health History:PEDIATRIC EYE


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Any difficulty climbing stairs or driving?

Tested for glaucoma? When? Result?

If with glaucoma, eye drops? What kind?

How well can Px instill eye drops?

Eyes feel dry? Burn? How treated?

Health History:ELDERLY EYE


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a good light source

a penlight one or two opaque cards

an ophthalmoscope (DOCTORS NEED THIS!)

vision-test cards

gloves tissues

cotton-tipped applicators

Physical Exam:EYE TOOLS


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Observe the patients face.

With the scalp line as the starting point check that hiseyes are in normal position.

They should be about one-third of the way down theface and about one eyes width apart from each other.

Then assess the eyelid, conjunctiva, cornea, anteriorchamber, iris, and pupil.

Physical Exam:GENERAL APPEARANCE


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Upper eyelid cover top quarter of the iris so the eyes look alike.

Check for an excessive amount of visible sclera above the limbus(corneo-scleral junction).

Ask the patient to open and close his eyes to see of they closecompletely. If the downward movement of the upper eyelid indown gaze is delayed, the patient has a condition known as lidlag, which is a common sign of hyperthyroidism.

Assess the lids for redness, edema, inflammation, or lesions.

Check for a stye, or hordeolum, a common eyelid lesion.

Physical Exam:EYELIDS


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Inspect the eyes for excessive tearing or dryness.

The eyelid margins should be pink, and the eyelashesshould turn outward. Observe whether the lowereyelids turn inward toward the eyeball, calledentropion, or outward, called ectropion.

Examine the eyelids for lumps. Note tenderness,swelling of the nasolacrimal duct or dischargethrough the lacrimal point, which could indicateblockage of the nasolacrimal duct.

Physical Exam:EYELIDS


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Bulbar conjunctiva should be clear and shiny (Px looks

up). Note excessive redness or exudate. Inspect thebulbar conjunctiva for color changes, foreign bodies,and edema.

Observe the scleras color, which should be white tobuff.

Palpebral conjunctiva should be uniformly pink (Pxlooks down). Cobblestone appearance in Pxs withallergies.

Physical Exam:CONJUNCTIVA


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The cornea should be clear and without lesions.

Test corneal sensitivity by lightly touching the cornea witha wisp of cotton. The patient should blink.

If he doesnt blink, he may have suffered damage to thesensory fibers of cranial nerve V to the motor fibers

controlled by cranial nerve VI. Keep in mind that people who wear contact lenses may have

reduced sensitivity because theyre accustomed to havingforeign objects in their eyes.

Physical Exam:CORNEA


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The iris should appear flat, and the cornea should

appear convex. Excess pressure on the eye such as that caused by

acute angle-closure glaucoma may push the irisforward, making the anterior chamber appear very

small. The irises should be the same size, color, and shape.

Physical Exam:ANTERIOR CHAMBER & IRIS


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Each pupil should be equal size, round,and about one-fourth the size of the

iris in normal room light. Test the pupils for accommodation

Place your finger approximately 4 inches(10.2 cm) from the bridge of thepatients nose.

Ask the patient to look at a fixed objectin the distance and then to look at yourfinger.

His pupils should constrict and his eyesconverge as he focuses on you finger.

Physical Exam:PUPIL


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Test the pupil for direct and consensual response.

In a slightly darkened room, hold a penlight about 20(50.8 cm) from the patients eyes

Direct the light at the eye from the side

Note the reaction of the pupil youre testing (directresponse) and the opposite pupil (consensual

response). They should both react the same way. Note sluggishness or inequality in the response.

Repeat the test with other pupil.

Physical Exam:PUPILS


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Snellen chart and near-vision chart test forfar and near vision

Snellen E chart for pediatric patients Eorientation

Visual acuity is recorded as a fraction. The top number (20) is the distance between

the patient and the chart (20 ft)

The bottom number is the distance from whicha person with normal vision could read the line.

The larger the bottom number, the poorer thepatients vision.

Physical Exam:VISUAL ACUITY


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Confrontation - to test peripheral vision

Sit directly across the patient and have her focus her gaze onyour eyes. Place your hands on either side of the patients head at the

level of her ears so that theyre about 2 feet apart. Tell the patient to focus her gaze on you as you gradually

bring your wiggling fingers into her visual field.

Instruct the patient to tell you as soon as she can see yourwiggling fingers; she should see them at the same time youdo.

Repeat the procedure while holding your hands at thesuperior and inferior positions.

Physical Exam:PERIPHERAL VISION


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Corneal light reflex

Ask the patient to look straight ahead Shine a penlight on the bridge of his nose from about 12

inches to 15 inches (30.5 cm to 38 cm) away.

The light should fall at the same spot on each cornea

If it doesnt, the eyes arent being held in the same planeby the extraocular muscles

This commonly occurs in a patient who lacks musclecoordination, a condition called strabismus.

Physical Exam:EYE MUSCLES


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Cardinal position of gaze - evaluate the oculomotor, trigeminaland abducent nerves as well as the extraocular muscles Ask the patient to remain still while you hold a pencil or other

small objects directly in front of his nose at a distance of about18 (45 cm)

Ask him to follow the object with his eye, without moving hishead

Move the object to each of the six cardinal positions, returning

to the midpoint after each movement The patients eyes should remain parallel as they move. Note abnormal findings such as nystagmus and ambylopia, the

failure of one eye to follow an object.



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The cover-uncover test only done when there is an abnormality

detected when assessing the corneal light reflex and cardinalpositions of gaze

Have the patient stare at a wall on the other side of the room.

Cover one eye and watch for movement in the uncovered eye.

Remove the eye cover and watch for movement again.

Repeat the test with other eye.

Eye movement while covering or uncovering the eye isconsidered abnormal.

It may result from weak or paralyzed extraocular muscles, whichmay be caused by cranial nerve impairment.



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Hearing loss, tinnitus, pain, discharge, and dizziness.

Discharge, history of head injury.

Vertigo (spinning), nausea, vomiting, or tinnitus.

Ear problem or injury

Chronic disorders.

Current treatments and medications

Allergies.

Health History:EARS


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Nasal stuffiness, nasal discharge, and epistaxis, or

nosebleed. Colds, hay fever, headaches, and sinus trouble.

Nose or head trauma.

Environmental allergies

Color and consistency of the discharge.

Health History:NOSE


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Bleeding or sore gums

Mouth or tongue ulcers

Bad taste in his mouth, bad breath

Toothaches, loose teeth, frequent sore throat,hoarseness or facial swelling

Smokes or uses other types of tobacco.

Neck pain or tenderness, neck swelling, or troublemoving his neck.

Health History:MOUTH, THROAT, NECK


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Changes in tolerating hot and cold weather?

Weight changes?

Breathing problems or feel as if heart skips beats?

Changes in menstrual pattern?

Tremors, agitation, or difficulty concentrating orsleeping?

Health History:GENERAL HEALTH


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Assess the ears for position and symmetry. The top of the ear should line up with the outer corner of the eye, Ears should look symmetrical, with an angle of attachment of no more

than 10 degrees The face and ears should be the same shade and color. Low-set ears - congenital disorders, including kidney problems. Inspect the auricle for lesions, drainage, nodules, or redness. Pull the helix back and note if its tender.

If pulling the ear back hurts the patient, he may have otitis externa. Inspect and palpate the mastoid area behind each auricle, notingtenderness, redness, or warmth.

Inspect the opening of the ear canal, noting discharge, redness,odor, or the presence of nodules or cysts.

Physical Exam:EARS


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Webers test - when the patient reports diminished or lost

hearing in one ear Strike the tuning fork lightly against your hand, and then

place the fork on the patients forehead at the midline or onthe top of his head.

Hears the tone equally well in both ears normal

Hears the tone better in one ear right or left lateralization

Hears the tone in impaired ear conductive hearing loss

Hears the tone in unaffected earsensorineural hearing loss

Physical Exam:HEARING ACUITY


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Rinne test - after Webers test to compare air conduction ofsound with bone conduction of sound

Strike the tuning fork against your hand, and then place it over thepatients mastoid process. Ask him to tell you when the tone stops;note this time in seconds.

Move the still-vibrating tuning fork to the ears opening withouttouching the ear. Ask him to tell you when the tone stops. Note thetime in seconds.

Air-conducted tone (ear) should be twice as long as the bone-conducted tone (mastoid) Bone-conducted tone air-conducted tone conductive hearing

loss Air-conducted tone bone-conducted tone sensorineural hearing

loss

Physical Exam:HEARING ACUITY


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Observe patients nose for position, symmetry, and color. Note variations, such as discoloration, swelling, or deformity.

Observe for nasal discharge of flaring. If discharge is present, note the color, quantity, and consistency. If you notice flaring, observe for other signs of respiratory distress.

To test nasal patency and olfactory nerve (cranial nerve I) function, Ask the patient to block one nostril and inhale a familiar aromatic substance

through the other nostril. Ask him to identify the aroma.

Repeat the process with the other nostril, using a different aroma. Inspect the nasal cavity. Ask the patient to tilt his head back slightly,

and then push the tip of his nose up. Check for severe deviation of perforation of the nasal septum. Examine the vestibule and turbinates for redness, softness, swelling, and

discharge.

Physical Exam:NOSE


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Examine the nostrils by direct inspection, using nasal

speculum, a penlight or small flashlight, or an otoscopewith a short, wide-tip attachment.

Observe the color and patency of the nostril, and check forexudate.

The mucosa should be moist, pink to light red, and freefrom lesions and polyps.

Palpate the patients nose with your thumb and forefinger,assessing for pain, tenderness, swelling, and deformity.

Physical Exam:NOSE


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Check for swelling around the eyes, especially over the sinus area. Palpate the sinuses, checking for tenderness.

Frontal sinusesplace your thumbs above the patients eyes just underthe bony ridges of the upper orbits, and place your fingertips on hisforehead. Apply gentle pressure.

Maxillary sinusesgently press your thumbs on each side of the nosejust below the cheekbones

Transillumination if there is tenderness Darken the room and have the patient close her eyes. Place the penlight on the supraorbital ring and direct the light upward to

illuminate the frontal sinuses just above the eyebrows Place the penlight on the patients cheekbone just below her eye and

ask her to open her mouth. The light should transilluminate easily and equally.

Physical Exam:SINUSES


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Inspect the patients lips Pink, moist, symmetrical, and without lesions

Bluish hue or flecked pigmentation is common in dark-skinned patients

Put gloves and palpate the lips for lumps or surfaceabnormalities.

Place a tongue blade on top of his tongue. The oral mucosa should be pink, smooth, moist, and free

from lesions and unusual odors.

Increased pigmentation is seen in dark-skinned patients.

Physical Exam:MOUTH & THROAT


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Observe the gingiva, or gums Pink, moist, and have clearly defined margins at each tooth. Shouldnt be retracted

Inspect the teeth, noting their number, condition, and whether anyare missing or crowded

If the patient is wearing dentures, ask him to remove them so you caninspect the gums underneath.

Inspect the tongue Midline, moist, pink, and free from lesions. The posterior surface should be smooth, and the anterior surface should

be slightly rough with shall fissures. The tongue should move easily in all directions, and it should lie straight to

the front at rest. Inspect the ventral surface of the tongue and the floor of the mouth. Inspect the lateral borders smooth and even-textured



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Inspect the patients oropharynx by asking him to open his mouthwhile you shine the penlight on the uvula and palate.

You may need to insert a tongue blade into the mouth and depressthe tongue. Place the tongue blade slightly off center to voideliciting the gag reflex.

The uvula and oropharynx should be pink and moist, withoutinflammation or exudates.

The tonsils should be pink and shouldnt be hypertrophied.

Ask the patient to say Ahhh. Observe for movement of the softpalpate and uvula. Palpate the lips, tongue, and oropharynx. Note lumps, lesions,

ulcers, or edema of the lips or tongue. Assess the patients gag reflex by gently touching the back of the

pharynx with a cotton-tipped applicator or the tongue blade.



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Observe the patients neck Symmetrical, and the skin should be intact.

Note any scars.

No visible pulsations, masses, swelling, venousdistention, or thyroid or lymph node enlargementshould be present.

Ask the patient to move his neck trough the entirerange of motion and to shrug his shoulder.

Ask him to swallow. Note rising of the larynx, trachea,or thyroid.

Physical Exam:NECK


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Palpate the patients neck to gather data. Using the finger pads of both hands, bilaterally palpate the chain

of lymph nodes under the patients chin in the preauricular area Proceed to the area under and behind the ears. Assess the nodes for size, shape, mobility, consistency,

temperature, and tenderness, comparing nodes on one side withthose on the other.

Palpate the trachea, which is normally located midline in the

neck. Place your thumbs along each side of the trachea near the lower

part of the neck. Assess whether the distance between the tracheas outer edge

and the sternocleidomastoid muscle is equal on both sides.

Physical Exam:NECK


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Palpate the thyroid, stand behind the patient and put your handsaround his neck, with the fingers of both hands over the lower

trachea. Ask him to swallow as you feel the thyroid isthmus. The isthmus should rise with swallowing because it lies across

the trachea, just below the cricoid cartilage. Displace the thyroid to the right and then to the left, palpating

both lobes for enlargement, nodules, tenderness, or a gritty

sensation. Lowering the patients chin slightly and turning toward the side

youre palpating helps relax the muscle and may facilitateassessment.

Physical Exam:NECK


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Auscultate the neck.

Using light pressure on the bell of the stethoscope, listen over

the carotid arteries.

Ask the patient to hold his breath while you listen to preventbreath sounds from interfering with the sounds of circulation.

Listen for bruits, which signal turbulent blood flow.

If you detect an enlarged thyroid gland, also auscultate thethyroid area with the bell.

Check for a bruit or a soft rushing sound, which indicates ahypermetabolic state.

Physical Exam:NECK

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06 EENT Assessment