Question

Please write a nursing assessment using medical terms to describe each assessment.

HEENT (head, ears, eyes, nose and throat)

Inspect head, eyes, ears, nose for size, shape, symmetry.

Palpate head, hair, face and sinuses for any deformities, tenderness, masses.

Upon palpitation of L.C.’s head she had no tenderness or masses. Her hair was

Assess eyes with penlight for pupil size, reactivity & accommodation. 6 cardinal fields of gaze. Symmetrical?

Assess hearing: vocal and soft sounds

Assess oral cavity: dentures? Difficulty swallowing, condition of teeth, mucous membranes, tongue, hard and soft palette, and posterior pharynx.

Inspect neck for trachea position and presence of lymph nodes

Respiratory Assessment

Inspect anterior and posterior chest wall for use of accessory muscles when breathing

Inspect for rhythm and ease of breathing

Palpate for chest expansion and fremitis

Auscultate anterior, lateral, and posterior chest wall at all assessment sites and verbalize appropriate location of sounds: adventitious sounds, bronchial, bronchovesicular and vesicular breath sounds. (listens to full inspiration and expiration at each site and compares side to side)

Answer 1

Head

Inspection and palpation

• position: normal( upright and midline to the trunk)
• head tilted to one side- unilateral hearing or visual loss
• a horizontal jerking/ hobbing- tremors
• size, shape, contour: normal( round with prominence in the frontal area anteriorly and occipital area posteriorly)
• in infants, large heads congenital anomaly or accumulation of cerebrospinal fluid in ventricles (hydrocephalus )
• jaws: enlarged (acromegaly)
• nodules or masses :

EYES

visual acuity: normal 20/20

larger the denominator poorer the visual acuity

extra occular movements :

nystagmus(an involuntary rhythmical oscillation of eyes )

position and alignment: exophthalmos (bulging eyes)

strabismus (crossing of eyes)

Eyebrows

size and shape: normal -symmetrical

• hypothyroidism( coarseness of hair failure to extend beyond the temporal canthus)
• inability to move eyebrows (facial nerve paralysis )

eyelids

• inspect position, colour, condition of the surface, condition and direction of eyelids
• ptosis(abnormal drooping of eyelid)
• hordeolum( an erythematous or yellow lump on the follicle of an eyelash)
• lacrimal gland: tenderness, oedema or redness
• conjunctiva and sclera: normal, white or light yellow

pigmented, yellow or green colour- liver disease

redness- conjunctivitis

bright red blood in conjuntiva- subconjunctival haemorrhage

• corneas: clarity and texture; normal- shiny transparent and smooth.

arcus senilis( A thin white ring along the margin of the iris)

• pupils and iris: size, shape, equity, accommodation and reaction to light

cloudy pupils ( cataract)

dilated pupils(glaucoma, trauma, neurologic disorders, eye medications.

• PERRLA ( pupils equal, round, reactive to light, and accommodation)

EARS

INSPECTION EXTERNAL EAR   

position: a low set of ears (down syndrome)

• size and shape of pinna
• signs of trauma to the pinna
• skin lesions on the pinna
• skin condition and scars

ear canal and eardrums :

• tears or break inflammation(pink or red bulging membrane), pus (white colour)

hearing tests

• webers' test

conduction deafness (sound best heard in impaired ear)

unilateral sensorineural hearing loss(sound heared in normal ear)

• rinne's test

conduction deafness( no bone conducted sound)

NOSE

• size and shape, bend or deformity (nasal septum deviation), swelling, redness, scars or abnormal creases, discharges, odour.

sinuses

• palpation: inflamed and swollen -infection or allergy

THROAT

inspection

• cherry coloured lips: carbon monoxide poisoning
• lesions (infection, irritation, skin cancer)
• thick white patches on the buccal mucosa -leukoplakia
• yellow or green exudate on pharynx- infection
• red and edematous uvula- infection