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Health Assessment
Mary Ann Hudson, RN
The Ohio State University College of Nursing
Nose
Mouth
Ears
Throat
Why does the RN assess the ears?
congenital (syphilis + other
TORCH infxns)
nerve damage CN VIII
infant ear infections (bottle-fed and
Infant anatomy)
structural changes (wax, trauma,
infection)
effects from medications (tinnitus,
vertigo)
Changes in the Elderly
Presbycusis
Prez bĭ cū’ sĭs
Sensorineural loss CN VIII
Loss of high pitched sounds > 50 y.o.
1. Whisper
2. Consonants
3. Vowels
http://www.youtube.com/watch?v=4YWSerwlWjM&feature=related
Changes in the Elderly
Otosclerosis of the
middle ear
20 – 40 y.o.
Hardening of
stapes
Hearing in general
is decreased
gradually
Why does the RN assess the nose?
To detect:
congenital anomalies
effects from trauma / obstruction
effects of illness (cancer, infections,
allergies, nerve damage)
Changes in the Elderly
Smell diminishes slightly (anosmia)
What are the implications to ADLs?
Why does the RN assess the mouth &
throat?
congenital anomalies
tooth decay (bottles, hygiene)
nerve damage (swallow, gag)
effects of illness (cancer, infections,
neurological & systemic disorders)
Changes in the Elderly
Xerostomia, less saliva & effects of meds
Receding gums; tooth loss
Taste ↓’s 80% (effect on ADLs?)
More lesions
Questions for the ENMT Interview
Chief complaint:
 Sensory perception, dryness, drainage, itching, pain, lesions
Past History:
 Injuries and accidents
 Infections, allergies
 Chronic illnesses, meds
Social
 Tobacco, Alcohol, Drugs/Rx and Abuse
Environment
 Noise, sun fumes, dust
Physical exam of the external structures of
the ear
Inspect
position, color, size and lesions
Palpate
tenderness (auricle and tragus)
External Otitis
Right 4x2 centimeter lesion
involving tragus, outer
canal, and lobule. Lesion
significant for swelling,
erythema, and purulent
discharge. Tragus and pinna
positive for pain 7/10 on
palpation.
Otitis Media
Assessment
 Otoscopic examination
Describe
 Erythema, absent light reflex, swelling or
bulging, visible bony landmarks, color,
devices (tympanostomy tube), discharge,
bleeding.
Etiology
 Supine bottle feed
 2nd hand smoke
 Group daycare
 Juvenile anatomy, genetics
Low Set External Ear
Cauliflower Ear
Etiology
 Distortion of the
cartilage due to
relatively poor
perfusion and venous
drainage of pinna after
blunt trauma. Can lead
to obstructive hearing
loss and may need
surgical correction.
Tophi
Deposits of sodium
biurate in the helix
of the ear in
uncontrolled states
of gouty arthritis.
May or may not be
painful on palpation.
Rule out other lesion
etiology via history.
Mastoid air cells are open, air-containing
spaces in one of the skull bones.
Mastoiditis
Inspection is incredibly important!
 infection of the bony air cells in the
mastoid bone
 drainage from the ear and redness
(erythema) behind the ear over the
mastoid bone
 Forward displacement displacement
of pinna
 Abscess over mastoid process is
possible. Tenderness, erythema,
swelling and warmth appear over
mastoid process.
 Trace around border of erythema with
felt-tip pen and document time of
tracing.
Inspection of the internal structures
Cerumen
Ear canal rich with specialized goblet cells
that secrete cerumen which protects the ear
canal with antibacterial and mechanical
measures.
Cerumen varies by ethnicity and genetics.
Q-tips can damage or pack cerumen.
Ceremun impaction may create conductive
hearing losses, pain or irritation and are most
often a result of physical insertion of objects
as cerumen will collect naturally at entrance
of canal and can be wiped away as a part of
normal hygiene. Commercial ear wax
removers or provider removal is rarely
needed.
Inspection of the internal structures
Otitis Externa/Swimmer’s Ear
Moisture expands the cerumen and
tissues of canal providing matrix for
opportunistic bacteria to overgrow. May
also arise from foreign body.
Erythema, tragus pain, exudate, and
obstruction of canal due to swelling are
typical presentation.
Patient may need to have wick
inserted for otic antibiotic drops to
reach site due to swelling.
Inspection of the internal structures
Normal tympanic anatomy
Cone of light is situated toward the face
Bony landmarks should be visualized
“Pearly gray” membrane, but wide range
of colors. Compare one side to the other.
Describe your findings: color, side to
side differences, lesion/erythema location
(use the face of the clock), exudate (in front
of or behind TM), devices, cerumen
disrupting view, scars (appear as bright
white lesions), fluid behind TM (appear as
bubbles behind TM).
Otoscopic assessment
 Client tips head away from examiner.
With infants and young children, have
caregiver secure head (against
caregiver shoulder, for example).
 Use correctly sized speculum. Insert
otoscope into auditory meatus.
 Pull pinna of ear up and back for
adults, down for children. Canal is a
flexible invagination into bony
structures of skull, use pinna and
speculum to “drive” canal until TM can
be visualized clearly.
 Speculum will clear normal amounts of
ceremun away for sufficient
visualization of TM.
Otitis Media
 Inflammatory involvement of TM and structures
behind the TM within middle and inner ear.
 Most often will see systemic signs and
symptoms (fever, upper respiratory).
 Common in infants and children due to
anatomical development of eustachian tubes.
 Describe absence of cone of light, TM
inflammation and erythema, exudate, rupture
(usually at margin of TM where it meets the
canal, but can be anywhere on TM), “bulging” of
TM outward from middle ear, loss of visualization
of bony landmarks, marked difference between
ears.
 Current guidelines require 6 AOM in 1 year to be
evaluated for TM tubes.
 May lead to effusions (fluid behind TMs), or other
anatomical changes like scarring, lesions,
changes in bone morphology.
How to irrigate
 Mineral oil and H2O2 (OTC preparations
are Vibrox, Cerumen-X, and Murine).
 Warm H2O with bulb syringe or water
pik (cold water may cause syncope,
vertigo, or nausea. Hot water will
damage canal and set up patient for
otitis externa).
 Direct toward posterior wall of canal
(not TM).
 Don’t irrigate with tympanic perforation.
 Patient should get up and walk slowly,
with RN support as irrigation may
disrupt balance dramatically.
 Should not be a routine procedure.
Pediatric otoscopic exam
 Do this system last.
 Let child play with “flashlight.”
 Important to hold still, may need
restraint from caregiver.
 Talking while examining is very loud
for the child.
 Hold handle of otoscope
downwards as the curve of the
relatively large infant/child head will
limit angle of otoscope help with
handle up (against head).
 Use correctly sized speculum.
Hearing Screens
Weber Test (CN VIII)
Tuning fork on middle
forehead or top of head
Negative test is normal
(i.e. no lateralization—
positive is abnormal and
is lateralization to either
a “good” or “bad” side)
Bypass the external
and middle ear
Hearing Screens
Weber Test
Sound “lateralizes” to the affected (bad)
ear (is heard loudest in bad ear because
pitch from fork bypasses ear structures
and skull transmits sound directly to
sensory nerves in inner ear. Lack of
hearing through the meatus is what
makes the ear “bad” and the skull
vibration louder in “bad” ear).
 impacted cerumen
 perforated ear drum
 middle ear infection
 foreign body
 otosclerosis
Hearing Screens
Weber Test
Sound “lateralizes” to the
unaffected (good) ear. If inner
ear sensory motor nerves
cannot transmit sound to brain,
tuning fork pitch will only be
heard by the good ear.
Acoustic nerve damage (drugs,
loud noises, brain insult).
Congenital
Hearing Screens
Rinne test (CN VIII):
Tuning fork on mastoid
process begin timing.
When patient raises hand to
note that has ringing
stopped (time ringing from
placement on MP to a
raised hand), move tines to
external meatus and begin
timing, patient raises hand
when ringing stops again.
Normal is Air Conduction >
Bone Conduction in both
ears (A.U.)
Hearing Screens
Rinne Test
If BC is longer or equal,
there is a conduction loss
If there is no BC or AC,
there is a sensorineural loss
Hearing Screens
Voice - Whisper (CN VIII):
Client occludes one ear
Nurse whispers 2-3
syllables from 2 feet
behind client (how are
you?)
Normal=50% accuracy
Normal conversational
speech is 40 decibels.
Physical exam of the nose
Patency
 Client occludes one nare while breathing through nose.
 Infants are obligate nose breathers. If they cannot feed,
their nares are not patent.
 Assess for lesions, obstruction, and discharge by patient
tipping head back, pulling tip of nose towards bridge,
and using a light source into the nares.
Internal structures
 Turbinates
 Septum
 Mucous membranes
 Describe lesions, color, anatomy visualized.
When would a physical exam of the nose be particularly
important?
Physical exam of the sinuses
Frontal:
 Deeply palpate at eyebrow level
 Observe for periorbital swelling,
symmetry, warmth, redness, nasal or
lacrimal discharge, abscess.
 Children to do not develop front sinus
until puberty. Palpate ethmoid sinus
in between eyebrows instead.
Maxillary:
 Deeply palpate medial to cheeks
 Observe for mid-face swelling,
symmetry, warmth, redness, nasal
discharge, mouth pain, abscess (look
into mouth).
Cranial Nerve I - Olfactory
Offer various scents for
client to identify
Client occludes one
nare while smelling
scent
Use scent readily
available and easy to
identify (alcohol pad,
toothpaste on gauze,
coffee from tray).
Epistaxis
Acute Treatment
Sit up
Tilt head forward
Pinch nose 5 – 15 min.
Etiology
Dry mucous membranes.
Trauma
Lesion
Allergy
Physical Exam of the Mouth and Throat
External Structures
Inspect:
 Breath: malodorous => systemic
disease, poor oral hygiene
 Lips: hydration, lesions,
symmetry, injury, skin, color
Palpate:
 Lips: lesions
 Perioral area: lesions, swelling,
warmth, symmetry
Physical Exam of the Mouth and Throat
Internal Structures (Oropharynx)
Inspect:
 Tongue, buccal mucosa, gums, palates,
tonsils, uvula, teeth
 Describe color, symmetry, lesions,
exudate, anatomical variations, dentation,
swelling, bleeding
 Use penlight or scope light. Use tongue
blade or gauze pad to hold tongue. Wear
gloves.
Palpate (with gloves):
 Buccal mucosa and gums for lesions or
tooth eruption (infants and children).
Palpate palate for symmetry and cleft
(infants).
Physical Exam of the Mouth and Throat
Grade Tonsils if Present
1+ normal
2+ half way btw pillars and
uvula
3+ touching uvula
4+ touching each other
Note presence of exudate,
stones, and describe color.
Note if size is bi or uni lateral
Abnormal Findings
Leukoplakia
Response to long term irritation
and inflammation of muscosal
membranes.
Overwhelming majority are
benign.
Document location, size, and
patient history of lesion.
Also found in female genital
muscosal tissue due to long
term irritation.
Abnormal Findings
Candidiasis/Oral Thrush
Opportunistic fungal infection
secondary to changes in normal
flora. Normal flora is protective and
can be disrupted by infection
(bacterial or viral), diet, stress,
medication, lifestyle, or
environment/habits.
Painful, thick, white plague over
tongue and mucosal surfaces that
cannot be scraped off (leukoplakia is
painless).
Presents in “satellite pattern” with
small plaques radiating from larger
central plaques.
Abnormal Findings
Xerostomia
 Cracked, dry, reddened
tongue indicative of severe
dehydration. May also be
caused by medication.
 Other signs of dehydration
will be present including
chapped lips and tacky
buccal mucosa.
 Elderly and pediatric
population vulnerable.
Abnormal Findings
Smooth Tongue
Vitamin and mineral
deficiencies including B vitamins
and iron (anemia)
Smooth burning tongue
History should corroborate
finding (alcoholism, Celiac’s, poor
nutrition, cystic fibrosis).
Abnormal Findings
Chancre
syphilitic lesion (painless). It is typically found periorally
or on lips. It is often ulcerated and can be large, but it is
painless and remits on its own.
Canker Sore
 inside the mouth on the mucosa. It will be painful,
ulcerated, sensitive to heat, cold, and acid. The patient may
have other GI complaints. Canker sores often recur.
Fever blister or cold sore
 Caused by the Herpes Simplex Virus. It is typically found
periorally or on the lips. It is a painful and gradually
ulcerated lesion that begins invisibly as the sensation of
tingling. The first instance of HSV infection may include
fever, facial swelling, flu-like symptoms. HSV is chronic and
lesions recur, though the use of ant-viral medications may
reduce occurrence or prevent it, especially if used after first
occurrence.
Abnormal Findings
Bruxsim
Chronic teeth grinding wears down
surfaces of the teeth, making them
vulnerable to decay and breakage.
Can be caused by pathophysiologic
states (like mandibular joint diseases),
medications, lifestyle, stress, or
patients may grind their teeth while
sleeping and be unaware. Dentists
can fit patients with appliances to
prevent tooth wear.
Abnormal Findings
Hyperplasia
 Overgrowth of gum tissue
that may need surgical
intervention
 Dilantin
 Pregnancy
 Puberty
 Leukemia
Abnormal Findings
Gingivitis
 A bacterially mediated process
that initiates an inflammatory
process of the gingiva, causing
loss of the gingiva tissues.
 Documented and rated according
to level of recession of gums
away from insertion areas of
teeth.
 Interventions include mechanical
removal of bacterial plaques
(flossing, scraping),
antimicrobials, and regular dental
hygiene.
Physical Exam of the Cranial Nerves
Cranial Nerve XII
 stick out tongue
 side-to-side
 strength
 “la-la-la”
 deviation to one side or weakness is abnormal
Palates and tonsils, CNs IX and X
 Inspect palates for shape, color and lesions
 Elevation of uvula when tongue blade is on middle
third of tongue and patient says “ah” is normal.
 Gag patient with blade on posterior 1/3 of tongue
(very small percentage of population do not have gag
reflex). Patient can swallow water instead of gagging.