Download Head and Neck

Chapter 10
Head, Eyes, Ears,
Nose, and Throat
DSN
Kevin Dobi, MS, APRN
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Anatomy&
Physiology
Review
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
2
Concept Overview
• Feature concept: Sensory perception
• Ability to understand and interact through senses:
• Sight
•
•
•
•
Hearing
Smell
Taste
Touch
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
3
Head
• Head and neck contain multiple structures:
• Skull encloses brain.
• Facial structures include eyes, ears, nose, and mouth.
• Neck structures include:
• Upper portion of spine
• Esophagus
• Trachea
• Thyroid gland
• Arteries
• Veins
• Lymph nodes
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
4
Anatomy and Physiology:
Head
• Skull is a bony structure that protects brain and upper
spinal cord:
• Contains special senses of vision, hearing, smell, taste.
• Comprises six bones fused at sutures.
• Covered by scalp tissue typically covered with hair.
• Face comprises 14 bones:
• Mandible articulates with temporal bone to form
temporomandibular joint. TMJ
• Facial muscles innervated by cranial nerves
V (trigeminal) and VII (facial).
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
5
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
6
Anatomy and Physiology:
Eyes – External Ocular Structures
• External ocular structures:
• External eye is composed of eyebrows, upper and lower eyelids, eyelashes,
conjunctivae, and lacrimal glands.
• Palpebral fissure is opening between eyelids.
• Conjunctivae are two thin, transparent mucous membranes, between
eyelids and eyeball. Conjunctivitis or Pink Eye.
• Bulbar conjunctiva covers scleral surface of eyeball.
• Palpebral conjunctiva lines eyelids and contains blood
vessels, nerves, hair follicles, and sebaceous glands.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
7
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
8
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
9
Anatomy and Physiology:
Eyes: External Ocular Structures (contd.)
• External ocular structures:
• Meibomian gland secretes substance to lubricate lids, slows evaporation of
tears, provides airtight seal when lids closed.
• Lacrimal glands form tears that combine with sebaceous secretions to
maintain constant film over cornea.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
10
Anatomy and Physiology:
Eyes: Ocular Structures
• Ocular structures
• Globe of the eye, the eyeball, is surrounded by three
separate layers:
• Sclera, outer layer
• Uvea, middle layer
• Retina, inner layer
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
11
Anatomy and Physiology:
Eye: Sclera
• Ocular structures: Sclera
• Sclera is tough, fibrous outer layer, “white” of eye.
• Limbus is junction where sclera merges with cornea.
• Cornea covers iris and pupil, is transparent, avascular, and richly
innervated with sensory nerves.
• Cornea allows light transmission through lens to retina.
• Tears provide cornea with oxygen and protect surface
from drying.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
12
Anatomy and Physiology:
Eyes: Uvea
• Ocular structures: Uvea
• Uvea, middle layer, consists of:
• Choroid layer, posteriorly, which supplies blood to retina.
• Iris, anteriorly, is circular, muscular membrane that
regulates pupil dilation and constriction via the
oculomotor nerve, cranial nerve III.
• Pupil, central opening of iris, allows light
transmission to retina.
• Ciliary body, anteriorly, adjusts lens to accommodate
vision at varying distances.
• Also produces transparent aqueous humor that flows
between lens and iris.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
13
Anatomy and Physiology:
Eye: Retina
• Ocular structures: Retina
• Retina, inner layer, extension of central nervous system
(CNS).
• Transparent layer with photoreceptor cells, rods
and cones, unevenly distributed over its surface.
• Rods and cones perceive images and colors in
response to varying light stimuli.
• Rods respond to low levels of light.
• Cones respond to higher levels of light.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
14
Anatomy and Physiology:
Eye: Optic Disc
• Ocular structures: Optic disc
• Optic disc, perforates retina, head of optic nerve,
CN II, which contains no rods or cones and causes small
blind spot at center of vision.
• Central retinal artery and central vein
bifurcate, emerge, and feed into smaller
branches throughout retinal surface.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
15
Anatomy and Physiology:
Eye: Ocular Function
• Vision occurs when:
• Rods and cones respond to varying light stimuli.
• Lenses constantly adjust to stimuli at different distances by
accommodation.
• When lens focus nerve impulses transmit information to
visual cortex.
• Then images are transmitted by visual nerve fibers to
occipital lobe of each cerebral hemisphere.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
16
Anatomy and Physiology:
Ears
• Ear is a sensory organ for hearing and maintaining equilibrium
• Divided into three sections:
• External ear
• Middle ear
• Inner ear
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
17
•
Anatomy and Physiology:
External ear
External Ear
• Auricle or pinna and external auditory ear canal composed of cartilage
and skin.
• Helix is prominent outer rim.
• Concha is deep cavity in front of external auditory
meatus.
• Lobule is bottom portion of ear.
• Auricle serves three main functions:
• Collection and focus of sound waves.
• Location and direction of sound.
• Protection of external ear from water and dirt.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
18
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
19
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
20
Anatomy and Physiology:
Middle Ear
• Middle ear
• Air-filled cavity separated from external ear canal by
tympanic membrane.
• Contains three tiny bones or ossicles:
• Malleus
• Incus
• Stapes
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
21
Anatomy and Physiology:
Middle Ear (contd.)
• Middle ear
• Eustachian tube is cartilaginous passage between middle ear
and nasopharynx
• Opens briefly during yawning, swallowing, or
sneezing to equalize pressure of middle ear to
atmosphere.
• Amplification of sound is the function of middle ear
• Sound waves cause tympanic membrane to
vibrate and transmit sound through ossicles to
inner ear.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
22
Anatomy and Physiology:
Inner Ear
• The inner ear
• Encased in a bony labyrinth containing three primary structures.
• Vestibule and semicircular canals contain receptors
responsible for balance and equilibrium.
• Cochlea, coiled and snail-shaped, contains Corti
structures responsible for hearing.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
23
Anatomy and Physiology:
Hearing
• Sound waves reach cochlea by middle ear causing movement of
hair cells.
• Sensory hair cells transmit impulses through nerve receptors and
vestibular nerve branch of acoustic nerve, CN VIII.
• Transmit to temporal lobe of the brain, where sound is interpreted.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
24
Anatomy and Physiology:
Nose
• Passageway for inspired and expired air
• Humidifies, filters, and warms air before entering lungs.
• Conserves heat and moisture during exhalation.
• Other functions include identifying odors and giving
resonance to laryngeal sounds.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
25
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
26
Anatomy and Physiology:
Nose (contd.)
• Upper third is encased in bone.
• Lower two thirds is composed of cartilage.
• Hard palate is the floor of nasal cavity.
• Septal cartilage maintains shape of nose and separates nares or
nostrils, which maintain an open passage for air.
• Nasal cavity lined with highly vascular ciliated mucous
membrane.
• Cilia trap particles before getting into lungs.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
27
Anatomy and Physiology:
Nose (contd.)
• Three turbinates line the lateral walls of the nasal cavity:
• Inferior meatus drains nasolacrimal duct.
• Middle meatus drains frontal, maxillary, and ethmoid sinuses.
• Superior meatus drains posterior ethmoid sinus.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
28
Anatomy and Physiology: Paranasal
Sinuses 4
• Extend out of nasal cavities through narrow openings into skull
bones to form four paired, air-filled cavities:
• Frontal sinus in frontal bone above nasal cavities.
• Ethmoid sinus near superior portion of nasal cavity.
• Sphenoid sinus deep in skull behind ethmoid.
• Maxillary sinuses on either side of cheekbones.
• Lined with mucous membrane and cilia to move and excrete
secretions.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
29
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
30
Anatomy and Physiology:
The Mouth
• Mouth
• Lips, tongue, teeth, gums, and salivary glands.
• Roof consists of hard palate (anterior), and soft palate
(posterior).
• Tongue has hundreds of papillae (taste buds).
• Dorsal surface has hundreds of papillae (taste
buds) to distinguish sweet, sour, bitter, and salty
tastes.
• Ventral surface is smooth and highly vascular.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
31
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
32
Anatomy and Physiology:
The Mouth: Teeth
• Two sets of teeth: Deciduous and permanent
• 32 teeth include:
• Incisors = 12
• Premolars = 8
• Molars = 12
• Teeth tightly encased:
• Mucous membrane ─ covered, fibrous gum tissue.
• Rooted in alveolar ridges of maxilla and mandible.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
33
Anatomy and Physiology:
The Mouth: Salivary Glands 3
• Three pairs of salivary glands release saliva in response to food
and begin digestive process:
• Parotid glands are anterior to ears, above mandibular angle, and drain into
oral cavity through Stensen’s ducts.
• Submandibular glands are under mandible and drain through Wharton’s
ducts under tongue.
• Sublingual glands, smallest salivary glands, lie on floor of mouth and
drain through 10 to 12 tiny microscopic ducts.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
34
Anatomy and Physiology:
The Oropharynx
• Oropharynx includes structures at back of mouth that are
visible on examination:
• Uvula is suspended from soft palate and extends to form
anterior pillar.
• Tonsils are lymphoid tissue between pillars.
• Posterior pharyngeal wall is visible when tongue is extended or
depressed.
• Highly vascular, red or pink due to small vessels
and lymphoid tissue.
• Epiglottis, a cartilaginous structure, protects laryngeal opening.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
35
Anatomy and Physiology:
Neck

Structures within neck include:
• Cervical spine
• Sternocleidomastoi
d muscle
• Hyoid bone
• Larynx
• Trachea
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
•
•
•
•
•
Esophagus
Thyroid gland
Lymph nodes
Carotid arteries
Jugular veins
36
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
37
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
38
Anatomy and Physiology:
Neck (contd.)
• Neck formed by cervical vertebrae, supported by ligaments, and
SCM and trapezius muscles:
• Allow extensive movement within neck.
• Mobility greatest at C4-5 or C5-6.
• Neck muscles and bones form triangles:
• Anterior (medial borders of SCM muscle and mandible).
• Posterior (trapezius muscle, SCM muscle, clavicle).
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
39
Anatomy and Physiology:
Neck: The Larynx
• Larynx, or voice box, lies just below pharynx and just above
trachea:
• Air passage into trachea, allows vocalization, and prevents food from
entering trachea.
• Thyroid cartilage, or Adam’s apple, is largest component (anterior
portion, shield-shaped) of larynx.
• Protects other structures within larynx: epiglottis, vocal
cords, and upper aspect of trachea.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
40
Anatomy and Physiology:
Neck: Thyroid Gland
• Thyroid gland is largest endocrine gland.
• Produces two hormones:
• Thyroxine (T4).
• Triiodothyronine (T3).
• Regulates cellular metabolism and mental and physical growth and
development.
• Accessible to examination with two lobes or isthmus on either sides of
trachea.
• Isthmus lies across trachea, under cricoid cartilage, and tucked behind
SCM muscle.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
41
Anatomy and Physiology:
Neck: Vascular Structures
• Cardiovascular structures:
• Carotid arteries and internal jugular vein lie deep and parallel anterior of
SCM muscle.
• Provide important data regarding cardiovascular status.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
42
Anatomy and Physiology:
Lymph Nodes
• Lymph nodes are in chains or clusters:
• Tiny oval clumps of lymphatic tissue, usually located in groups along
blood vessels.
• Superficial nodes in subcutaneous tissue:
• Become enlarged and tender, providing early signs of
inflammation.
• Deep nodes are inaccessible beneath fascia of muscles or within various
body cavities.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
43
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
44
Anatomy and Physiology:
Lymph Nodes (contd.)
• Lymph nodes in head categorized as:
• Preauricular, postauricular, occipital, parotid, retropharyngeal (tonsillar),
submandibular, submental, and sublingual.
• Lymph nodes in neck are found in chains:
• Named according to relation to SCM muscle.
• Include anterior and posterior cervical chains, sternomastoid nodes, and
supraclavicular nodes.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
45
Assessment
Collecting Data
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
46
Health History:
Present Health Status
• Present health status:
• Have you noticed any changes to your eyes, ears, nose, or
•
•
•
•
mouth?
Do you have any chronic conditions that affect eyes, ears,
nose, mouth, head, or neck?
Examples: Cataracts, glaucoma, migraine headaches,
hearing loss, oral cancer, hypothyroidism
Other chronic conditions include:
• Hypertension, human immunodeficiency virus (HIV)
infection, diabetes mellitus, autoimmune disorders
Chronic diseases often impact clinical findings.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
47
General Health History:
Present Health Status (contd.)
• Medications: What, and how often?
• Side effects of medications are common and may explain
symptoms or clinical findings associated with head and
neck regions.
• Headaches, dizziness, changes in vision, ringing in ears, and
dry mouth are all examples of medication side effects.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
48
General Health History:
Past Medical History
• Have you ever had an injury to your eyes, ears,
mouth, or neck?
• Do you continue to have any problems related to injury?
• Have you had surgery involving eyes, nose, ears,
mouth, or neck?
• Have you had chronic infections affecting eyes, ears,
sinuses, or throat?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
49
General Health History:
Family History
• Is there a history of cancer in your family?
• Which of the family members and what kind of cancer was
diagnosed?
• Does anyone in your family have conditions impacting
hearing, vision, or thyroid?
• Cataracts.
• Glaucoma.
• Sensorineural hearing loss.
• Ménière’s disease.
• Hyperthyroidism.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
50
Personal and
Psychosocial History
•
•
•
•
When were your last routine exams?
Do you use corrective devices?
Describe your daily practice to maintain health.
Are there any occupational or recreational risks for
injury to your eyes, ears, or mouth?
• Do you use nicotine products or drink alcohol?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
51
Problem-Based History
• Most common problems related to head and related
structures (eyes, ears, nose, throat, and neck) include:
• Headache
• Dizziness
• Difficulty with vision
• Hearing loss
• Ringing in ears
• Earache
• Nasal discharge
• Sore throat
• Oral lesions
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
52
Problem-Based History:
Headache Assessment
• How long have you been having headaches?
• How often, and how long does it last?
• Cluster headaches occur more than once a day and for less
than one hour to about 2 hours. May follow pattern for a
couple of months and then disappear for months or years.
• Migraines may occur at periodic intervals and may last
from a few hours to 1 to 3 days.
• Identification of patterns may determine aggravating
factors and causes.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
53
Problem-Based History:
Headache Types
• Location of pain, in single area or generalized:
• Sinus headaches may cause tenderness over frontal or
maxillary sinuses.
• Tension headaches tend to be located in the front or back of
the head, and migraine and cluster headaches are usually
unilateral.
• Cluster headaches produce pain over the eye, temple,
forehead, and cheek.
• Tension headaches are described as viselike, migraine
headaches produce throbbing pain, and cluster headaches
cause a burning or stabbing feeling behind one eye.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
54
Problem-Based History:
Headache (contd.)
• Can you think of any factors that trigger headaches?
• Possible triggers include stress, fatigue, exercise, food, and
alcohol.
• Conditions that can precipitate headaches include
hypertension, hypothyroidism, and vasculitis.
• Migraines are frequently associated with menstrual period.
• What do you usually do to treat headache?
• Is it effective?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
55
Problem-Based History:
Dizziness and Vertigo
• Describe sensation of dizziness you are experiencing:
• When did it begin?
• How often?
• How long?
• Dizziness is a feeling of faintness.
• Vertigo is a sensation that the environment is
whirling around.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
56
Problem-Based History:
Dizziness and Vertigo (contd.)
• Does dizziness interfere with activities?
• Do you experience symptoms when driving or operating
machinery?
• Ever fallen as a result of dizziness?
• Patients with vertigo should be advised about hazards of
driving or operating machinery.
• What have you done to treat dizziness? Has it been
effective?
• Important to note attempts at self-treatment by patient.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
57
Problem-Based History:
Difficulty with Vision
• What type of vision difficulty?
• Did it begin suddenly or gradually?
• Does it affect one eye or both?
• Patient’s description is essential in determining cause of
visual difficulty:
• Sudden onset may indicate detached retina, which requires
emergency referral.
• Involvement of both eyes tends to indicate systemic problems,
but involvement of one eye is local problem.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
58
Problem-Based History:
Difficulty with Vision (contd.)
• What other symptoms are you experiencing?
• Headaches
• Dizziness
• Nausea
• What makes vision worse?
• What makes it better?
• Has vision problem interfered with daily life?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
59
Problem-Based History:
Hearing Loss
• How long have you had trouble hearing?
• What tones or sounds are difficult to hear?
• Onset sudden or gradual?
• Sudden loss in one or both ears not associated with ear or
upper respiratory infection requires further evaluation.
• Hearing loss associated with aging (presbycusis) occurs
gradually, increasing with age, particularly in high
frequencies.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
60
Problem-Based History:
Hearing Loss (contd.)
• Other symptoms with hearing loss?
• Fevers
• Headaches
• Visual changes
• Does loss interfere with daily routine, job, or social
interactions?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
61
Problem-Based History:
Ringing in the Ears (Tinnitus)
• Describe noise you are hearing. Is it ringing, hissing,
crackling, or buzzing?
• When did it begin?
• Ringing of ears (tinnitus) is a sensation or sound heard only by
affected individual and can manifest with a variety of sounds
or sensations.
• Does sound occur continuously, or come and go? If it
comes and goes, does it occur with certain activities, or at
the same time of day?
• Pattern of symptoms may provide clues to cause.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
62
Problem-Based History:
Earache
• How long have you had earache? Could it be related
to infection in mouth, sinuses, or throat?
• Describe location of pain.
• Is pain constant, or does it come and go?
• Ear pain can be unilateral or bilateral; internal or external;
if intermittent, explore possible triggering mechanisms.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
63
Problem-Based History:
Earache (contd.)
• What does pain feel like?
• Does it hurt when you pull or touch ear?
• Does pain change when you change your position or lie down?
• Pain caused by infection involving external ear or ear canal
increases with movement of ear.
• Pain caused by otitis media does not change with manipulation
of ear.
• Is there discharge from ear?
• Description of discharge may help determine cause of
symptoms.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
64
Problem-Based History:
Nasal Discharge/Nose Bleed
• When did nasal discharge or nose bleed begin?
• Can you describe it?
• A thick or purulent green-yellow, malodorous discharge
usually results from a bacterial infection.
• Foul-smelling discharge, especially unilateral discharge, is
associated with a foreign body or chronic sinusitis.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
65
Problem-Based History:
Nasal Discharge/Nose Bleed (contd.)
• Profuse watery discharge is typical with allergies.
• Bloody discharge may result from neoplasm, trauma, or
opportunistic infection such as fungal disease.
• Nose bleed (epistaxis) may occur secondary to trauma, chronic
sinusitis, malignancy, or bleeding disorder.
• May also result from cocaine abuse.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
66
Problem-Based History:
Nasal Discharge/Nose Bleed (contd.)
• What other symptoms do you have?
• Associated symptoms with allergic rhinitis include itching,
swelling, discharge from eyes, postnasal drip, and cough.
• Fatigue, fever, and pain may be associated with infections.
• What do you do to treat discharge or bleeding? Is it
effective?
• Determining what has been successful may guide current
treatment strategies.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
67
Problem-Based History:
Sore Throat
• How long have you had a sore throat?
• Can you describe it?
•
•
•
•
•
Lump?
Burning?
Scratchy?
Hurt to swallow?
Painful lymph nodes?
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
68
Problem-Based History:
Sore Throat (contd.)
• Are others in your home ill or just recovered from sore
throat or cold?
• Explore possible environmental factors that contribute to
sore throat and whether sore throat may be
communicable.
• How have you been treating your sore throat? Is it
effective?
• Determining what has been successful may guide current
treatment strategies.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
69
Problem-Based History:
Oral Lesions
• Where is mouth sore?
• Mouth lesions have many causes including:
•
•
•
•
•
Trauma
Infection
Nutritional deficits
Immunologic problems
Cancer- most seen under tongue or inner lip.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
70
Problem-Based History:
Oral Lesions (contd.)
• What other symptoms have you noticed?
• Bleeding, lumps, thickened areas in mouth are possible
symptoms of oral cancer.
• Enlarged lymph nodes may be associated with cancer or an
infection.
• Painful ulcerations may impair nutritional intake.
• Are there sores anywhere else on your body, such as in the
vagina, urethra, penis, or anus?
• Sexually transmitted diseases such as herpes may be
transmitted through oral sex.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
71
Age-Related Variations
• Several differences to be aware of:
•
•
•
•
Interview questions
Anatomic differences
Examination procedures
Many of these are age-related changes that impact
assessment findings.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
72
Common Problems and Conditions:
Headaches
• Most common medical complaint.
• Recurrent headaches are a symptom of chronic
primary headache disorder.
• May be associated with ophthalmologic or dental
problems, sinusitis, infections, side effects from
medications, hemorrhage, or tumor.
• Headaches are classified on the basis of symptoms and
history.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
73
Common Problems and Conditions:
Migraine Headache
• Migraine is second most common headache syndrome in the
United States and can occur in childhood, adolescence, or early
adult life; young women are most susceptible.
• Clinical findings:
• Starts with aura from vasospasm of intracranial arteries; throbbing
unilateral distribution of pain.
• May be accompanied by depression, restlessness, irritability,
photophobia, nausea, or vomiting.
• May last up to 72 hours.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
74
Common Problems and Conditions:
Cluster Headache
• Most painful of primary headaches.
• Common from adolescence to middle age.
• Clinical findings:
• Intense episodes of excruciating unilateral pain.
• Lasts 30 minutes to 1 hour and may repeat daily for weeks
with some remissions or 6 to 12 weeks with remissions for 1
or more years.
• Pain is burning, drilling, stabbing behind one eye.
• May be accompanied with unilateral ptosis, ipsilateral
lacrimation, nasal stuffiness, and drainage.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
75
Common Problems and Conditions:
Tension Headache
• Most common headache experienced by adults between
20 and 40 years of age.
• Clinical findings:
• Usually bilateral; may be diffuse or confined to frontal,
temporal, parietal, or occipital area.
• Onset may be gradual and last for several days.
• May be accompanied by contraction of skeletal muscles of
face, jaw, and neck
• Patients frequently describe as feeling of tight band around
their heads.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
76
Common Problems and
Conditions: Post-traumatic Headache
• Secondary to head injury or concussion.
• Most common cause is motor vehicle accident.
• Clinical findings:
• Dull, generalized head pain.
• Accompanying symptoms may be lack of ability to concentrate, giddiness,
or dizziness.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
77
Common Problems and Conditions:
Hydrocephalus
• Abnormal accumulation of cerebrospinal fluid (CSF) may
develop from infancy to adulthood.
• In infants: As a result of obstruction of CSF drainage
• In adults: As an obstruction, increased production, or
decreased absorption of CSF
• Clinical findings:
• In infants: Gradual increase in intracranial pressure leads to an
actual enlargement of head, fontanels may bulge, and scalp
veins dilate.
• In adults: Signs of increased intracranial pressure (decreased
mental status, headache) are noted because skull is unable to
expand.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
78
Common Problems and Conditions: Chalazion
and Hordeolum
• Chalazion is nodule of meibomian gland in eyelid, may be tender
if infected. Along the eyelash line
• Often follows conjunctivitis, blepharitis, or meibomian cyst.
• Clinical findings: Firm, nontender nodule observed in eyelid.
• Hordeolum (sty) is acute infection originating in sebaceous gland
of eyelid: Above or below eyelash line-on the lid itself.
• Staphylococcus aureus.
• Affected area usually is painful, red, and edematous.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
79
Common Problems and Conditions:
Conjunctivitis
• Conjunctivitis is inflammation of palpebral or bulbar
conjunctiva caused by local infection of bacteria or
virus, or by allergic reaction, systemic infection, or
chemical irritation.
• Clinical findings:
• Eye appears red, with thick, sticky discharge on eyelids in
mornings.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
80
Common Problems and Conditions:
Corneal Abrasion
• Corneal abrasion or ulcer is disruption of corneal
epithelium and stroma:
• Caused by fungal, viral, or bacterial infections or desiccation
because of incomplete lid closure or poor lacrimal gland
function.
• May also be caused by scratches, foreign bodies, or contact
lenses poorly fitted or overworn.
• Clinical findings:
• Intense pain, has a foreign body sensation, and reports
photophobia; tearing and redness are observed.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
81
Common Problems and Conditions:
Strabismus (lazy eye)
• Strabismus is abnormal ocular alignment as visual axes do not
meet at desired point.
• Nonparalytic strabismus due to muscle weakness, focusing difficulties,
unilateral refractive error, or anatomic differences in eyes.
• Paralytic strabismus is motor imbalance caused by paresis or paralysis
of an extraocular muscle.
• Clinical findings:
• Two most common types:
• Esotropia is an inward-turning eye; most common
type of strabismus in infants.
• Exotropia is an outward-turning eye.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
82
Common Problems and Conditions:
Cataract
• Cataract is opacity of crystalline lens from denaturation
of lens protein caused by aging and may be congenital or
caused by trauma.
• Clinical findings:
• Cloudy or blurred vision; glare from headlights, lamps, or
sunlight; and diplopia.
• May also report poor night vision and frequent changes in
prescriptions for glasses.
• A cloudy lens can be observed on inspection.
• Red reflex is absent because light cannot penetrate opacity of
lens.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
83
Common Problems and Conditions:
Diabetic Retinopathy
• Diabetic retinopathy is visual alteration with diabetes mellitus
caused by changes in retinal capillaries; leading cause of
blindness.
• Clinical findings:
• Patients report decrease in vision.
• In background diabetic retinopathy, microaneurysms and
hemorrhages are seen.
• Exudates may also be seen around macula.
• Patients with proliferative diabetic retinopathy report a sensation of
“curtain over eye” (from a detached retina).
• On examination, a network of new blood vessels is seen along retinal
surface.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
84
Common Problems and Conditions:
Glaucoma
• Glaucoma is a group of diseases that increases
intraocular pressure and damages optic nerve, leading
to blindness.
• Two types of glaucoma: Open-angle and closed-angle (the
angle created by cornea and iris).
• Clinical findings:
• No specific symptoms of open-angle glaucoma.
• Most reliable indicator is intraocular pressure measurement.
• Patients with closed-angle glaucoma complain of sharp eye
pain and seeing halo around lights.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
85
Common Problems and Conditions:
Ears
• Foreign body within ear is frequently seen in children, but
may occur in all age groups.
• Can be a small object such as small stone, small part of a toy,
or an insect.
• Clinical findings:
• Patient feels sense of fullness in ear and experiences decreased
hearing.
• If a live insect, may hear movement of insect and often
experience severe pain and fever.
• Inspection of auditory canal reveals foreign body.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
86
Common Problems and Conditions:
Otitis Media
• Infection: Acute otitis media (AOM) is infection of middle ear.
• Clinical findings:
• Major symptom with AOM is ear pain (otalgia).
• May include fever, vomiting (infants), and decreased
hearing (older children and adults).
• In early stages, tympanic membrane (TM) appears inflamed, red, and
may be bulging and immobile.
• Later stages may reveal discoloration (white or yellow drainage) and
opacification to the TM.
• Purulent drainage from the ear canal with a sudden relief of pain
suggests perforation.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
87
Common Problems and Conditions:
Otitis Media with Effusion
• Infection: Otitis media with effusion (OME) is inflammation of
middle ear space, resulting in accumulation of serous fluid in
middle ear.
• Clinical findings:
• Common symptoms include clogged sensation in ears, problems with
hearing and balance.
• Some report clicking or popping sounds in ear.
• Because OME is not associated with acute inflammation, fever and
ear pain are absent.
• TM is often retracted and yellow or gray in color with limited
mobility.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
88
Common Problems and Conditions:
Conductive Hearing Loss
• Conductive hearing loss caused by interference of air
conduction to middle ear.
• May result from blockage of external auditory canal, problems
with TM, or problems within middle ear.
• Clinical findings:
• Decreased ability to hear and report of muffled tones.
• Obstructions within auditory canal or problems with TM may
be visible with otoscopic examination.
• Problems within middle ear may not be visible.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
89
Common Problems and Conditions:
Sensorineural Hearing Loss
• Sensorineural hearing loss (SNHL) caused by structural changes,
disorders of inner ear, or problems with auditory nerve:
• SNHL accounts for more than 90% of hearing loss.
• Presbycusis is caused by atrophy and deterioration of cells in
cochlea or atrophy, degeneration, and stiffening of cochlear
motion.
• Clinical findings:
• Usually manifests as gradual and progressive bilateral deafness
with a loss of high-pitched tones.
• Patients have difficulty filtering background noise, making
listening difficult.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
90
Common Problems and Conditions:
Epistaxis
• Epistaxis is bleeding from nose, recognized as one of most
common problems of nose:
• Common causes of nosebleeds include forceful sneezing or coughing,
trauma, picking of nose, or heavy exertion.
• Some nosebleeds occur spontaneously without an obvious causative event.
• Clinical findings:
• Bleeding due to high vascularity; most occur anterior of septum.
• Bleeds from posterior septum may also occur and tend to be more severe.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
91
Common Problems and Conditions:
Allergic Rhinitis
• Inflammation: Allergic rhinitis is inflammation of nasal
mucosa.
• Chronic rhinitis caused by inhalant allergy, seasonal or yearround sensitivity to dust and molds.
• Strong family histories with allergic rhinitis.
• Clinical findings:
• Exposure to allergen causes sneezing, nasal congestion, and
nasal drainage, and may include itchy eyes, cough, and fatigue.
• Turbinates are often enlarged and may appear pale or darker
red.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
92
Common Problems and Conditions:
Acute Sinusitis
• Inflammation: Acute sinusitis is infection as a result of
pooling secretions within sinuses.
• Secretions provide a medium for bacterial growth.
• Clinical findings:
• Most common symptom is throbbing pain in affected sinus.
• May also have fever, thick purulent discharge, and edematous,
erythematous nasal mucosa.
• Transillumination shows absence of red glow in affected sinus.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
93
Common Problems and Conditions:
Herpes Simplex Type 1
• Inflammation/infection: Herpes simplex type 1 (cold
sore) a highly contagious, viral infection spread by direct
contact.
• Clinical findings:
• Typically a prodromal burning, tingling, or pain sensation
before outbreak of lesions.
• Lesions appear on lip and skin junction as groups with an
erythematous base.
• Like other herpes infections, lesions progress from vesicles to
pustules and finally to crusts.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
94
Common Problems and Conditions:
Gingivitis
• Inflammation/infection: Gingivitis is an inflammation of
gingivae (gums).
• Poor dental hygiene results in bacterial plaque on tooth surface
at gum line causing inflammation.
• Clinical findings:
• Hyperplasia of gums, erythema, and bleeding with
manipulation are most common signs.
• Edema deepens crevice between gingivae and teeth, allowing
for pockets where food particles collect, causing further
inflammation.
• Periodontitis occurs when inflammatory process causes
erosion of gum tissue and loosening teeth.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
95
Common Problems and Conditions:
Tonsillitis
• Inflammation/infection: Tonsillitis is infection of tonsils
from common bacterial pathogens: beta-hemolytic and
other streptococci.
• Clinical findings:
• Classic presentation includes sore throat, pain with swallowing
(odynophagia), fever, chills, and tender cervical lymph nodes.
• Some may also complain of ear pain.
• On inspection, tonsils appear enlarged and red and may be
covered with white or yellow exudates.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
96
Common Problems and Conditions:
Candidiasis
• Inflammation/infection: Candidiasis (thrush) is oral
infection caused by Candida albicans in those chronically
debilitated or immunosuppressed, or as a result of
antibiotic therapy.
• Clinical findings:
• Appears as soft white plaques on tongue, buccal mucosa, or
posterior pharynx.
• If membrane is peeled off, a raw, bleeding, erythematous,
eroded, or ulcerated surface results.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
97
Common Problems and
Conditions: Aphthous Ulcer
• Lesions: Aphthous ulcer (canker sore) is a common
oral lesion with unknown etiology.
• Affects up to 30% of adults and 37% of school-age
children.
• Clinical findings:
• Lesions are very painful and appear on buccal mucosa, lips,
tongue, or palate as round or oval ulcerative lesions with a
yellow-white center and an erythematous halo.
• May last up to 2 weeks.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
98
Common Problems and Conditions:
Oral Cancer
• Lesions: Oral cancer can occur on lip or within oral
cavity and oropharynx.
• Clinical findings:
• Lesions subtle and asymptomatic in early stages.
• Premalignant changes of oral mucosa; red or white patches
may be seen progressing to painless, nonhealing ulcers.
• Later-stage signs and symptoms include enlarged, hard,
nontender cervical chain or submental lymph nodes;
noticeable mass, bleeding, loosening of teeth, difficulty
wearing dentures, and difficulty swallowing.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
99
Common Problems and Conditions:
Hyperthyroidism
• Thyroid disorders: Hyperthyroidism is a condition
associated with excessive production and secretion of
thyroid hormone; Graves’ disease, a familial autoimmune
disorder, is most common cause.
• Clinical findings:
• Because thyroid hormone affects all body tissue, most body
systems are affected.
• Signs and symptoms reflect increased metabolism and may
include enlargement of thyroid gland and exophthalmos.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
100
Common Problems and Conditions:
Hypothyroidism
• Thyroid disorders: Hypothyroidism is result of decreased
production of thyroid hormone.
• Etiologies include autoimmune thyroiditis, decreased secretion
of thyroid releasing hormone from hypothalamus, congenital
defects, as a result of treatment for hyperthyroidism, atrophy
of thyroid gland, and iodine deficiency.
• Clinical findings:
• Clinical findings reflect an overall decreased metabolism;
patients seem to be in “slow motion,” with a depressed affect.
• Goiter may be seen with hypothyroidism.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
101
Common Problems and Conditions:
Thyroid Cancer
• Thyroid disorders: Thyroid cancer is most common
type of endocrine malignancy.
• Clinical findings:
• Frequently does not cause symptoms.
• Typically is first discovered as a small nodule on thyroid
gland.
• As tumor grows, changes in voice and problems with
swallowing or breathing may be experienced because of
invasion of tumor into larynx, esophagus, and trachea,
respectively.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
102
Common Problems and Conditions:
Lymphomas
• Lymphomas are a group of disorders with malignant
neoplasms of lymph tissue.
• Clinical findings:
• Malignancy causes lymph nodes to be large, discrete,
nontender, and firm to rubbery.
• Enlarged nodes usually unilateral and localized; however,
chronic lymphocytic leukemia causes generalized
lymphadenopathy.
• Hodgkin's disease, a malignant lymphoma, is a painless,
progressive enlargement of lymphoid tissue, usually first
evident by cervical lymph nodes, splenomegaly, and atypical
macrophages.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
103
Question 1
As the nurse assesses facial symmetry, a significant
finding is:
Ptosis.
B. Pseudostrabismus.
C. Widow’s peak.
D. Candidiasis.
A.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
104
Question 2
On inspection of the oral cavity, the nurse knows that:
A.
B.
C.
D.
Kaposi’s sarcoma can present on the palate of the
mouth.
Oral cancer is often painful on initial presentation.
Aphthous ulcers are often painless lesions that
usually are only seen in adults.
Patients with cancer cannot have candidiasis.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
105
The End
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
106