NURS 2910 > HEENT Assessment > Flashcards

HEENT Assessment Flashcards

(72 cards)

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1
Q

What is HEENT

A

Head, Ears, Eyes, Nose, Throat

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2
Q

Subjective data for HEENT assessment

A
  • Present history
  • Past history
  • family history
  • lifestyle
  • health practices
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3
Q

Objective data for HEENT assessment

A
  • Inspect
  • Palpate
  • Auscultate
  • Percussion
  • mainly INSPECT AND PALPATE
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4
Q

Skull is made up of

A

two subsections
- cranium and facial bones

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5
Q

Cranium

A
  • houses and protects the brain and major sensory organs
  • consist of 8 BONES
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6
Q

Facial bones

A
  • Gives shape to the face
  • All immovable except the mandible
  • Consists of 14 BONES
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7
Q

Subjective data questions HEAD AND FACE

A
  • Do you have a history of headaches?
  • Have you ever had head injuries or loss of consciousness?
  • Do you have any jaw or facial pain?
  • Have you ever had a seizure?
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8
Q

Normal findings: HEAD

A
  • Skull rounded and symmetrical
  • Size of head is typical for family, proportional for body size, and age
  • Head is erect and midline
  • non-tender, smooth/normal contours, no lesions, scalp mobility
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9
Q

Abnormal findings: HEAD

A
  • Larger or smaller than expected size
  • Asymmetry of skull, not rounded
  • Masses, tenderness, abnormal contour/bumps
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10
Q

Normal Findings: FACE

A
  • symmetrical appearance and smooth movement of facial features
  • facial expression is appropriate for the situation
  • no visible lesions and normal hair distribution
  • non-tender
  • normal muscle tone
  • normal TMJ function
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11
Q

Abnormal Findings: FACE

A
  • Asymmetry of the face
  • lesions, lumps, abnormal hair distribution
  • the irregular or uneven movement of the jaw or popping/cracking
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12
Q

Pediatric variations: HEAD AND FACE

A
  • newborn head is misshapen
  • anterior fontanel> 9-18 mo
  • posterior fontanel> birth- 2mo
  • look for abnormal fontanel
  • cradle cap is common
  • potential flat spot on head
  • observe face when crying
  • hold head up> around 4mo
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13
Q

Subjective data questions: EYES

A
  • Have you noticed any changes in eyesight?
  • Do you wear glasses or contacts?
  • Have you ever had an eye injury?
  • Have you ever had eye surgery?
  • When was your last eye exam?
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14
Q

Eyelids

A

two movable structures made up of skin and muscle

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15
Q

Eyelashes

A

filter dust and dirt

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16
Q

Conjunctivia

A

the mucous membrane that covers eyelids, is peach and moist

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17
Q

Sclera

A

White outer coating of the eye

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18
Q

Iris

A

eye color

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19
Q

PERRLA

A

pupils equal, round and reactive to light, and accomodation

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20
Q

Extraocular muscles

A

the six muscles attached to the outer surface of the eyeball

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21
Q

rectus muscles

A

superior, inferior, lateral and medial

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22
Q

oblique muscles

A

superior and inferior

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23
Q

How many rectus muscles and oblique muscles control six different directions

A
  • 4 RECTUS
  • 2 OBLIQUE
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24
Q

Snellen Chart

A
  • based on age and literacy level
  • top number is distance in feet from chart
  • bottom number is distance at which a person with normal eyesight can read the same line
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25
Expected/ normal findings: EYES
20/20 vision, 6-7 years or older
26
Abnormal: EYES
Small fraction: diminished distant vision, near sited Larger fraction: diminished near vision, far sited
27
Visual acuity
Eye's ability to detect the details of an image
28
What cranial nerves allow to tract movement
CN III, IV, VI
29
Peripheral vision
boundaries of the eye when the eye is in a fixed position
30
Expected/abnormal: Peripheral vision
expected: no deficits abnormal: strabismus, amblyopia> loss of peripheral vision
31
Extraocular Movements(EOMs)
- inspect for parallel alignment - 6 cardinal fields of gaze - test corneal lights reflex
32
Inspect/ palpate: EYES
- inspect general appearance, eyelids, eyelashes, conjunctiva, sclera, lacrimal ducts and glands, iris and pupils - palpate external structures - test distance, near, and color vision, peripheral vision, EOMs, and PERRLA
33
Pediatric considerations: EYES
- newborn: 20/100 or 20/400 - not able to distinguish color well and other details - 3 mo: eyes should be aligned and movement coordinated - 5 yrs: 20/40 or 20/30 - 7 yrs: 20/20 - strabismus is normal until about 4-6 mo
34
Older adult considerations: EYES
- eyeball appearance can appear sunken in - lens of eyes begin to lose ability to accommodate to near objects - color vision declines - PERRLA reaction becomes slower - iris pigmentation causes iris to look brownish and pale - lower lid sags - conjunctiva may be pale or slight yellowish
35
Accommodation
the eyes ability to focus on something as it comes closer to the eye
36
Middle Ear
- conducts sound waves to the inner ear - compromised of tympanic membrane, eustachin tube, and auditory osicles
36
External Ear
- collects and conveys sound waves to middle ear - protects middle ear - physically can see
37
Inner ear
- responsible for hearing and equilibrium - bony labyrinth> cochlea, vestibule, semicircular canals
38
Subjective data questions: EARS
- Do you have any hearing problems? - Have you had any changes in your hearing? - Do you have any ear damage? - Do you have any ear pain? - Do you have any balance problems? - Have you ever had ringing in your ear?
39
Inspect/palpate: EARS
- symmetry in size, note the appearance of piercings - pinna level with corner of eye - color and condition of the skin - drainage, lesions, tenderness - palpate external ear> condition of skin/color - tympanic membrane> grey/ pearly/ shiny
40
Weber test: EAR
- ALWAYS start with - hearing wand top of patients head - sound is the same in both ears(negative) - sound is louder in one ear(negative) - if test is positive move to rinne test
41
Rinne Test: EAR
- ONLY perform when weber test is positive - this test compares AC and BC, normal= AC 2x as long as BC
42
Gross hearing (whispering test) assess
- assess low tone hearing
43
Romberg test assesses
BALANCE
44
Pediatrics consideration: EAR
- 20 week gestation fetus can hear - infants are more prone to ear infections - tubes are shorter, wider, horizontal - infant/toddler> gently pull down - older child> gently tug up
45
Older Adult consideration: EAR
- presbycusis - earwax increases - longer earlobes - coarse hair and dry skin
46
Cerumen
Ear wax
47
Subjective data questions: NOSE
- Do you have nasal congestion? - Do you have history of sinus problem? - Do you have seasonal allergies? - Do you experience nose bleeds? - Have you ever broken your nose?
48
The nose and sinuses are responsible for.....
smell
49
vaporized molecules trigger what CN?
CN I
50
Sinuses
- Air filled cavities to decrease weight of the skull - 4 sinuses( frontal, ethmoid, sphnoid, maxillary) - lined with ciliated mucous membrane - Act as resonance chambers during speech
51
inspect/palpate: NOSE
- inspect external position, size, and shape - observe and palpate for discharge - inspect internal structures with otoscope or light - palpate external structures, frontal and maxillary sinuses
52
Pediatric consideration: NOSE
- infants 3-6 mo are nose breathers
53
Older adult consideration: NOSE
- the sense of smell diminishes
54
Subjective data questions: THROAT/MOUTH/NECK
- Do you have any problems with your teeth? - When was your last dental exam? - How often do you brush your teeth? - Do you have any sores or irritation in your mouth? - Do you smoke or chew tobacco?
55
The neck is composed of...
- muscles, ligaments, and cervical vertebrae - jugular veins are carotid artery - thyroid gland - CN XI - cervical vertebrae
56
Lymph nodes size and shape may vary T or F
TRUE
57
Lymph nodes in the neck are usually palpable T or F
FALSE
58
Inspect/ palpate: NECK
- check symmetry, ROM, and condition - condition of skin and cervical vertebrae - Is the neck erect and midline - look for lesions, lumps, bumps -check lymph nodes, trachea, and thyroid gland
59
Palpating lymph nodes
- note size, tenderness, consistency, mobility, and temperature
60
Palpating the thyroid
- stand behind, having client flex neck forward and to the left - thumbs at nape of neck - palpate cricoid cartilage below thyroid cartilage - push trachea slightly to left with right hand as palpate below cricoid -TYPICALLY NOT PALPABLE
61
What color should nasal mucosa be?
PINK
62
What color is the tympanic membrane
GREY & PEARLY
63
When do babies typically begin to get their deciduous teeth
6 months
64
Deciduous teeth are
baby teeth
65
Subjective data questions: NECK
- Any neck pain or stiffness? - Any neck masses or lumps? - Is there any history of thyroid disorders? - Do you have difficulty swallowing?
66
Throat structure and function
- behind mouth and nose - passageway for food and air - below the nasopharynx is the oropharynx - tonsil
67
Mouth structure and function
- structure includes lips, tongue, teeth, gums, uvula, hard and soft palate, salivary glands, and ducts - beginning of the digestive tract - airway for the respiratory tract
68
inspect/palpate: MOUTH
- inspect mouth externally> lip placement, color, condition -oral mucosa and gums> color, condition - buccal mucosa> color, condition - inspect teeth and tongue - inspect oropharynx> say ahh - palpate lower lip> note tenderness, lesions, mobility - palpate inside of cheek, tongue, and floor of mouth
69
Mouth tests
- test gag reflex, touch back of soft palate of tongue with depressor
70
pediatric considerations: MOUTH
- primary nose breathers - tonsils typically larger - deciduous teeth at about 6 months - permanent teeth about 6 years
71
older adult considerations: MOUTH
NURS 2910
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