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HEENT Assessment

Nursing Assessment Class Notes of the Ears, Eyes, Nose, and Throat

HEENT Assessment

HEENT Nursing Assessment

HEENT Assessment

Components of HEENT Assessment

  • Head: Cranial assessment, jaw palpation, and inspection of the face
  • Eyes
  • Ears
  • Nose
  • Throat and oral cavity: Palpation and inspection of the thyroid gland

Head

Cranial Assessment 

  • Nits
  • Hair distribution patterns
  • Cranial shape and size
  • Infants: fontanels and sutures

Face Inspection

  • Face shape
  • Fat distribution patterns
  • Symmetry of the eyes, eyebrows, nose, mouth, and ears
  • Stable with attempts at manipulation

Jaw Palpation  

  • The temporomandibular joint is palpated for crepitation
  • The patient opens and closes the jaw as the nurse listens for audible clicks

Abnormal Findings of the Cranium and Face

  • Acromegaly: massive face, elongated head, prominent nose and lower jaw, heavy eyebrow ridge, and coarse facial features
  • Bell’s palsy: asymmetry of palpebral fissures as a result of cranial nerve VII damage
  • Cushing’s syndrome: moon face and buffalo hump, prominent jowls, erthymia of the cheeks, and hirsutism (facial hair in women) on the upper lip, lower cheeks, and chin
  • Kyphosis: head and neck is extended forward
  • Hematoma
  • Parkinson disease: mask-like expression or flat affect, elevated eyebrows, a staring gaze, and drooling
  • TMJ (lock jaw): crepitation in the temporomandibular joint
  • Xerostomia (dry mouth)

Abnormal Cranial Findings in the Infant

  • Craniosynostosis: a deformity of the skull caused by premature closing of the sutures
  • Hydrocephalus: enlarged head that results form increasing intracranial pressure secondary to accumulation of cerebrospinal fluid
  • Cephalhematoma: a subperiosteal hemorrhage caused by bleeding into the periosteum
  • Caput succedaneum: edematous swelling and ecchymosis of the head resulting from birth trauma

Eyes

Interview Questions Regarding the Eyes

  • Visual changes
  • Pain
  • Photophobia
  • Blurred vision, diplopia
  • Spots, floaters
  • Itching or discharge

Inspecting the Eyes

  • Pupils: Size, shape, and reaction to light
  • PERRLA
  • EOMs (extraocular movements)
  • Conjunctivae and lids
  • Ophthalmoscopic examination: Usually performed by a specialist

Normal Findings of the Eyes

  • PERRLA noted
  • Pupils of normal size, shape, and react bilaterally to light
  • Vision and extraocular movements intact
  • Conjunctivae and lids non-inflamed

Ears

Anatomy and Function of the Ears

  • Inner ear: Cochlea. The cochlea interprets amplitude (volume) and frequency (pitch). The cochlear window is also known as the round window
  • Middle ear: Includes the Eustachian tube (ear canal), oval window, round window, and tympanic membrane. Many NCLEX-style questions regarding the ear are focused on the tympanic membrane, especially the appearance
  • Pinna, helix, and tragus
  • External canal

Interview Questions Regarding the Ears

  • Hearing changes
  • Use of hearing aids
  • Habits that could affect hearing (loud music, occupational hazards)

Inspecting the Ears

  • Otoscopic examination of the external auditory canals
  • Otoscopic examination of the tympanic membranes

The exam begins with inspection of the ears for cerumen impaction, foreign body, infection, inflammation, or tympanic membrane perforation or scarring that can affect hearing loss and related issues. Otoscopy might reveal a blue or red mass behind the tympanic membrane in cases of pulsatile tinnitus caused by vascular origin.

Cranial nerves are assessed to evaluate hearing loss or brainstem dysfunction

Hearing is assessed through methods such as the whisper test, Weber test, and Rinne tests. This identi to determine any sensorineural or conductive hearing loss (see Determining the type of hearing loss).18,19 An oral inspection can reveal any dental issues or palatal muscle contractions. Temporomandibular joint (TMJ) dysfunction should be assessed, noting any snapping or clicking during palpation. – See more at: http://www.nursingcenter.com/lnc/cearticle?tid=1436010#sthash.AFHhow1Q.dpuf

Normal Findings of the Ears

  • Hearing intact
  • External ears: symmetrical, no deformities
  • Darwin’s tubercle: painless nodules on the helix
  • Tympanic membrane: bilaterally pink, pearly colored

Abnormal Findings of the Ear

  • Hearing loss: Sensorineural, conductive, or presbycusis
  • External ears: Asymmetrical, deformities
  • External canal: Inflammation, redness, purulent discharge
  • Tinnitus: Ringing in the ear
  • Tympanic membrane: Foreign body present, excessive cerumen, blood or hemotympanum
  • Vertigo: Altered balance that may be associated with an ear infection

Conditions of the Ear

  • Acoustic neuroma: Sensorineural hearing loss and tinnitus
  • Benign positional vertigo: Sudden onset of episodes of nausea, spinning sensation that worsens head position changes
  • Otitis externa: Also known as swimmer’s ear, an infection that occurs in the external ear. Presents with pain and swelling of the ear canal, fever, and purulent drainage from the external canal
  • Otitis media: Infection that occurs behind the tympanic membrane; presents with purulent discharge, and pain in the tragus and pinna. The tympanic membrane appears as bright red. Common in children
  • Meniere’s disease: Sensorineural hearing loss and tinnitus
  • Perforated tympanic membrane: Presents with drainage in the ear canal and pain resulting from high pressure in the ear. Visible upon otoscopic examination of the tympanic membrane. Pain is usually relieved once the pressure in the ear is released

Four Major Forms of Hearing Loss

  1. Sensorineural hearing loss: Associated with inner ear damage, such as the cochlea or auditory nerve. It may result from genetic anomalies, ototoxic drugs, Meniere’s disease, or infections that damage the cochlea or the auditory nerve
  2. Presbycusis: A type of sensorineural loss caused by changes in the inner ear. Common in older adults, it usually presents with progressive bilateral hearing loss of high-pitched tones, acuity, auditory threshold, and pitch
  3. Conductive hearing loss: Involves hearing loss in the external or middle ear that impacts the transmission of sound waves. It usually results from a physical disruption, such as perforation, infection, otosclerosis, or an obstruction, including a foreign body or severe cerebrum build-up
  4. Mixed hearing loss: Associated with factors related to both sensorineural and conductive causes of hearing loss. Damage is present in multiple areas, such as the outer or middle ear, along with the inner ear (cochlea) or auditory nerve (Adams-Wendling, Pimple, Adams, & Titler, 2008)

There are three major categories of hearing loss in older adults:

  • Sensorineural hearing loss is the result of damage to the inner ear, including the . Common causes include birth-related causes; heredity; viral or bacterial infections; mumps; spinal meningitis; encephalitis; trauma; tumors; noise; hypertension; coronary artery or vascular disease; ototoxic drugs, including aminoglycosides, diuretics, some antibiotics, and cancer medications; and (National Institute of Neurological and Communicative Disorders and Stroke [NINCDS], 1982, 1984).
  • Presbycusis, the most common kind of hearing impairment in older adults, is defined as a  ear (Bagai et al., 2006; Gates & Mills, 2005). Presbycusis is the term most often used to describe hearing impairment that is age related and generally presents as a gradual and . With presbycusis, there is a loss of high-pitched tones (1,000 to 8,000 Hz) in . Consonants such as f, sh, ch, h, t, p, and s are high-frequency sounds that become inaudible with presbycusis, resulting in the inability to comprehend words (Bagai et al., 2006; Brender, Burke, & Glass, 2006; Wallhagen et al., 2006).
  • Conductive hearing loss results from a in the ear transmission of sound waves through the external or middle  (Ignatavicius & Workman, 2006; Wallhagen et al., 2006). Causes of conductive hearing loss include external blockage, perforated eardrum, genetic or congenital abnormality, otitis media, and otosclerosis (Bagai et al., 2006; Wallhagen et al., 2006). The most common cause of conductive hearing loss in older adults is buildup of cerumen in the auditory canal (Wallhagen et al., 2006; Zivic & King, 1993). As individuals age, cerumen becomes drier, and the cilia become coarse and stiff, reducing their function and causing cerumen buildup (Zivic & King, 1993). Cerumen impaction obstructs sound transmission and can cause up to a 40 to 45 dB loss (Meador, 1995; Zivic & King, 1993). The estimated incidence of cerumen impaction in nursing home residents is nearly 40% (Freeman, 1995).

Mixed hearing loss includes both conductive and sensorineural components (Bagai et al., 2006; Kennedy-Malone et al., 2004). In other words, there may be .

Rinne Test and Conductive Hearing Loss

The Rinne test assesses for hearing loss related to air conduction. It uses a tuning fork to measure bone conduction (BC) versus air conduction (AC). Normally, bone conduction hearing is longer or equal to air conduction. In patients with conductive hearing loss, air conduction is heard longer than bone conduction. To conduct the Rhinne test, strike a tuning fork against a hard object in order to produce a vibration. Place the base of the vibrating instrument on the patient’s mastoid bone. Instruct the patient to report when the vibration is no longer heard. Once the noise is no longer heard, the tuning fork is placed in front of the ear. If the patient can not hear the vibration, the Rinne test is said to be positive. A positive Rinne test indicates conductive hearing loss

Weber Test and Unilateral Hearing Loss

  • The Weber test evaluates unilateral hearing loss

Whisper Test and Conductive Hearing Loss

  • The Whisper test evaluates loss of high-frequency sounds

Communication and Patients with Hearing Loss

  • Face the patient so your face in in direct view
  • Avoid ambient noise (background noise)
  • Do not raise your voice but talk slow and clear
  • Use plain English (Adams-Wendling, Pimple, Adams, & Titler, 2008)
  • Do not yell into the “good ear”
  • Do not assume thy can understand you

Nose

Interview Questions Regarding the Nose

  • Nasal discomfort
  • Epistasis (nosebleed)
  • Sinus issues
  • Rhinorrhea
  • Congestion

Inspecting the Nose

  • Nasal septum midline
  • nasal mucosa
  • Turbinates

Throat

Normal Swallowing Process

  • Oral: tongue propels mass towards oropharynx, and then muscle of the pharynx (risk: pocketing and aspiration)
  • Pharyngeal: propelled to the oropharynx, which triggers the swallow reflex
  • Esophageal

Palpation of the Throat  

  • Normal finding: neck is supple
  • Trachea
  • Lymph nodes
  • Salivary glands
  • Thyroid gland

Normal Findings in the Neck

  • Neck: supple
  • Clavicles: symmetrical
  • Trachea: midline
  • Thyroid gland: no masses and not enlarged

Abnormal Findings in the Neck

  • Neck: non-supple, vertebral point, paraspinal tenderness, step-offs, palpable muscular spasms, jugular vein distention, thyromegaly, lymphadenopathy, trachea deviated from midline, carotid bruits
  • Clavicles: crepitus, asymmetrical
  • Trachea: deviated from midline
  • Thyroid gland: masses, lumps, or enlargement (thyromegaly is an enlarged thyroid gland; similar to a goiter)

Oral Cavity

Interview

  • Have you ever had your tonsils removed?
  • Do you have a history of frequent infections of your tonsils (tonsillitis)?
  • Difficulty chewing?

Oropharynx Inspection   

  • Appearance of the tongue
  • Oral mucosa
  • Salivary glands
  • Hard and soft palates
  • Palatine tonsils

Salivary Glands 

  • Sublingual salivary glands
  • Submandibular salivary glands
  • Parotid glands: not normally palpable

Normal Findings

  • Mouth: clear of lacerations or deformities
  • Tonsils: same color as the surrounding mucous membrane, granular appearance with deep crypts on the surface
  • Oral mucosa: mucous membranes should appear to be pink and not inflamed

Abnormal Findings of the Oral Cavity

  • Abnormal findings of the tongue: enlarged, strawberry-like appearance, or furry
  • Tonsils: tonsillitis, peritonsillar abscess, or tonsil asymmetry
  • Laryngospasm

Lymph Node Assessment

Lymph Node Palpation  

  • Lymph nodes are mobile- they can be moved up and down and side to side
  • Muscles and arteries can’t be moved in this way
  • The lymph nodes can be palpated on the neck, axillae, groin, or other areas

Lymph Nodes

  • Axillary lymph node
  • Preauricular nodes: in front of the ear
  • Posterior auricular nodes: superficial to the mastoid process
  • Occipital nodes: base of the skull
  • Submental nodes: midline behind the tip of the mandible
  • Submandibular nodes: midway between the angle of the mandible and its tip
  • Jugulodigastric nodes: under the angle of the mandible
  • Superficial cervical nodes: overlay the sternomastoid muscle
  • Deep cervical nodes: deep under the sternomastoid muscle
  • Posterior cervical nodes: posterior triangle along the edge of the trapezius muscle
  • Supraclavicular nodes: above and behind the clavicle, at the sternomastoid muscle

Abnormal Findings of the Lymph Nodes

  • Infection
  • Swollen
  • Tender

Thyroid Gland Assessment

Thyroid Gland Function

  • Secretes thyroxine (T4) and tri-iodothyronine (T3), hormones that are imperative to metabolic function

Thyroid Gland Palpation

  • Located on the midline of trachea
  • The thyroid cartilage lies above the thyroid isthmus and has a small palpable notch
  • The thyroid gland normally enlarges during pregnancy

Abnormal Findings of the Thyroid Gland

  • Nodes, masses, and nodules
  • Hypothyroidism
  • Hyperthyroidism, most commonly caused by Grave’s disease

 

Resources for Nursing Students on EENT Assessment

 

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