ASSESSMENT

NCM 101 HEALTH ASSESSMENT
CHONA Q. LIM, RN MAN | HOLY NAME UNIVERSITY
ASSESSMENT OF SKIN, HAIR, NAILS cell division and contains melanin and keratin
forming cell.
§ The major determinant of skin color is melanin.
STRUCTURE and FUNCTION § Other significant determinants include
capillary blood flow, chromophores and
§ The integumentary system consists of the skin, collagen.
hair, and nails which are the external structures Dermis
that serve a variety of specialized functions. § The inner layer of the skin is the dermis.
§ The sebaceous and sweat glands originating § Dermal papillae connect the dermis to the
within the skin also have many vital functions. epidermis. They are visible in the hands and
SKIN feet and create the unique pattern of the friction
§ The skin is the largest organ in the body. ridges commonly called as fingerprints.
§ It is a physical barrier that protects the § The dermis is a well vascularized, connective
underlying tissues and organs from tissue layer containing collagen and elastic
microorganisms, physical trauma, ultraviolet fibers, nerve endings, and lymph vessels.
radiation, and dehydration. § It is also the origin of sebaceous glands, sweat
§ It plays a vital role in temperature glands, and hair follicles.
maintenance, fluid and electrolyte balance, Sebaceous glands
absorption, excretion, sensation, immunity, § The sebaceous glands are attached to hair
and vitamin D synthesis. follicles and are present over most of the body,
§ It also provides an individual identity to a excluding the soles and palms.
person’s appearance. § They secrete an oily substance called sebum
§ The skin is thicker on the palms of the hands that waterproofs the hair and skin.
and soles of the feet and is continuous with the § There are two types of sweat glands:
mucous membranes at the orifices of the body. A. Eccrine glands B. Apocrine glands
§ It is composed of three layers: Sweat glands
o A. Epidermis § The eccrine glands are located over the entire
o B. Dermis skin.
o C. Subcutaneous Tissue - Their primary function is secretion of sweat
Epidermis and thermoregulation, which is
§ Epidermis – the outer layer of the skin. accomplished by evaporation of sweat from
§ Composed of four distinct layers: the skin surface.
A. Stratum Corneum § The apocrine glands are associated with hair
B. Stratum Lucidum follicles in the axillae, perineum, and areolae of
C. Stratum Granulosum the breasts.
D. Stratum Germinativum - Apocrine glands are small and non-
§ The outermost layer consists of dead, functional until puberty, at which time they
keratinized cells that render the skin are activated and secrete a milky sweat.
waterproof. - The interaction of sweat with skin bacteria
§ The epidermal layer is almost completely produces a characteristic body odor. In
replaced every 3 to 4 weeks. women, apocrine secretions are linked with
§ The innermost layer of the epidermis (stratum the menstrual cycle.
germinativum) is the only layer that undergoes
PHILIPP CHESTER T. LIBASORA| 1

Subcutaneous tissue § Hair color varies and is determined by the type
and amount of pigment (melanin and
§ Beneath the dermis lies the subcutaneous pheomelanin) production.
tissue, a loose connective tissue containing fat § A reduction in production of pigment can result
cells, blood vessels, nerves, and the remaining in gray or white hair.
portions of sweat glands and hair follicles. § Hair on the head protects the scalp, provides
§ The subcutaneous tissue stores fat as an insulation, and allows for self-expression.
energy reserve, provides insulation to § Nasal hair, auditory canal hair, eye lashes, and
conserve internal body heat, serves as a eyebrows filter dust and other airborne debris.
cushion to protect bones and internal organs, NAILS
and contains vascular pathways for the supply § The nails located on the distal phalanges of
of nutrients and removal of waste products to fingers and toes.
and from the skin. § Nails are hard, transparent plates of keratinized
epidermal cells that grow from the cuticle.
HAIR § The nail body extends over the entire nail bed
§ Hair consists of layers of keratinized cells. and has a pink tinge because of blood vessels
§ Found over much of the body except for the underneath.
lips, nipples, soles of the feet, palms of the § The lunula is a crescent-shaped area located at
hands, labia minora, and penis. the base of the nail.
§ Hair develops within a sheath of epidermal cells § It is the visible aspect of the nail matrix.
called the hair follicle. § The nails protect the distal ends of the fingers
§ Hair growth occurs at the base of the follicle, and toes, enhance precise movement of the
where cells in the hair bulb are nourished by digits, and allow for an extended precision grip.
dermal blood vessels.
ASSESSMENT (Skin, Hair and Nails)
§ The hair shaft is visible above the skin; the hair
root is surrounded by the hair follicle.
§ Attached to the follicle are the erector pili COLLECTING SUBJECTIVE DATA:
muscles, which contract in response to cold or The Nursing Health History
fright, decreasing skin surface area and § Diseases and disorders of the skin, hair, and
causing the hair to stand erect (goose flesh). nails can be local, or they may be caused by an
§ There are two general types of hair: underlying systemic problem.
A. Vellus hair B. Terminal hair § To perform a complete and accurate
assessment, the nurse needs to collect data
VELLUS HAIR TERMINAL HAIR about current symptoms, the client’s past and
family history, and lifestyle and health practices.
Short, pale, fine, and § Longer, generally
present over much of darker, and coarser
When Interviewing a Client for Information:
the body. It provides than vellus hair.
thermoregulation by § Particularly found in § Ask questions in a straightforward manner.
wicking sweat away the scalp and § Keep in mind that a non-judgmental and
from the body. eyebrows. sensitive approach is needed if the client has
§ Puberty initiates the abnormalities that may be associated with poor
growth of additional hygiene or unhealthful behaviors.
terminal hair in
both sexes on the
axillae, perineum,
and legs.

SELF ASSESSMMENT: HOW TO § During the examination ensure privacy by
EXAMINE YOUR OWN SKIN exposing only the body part being examined.
1. Examine head and face using one or both EQUIPMENT
mirrors. Use a blow dryer to inspect scalp. § Examination light
§ Penlight
2. 2. Check hands, including nails. In full length
§ Mirror for client’s self examination of skin
mirror, examine elbows, arms and
§ Magnifying glass
underarms. § Centimeter ruler
3. Focus on neck, chest, torso. § Gloves
Women: check under breasts. § Examination gown
4. With back to the mirror, use hand mirror to § Woods light
inspect back of neck, shoulders, upper arms, Important Key Points To Remember:
back, buttocks, legs. • Inspect skin color, temperature, moisture,
5. Sitting down, check legs and feet, including texture.
soles, heels, and nails. Use hand mirror to • Check skin integrity.
examine genitals. • Be alert of skin lesions
COLLECTING OBJECTIVE DATA: THE • Evaluate hair condition (loss or unusual
PHYSICAL ASSESSMENT growth)
§ Physical assessment of the skin, hair, and nails • Note nail bed condition and capillary refill.
provides data that may reveal local or systemic ASSESSMENT PROCEDURE OF THE SKIN
problems or alterations in a client’s self-care § INSPECTION
activities. Inspect general skin coloration.
§ Local irritation, trauma, or disease can alter the Keep in mind that the amount of pigment in
condition of the skin, hair, or nails. the skin accounts for the intensity of color as
§ Systemic problems related to impaired well as the hue.
circulation, endocrine imbalances, allergic § NORMAL FINDINGS.
reactions, or respiratory disorders may also Inspection reveals evenly
be revealed with alterations in the skin, hair, colored skin tones without unusual or
or nails. prominent discoloration
§ The appearance of the skin, hair, and nails § ABNORMAL FINDINGS.
also provides the nurse with data related to Inspection reveals evenly colored skin tones
health maintenance and self-care activities without unusual or prominent discoloration.
such as hygiene, exercise, and nutrition. - Pallor (loss of color) is seen in
arterial insufficiency, decreased
PREPARING THE CLIENT blood supply, and anemia. Pallid
§ To prepare for the skin, hair, and nail tones vary from pale to ashen
examination, ask the client to remove all clothing without underlying pink.
and jewelry and put on an examination gown. - Cyanosis may cause white skin to
§ Ask the client to remove nail enamel, artificial appear blue-tinged, especially in the
nails, wigs, toupees, or hairpieces as perioral, nail bed, and conjunctival
appropriate. areas. Dark skin may appear blue,
§ Have the client sit comfortably on the dull, and lifeless in the same areas.
examination table or bed for the beginning of - Bluish cyanotic skin associated with
the examination. oxygen deficiency.
§ To assess the skin on the buttocks and dorsal - Central cyanosis results from a
surfaces of the legs properly, the client may lie cardiopulmonary problem, whereas
on her side or abdomen. peripheral cyanosis may be a local

problem resulting from - Freckle-like or dark streaks of pigmentation
vasoconstriction. are also common in the sclera and nail beds
- To differentiate between central and of dark-skinned clients.
peripheral cyanosis, look for central - Pale or light-skinned clients have darker
cyanosis in the oral mucosa. pigment around nipples, lips, and genetalia.
- Jaundice in light and dark-skinned § ABNORMAL FINDINGS:
people is characterized by yellow - Includes rashes, such as the reddish (in
skin tones, from pale to pumpkin, light-skinned people) or darkened (in
particularly in the sclera, oral dark-skinned people) butterfly rash (also
mucosa, palms, and soles. called Malar rash) across the bridge of the
Associated with hepatic dysfunction. nose and cheeks, characteristics of lupus
- Acanthosis nigricans is a erythematosus. SLE is seen in a 9.1 female-
roughening and darkening of skin in to-male ratio and is more common in black
localized areas, especially the and Hispanic people.
posterior neck. A linear streak-line - Erythema (skin redness and warmth) is seen
pattern in dark-skinned people, in inflammation, allergic reactions, or
suggests diabetes mellitus. trauma.
§ INSPECTION - Erythema in the dark-skinned client may be
While inspecting the skin coloration, note difficult to see. However, the affected skin
any odors emanating from the skin. feels swollen and warmer than the
§ NORMAL FINDINGS: surrounding skin.
Client has slight or no odor of perspiration, § INSPECTION
depending on activity. Check skin integrity. Pay attention to
§ ABNORMAL FINDINGS: pressure points areas.
- A strong odor of perspiration or foul § NORMAL FINDINGS:
odor may indicate disorder of sweat Skin is intact, and there are no reddened
areas.
glands.
§ ABNORMAL FINDINGS:
- Poor hygiene practices may indicate
- Skin breakdown is initially noted as a
a need for client teaching or reddened area on the skin that may
assistance with activities of daily progress to serious and painful pressure
living. ulcers.
§ INSPECTION - Depending on the color of the client’s
Inspect for color variations. Inspect skin, reddened areas may not be
localized parts of the body, noting any color prominent, although the skin may feel
variation. warmer in the area of breakdown than
§ NORMAL FINDINGS: elsewhere.
- Common variations include § INSPECTION
suntanned areas, freckles, or white - Inspect for lesions.
patches known as vitiligo. - Observe the skin surface to detect
- The variations are due to different abnormalities.
amounts of melanin in certain areas. - If you observe a lesion
- A generalized loss of pigmentation is o Note color, shape, and size of
lesions. For very small lesions, use
seen in albinism.
a magnifying glass to note these
- Darked-skinned clients have lighter-
characteristics.
colored palms, soles, nail beds, and lips.
o Note its location, distribution, and
configuration.
o Measure the lesion with a tenderness. Observe for drainage or
centimeter ruler. other characteristics.
§ NORMAL FINDINGS: § NORMAL FINDINGS:
Skin is smooth, without lesions. Stretch - Skin is normally thin but calluses (rough,
marks (striae), healed scars, freckles, moles, thick sections of epidermis) are common
or birthmarks are common findings. Freckles on areas of the body that are exposed to
or moles may be scattered over the skin in constant pressure.
no particular pattern. - No lesions palpated.
§ ABNORMAL FINDINGS: § ABNORMAL FINDINGS:
- Lesions may indicate local or systemic - Very thin skin may be seen in clients with
problems. arterial insufficiency or in those on steroid
- Primary lesions arise from normal skin therapy.
due to irritation or disease. - Infected lesions may be tender to palpate.
- Secondary lesions arise from changes in Nonmobile, fixed lesions may be cancer.
primary lesions. § PALPATION
- Vascular lesions reddish-bluish lesions - Palpate to assess moisture.
are seen with bleeding, venous pressure, - Check under skin folds and in unexposed
aging, liver disease, or pregnancy. areas.
- Cancerous lesions can be either primary § NORMAL FINDINGS:
or secondary lesions and are classified - Skin surfaces vary from moist to dry
as squamous cell carcinoma, or depending on the area assessed.
malignant melanoma. - Recent activity or a warm environment
§ INSPECTION may cause increased moisture.
If you suspect a fungus, shine a wood’s light § ABNORMAL FINDINGS:
(an ultraviolet light filtered through a special - Increased moisture or diaphoresis
glass) on the lesion. (profuse sweating) may occur in
§ NORMAL FINDINGS conditions such as fever or
Lesion does not fluoresce. hyperthyroidism.
§ ABNORMAL FINDINGS: - Clammy skin is typical in shock or
Blue-green fluorescence indicates fungal hypotension.
infection. § PALPATION
§ PALPATION - Palpate to assess temperature.
- Palpate skin to assess texture. - Use the dorsal surfaces of your hands
- Use the palmar surface of your three to palpate skin.
middle fingers to palpate skin texture. § NORMAL FINDINGS:
§ NORMAL FINDINGS Skin is normally a warm temperature.
Skin is smooth and even.’ § ABNORMAL FINDINGS:
§ ABNORMAL FINDINGS: - Cold skin may accompany shock or
- Rough, flaky, dry skin is seen in hypotension.
hypothyroidism. - Cool skin may accompany arterial
- Obese clients often report dry, itchy disease.
skin. - Very warm skin may indicate a
§ PALPATION febrile state or hyperthyroidism.
- Palpate to assess thickness. § PALPATION
- If lesions are noted when assessing skin - Palpate to assess mobility and turgor.
thickness, put gloves on and palpate the - Ask the client to lie down.
lesion between the thumb and index - Using two fingers gently pinch the skin
finger for size, mobility, consistency, and over the clavicle.
> Mobility – how easily the skin can be - The color is determined by the amount of
pinched. melanin present.
> Turgor – the skin’s elasticity and how - Scalp is clean and dry. Sparse dandruff
quickly the skin returns to its original may be visible. Hair is smooth and firm,
shape after being pinched. somewhat elastic.
§ NORMAL FINDINGS: - As people age, hair feels coarser and
- Normally the skin is mobile, elastic and drier.
returns to original shape quickly. § ABNORMAL FINDINGS:
- The older client’s skin loses its turgor - Nutritional deficiencies may cause
because of a decrease in elasticity and patchy gray hair in some clients. Severe
collagen fibers. malnutrition in African American
- Sagging or wrinkled skin appears in the children may cause a copper red hair
facial, breast, and scrotal areas. color.
§ ABNORMAL FINDINGS: - Excessive scaliness may indicate
- Decrease mobility is seen with dermatitis. Raised lesions may indicate
edema. infections or tumor growth.
- Decreased turgor (a slow return of the - Dull, dry hair may be seen with
skin to its normal state taking longer hypothyroidism and malnutrition.
than 30 secs.) is seen in dehydration. - Poor hygiene may indicate a need for
§ PALPATION client teaching or assistance with
- Palpate to detect edema. activities of daily living.
- Use your thumbs to press down on the - Pustules with hair loss in patches are
skin of the feet or ankles to check for seen in tinea capitis, a contagious fungal
edema (swelling related to accumulation disease.
of fluid in the tissue) - Infections of hair follicle appear as
§ NORMAL FINDINGS: pustules surrounded by erythema.
- Skin rebounds and does not remain § INSPECTION
indented when pressure is released. - Inspect amount and distribution of
§ ABNORMAL FINDINGS: scalp, body, axillae, and pubic hair.
Indentations on the skin may vary from - Look for unusual growth elsewhere on
slight to great and may be in one area or all the body.
over the body. § NORMAL FINDINGS:
ASSESSMENT PROCEDURE OF SCALP AND HAIR - Varying amounts of terminal hair cover
§ INSPECTION and PALPATION the scalp, axillary, body, and pubic areas
- Inspect the scalp and hair for general according to normal gender distribution.
color and condition. - Fine vellus hair covers the entire body
- At 1 inch intervals, separate the hair from except for the soles, palms, lips, and
the scalp and inspect and palpate the nipples.
hair and scalp for cleanliness, dryness or - Normal male pattern balding is
oiliness, parasites, and lesions. symmetric.
- Wear gloves if lesions are suspected or if - Older clients have thinner hair because
hygiene is poor. of a decrease in hair follicles.
§ NORMAL FINDINGS: - Pubic, axillary, and body hair also
- Natural hair color, as opposed to decrease with aging.
chemically colored hair, varies among
clients from pale blond to black to gray - Alopecia is seen, especially in men.
or white. - Hair loss occurs from the periphery of the
scalp and moves to the center.
- Older women may have terminal hair § NORMAL FINDINGS:
growth on the chin owing to hormonal There is normally a 160-degree angle
changes. between the nail base and the skin.
§ ABNORMAL FINDINGS: § ABNORMAL FINDINGS:
- Excessive generalized hair loss occurs - Early clubbing (180-degree angle with
with infection, nutritional deficiencies, spongy sensation) and late clubbing
hormonal disorders, thyroid or liver (greater than 180-degree angle) can
disease, drug toxicity, hepatic or renal occur from hypoxia.
failure. - Spoon nails (concave) may be present
- It may also result from chemotherapy or with iron deficiency anemia.
radiation therapy. § PALPATION
- Patchy hair loss may result from Palpate nails to assess texture.
- infections of the scalp, discoid or § NORMAL FINDINGS:
systemic lupus erythematosus, and - Nails are hard and basically immobile.
some types of chemotheraphy. - Dark-skinned clients may have thicker nails.
- Hirsutism (facial hair on females) is a - Older clients nail may appear thickened,
characteristic of cushing’s disease and yellow, and brittle because of decreased
results from an imbalance of adrenal circulation in the extremities.
hormones or it may be a side effect of § ABNORMAL FINDINGS:
steroids. Thickened nails (especially toenails) may be
§ INSPECTION caused by decreased circulation and is also
Inspect nail grooming and cleanliness. seen in onychomycosis. Onychomycosis,
ASSESSMENT PROCEDURE OF NAILS also known as tinea unguium, is a fungal
§ NORMAL FINDINGS: infection of the nail. Symptoms may include
Nails are clean and manicured. white or yellow nail discoloration, thickening
§ ABNORMAL FINDINGS: of the nail, and separation of the nail from
- Dirty, broken, or jagged fingernails may the nail bed.
be seen with poor hygiene. § PALPATION
- They may also result from client’s hobby Palpate to assess texture and consistency,
or occupation. noting whether nail plate is attached to nail
§ INSPECTION bed.
Inspect nail color and markings. § NORMAL FINDINGS:
§ NORMAL FINDINGS: Nails are smooth and firm; nail plate should
- Pink tone should be seen. be firmly attached to nail bed.
- Some longitudinal ridging is normal. § ABNORMAL FINDINGS:
- Dark-skinned clients may have freckles - Paronychia (inflammation) indicates local
or pigmented streaks in their nails. infection.
§ ABNORMAL FINDINGS: - Detachment of nail plate from nail bed
- Pale or cyanotic nails may indicate (onycholysis) is seen in infection or trauma.
hypoxia or anemia. CAPILLARY REFILL TEST
- Splinter hemorrhages may be caused by Test capillary refill in nail beds by pressing the
trauma. nail tip briefly and watching for color change.
- Beau’s lines occur after acute illness and Normally pink tone returns immediately to
eventually grow out. blanched nail beds when pressure is released. If
§ INSPECTION there is slow (greater than 2 seconds) capillary
- Inspect shape of nails nail bed refill (return of pink tone) client has
- Yellow discoloration may be seen in respiratory or cardiovascular disease that cause
fungal infections or psoriasis. hypoxia.
VALIDATING AND DOCUMENTING FINDINGS • Temporal artery, a major artery, is located
§ Validate your normal and abnormal findings between the eye and the top of the ear.
with the client, other health care workers, or • Two other important structures located in
your instructors. the facial region are the parotid and
§ Document the skin, hair and nail assessment submandibular salivary glands.
data that you have collected on the o Parotid glands – located on each
appropriate form your school or agency side of the face anterior and inferior
uses. to the ears and behind the mandible.
§ Document both normal and abnormal o Submandibular glands – located
findings. Normal findings can act as a inferior to the mandible underneath
baseline for findings that may change later. the base of the tongue.
ANALYSIS OF DATA: DIAGNOSTIC REASONING THE NECK
1. Selected Nursing Diagnoses • The structure of the neck is composed of
2. Selected Collaborative Problems muscles, ligaments, and the cervical
3. Medical Problems vertebrae.
• Contained within the neck are the hyoid
ASSESSMENT OF HEAD AND NECK bone, several major blood vessels, the
larynx, trachea, and the thyroid gland,
HEAD AND NECK ASSESSMENT which is the anterior triangle of the neck.
• Focuses on the cranium, face, thyroid MUSCLES AND CERVICAL VERTEBRAE
gland, and lymph node structures • Two major muscles of the neck:
contained within the head and neck. - Sternomastoid (sternocleidomastoid)
THE HEAD muscles- rotates and flexes the head.
• Skull – the framework of the head. - Trapezius muscles- extends the head
Subsections of the Skull and moves the shoulder.
• Cranium- houses and protects the brain and • The eleventh cranial nerve is responsible for
major sensory organs. Consists of 8 bones: muscle movement that permits shrugging
frontal (1), parietal (2), temporal (2), of the shoulders by the trapezius muscles
occipital (1), ethmoid (1), sphenoid (1). In and turning the head against resistance by
adults, the cranial bones are joined together the sternomastoid muscles.
by immovable sutures. • Two major muscles that form two triangles
that provide important landmarks for
• Sutures that joined the cranial bones: assessment:
Sagittal, Coronal, Squamosal, Lambdoid 1. Anterior triangle – located under the
mandible.
• Face- facial bones give shape to the face 2. Posterior triangle – located between
and consists of 14 bones: Maxilla (2), the trapezius and sternomastoid
Zygomatic (2), Inferior conchae (2), Nasal muscle.
(2), Lacrimal (2), Palatine (2), Vomer (1), • The cervical vertebrae (C1 through C7) are
Mandible (1) in the posterior neck and support the
cranium.
• All the facial bones are immovable except • The vertebra prominens is C7, which can
for the mandible, which has free movement easily be palpated when the neck is flexed.
joint. • Using C7 as landmark will help you locate
• The face also consists of many muscles that other vertebrae.
produce facial movement and expressions. BLOOD VESSELS

• The internal jugular veins and carotid • If cancer metastasizes to the lymph nodes,
arteries are located bilaterally, parallel, and they may enlarge but not painful.
anterior to the sternomastoid muscles.
• The external jugular vein lies diagonally THE MOST COMMON HEAD AND NECK
over the surface of these muscles. LYMPH NODES
• It is important to avoid bilaterally Preauricular Submental
compressing the carotid arteries when Postauricular Superficial cervical
assessing the neck, as bilateral compression Tonsillar Posterior cervical
can reduce the blood supply to the brain. Occipital Deep cervical
Submandibular Supraclavicular
THYROID GLAND
• The largest endocrine gland in the body.
Ø Preauricular- located Infront of the ear.
• It produces thyroid hormones that increases
Ø Postauricular– located behind the ear.
the metabolic rate of most body cells.
Ø Occipital– located at the posterior base of
• The trachea, through which air enters the the skull.
lungs, is composed of C-shaped hyaline Ø Tonsillar– located at the angle of the
cartilage rings. mandible on the anterior edge of the
• The first upper tracheal ring, called the sternomastoid muscle.
cricoid cartilage, has a small notch in it. Ø Submandibular– located at the medial
• The thyroid cartilage (Adam’s apple) is border of the mandible.
larger and located just above the cricoid Ø Submental – located a few centimeters
cartilage. behind the tip of the mandible.
• The hyoid bone, which is attached to the Ø Superficial cervical – located in the area
tongue, lies above the thyroid cartilage and superficial to the sternomastoid muscle.
under the mandible. Ø Posterior cervical– located in the area
LYMPH NODES OF THE HEAD AND NECK posterior to the sternomastoid and anterior
• Several lymph nodes are located in the head to the trapezius in the posterior triangle.
and neck. Ø Deep cervical– located deeply and around
• Lymph nodes filter lymph, a clear substance the sternomastoid muscle.
composed mostly of excess tissue fluid, Ø Supraclavicular – can be palpated by
Filtering removes bacteria and tumor cells hooking your fingers over the clavicles
from lymph. feeling deeply between the clavicles and the
• The lymph nodes produce lymphocytes and sternomastoid muscles.
antibodies as a defense against invasion by
foreign substances.
ASSESSMENT
• The size and shape of lymph nodes vary but
most are less than 1 cm long and are buried
deep in the connective tissue. Collecting Subjective Data: The Nursing
• Normally lymph nodes are either not Health History
palpable or they may feel like very small • Abnormalities that cannot be directly
beads. observed in the physical appearance of the
• Lymph nodes usually appears in clusters head and neck are often detected in the
that vary in size from 2 to 100 individual client’s history.
nodes. Collecting Objective Data: Physical
• If the nodes become overwhelmed by Examination
microorganisms, as happens with an • Assessment of both the head and the neck
infection such as mononucleosis, they swell assists the nurse to detect enlarged or
and become painful. tender lymph nodes.
• Thyroid enlargement, nodules, masses, or - No lesions are visible.
tenderness may be detected by palpating
the thyroid gland.
• Palpation may also detect abnormalities of Abnormal Findings:
the neck and facial muscles. - An abnormally small head is called
• The assessment steps and findings to be microcephaly.
described provide parameters for the - The skull and facial bone are larger and
examination. thicker in acromegaly.
Preparing The Client - Acorn-shaped, enlarged skull bones are seen
• Prepare the client for the head and neck in Paget s disease of the bone.
examination by instructing him or her to
remove any wig, hat, hair ornaments, pins, • Inspect for involuntary movement.
rubber bands, jewelry, and head or neck Abnormal Findings:
scarves. - Neurologic disorders may cause a horizontal
• Cultural Considerations jerking movement.
- Take care to consider cultural norms for - An involuntary nodding movement may be
touch when assessing the head. Some seen in patients with aortic insufficiency.
cultures (e.g. Southeast Asian) prohibit - Head tilted to one side may indicate
touching the head or touching the feet unilateral vision or hearing deficiency or
before touching the head (Purnell & shortening of the sternomastoid muscle.
Paulanka,2008).
• Ask the client to sit in an upright position • Palpate the head.
with the back and shoulders held back and - Note consistency (wear gloves to protect
straight. yourself from possible drainage)
• Explain the importance of remaining still Normal Findings:
during most of the inspection and palpation - The head is normally hard and smooth
of the head and neck. without lesions.
• Explain the need for the client to move and Abnormal Findings:
bend the neck for examination of muscles - Lesions or lumps of the head may indicate
and for palpation of the thyroid gland. recent trauma or a sign of cancer.
• Be aware that some clients may be anxious
as you palpate the neck for lymph nodes, • Inspect the face.
especially if they have a history of cancer - Inspect for symmetry, features, movement,
that caused lymph node enlargement. expression, and skin condition.
• Tell the client what you are doing and share Normal findings:
your assessment findings. - The face is symmetric with a round, oval,
elongated. or square appearance.
• EQUIPMENT
- No abnormal movements noted.
- Small cup of water
Abnormal findings:
- Stethoscope
- Asymmetry in front of the earlobes occurs
HEAD AND FACE INSPECTION AND PALPATION
with parotid gland enlargement from an
• Inspect the head.
abscess or tumor.
- Inspect for size, shape, and configuration.
Normal Findings:
• Viral infections such as mumps, flu, and
- Head size and shape vary, especially in
others can cause swelling of the salivary
accord with ethnicity.
glands. Swelling happens in parotid glands
- Usually the head is symmetric, round, erect
on both sides of the face, giving the
and in midline and appropriately related to
appearance of "chipmunk cheeks."
body size (normocephalic).
• Abnormal findings:
- Unusual or asymmetric orofacial • Palpate the Temporomandibular Joint
movements may be from an organic disease (TMJ).
or neurologic problem, which should be - To assess the TMJ, place your index finger
referred for medical follow-up. over the front of each ear as you ask the
- Drooping, weakness, or paralysis on one side client to open the mouth.
of the face may result from a stroke Normal Findings:
(cerebrovascular accident) and usually is - Normally there is no swelling, tenderness, or
seen with paralysis or weakness of other crepitation with movement.
parts on that side of the body. - Mouth opens and closes fully (3 to 5 cm
- Drooping, weakness, or paralysis on one side between upper and lower teeth).
of the face may also result from a neurologic - Lower jaw moves laterally 1 to 2 cm in each
condition known as Bell s palsy. direction.
- Bell's palsy is a condition in which the Abnormal Findings:
muscles on one side of your face become - Limited range of motion, swelling,
weak or paralyzed. It affects only one side of tenderness, or crepitation may indicate TMJ
the face at a time, causing it to droop or syndrome. (when assessing TMJ syndrome,
become stiff on that side. It's caused by be sure to explore the client’s history of
some kind of trauma to the seventh cranial headaches, if any).
nerve. THE NECK INSPECTION
- A “mask-like” face marks Parkinson s • Inspect the Neck
disease, a sunken face with depressed eyes - Observe the client’s slightly extended neck
and hollow cheeks is typical of cachexia for position, symmetry, and lumps or
(emaciation or wasting); and a pale, swollen masses.
face may result from nephrotic syndrome. - Shine a light from the side of the neck across
- Cachexia is loss of weight, muscle atrophy, to highlight any swelling.
fatigue, weakness and significant loss of Normal Findings:
appetite in someone who is not actively - Neck is symmetric, with head centered and
trying to lose weight. without bulging masses.
Abnormal Findings:
- Nephrotic syndrome is a kidney disorder - Swelling enlarged masses – or nodules – may
caused by damage to the clusters of small indicate an enlarged thyroid gland,
blood vessels in your kidneys that filter waste inflammation of lymph nodes, or a tumor.
and excess water from your blood.
• Inspect Movement of the Neck Structures.
• Palpate the Temporal Artery - Ask the client to swallow a small sip of water.
- Located between the top of the ear and the - Observe the movement of the thyroid
eye. cartilage, thyroid gland.
Normal Findings: Normal Findings:
- The temporal artery is elastic and - The thyroid cartilage, cricoid cartilage move
not tender. (the strength of the pulsation of the upward symmetrically as the client
temporal artery may be decreased in older swallows.
client). Abnormal Findings:
Abnormal Findings: - Asymmetric movement or generalized
- The temporal artery is hard, thick and tender enlargement of the thyroid gland is
with inflammation as seen with temporal considered abnormal.
arteritis (inflammation of the temporal
arteries that may lead to blindness). • Inspect the Cervical Vertebrae.
- Ask the client to flex the neck (chin to chest). - The trachea may be pulled to the affected
Normal Findings: side in cases of lung atelectasis, fibrosis or
- C7 (vertebrae prominens) is usually visible pleural adhesions.
and palpable. - The trachea is pushed to the unaffected side
- (In older clients, cervical curvature may in cases of a tumor, enlarged thyroid lobe,
increase because of kyphosis of the spine. pneumothorax, or with an aortic aneurysm.
Moreover, fat may accumulate around the • Palpate the Thyroid Gland
cervical vertebrae especially in women). This - Locate key landmarks with your index finger
is sometimes called dowager s hump . and thumb.
• Kyphosis is an exaggerated curvature of the NECK LANDMARKS

upper (thoracic) spine that creates a Hyoid bone: arch shaped
hunchback appearance. bone that does not
• Dowager s hump - An abnormal outward articulate directly with
any other bone; located
curvature of the thoracic vertebrae of the
high in
upper back. anterior neck.
Abnormal Findings:
- Prominens or swellings other than C7
vertebrae may be abnormal.
• Inspect Range of Motion.

- Ask the client to turn the head to the right
and to the left (chin to shoulder), touch each
ear to the shoulder, touch chin to chest, and Thyroid cartilage: under
the hyoid bone; the area
lift the chin to the ceiling. that widens at the top of
Normal Findings: the trachea, also known
- Normally neck movement should be smooth as the Adam’s apple”.
and controlled with 45-degree flexion, 55-
degree extension, 40-degree lateral
abduction, and 70-degree rotation.
Abnormal Findings:
- Muscle spasms, inflammation, or cervical
arthritis may cause stiffness, rigidity, and
limited mobility of the neck, which may
affect daily functioning.
- A stiff neck is often a late symptom seen in Cricoid cartilage:
meningitis. smaller upper tracheal
THE NECK PALPATION ring under
• Palpate the Trachea the thyroid cartilage.
- Place your finger in the sternal notch. Feel
each side and palpate the tracheal rings. The
upper ring above the smooth tracheal rings
is the cricoid cartilage.
Normal Findings:
- Trachea is midline.
Abnormal Findings:

hyperthyroidism, Grave’s disease, or an
Surface anatomy endemic goiter, the thyroid gland may be
The prominent landmarks palpated.
of the neck are: - An enlarged, tender gland may result from
- Hyoid bone
- Thyroid cartilage thyroiditis.
- Cricoid cartilage - Multiple nodules of the thyroid may be seen
- Trachea in metabolic processes.
- Sternocleidomast - Rapid enlargement of a single nodule
oid muscles suggests a malignancy and must be
evaluated further.
• To palpate the thyroid use a posterior Palpating the Thyroid

approach. - Ask the client to swallow as you palpate the
• Stand behind the client and ask the client to right side of the gland.
lower the chin to the chest and turn the neck - Reverse the technique to palpate the left
slightly to the right (this will relax the client’s lobe of the thyroid.
neck muscles). Normal Findings:
• Then place your thumbs on the nape of the - Glandular thyroid tissue may be felt rising
client’s neck with your other fingers on either underneath your fingers.
side of the trachea below the cricoid - Lobes should feel smooth, rubbery, and free
cartilage. of nodules.
• Use your left fingers to push the trachea to Abnormal Findings:
the right. - Coarse tissue or irregular consistency may
• Then use your right fingers to feel deeply in indicate an inflammatory process. Nodules
front of the sternomastoid muscle. should be described in terms location, size
and consistency.
Normal Findings: THE NECK AUSCULTATION
- Landmarks are positioned midline. • Auscultate the thyroid only if you find an
- Unless the client is extremely thin with a enlarged thyroid gland during inspection
long neck, the thyroid gland is usually not or palpation.
palpable. - Place the bell of the stethoscope over the
- The isthmus may be palpated, the lobes are lateral lobes of the thyroid gland.
smooth, firm, and nontender. - Ask the client to hold his/her breath (to
- The right lobe is often 25% larger than the left obscure any tracheal breath sounds while
lobe. you auscultate).
Older Adult Consideration Normal Findings:
- If palpable, the older client’s thyroid gland - No bruits are auscultated
may feel more nodular or irregular because Abnormal Findings:
of fibrotic changes that occur with aging; the - A soft, blowing, swishing sound auscultated
thyroid may also be felt lower in the neck over the thyroid lobes is often heard is
because of age related structural changes. hyperthyroidism because of an increase in
Abnormal Findings: blood flow through the thyroid arteries.
- Landmarks deviate from midline or are Lymph Nodes of the Head and Neck
obscured because of masses or abnormal Palpate the Lymph Nodes
growths. - Preauricular nodes – infront of the ears
- In cases of diffuse enlargement, such as - Postauricular nodes – behind the ears
- Occipital nodes – at the posterior base of
the skull
- Tonsillar nodes – at the angle of the ASSESSMENT OF THE EYES
mandible on the anterior edge of the
sternomastoid muscle. STRUCTURE AND FUNCTION OF THE EYES
- Submandibular nodes – located on the
medial border of the mandible. • The eye transmits visual stimuli to the brain
- Submental nodes – which are a few for interpretation.
centimeters behind the tip of the mandible.
• The eye functions as the organ of vision.
- Superficial cervical nodes – in the area
• The eyeball is in the eye orbit, a round, bony
superficial to the sternomastoid muscle.
hollow formed by several different bones of
- Posterior cervical nodes – in the area
the skull.
posterior to the sternomastoid and anterior
• In the orbit, a cushion of fat surrounds the
to the trapezius in the posterior triangle.
eye.
- Deep cervical chain nodes – deeply within
• The bony orbit and fat cushion protect the
and around the sternomastoid muscle.
eyeball.
- Supraclavicular nodes – by hooking your
• To perform a thorough assessment of the
fingers over the clavicles and feeling deeply
eye, you need a good understanding of the
between the clavicles and the sternomastoid
external and internal structures of the eye,
muscle.
the visual fields and pathways, and the
Normal Findings:
visual reflexes.
- There is no swelling or enlargement and no
tenderness is present. EXTERNAL STRUCTURES OF THE EYE
Abnormal Findings: Ø Eyelids
- Head and neck cancer includes cancer of the Ø Eyelashes
mouth, nose, sinuses, salivary glands, throat, Ø Conjunctiva
and lymph nodes in the neck. Ø Lacrimal apparatus
- Enlarged nodes are abnormal. Ø The extraocular muscles
- Swelling, tenderness, immobility are THE EYELIDS
abnormal. • The Eyelids (upper and lower) – are two
- Enlargement and tenderness are abnormal. movable structures composed of skin and
- An enlarged, hard, nontender node, two types of muscles: striated and smooth.
particularly on the left side, may indicate a
metastasis from a malignancy in the FUNCTIONS OF THE EYELIDS
abdomen or thorax. - To protect the eye from foreign bodies
VALIDATING AND DOCUMENTING FINDINGS - To limit the amount of light entering the
• Validate the head and neck assessment eye
data that you have collected. - They serve to distribute tears that
• This is necessary to verify that the data are lubricate the surface of the eye.
reliable and accurate.
• Document the assessment data following the • The upper eyelid is larger, more mobile, and
health care facility or agency policy. contains tarsal plates made up of connective
ANALYSIS OF DATA: DIAGNOSTIC tissue. This plate contains the meibomian
REASONING glands, which secrete an oily substance that
• After collecting the assessment data, identify lubricates the eyelid.
abnormal findings and client’s strengths • The Eyelids join at two points:
using diagnostic reasoning. Then, cluster the - Lateral (outer) canthus and medial
data to reveal any significant patterns or (inner) canthus.
abnormalities. - The medial canthus contains the
puncta, two small openings that

allow drainage of tears into the • Two oblique muscles are responsible for
lacrimal system, and the caruncle, a diagonal movement.
small, fleshy mass that contains • Each muscle coordinates with a muscle in
sebaceous glands. the opposite eye.
• The white space between open eyelid is • This allows for parallel movement of the eyes
called the palpebral fissure. and thus the binocular vision characteristics
• When closed the eyelid should touch. of humans.
• When open, the upper lid position should be • Innervations of these muscles is supplied by
between the upper margin of the iris and the three cranial nerves:
upper margin of the pupil. The lower lid Ø the oculomotor (lll), throclear (lV)
should rest on the lower border of the iris. abducens (Vl)
No sclera should be seen above or below the
limbus (the point where the sclera meets the THE INTERNAL STRUCTURE OF THE EYE
cornea). Ø THE EYEBALL
THE EYELASHES Composed of three separate coats or layers:
• Eyelashes are projections of stiff hair curving - The external layer consists of the sclera
outward along the margins of the eyelids. and cornea.
• FUNCTION OF EYELASHES: Filter dust and - The middle layer contains both an
dirt from air entering the eye. anterior portion, which includes the iris
THE CONJUNCTIVA and the ciliary body, and a posterior
layer, which includes the choroid.
• The conjunctiva is a thin, transparent,
continuous membrane that is divided into - The innermost layer, the retina
two portions: Palpebral and Bulbar - Contains several chambers that
maintain structure, protect against
• Palpebral conjunctiva – lines the inside of
injury, and transmit light rays.
the eyelids.
• Sclera: dense protective white covering that
• Bulbar conjunctiva – covers most of the
physically supports the internal structures of
anterior eye, merging with the cornea at the
the eye.
limbus.
• Cornea (window of the eye): permits the
• The point at which the palpebral and
entrance of light which passes through the
bulbar conjunctivae meet creates a folded
lens to the retina. It is well supplied with
recess that allows movement of the eyeball.
nerve endings, making it responsive to pain
• This transparent membrane allows for
and touch.
inspection of underlying tissue and protects
• Ciliary body: consists of muscle tissue that
the eye from foreign bodies.
controls the thickness of the lens, which must
THE LACRIMAL APPARATUS
be adapted to focus on near and far objects.
• The lacrimal apparatus consists of glands
• Iris: is a circular disc of muscle containing
and ducts that lubricate the eye.
pigments that determine eye color.
• The lacrimal gland, located upper outer
• Pupil: central aperture of the iris; the
corner of the orbital cavity just above the
muscles in the iris adjust to control the
eye, produces tears.
pupil’s size which controls the amount of
THE EXTRAOCULAR MUSCLES light entering the eye.
• There are six muscles attached to the outer o The muscle fibers of the iris decrease
surface of each eyeball. the size of the pupil to accommodate
• These muscles control six different directions for near vision and dilate the pupil
of eye movement. when far vision is needed.
• Four rectus muscles are responsible for • Lens: biconvex, transparent, avascular
straight movement. encapsulated structure posterior to the iris.
It functions to refract (bend) light rays unto VISUAL REFLEXES
the retina. The lens bulges to focus on close • The pupillary light reflex causes pupils
objects and flattens to focus on far objects. immediately to constrict when exposed to
• Choroid layer: contains the vascularity bright light.
necessary to provide nourishment to the • Direct reflex: constriction occurs in the eye
inner aspect of the eye and prevents light exposed to the light.
from reflecting internally. • Indirect or consensual reflex: exposure to
• Retina: receives visual stimuli and sends it to light in one eye results in constriction of the
the brain. Consist of specialized nerve cells, pupil in the opposite eye.
photoreceptors which are responsive to light • Accommodation is a functional reflex
called the rods & cones. allowing the eyes to focus on near objects.
o The rods are highly sensitive to light, This is accomplished through movement of
regulate black-and-white vision and the ciliary muscles, causing an increase in
function in dim light. the curvature of the lens.
o The cones function in bright light and ASSESSMENT
are sensitive to color. - Collecting Subjective Data: The Nursing
• Optic disc: cream colored, circular area Health History
located on the retina toward the medial or Ø Asking clients specific questions
nasal side of the eye. Can be seen with the about their vision may help with
use of an ophthalmoscope. early detection of disorders.
• Physiologic cup: a smaller circular area that Ø Gather data from the client about
appears slightly depressed. This area is his or her current level of eye
approximately one-third the size of the health.
entire optic disc and appears somewhat - Collecting Objective Data: Physical
lighter/whiter than the disc borders. Examination
• Retinal vessels: can be viewed with aid of an Ø The purpose of the eye and vision
ophthalmoscope. Vessels are dark red and examination is to identify any
grow progressively narrower as they extend changes in vision or signs of eye
out to the peripheral areas. disorders in an effort to initiate early
• Aqueous humor: cleanse and nourish the treatment or corrective procedures.
cornea and lens & maintain intraocular § Preparing The Client
pressure. Ø Explain each vision test thoroughly to
VISUAL FIELDS AND VISUAL PATHWAYS guarantee accurate results.
• A visual field refers to what a person sees Ø For the eye examination, position the
with one eye. client to be seated comfortably.
• The visual field of each eye can be divided Ø During examination of the internal
into four quadrants: eye with the ophthalmoscope, you
o Upper temporal will move very close to the client’s
o Lower temporal face to view the retina and internal
o Upper nasal structures.
o Lower nasal Ø Explain to the client that this may be
• Visual perception occurs as light rays strike slightly uncomfortable.
the retina, where they are transformed into Ø To ease the client’s anxiety, explain
nerve impulses, conducted to the brain in detail what you will be doing and
through the optic nerve and interpreted. answer any questions the client may
have.

§ Equipment - Have the client cover one eye with an
o Snellen or E chart opaque card before reading from top to
o Hand-held Snellen card or near- bottom. Repeat test for other eye.
vision screener Normal Findings:
o Penlight - Normal near visual acuity 14/14 (with or
o Opaque cards without corrective lenses).
o Ophthalmoscope - This means that the client can read what
o Disposable gloves (wear as needed the normal eye can read from a distance
to prevent spreading infection or of 14 inches.
coming in contact with exudate) Abnormal Findings:
PHYSICAL ASSESSMENT - Presbyopia (impaired near vision) is
§ Key Points to Remember while indicated when the client moves the
Performing the Examination: chart away from the eyes to focus on the
• Administer vision tests competently and print.
record the results. - It is caused by decreased
• Use the ophthalmoscope correctly and accommodation.
confidently. - It is a common condition in clients over
• Recognize and distinguish normal 45 years of age.
variations from abnormal findings. o Test Visual Fields for Gross Peripheral
ASSESSMENT PROCEDURE Vision.
- To perform the confrontation test,
EVALUATING VISION
position yourself approximately 2 feet
o Test Distant Visual Acuity.
away from the client at eye level.
- Position the client 20 feet from the
- Have the client cover the left eye while
Snellen or E chart and ask him/her to
you cover your right eye.
read each line until she cannot decipher
- Look directly at each other with your
the letters or their direction.
uncovered eyes.
Normal Findings:
- Fully extend your left arm at midline and
- Normal distant visual acuity is 20/20
slowly move one finger (or a pencil)
with or without corrective lenses.
upward from below until the client sees
- This means that the client can distinguish
your finger (or pencil).
from 20 feet away.
- Test the remaining three visual fields on
Abnormal Findings:
the client’s right eye.
- Myopia (impaired far vision) is present
- Repeat the test for the opposite eye.
when the second number in the test
Normal Findings:
result is larger than the first (20/40).
- With normal peripheral vision, the client
- The higher the second number, the
should see the examiner’s finger at the
poorer the vision.
same time the examiner sees it.
- A client is considered legally blind when
- Normal visual field degrees are
vision in the better eye with corrective
approximately as follows:
lenses is 20/200 or less.
Ø Inferior: 70 degrees
- Refer any client with vision worse than
Ø Superior: 50 degrees
20/30 for further evaluation.
Ø Temporal: 90 degrees
o Test Near Visual Acuity
Ø Nasal: 60 degrees
- Use this test for middle-aged clients and
Abnormal Findings:
others who complain of difficulty reading.
o A delayed or absent perception of the
- Give the client a hand-held vision chart
examiner’s finger indicates reduced
to hold 14 inches from the eyes.
peripheral vision.
TESTING EXTRAOCULAR MUSCLE - Either of this finding indicates a deviation
FUNCTION in alignment of the eyes and muscle
o Perform Corneal Light Reflex Test. weakness.
- This test assesses parallel alignment of - Phoria: misalignment that occurs only
the eyes. when fusion reflex is blocked.
- Hold a penlight approximately 12 inches - Tropia: a specific type of misalignment.
from the client’s face. - Esotropia: inward turn of the eye.
- Shine the light towards the bridge of the - Exotropia: outward turn of the eye.
nose while the client stares straight - Strabismus: constant malalignment of
ahead. the eyes.
- Note the light reflected on the corneas. o Perform the Position Test
Normal Findings: - Assesses eye muscle strength and
- The reflection of light on the corneas cranial nerve function.
should be in the exact same spot on - Instruct the client to focus on an object
each eye, which indicates parallel you are holding (approximately 12 inches
alignment. from the client’s face).
Abnormal Findings: - Move the object through the six cardinal
- Asymmetric position of the light reflex positions of gaze in a clockwise direction
indicates deviated alignment of the eyes. and observe the client’s eye movement.
- This may be due to muscle weakness or Normal Findings:
paralysis. - Eye movement should be smooth and
o Perform Cover Test symmetric throughout all six directions.
- The cover test detects deviation in Abnormal Findings:
alignment or strength and slight - Failure of the eyes to follow movement
deviations in eye movement by symmetrically in any or all directions
interrupting the fusion reflex that indicates a weakness in one or more
normally keeps the eyes parallel. extraocular muscles or dysfunction of
- Ask the client to stare straight ahead the cranial nerve that innervates the
and focus on a distant object. particular muscle.
- Cover one of the client’s eyes with an - Nystagmus – an oscillating (shaking)
opaque card. movement of the eye, may be associated
- As you cover the eye, observe the with an inner ear disorder, multiple
uncovered eye for movement. sclerosis, brain lesions, or narcotics use.
- Remove the opaque card and observe EXTERNAL EYE STRUCTURES INSPECTION
the previously covered eye for AND PALPATION
movement. o Inspect the Eyelids and Eyelashes
- Repeat test on the opposite eye. - Note width and position of palpebral
Normal Findings: fissures.
- The uncovered eye should remain fixed - Assess ability eyelids to close.
straight ahead. - Note the position of the eyelids in
- The covered eye should remain fixed comparison with the eyeballs.
ahead after being uncovered. - Note any unusual: Turnings, Color,
Abnormal Findings: Swelling, Lesions, Discharge
- The uncovered eye will move to establish Observe for redness, swelling, discharge or
focus when the opposite eye is covered. lesions.
- When the covered eye is uncovered,
movement to reestablish focus occurs.

Normal Findings: - Exophthalmos: protrusion of the
- The upper lid margin should be between eyeballs accompanied by retracted
the upper margin of the iris and the eyelid margins.
upper margin of the pupil. o Inspect the Bulbar Conjunctiva and Sclera
- The lower lid margin rests on the lower - Have the client keep the head straight
border of the iris. while looking from side to side then up
- No white sclera is seen above or below toward the ceiling.
the iris. - Observe clarity, color and texture.
- Palpebral fissure may be horizontal. Normal Findings:
- The upper and lower lids close easily and - Bulbar conjunctiva is clear, moist, and
meet completely when closed. smooth.
- The lower is upright with no inward or - Underlying structures are clearly visible.
outward turning. - Sclera is white.
- Eyelashes are evenly distributed and Abnormal Findings:
curve outward along the lid margins. - Areas of dryness are associated with
- Skin on both eyelids is without redness, allergies or trauma.
swelling, or lesions. - Conjunctivitis: generalized redness of
Abnormal Findings: the conjunctiva (pink eye)
- Drooping of the eyelid - Episcleritis: local, non-infectious
- Refracted lid margins inflammation of the sclera. This condition
- Failure of the lids to close completely. is usually characterized by either a
- Xanthelasma: raised yellow plaques nodular appearance or by redness with
located most often near the inner dilated vessels.
canthus, normal variation associated o Inspect the Palpebral Conjunctiva
with increasing age and high lipid levels. - Put on gloves for this assessment
- Ptosis: drooping of the upper eyelid procedure.
- Entropion: an inverted lower lid that - Inspect the palpebral conjunctiva of the
may cause pain an injure the cornea as lower eyelid by placing your thumbs
the eyelash brushes against the bilaterally at the level of the bony orbital
conjunctiva and cornea. rim and gently pulling down to expose
- Ectropion: an averted lower eyelid, the palpebral conjunctiva.
results in exposure and drying of the - Avoid pressuring the eye.
conjunctiva. - Ask the client to look up as you observe
- Seborrhea or Blepharitis: redness and the exposed areas.
crusting along the lid margins. It is an Normal Findings:
infection caused by staphylococcus - The lower and upper conjunctiva are
aureus. clear and free of swelling or lesions.
- Hordeolum (stye): a hair follicle Abnormal Findings:
infection, causes local redness, swelling - Cyanosis of the lower lid suggests a
and pain. heart or lung disorder.
- Chalazion: an infection of the o Inspect the Palpebral Conjunctiva
meibomian gland, may produce extreme - Evert the upper eyelid.
swelling of the lid, moderate redness, but - Ask the client to look down with his or
minimal pain. her eyes slightly open.
o Observe the Position and Alignment of the - Gently grasp the client’s upper eyelashes
Eyeball in the Eye Socket. and pull the lid downward.
- Eyeballs are symmetrically aligned in
sockets without protruding or sinking.
Normal Findings: Abnormal Findings:
- Palpebral conjunctiva is free of swelling, - Areas of roughness or dryness on the
foreign bodies or trauma. cornea are often associated with injury
Abnormal Findings: or allergic responses.
- A foreign body or lesion may cause - Opacities of the lens are seen with
irritation, burning, pain and/or swelling of cataracts.
the upper eyelid. o Inspect the Iris and Pupil
o Inspect the Palpebral Conjunctiva - Inspect shape and color of iris and size
- Place a cotton tipped applicator and shape of pupil.
approximately 1cm above the eyelid - Measure pupils against a gauge if they
margin and push down with the appear larger or smaller than normal or
applicator while still holding the if they appear to be two different sizes.
eyelashes. Normal Findings:
- Hold the eye lashes against the upper - The iris is typically round, flat, and evenly
ridge of the body orbit just below the colored.
eyebrow, to maintain the everted - The pupil, round with a regular border, is
position of the eyelid. centered in the iris.
- Examine the palpebral conjunctiva for - Pupils are normally equal in size (3-
swelling, foreign bodies, or trauma. 5mm).
- Return the eyelid to normal by moving - PERLAA (pupils equally round reactive to
the lashes forward and asking the client light and accommodation)
to look up and blink. - An equality in pupil size of less than
- The eyelid should return to normal. 0.5mm occurs in 20% of clients.
o Palpate the Lacrimal Apparatus - This condition, called anisocoria, is
- Put on disposable gloves to palpate the normal.
nasolacrimal duct to assess for blockage. Abnormal Findings:
- Use one finger and palpate just inside - Typical abnormal findings include
the lower orbital rim. irregularly shaped irises, miosis,
Normal Findings: mydriasis, and anisocoria.
- No drainage should be noted from the - If the difference in pupil size changes
puncta when palpating the nasolacrimal throughout pupillary responses tests, the
duct. inequality of size is abnormal.
Abnormal Findings: - Anisocoria is a condition characterized
- Expressed drainage from the puncta on by an unequal size of the eyes' pupils.
palpation occurs with duct blockage. Affecting 20% of the population, it can be
o Inspect Cornea and the Lens an entirely harmless condition or a
- Shine a light from the side of the eye for symptom of more serious medical
an oblique view. problems.
- Look through the pupil to inspect the - Mydriasis is the dilation of the pupil,
lens. usually having a non-physiological
Normal Findings: cause, or sometimes a physiological
- The cornea is transparent, with no pupillary response. Non-physiological
opacities. causes of mydriasis include disease,
- The oblique view shows a smooth and trauma, or the use of drugs.
overall moist surface; the lens is free of MIOSIS VS. MYDRIASIS
opacities. - Miosis or myosis is excessive constriction
of the pupil. The opposite condition,
mydriasis, is the dilation of the pupil.
o Test Pupillary Reaction to Light o Test Pupillary Reaction to Light Abnormal
- Test for direct response by darkening the Findings:
room and asking the client to focus on a - Pupils do not constrict; eyes do not
distant object. converge.
- To test direct pupil reaction, shine a light
obliquely into one eye and observe the
pupillary reaction. ASSESSMENT OF THE EARS
- Shining the light obliquely into the pupil
STRUCTURE AND FUNCTION OF THE EYES
and asking the client to focus on an
object in the distance ensures that § The ear Consist of three distinct parts:
pupillary constriction is a reaction to light Ø External ear
and not a near reaction. Ø Middle ear
Normal Findings: Ø Inner ear
- The normal direct pupillary response is EXTERNAL EAR
constriction. § Compose of auricle or pinna and external
Abnormal Findings: auditory canal (S-shape in adult).
- Monocular blindness can be detected § The outer part of the canal curves up and
when light directed to the blind eye results in back.
no response in either pupil. § The inner part of the canal curves down and
- When light is directed into the unaffected forward.
eye, both pupils constrict. § Modified sweat glands secretes cerumen
- Assess consensual response at the same (wax-like substance that keeps the
time as direct response by shining a light tympanic membrane soft, and it has
obliquely into one eye and observing the bacteriostatic properties, sticky in
pupillary reaction in the opposite eye. consistency as defense against foreign
Normal Findings: bodies.
- The normal consensual pupillary § Tympanic membrane or eardrum has a
response is constriction. translucent pearly gray appearance serves
Abnormal Findings: as partition across the inner end of the
- Pupils do not react at all to direct and auditory canal.
consensual pupillary testing. § The membrane itself is concave and
o Test Accommodation of Pupils located at the end of the auditory
- Accommodation occurs when the client canal in a tilted position such that
moves his or her focus of vision from a the top of the membrane is closer to
distant point to a near object, causing the auditory meatus than the bottom.
the pupils to constrict. § Distinct landmarks of the tympanic
- Hold your finger or a pencil about 12-15 membrane:
inches from the client. - Handle and short process of the
- Ask the client to focus on your finger or malleus: the nearest auditory ossicle
pencil and to remain focused on it as you that can be seen through the translucent
move it closer in toward the eyes. membrane.
Normal Findings: - Umbo: the base of the malleus, serving
- The normal pupillary response is as a center point landmark.
constriction of the pupils and - Cone of light: the reflection of the
convergence of the eyes when otoscope light seen as a cone due to the
focusing on a near object concave nature of the membrane.
(accommodation and convergence).

- Pars flaccida: the top portion of the § The transmission of sound waves in the inner
membrane that appears to be less taut ear is referred to as “perceptive or
than the bottom portion. sensorineural hearing.
- Pars tensa: the bottom of the § Conductive hearing loss: the client reports
membrane that appears to be taut. lateralization of sound to the poor ear-that
MIDDLE EAR OR TYMPANIC CAVITY is, the client “hears” the sounds in the poor
§ A small, air-filled chamber in the temporal ear. The good ear is distracted by
bone. background noise and conducted air, which
§ It is separated from the external ear by the the poor ear has trouble hearing. Thus, the
eardrum and from the inner ear by a bony poor ear receives most of the sound
partition containing two openings, the round conducted by bone vibration.
and oval windows. o Conductive hearing loss would be
§ The middle ear contains three auditory related to a dysfunction of the
ossicles: malleus, incus, and the stapes. external or middle ear (e.g.,
These tiny bones are responsible for impacted ear wax, otitis media,
transmitting sound waves from the eardrum foreign object, perforated eardrum,
to the inner ear through the oval window. drainage of the middle ear, or
§ Eustachian tube connects the ear to the otosclerosis).
nasopharynx that equalize the air pressure. § Sensorineural hearing loss: the client
THE INNER EAR OR LABYRINTH reports lateralization of sound to the good
§ Fluid filled and made up of the bony ear. This is because of limited perception of
labyrinth and an inner membranous the sound due to nerve damage in the bad
labyrinth. ear, making sound seem louder in the
§ The bony labyrinth has three parts: the unaffected ear.
cochlea, the vestibule, and the semicircular o Sensorineural loss would be related
canals. to dysfunction of the inner ear (i.e.,
§ The inner cochlear duct contains the spiral organ of Corti, cranial nerve VIII, or
organ of Corti, which is the sensory organ of temporal lobe of brain).
hearing. Sensory receptors in the vestibule ASSESSEMENT PROCEDURE
and in the membranous semicircular canals, Ø Collecting Subjective Data: The Nursing
sense position and head movements to help Health History:
maintain both static and dynamic - It is important to gather data from the client
equilibrium. about the current level of hearing and ear
§ Vestibular nerve fibers connect to the health as well as past and family history
cochlear nerve to form the eight cranial problems related to ear.
nerve (acoustic or vestibulocochlear nerve). - During data collection, the examiner should
HEARING be alert to signs of hearing loss such as in
§ Sound waves travelling through air are appropriate answers, frequent requests for
collected by and funneled through the repetition, etc.
external ear, causing the eardrum to Ø Collecting Objective Data: Physical
vibrate. Examination
§ Sound waves are then transmitted through - The purpose of the ear and hearing
auditory ossicles as the vibration of the examination is to evaluate the condition of
eardrum causes the malleus, the incus, and the external ear, the condition and patency
then the stapes to vibrate. of the ear canal, the status of the tympanic
§ The transmission of sound waves through membrane, bone and air conduction of
the external and middle ear is referred to as sound vibrations, hearing acuity, and
“conductive hearing”. equilibrium.
Preparing The Client Some Abnormal Findings
o Make sure that the client is seated - Enlarged preauricular and
comfortably during the ear examination. postauricular lymph nodes caused
o This promotes the client’s participation, by infection.
which is very important in this - Tophi (nontender, hard, cream-
examination. colored nodules on the helix or
o The test should be explained thoroughly antihelix, containing uric acid
to guarantee accurate results. crystals) – gout.
o To ease any client anxiety, explain in - Blocked sebaceous glands-
detail what you will be doing. postauricular cysts.
o Answer any questions the client may - Ulcerated crusted nodules that
have. bleed- skin cancer.
o Carefully note how the client responds to - Redness, swelling, scaling, or itching –
your explanations. otitis externa.
Equipment: - Pale blue ear color – frostbite
o Watch with a second hand for Romberg § Palpate the auricle and mastoid
test. process
o Tuning fork Normal Findings:
o Otoscope - The auricle, tragus, and mastoid
Inspection and Palpation of External Ear process are non-tender.
Structures Abnormal Findings:
§ Inspect the auricle, tragus and lobule. - Painful auricle or tragus is associated
- Note size, shape, and Position. with otitis externa or a postauricular
- Observe for lesions, discolorations, and cyst.
discharge. - Tenderness over the mastoid
Normal Findings: process-mastoiditis.
- Ears are equal in size bilaterally - Otitis media-tenderness behind the
(normally 4-10cm) ear.
- The auricle aligns with the corner of each Inspection of Internal Ear Structures Using
eye and within a 10-degree angle of the Otoscope
vertical position. § Perform the Whisper Test
Abnormal Findings: - Test by asking the client to gently
- Ears are smaller than 4cm or larger than occlude the ear not being tested and
10 cm. rub the tragus with a finger in a
- Misaligned or low set ears may be seen circular motion.
with genitourinary disorders or - Start with testing the better hearing
chromosomal defects. ear and then the poorer one.
Normal Findings: - With your head 2 feet behind the
- The skin is smooth, no lesions, lumps, or client (so that the client cannot see
nodules. your lips move), whisper a two-
- Color is consistent with facial color. syllable word such as “popcorn” or
- No discharge should be present. “football”.
Abnormal Findings: - Ask the client to repeat it back to
- Infection - Frostbite you.
- Gout - If the response is incorrect the first
- Postauricular cysts time, whisper the word one more
- Skin cancer time.
- Otitis externa
- Identifying three out of six - Strike a tuning fork and place the
whispered words is considered base of the fork on the client’s
passing the test. mastoid process.
Normal Findings:
- Able to repeat the two-syllable word - Ask the client to tell you when the
as whispered. sound is no longer heard.
Abnormal Findings:
- Unable to repeat the two-syllable - Move the prongs of the tuning fork to
word after two tries indicates hearing the external auditory canal.
loss and requires follow-up testing by
audiologist. - Ask the client to tell you if the sound
§ Perform Weber’s Test is audible after the fork is moved.
- The test helps to evaluate the Normal Findings:
conduction of sound waves through - Air conduction sound is normally
bone to help distinguish between heard longer than bone conduction
conductive hearing (sound waves sound (AC>BC).
transmitted by the external and middle Abnormal Findings:
ear) and sensorineural hearing (sound - Sensorineural hearing loss, air
waves transmitted by the inner ear). conduction sound is heard longer
- Strike a tuning fork softly with the back than bone conduction sound
of your hand and place it at the center (AC>BC) if anything is heard at all.
of the client s head or forehead - Sensorineural hearing loss occurs
(centering is important). with damage to the inner ear
- Ask whether the client hears the sound (cochlea), or to the nerve pathways
better in one ear or the same in both between the inner ear and brain. This
ears. is the common type of permanent
Normal Findings: hearing loss. It decreases one’s
- Vibrations are heard equally well in both ability to hear faint sounds. Even loud
ears. speech may be muffled. Causes
- No lateralization of sound to either ear. include ototoxic drugs, genetic
Abnormal Findings: hearing loss, aging, head trauma,
- Conductive hearing loss, bone malformation of the inner ear, and
conduction (BC) sound is heard longer loud noise exposure.
than or equally as long as air conduction § Perform Romberg Test
(AC) sound. - This tests the client s equilibrium.
- Conductive hearing loss occurs when - Ask the client to stand with feet
sound is not conducted through the together, arms at sides, with eyes
outer ear canal to the eardrum and open then with eyes closed.
ossicles of the middle ear. - When performing this test put your
- Possible causes include fluid in middle arms around the client without
ear, middle ear infection, allergies, touching him or her to prevent falls.
eustachian tube dysfunction, perforated Normal Findings:
eardrum benign tumors, impacted - Client maintains position for 20
cerumen, infection in the ear canal or seconds without swaying or with
presence of foreign body. minimal swaying.
§ Perform the Rinne Test
- The rinne test compares air and bone
conduction sounds.
Abnormal Findings: glands (parotid, submandibular and
- Client moves feet apart to prevent sublingual).
falls or starts to fall from loss of § The tongue is a mass of muscle, attached to
balance. the hyoid bone and styloid process of the
- This may indicate a vestibular temporal bone.
disorder. § It is connected to the floor of the mouth by a
fold of tissue called frenulum.
§ The tongue assists with moving food,
ASSESSING MOUTH, THROAT, swallowing, and speaking.
NOSE, AND SINUSES § The gums (gingiva) are covered by mucous
membrane and normally hold 32
STRUCTURE AND FUNCTION permanent teeth in the adult.
§ The mouth and throat make up the first part § The top, visible, white enameled part of the
of the digestive system and are responsible tooth is the crown.
for receiving food (ingestion), taste, § The portion of the tooth that is embedded in
preparing food for digestion, and aiding the gums is the root.
speech. § The crown and root are connected by the
§ The nose and paranasal sinuses constitute region of the tooth referred to as the neck.
the first part of the respiratory system and § Small bumps called papillae cover the dorsal
are responsible for receiving, filtering, surface of the tongue.
warming, and moistening air to be § Taste buds, scattered over the tongue’s
transported to the lungs. surface, carry sensory impulses to the brain.
MOUTH § The parotid glands, located below and in
§ The mouth or oral cavity is formed by the front of the ears, empty through Stensen’s
lips, cheeks, hard and soft palates, uvula, ducts, which are located inside the cheek
and the tongue and its muscles. across from the second molar.
§ The mouth is the beginning of the digestive § The submandibular glands, located in the
tract and serves as an airway for the lower jaw, open under the tongue or either
respiratory tract. side of the frenulum through openings called
§ The upper and lower lips form the entrance Wharton’s ducts.
to the mouth, serving as a protective § The sublingual glands, located under the
gateway to the digestive and respiratory tongue, open through several ducts located
tracts. on the floor of the mouth.
§ The roof of the oral cavity is formed by the THROAT
anterior hard palate and the posterior soft § The throat (pharynx), located behind the
palate. mouth and nose, serves as a muscular
§ An extension of the soft palate is the uvula, passage for food and air.
which hangs in the posterior midline of the § The upper part of the throat is the
oropharynx. nasopharynx.
§ The cheeks form the lateral walls of the § Below the nasopharynx lies the oropharynx,
mouth. and below the oropharynx lies the
§ The tongue and its muscles form the floor of laryngopharynx.
the mouth. § The soft palate, anterior and posterior pillars,
§ The mandible (jawbone) provides the and uvula connect behind the tongue to
structural support for the floor of the mouth. form arches.
§ Contained within the mouth are the tongue, § Masses of lymphoid tissue referred to as the
teeth, gums and the openings of the salivary palatine tonsils are located on both sides of

the oropharynx at the end of the soft palate § Sinuses are air-filled cavities that decrease
between the anterior and posterior pillars. the weight of the skull and act as resonance
§ Lingual tonsils lie at the base of the tongue. chamber during speech.
§ Pharyngeal tonsils, or adenoids, are found § The sinuses are often a primary site of
high in the nasopharynx. infection because they can easily become
§ Tonsils are masses of lymphoid tissue, they blocked.
help protect against infection. § The frontal and maxillary sinuses are
NOSE accessible to examination by the nurse.
§ The nose consists of an external portion § The ethmoidal and sphenoidal sinuses are
covered with skin and an internal nasal smaller, located deeper in the skull, and are
cavity. not accessible for examination.
§ It is composed of bone and cartilage and is ASSESSEMENT
lined with mucous membrane. Collecting Subjective Data: The Nursing Health
§ The external nose consists of a bridge (upper History
portion), tip, and two oval openings called § Subjective data related to the mouth, throat,
nares. nose, and sinuses can aid in detecting
§ The nasal cavity is located between the roof diseases and abnormalities that may affect
of the mouth and the cranium. the client’s activities of daily living (ADLs).
§ It extends from the anterior nares (nostrils) § Screening for cancer of the mouth, throat,
to the posterior nares, which open into the nose, and sinuses is an important area of
nasopharynx. this assessment.
§ The nasal septum separates the cavity into Collecting Objective Data: Physical
two halves. Examination
§ The front of the nasal septum contains a rich § Examination of the mouth and throat can
supply of blood vessels and is known as help the nurse to detect abnormalities of the
Kiesselbach’s area. This is a common site for lips, gums, teeth, oral mucosa, tonsils, and
nasal bleeding. uvula.
§ The superior, middle, and inferior turbinate Preparing the Client
are bony lobes, sometimes called conchae, - Ask the client to assume a sitting
that project from the lateral walls of the position with the head erect.
nasal cavity. - It is best if the client’s head is at your
§ The three turbinate increase the surface eye level.
area that is exposed to incoming air. - Explain the specific structures you
§ As the person inspires air, nasal hairs will be examining, and tell the client
(vibrissae) filter large particles from the air. who wears dentures, a retainer, or
§ Ciliated mucosal cells then capture and rubber bands on braces that they will
propel debris toward the throat, where it is need to be removed for an adequate
swallowed. oral examination.
§ A meatus underlies each tubernate and Equipment
receives drainage from the paranasal - Non latex gloves (wear gloves when
sinuses and the nasolacrimal duct. examining any mucous membrane)
SINUSES - 4X4 inch gauze pad
§ Four pairs of paranasal sinuses located in - Penlight
the skull: - Short, wide-tipped speculum
Ø Fontal (above the eyes) attached to the
Ø Maxillary (in the upper jaw) - head of an otoscope
Ø Ethmoidal - Tongue depressor
Ø Sphenoidal - Nasal speculum
ASSESSEMENT PROCEDURE OF THE MOUTH Abnormal Findings:
- Clients who smoke, drink large quantities
Inspection and Palpation of coffee or tea, or have an excessive
§ Inspect the lips. intake of fluoride may have yellow or
- Observe lip consistency and color. brownish teeth.
Normal Findings: - Brown or yellow stains or white spots on
- Lips are smooth and moist without teeth may result from antibiotic therapy
lesions or swelling. or tooth trauma.
- Pink lips are normal in light-skinned - Receding gums are abnormal in younger
clients, as are bluish or freckled lips in clients; in older clients, the teeth may
some dark-skinned clients. appear longer because of age-related
Abnormal Findings: gingival recession, which is common.
- Pallor around the lips (circumoral pallor) - Red, swollen gums that bleed easily are
is seen in anemia and shock. seen in gingivitis, scurvy (vitamin C
- Bluish (cyanotic) lips may result from deficiency), and leukemia (Periodontal
cold or hypoxia. Disease).
- Reddish lips are seen in clients with - Enlarged reddened gums (hyperplasia)
ketoacidosis, carbon monoxide that may cover some of the normally
poisoning, and COPD with polycythemia. exposed teeth may be seen in
- Swelling of the lips or systemic allergic or pregnancy, puberty, leukemia, and with
anaphylactic reactions. use of some medications, such as
§ Inspect the teeth and gums. phenytoin.
- Ask the client to open the mouth. - A bluish-black or grey-white line along
- Note the number of teeth, color, and the gum line is seen in lead poisoning.
condition. § Inspect the buccal mucosa
- Note any repairs such as crowns and - Use a penlight and tongue depressor to
any cosmetics such as veneers. retract the lips and cheeks to check color
- Ask the client to bite down as though and consistency.
chewing on something and note the Normal Findings:
alignment of the lower and upper jaws. - In all clients, tissue is smooth and moist
- Put on gloves and retract the client’s lips without lesions.
and cheeks to check gums for color and Abnormal Findings:
consistency. - Leukoplakia (precancerous lesion) may
Normal Findings: be seen in chronic irritation and smoking.
- 32 pearly whitish teeth with smooth - Candida Albicans: Whitish, curd-like
surfaces and edges. patches that scrape off over reddened
- Upper molars should rest directly on mucosa and bleed easily indicate
lower molars and the front upper incisors “thrush” infection.
should slightly override the lower § Inspect Stensen ducts (parotid ducts)
incisors. - openings of the parotid salivary glands-
- Some clients normally have only 28 teeth located on the buccal mucosa across
if the 4 wisdom teeth do not erupt. from the second upper molar.
- No decayed areas Normal Findings:
- No missing teeth - Stensen ducts are visible with flow of
- Gums are pink, moist, and firm with tight saliva. No redness, swelling, pain, or
margins to the tooth. moistness in area.
- No lesions or masses.

Abnormal Findings: - either side of frenulum.
- Reddened opening of Stensen ducts is § Observe the sides of the tongue.
seen with mumps. - Use a square gauze pad to hold the
§ Inspect and palpate the tongue. client’s tongue to each side.
- Ask client to stick out the tongue. - Palpate any lesions, ulcers, or nodules for
- Inspect for color, moisture, size, and induration.
texture. Normal Findings:
- Observe for fasciculations (fine tremors), - No lesions, ulcers, or nodules are
and check for midline protrusion. apparent.
- Palpate any lesions present. Abnormal Findings:
Normal Findings: - Canker sores may be seen.
- Tongue should be pink, moist, a - Leukoplakia, persistent lesions, ulcers, or
moderate size with papillae (little nodules may indicate cancer.
protuberances) present. § Check the strength of the tongue.
- A common variation is a fissured, - Place your finger on the external surface
topographic-map-like tongue, which is of the client’s cheek.
not unusual in older clients. - Ask the client to press the tongue’s tip
Abnormal Findings: against the inside of the cheek to resist
- Deep longitudinal fissures seen in pressure from your fingers.
dehydration. - Repeat on the opposite cheek.
- Black tongue indicative of bismuth Normal Findings:
toxicity: black hairy tongue. - The tongue offers strong resistance.
§ Assess the ventral surface of the tongue. Abnormal Findings:
- Ask the client to touch the tongue to the - Decreased tongue strength may occur
roof of the mouth and use a penlight to with a defect of the 12th cranial nerve
inspect the ventral surface of the tongue, (hypoglossal) or with a shortened
frenulum, and area under the tongue. frenulum that limits motion.
Normal Findings: § Check the anterior tongue s ability to taste
- The tongue’s ventral surface is smooth, - Place drops of sugar and salty water on
shiny, pink, or slightly pale, with visible the tip and sides of tongue with a tongue
veins and no lesions. depressor.
Abnormal Findings: Normal Findings:
- Leukoplakia, persistent lesions, ulcers, or - The client can distinguish between sweet
nodules may indicate cancer and should and salty.
be referred. Abnormal Findings:
§ Inspect for Wharton ducts - Loss of taste discrimination occurs with
- openings from the submandibular zinc deficiency, a 7th cranial nerve
salivary glands – located on either side of (facial) defect, chronic sinus infections,
the frenulum on the floor of the mouth. and certain medication use (“Smell and
Normal Findings: taste disorders”).
- The frenulum is midline. § Inspect the hard (anterior) and soft
- Wharton ducts are visible, with salivary (posterior) palates and uvula.
flow or moistness in the area. - Ask the client to open the mouth wide
- The client has no swelling, redness, or while you use a penlight to look at the
pain. roof.
Abnormal Findings: - Observe color and integrity.
- Include lesions, ulcers, nodules, or
hypertrophied duct openings on
Normal Findings: - No redness of or exudate from uvula or
- The hard palate is pale or whitish with soft palate.
firm, transverse rugae (wrinkle-like - Midline elevation of uvula and symmetric
folds). elevation of the soft palate.
- Palatines tissues are intact; the soft Abnormal Findings:
palate should be pinkish, movable, - Asymmetric movement or loss of
spongy, and smooth. movement may occur after a
Abnormal Findings: cerebrovascular accident (stroke).
- Candida infection may appear as thick - Palate fails to rise and uvula deviates to
white plaques on the hard palate. normal side with cranial nerve X (vagus)
- Deep purple, raised, or flat lesions may paralysis.
indicate a Kaposi’s sarcoma (seen in § Inspect the tonsils.
clients with AIDS) - Using the tongue depressor to keep the
- A yellow tint to the hard palate may mouth open wide.
indicate jaundice because bilirubin - Inspect the tonsils for color, size, and
adheres to elastic tissue (collagen). presence of exudate and lesions.
- An opening in the hard palate is known - Grade the tonsils.
as a cleft palate. Normal Findings:
§ Note odor. - Tonsils may be present or absent.
- While the mouth is wide open, note any - They are normally pink and symmetric
unusual or foul odor. and may be enlarged to 1+ in healthy
Normal Findings: clients.
- No unusual or foul odor is noted. - No exudate, swelling, or lesions should
Abnormal Findings: be present.
- Fruity or acetone breath is associated Abnormal Findings:
with diabetic ketoacidosis. - Tonsils are red, enlarged (to 2+, 3+, or 4+),
- Ammonia odor is often associated with and covered with exudate in tonsilitis.
kidney disease. - They also may be indurated with patches
- Foul odors may indicate an oral or of white or yellow exudate.
respiratory infection, or tooth decay. Ø Grading of Tonsils in Tonsilitis
- Alcohol or tobacco use may be identified o 1+ = Tonsils are visible
by breath odor. o 2+ = Tonsils are midway between
- Fecal breath odor occurs in bowel tonsillar pillars and uvula
obstruction. o 3+ = Tonsils touch the uvula
- Sulfur odor (fetor hepaticus) occurs in o 4+ = Tonsils touch each other
end stage liver disease. § Inspect the posterior pharyngeal wall.
§ Assess the uvula. - Keeping the tongue depressor in place,
- Apply a tongue depressor to the tongue shine the penlight on the back of the
(halfway between the tip and back of the throat.
tongue) and shine a penlight into the - Observe the odor of the throat and note
client’s wide-open mouth. any exudate or lesions.
- Note the characteristics and positioning Normal Findings:
of the uvula. Ask the client to say “aaah” - Throat is normally pink, without exudate
and watch for the uvula and soft palate or lesions.
to move. Abnormal Findings:
Normal Findings: - A bright red throat with white or yellow
- The uvula is fleshy, solid structure that exudate indicates pharyngitis.
hangs freely in the midline.
- Yellowish mucus on throat may be seen, - If the client has a large amount of
with postnasal sinus drainage. exudate, you may feel crepitus upon
ASSESSEMENT PROCEDURE OF THE NOSE palpation over the maxillary sinuses.
- Before inspecting the nose, discard
gloves and perform hand hygiene. § Percuss the sinuses.
Inspection and Palpation - Lightly tap (percuss) over the maxillary
§ Inspect and palpate the external nose. sinuses for tenderness.
- Note nasal color, shape, consistency, and Normal Findings:
tenderness. - The sinuses are not tender on percussion.
Normal Findings: Abnormal Findings:
- Color is the same as the rest of the face. - The frontal and maxillary sinuses are
- The nasal structure is smooth and tender upon percussion in clients with
symmetric. allergies or sinus infection.
- No tenderness § Transilluminate the sinuses.
Abnormal Findings: - If sinus tenderness was detected during
- Nasal tenderness on palpation palpation and percussion,
accompanies a local infection. transillumination will let you see if the
§ Check patency of air flow through the sinuses are filled with fluid or pus.
nostrils Ø Transillumination
- Occlude one nostril at a time and asking o Transilluminate the frontal
client to sniff. sinuses by holding a strong,
Normal Findings: narrow light source snugly under
- Client is able to sniff through each nostril the eyebrows (the room should
while other is occluded. be dark)
Abnormal Findings: o Repeat this technique for the
- Client cannot sniff through the nostril other frontal sinuses.
that is not occluded, nor can he or she Normal Findings:
sniff or blow air through the nostrils. - A red glow transilluminates the frontal
sinuses. This indicates a normal, air-filled
When an infection is suspected, the nurse sinus.
can examine the sinuses through palpation, Abnormal Findings:
percussion, and transillumination. - Absence of red glow usually indicates a
ASSESSEMENT PROCEDURE OF THE SINUESE sinus filled with fluid or pus.
§ Palpate the sinuses.
- Palpate the frontal sinuses by using your Transilluminate the maxillary sinuses.
thumbs to press up on the brow on each - Hold a strong, narrow light source over
side of nose. the maxillary sinus and asking the client
- Palpate the maxillary sinuses by pressing to open her mouth.
with thumbs up on the maxillary sinuses. - Repeat this technique for the other
Normal Findings: maxillary sinus.
- Frontal and maxillary sinuses are Normal Findings:
nontender to palpation, and no crepitus - A red glow transilluminates the maxillary
is evident. sinuses. The red glow will be seen on the
Abnormal Findings: hard palate.
- Frontal and maxillary sinuses are tender Abnormal Findings:
to palpation in clients with allergies or - Absence of red glow usually indicates a
acute bacterial rhinosinusitis. sinus filled with fluid, pus, or thick mucus
(from chronic sinusitis).
VALIDATING AND DOCUMENTING FINDINGS
- Validate the mouth, throat, nose, and sinus
assessment data that you have collected (by
asking additional questions, verifying data
with another health care professional, or
comparing objective with subjective
findings).
- This is necessary to verify that the data are
reliable and accurate.
- Document the assessment data following the
health care facility or agency policy.

ASSESSMENT

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NCM 101 HEALTH ASSESSMENT

CHONA Q. LIM, RN MAN | HOLY NAME UNIVERSITY

PHILIPP CHESTER T. LIBASORA| 1

PHILIPP CHESTER T. LIBASORA| 2

PHILIPP CHESTER T. LIBASORA| 3

PHILIPP CHESTER T. LIBASORA| 8

• Kyphosis is an exaggerated curvature of the NECK LANDMARKS

• Inspect Range of Motion.

PHILIPP CHESTER T. LIBASORA| 12

• To palpate the thyroid use a posterior Palpating the Thyroid

PHILIPP CHESTER T. LIBASORA| 14

PHILIPP CHESTER T. LIBASORA| 16

PHILIPP CHESTER T. LIBASORA| 18

PHILIPP CHESTER T. LIBASORA| 21

PHILIPP CHESTER T. LIBASORA| 25

PHILIPP CHESTER T. LIBASORA| 27

PHILIPP CHESTER T. LIBASORA| 31

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ASSESSMENT

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Document Informationclick to expand document informationNCM 101: HEALTH ASSESSMENT NOTES

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ASSESSMENT

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ASSESSMENT

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NCM 101 HEALTH ASSESSMENT

CHONA Q. LIM, RN MAN | HOLY NAME UNIVERSITY

PHILIPP CHESTER T. LIBASORA| 1

PHILIPP CHESTER T. LIBASORA| 2

PHILIPP CHESTER T. LIBASORA| 3

PHILIPP CHESTER T. LIBASORA| 8

• Kyphosis is an exaggerated curvature of the NECK LANDMARKS

• Inspect Range of Motion.

PHILIPP CHESTER T. LIBASORA| 12

• To palpate the thyroid use a posterior Palpating the Thyroid

PHILIPP CHESTER T. LIBASORA| 14

PHILIPP CHESTER T. LIBASORA| 16

PHILIPP CHESTER T. LIBASORA| 18

PHILIPP CHESTER T. LIBASORA| 21

PHILIPP CHESTER T. LIBASORA| 25

PHILIPP CHESTER T. LIBASORA| 27

PHILIPP CHESTER T. LIBASORA| 31

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