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Islamic University of GazaIslamic University of GazaFaculty of NursingFaculty of Nursing

Chapter 6Chapter 6Head AssessmentHead Assessment

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Head assessmentHead assessment

• Inspects for size, shape, and contour of head. • The skull is generally round with anterior & posterior

prominences. • Large infant's head may be hydrocephalus. • Large adult's head & facial bones resulting from

acromegaly (Acromegaly is a condition in which there is too much growth hormone and the body tissues get larger over time).

• Palpates the skull for nodules or masses.

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Assessment of the eye

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Assessment of the eye

• Eye chart (Snellen chart). • Chart or newsprint.• Cover card.• Penlight, ophthalmoscope.

• Ask your client about:• History of previous eye surgery, trauma, use of

corrective glasses or contact lenses, blurred vision, diplopia, strabismus.

• Recent changes in vision. • Date of previous vision test.• Allergies, eye redness, frequent watering discharge.

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Assessment of the eye cont..

• Assess:- external eye structures, pupils, and iris (قزحية), visual

acuity, ocular movements, peripheral vision.

• Consider the following factors:• age, use of corrective lens, artificial eye, allergies,

pain, visual disturbances, and health related factors such increase Blood Pressure, or Diabetes Mellitus.

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• Assessment of external eye structures:-Position and alignment of eyes, eye brow, eye lids, eye

lashes, lacrimal glands, pupils and iris.

• Assessment of pupils:-Use penlight to produce constriction of pupils.

-Must be done for accommodation and convergence of pupils.

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• Assessment of visual acuity:-Place the client 20 feet from the snellen eye chart and

test each eye alone.• Assessment of extra ocular movements:-Ask client to hold his head and follow movements of

your forefinger. • Assessment of peripheral vision (visual fields):-Hemianopsia: blindness of 1/2 field in one or both

eyes.-Quadrantanopsia: blindness of 1/4 of visual field in

one or both eyes.-Ascotoma: Island like blindness in visual field.

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Eye Pathologies

• Orbital Hematoma• Orbital fractures (Blowout fracture)• Ruptured Globe• Corneal Abrasion• Corneal Laceration• Hyphema• Iritic• Detached Retina• Conjunctivitis• Hordeolum• Periorbital Lacerations• Foreign Bodies• Contact Lens Removal

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Assessment of the Ear

• Ask about: History of ear surgery, trauma, frequent infection, ear pain, drainage, hearing loss, tinnitus, vertigo, ototoxic medications, last hearing examination.

• Assess client in sitting position & inspect the auricle’s placement, size, symmetry, and color.

• Color of ears must be the same as of the face. • Redness: sign of inflammation or fever. • Pallor: indicates frost bite. • Palpate the auricles for texture, tenderness, and

skin lesion.

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Ear assessment cont…• If client complains of pain: pull the auricle and press

on the tragus and behind the ear over the mastoid process if pain increases, means external ear infection, if pain does not increase, means middle ear infection may be present.

• Inspect ear canal for size and discharge. • Assess cerumen if it is yellow or green (may indicate

infection). • Assess hearing acuity: by identification of voice

tones, with the client repeating testing words spoken by the nurse

**N.B: deeper structure and middle ear can be observed only by otoscope.

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The Otoscope Examination

Using the Otoscope :

•choose the largest speculum.

•head toward the opposite shoulder.

•pull adult ear : pinna upper and back.

•pull infant and child ( <3 age ) : pinna down.

•hold the otoscope : upside down.

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The Otoscope Examination cont..

• The External Canal: -Assess for redness, swelling, lesion, foreign body,

discharge.

• Tympanic Membrane:-Assess for color, character, perforation: shiny,

translucent, pearl-gray color, Cone-shaped light reflex.

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Functions of the nose•Identifying odors (upper 1/3 of septum)•Air passageway (obligate in newborns)•Air conditioning:

-Humidifying-Warming/cooling air-Cleaning and filtering air of dust and most bacteria•Voice resonance

Assessment of the nose

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Inspect and palpate

Eternal Nose 1)Symmetric , in the midline , skin lesion , pain.

2)Nostril patency: each time test one side.

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Assessment of the nose cont..

• Inspect & observe symmetry, inflammation, & deformity.

• In case of swelling or deformities of nose, the nose is palpated gently for tenderness, swelling and underlying deviations.

• Normally the external nose is symmetrical, strait, non tender, and without discharge.

• Assess mucosa which is normally pink in color. • Yellowish or greenish discharge: means sinus infection. • Pale mucosa with clear discharge: means allergy. • N.B: For client with NGT, nurse routinely checks for

local breakdown of skin “Excoriation” of the naris characterized by redness and sloughing of the skin

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Assessment of the sinuses

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Palpate sinuses

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Transillumination-Frontal& Maxillary Sinuses

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Palpation for the sinus areas

-Frontal sinus below the eyebrow

-Maxillary sinus below cheekbones

• Transillumination sinusitis:

1)Frontal sinus under the superior orbital

2)Maxillary sinus inside the mouth on the hard

palate

normal light up symmetrically

• Transillumination is the transmission of light through tissues of the body. A common example is the transmission of a flash of light through fingers, producing a red glow. This is because red blood cells absorbed other colors of the beam and transmitted only the red component.

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Assessment of the sinuses

• Frontal and maxillary sinuses are examined for pain and edema.

• Palpate sinuses (both frontal and maxillary) for tenderness, which verbalized by client during exam.

• Percuss sinuses for resonance which is normally hollow tone, and noting abnormality e.g. flat, dull tone elicited or expresses pain on percussion.

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Assessment of mouth and pharynx

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• Assessment of oral cavity can be made during administration of oral hygiene.

• Lips: inspected for color, texture, hydration, contour, and lesions.

• Inner and buccal mucosa, gums and teeth inspected for color, hydration, texture and lesions e.g. ulcers, abrasions or crusts.

• Tongue and floor of mouth should be carefully inspected.

• Assessment of palate “soft and hard” by extending client’s backward, assessment for color, shape, texture, and extra bony prominences or defects

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Assessment of pharynx

• Assessment for pharynx done: by using tongue depressors.

• Pharyngeal tissues are normally pink and smooth.

• Edema, ulceration, or inflammation indicates infections or abnormal lesions.

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Assessment of neck

• Client in sitting position: assessment done by inspection and palpation.

• Assess neck muscles, trachea, thyroid gland, carotid arteries and jugular veins, cervical lymph nodes and cervical vertebrae.

• Assess neck size and position of trachea and thyroid

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• Assess range of motion by asking the client to tilt the head backward and side to side.

• Assess lymph nodes and venous distention.• Neck should be symmetrical with full range of

motion.• No neck vein distention should be visible. • Inspect and palpate cervical vertebrae on the

posterior aspects of the neck for symmetry, tenderness, masses or swelling.

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• Thyroid gland is assessed by palpation, observation and auscultation.

• Normal thyroid gland not palpable. • - Palpation: for gland itself. • - If enlargement of thyroid gland is detected, the

area over the gland is auscultated for a bruit.• Bruit: vibrations & sound of blood flow through

arteries in enlarged gland heard with the bell of stethoscope

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Thyroid dysfunction

• Changes in sleep pattern: e.g. fatigue, drowsiness, lethargy, or insomnia.

• Emotional disturbances: e.g. mood changes, irritability, nervousness.

• Hair loss, brittleness (fragility) of nails.• Altered sensitivity to heat or cold.• dyspnea on exertion, tachycardia.• Changes in appetite: weight loss, abnormal

bowel habits...etc.• Changes in menstruation.• Hoarseness , difficulty swallowing ….etc.• History of radiation for to head or neck.

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Trachea

• Trachea normally centered; (at the supra-sternal notch).

• The cartilages should be smooth, non tender and move easily under examiner’s fingers when the client swallow.

• Palpation done by placing the thump and forefinger on each side of the trachea.

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Assessment of the lymphatic system

Functions of lymphatic system1. Movement and transportation of lymphocytes 2. Production of lymphocytes.3. Production of antibodies.4. Phagocytosis5. Absorption of fat and fat soluble substances.• Enlargement of lymph node: provides early

indication of infection or malignancy. • Lymphatic System consists of a network of

collecting ducts, lymph fluids e.g. spleen, thymus, tonsils, adenoids--- etc

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• Examination of lymphatic System: 2 steps1- Inspection for enlarged lymph nodes, skin lesions,

edema, erythematic, and red streaks (lines) on the skin.

2- Palpating gently the lymph nodes areas using pads of "2, 3, 4" fingers in gentle circular motion.

*Press lightly and then increasing pressure gradually. *Move skin lightly over the underlying tissues & not

moving the examining fingers over the skin. **NB: Large nodes due to malignancy are generally not

tender, vary in size, hard, asymmetrical.

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Some areas of lymph nodes

• Pre auricular: in front of the ear.• Mastoid or posterior auricular: behind the ear.

Above the mastoid process. • Occipital: at the base of skull posterior. • Parotid: near the angle of the jaw. • Sub-mandibular: midway between angle of jaw

and the tip of the mandible. • Sub mental: in the midline posterior to the tip of

the mandible. • Anterior superficial nodes: in the anterior

triangle of the neck.

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Some areas of lymph nodes cont..

• Posterior cervical nodes: in the posterior triangle of the neck.

• Deep cervical nodes: very deep and difficult to be examined.

• Supra clavicular or scalene nodes: In the angle formed by clavicle and Sternocleidomastoid muscle.

• ** Axilla, breast & lower extremity (inguinal and popliteal nodes)

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The end

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