Health AssessmentMary Ann Hudson, RNThe Ohio State University College of Nursing

EarsNoseMouth

Throat

Why does the RN assess the ears?

congenital (syphilis + other TORCH infxns)

nerve damage CN VIII infant ear infections (bottle-

fed and Infant anatomy) structural changes (wax,

trauma, infection) effects from medications

(tinnitus, vertigo)

Changes in the Elderly

Presbycusis

Prez bĭ cū’ sĭs

Sensorineural loss CN VIII

Loss of high pitched sounds > 50 y.o.1. Whisper2. Consonants3. Vowels

http://www.youtube.com/watch?v=4YWSerwlWjM&feature=related

Changes in the Elderly

Otosclerosis of the middle ear

20 – 40 y.o.

Hardening of stapes

Hearing in general is decreased gradually

Why does the RN assess the nose?

To detect:

congenital anomalies

effects from trauma / obstruction

effects of illness (cancer, infections, allergies, nerve damage)

Changes in the Elderly

Smell diminishes slightly (anosmia)

What are the implications to ADLs?

Why does the RN assess the mouth & throat?

congenital anomalies

tooth decay (bottles, hygiene)

nerve damage (swallow, gag)

effects of illness (cancer, infections, neurological & systemic disorders)

Changes in the Elderly

Xerostomia, less saliva & effects of meds

Receding gums; tooth loss

Taste ↓’s 80% (effect on ADLs?)

More lesions

Questions for the ENMT InterviewChief complaint:

Sensory perception, dryness, drainage, itching, pain, lesions

Past History:

Injuries and accidents

Infections, allergies

Chronic illnesses, meds

Social

Tobacco, Alcohol, Drugs/Rx and Abuse

Environment

Noise, sun fumes, dust

Physical exam of the external structures of the ear

Inspect

position, color, size and lesions

Palpate

tenderness (auricle and tragus)

External Otitis

Right 4x2 centimeter lesion involving tragus, outer canal, and lobule. Lesion significant for swelling, erythema, and purulent discharge. Tragus and pinna positive for pain 7/10 on palpation.

Otitis Media

Assessment

Otoscopic examination

Describe

Erythema, absent light reflex, swelling or bulging, visible bony landmarks, color, devices (tympanostomy tube), discharge, bleeding.

Etiology

Supine bottle feed

2nd hand smoke

Group daycare

Juvenile anatomy, genetics

Low Set External Ear

Cauliflower Ear

Etiology

Distortion of the cartilage due to relatively poor perfusion and venous drainage of pinna after blunt trauma. Can lead to obstructive hearing loss and may need surgical correction.

Tophi

Deposits of sodium biurate in the helix of the ear in uncontrolled states of gouty arthritis. May or may not be painful on palpation. Rule out other lesion etiology via history.

Mastoid air cells are open, air-containing spaces in one of the skull bones.

Mastoiditis

Inspection is incredibly important!

infection of the bony air cells in the mastoid bone

drainage from the ear and redness (erythema) behind the ear over the mastoid bone

Forward displacement displacement of pinna

Abscess over mastoid process is possible. Tenderness, erythema, swelling and warmth appear over mastoid process.

Trace around border of erythema with felt-tip pen and document time of tracing.

Inspection of the internal structures

Cerumen

Ear canal rich with specialized goblet cells that secrete cerumen which protects the ear canal with antibacterial and mechanical measures.

Cerumen varies by ethnicity and genetics.

Q-tips can damage or pack cerumen.

Ceremun impaction may create conductive hearing losses, pain or irritation and are most often a result of physical insertion of objects as cerumen will collect naturally at entrance of canal and can be wiped away as a part of normal hygiene. Commercial ear wax removers or provider removal is rarely needed.

Inspection of the internal structures

Otitis Externa/Swimmer’s Ear

Moisture expands the cerumen and tissues of canal providing matrix for opportunistic bacteria to overgrow. May also arise from foreign body.

Erythema, tragus pain, exudate, and obstruction of canal due to swelling are typical presentation.

Patient may need to have wick inserted for otic antibiotic drops to reach site due to swelling.

Inspection of the internal structures

Normal tympanic anatomy

Cone of light is situated toward the face

Bony landmarks should be visualized

“Pearly gray” membrane, but wide range of colors. Compare one side to the other.

Describe your findings: color, side to side differences, lesion/erythema location (use the face of the clock), exudate (in front of or behind TM), devices, cerumen disrupting view, scars (appear as bright white lesions), fluid behind TM (appear as bubbles behind TM).

Otoscopic assessment

Client tips head away from examiner. With infants and young children, have caregiver secure head (against caregiver shoulder, for example).

Use correctly sized speculum. Insert otoscope into auditory meatus.

Pull pinna of ear up and back for adults, down for children. Canal is a flexible invagination into bony structures of skull, use pinna and speculum to “drive” canal until TM can be visualized clearly.

Speculum will clear normal amounts of ceremun away for sufficient visualization of TM.

Otitis Media Inflammatory involvement of TM and

structures behind the TM within middle and inner ear.

Most often will see systemic signs and symptoms (fever, upper respiratory).

Common in infants and children due to anatomical development of eustachian tubes.

Describe absence of cone of light, TM inflammation and erythema, exudate, rupture (usually at margin of TM where it meets the canal, but can be anywhere on TM), “bulging” of TM outward from middle ear, loss of visualization of bony landmarks, marked difference between ears.

Current guidelines require 6 AOM in 1 year to be evaluated for TM tubes.

May lead to effusions (fluid behind TMs), or other anatomical changes like scarring, lesions, changes in bone morphology.

How to irrigate

Mineral oil and H2O2 (OTC preparations are Vibrox, Cerumen-X, and Murine).

Warm H2O with bulb syringe or water pik (cold water may cause syncope, vertigo, or nausea. Hot water will damage canal and set up patient for otitis externa).

Direct toward posterior wall of canal (not TM).

Don’t irrigate with tympanic perforation.

Patient should get up and walk slowly, with RN support as irrigation may disrupt balance dramatically.

Should not be a routine procedure.

Pediatric otoscopic exam

Do this system last.

Let child play with “flashlight.”

Important to hold still, may need restraint from caregiver.

Talking while examining is very loud for the child.

Hold handle of otoscope downwards as the curve of the relatively large infant/child head will limit angle of otoscope help with handle up (against head).

Use correctly sized speculum.

Hearing ScreensWeber Test (CN VIII) Tuning fork on middle

forehead or top of head

Negative test is normal (i.e. no lateralization—positive is abnormal and is lateralization to either a “good” or “bad” side)

Bypass the external and middle ear

Hearing ScreensWeber Test Sound “lateralizes” to the affected

(bad) ear (is heard loudest in bad ear because pitch from fork bypasses ear structures and skull transmits sound directly to sensory nerves in inner ear. Lack of hearing through the meatus is what makes the ear “bad” and the skull vibration louder in “bad” ear).

impacted cerumen perforated ear drum middle ear infection foreign body otosclerosis

Hearing Screens

Weber TestSound “lateralizes” to the unaffected (good) ear. If inner ear sensory motor nerves cannot transmit sound to brain, tuning fork pitch will only be heard by the good ear.

Acoustic nerve damage (drugs, loud noises, brain insult).

Congenital

Hearing ScreensRinne test (CN VIII): Tuning fork on mastoid

process begin timing.

When patient raises hand to note that has ringing stopped (time ringing from placement on MP to a raised hand), move tines to external meatus and begin timing, patient raises hand when ringing stops again.

Normal is Air Conduction > Bone Conduction in both ears (A.U.)

Hearing Screens

Rinne Test

If BC is longer or equal, there is a conduction loss

If there is no BC or AC, there is a sensorineural loss

Hearing Screens

Voice - Whisper (CN VIII): Client occludes one ear Nurse whispers 2-3

syllables from 2 feet behind client (how are you?)

Normal=50% accuracy Normal conversational

speech is 40 decibels.

Physical exam of the nose

Patency

Client occludes one nare while breathing through nose.

Infants are obligate nose breathers. If they cannot feed, their nares are not patent.

Assess for lesions, obstruction, and discharge by patient tipping head back, pulling tip of nose towards bridge, and using a light source into the nares.

Internal structures

Turbinates

Septum

Mucous membranes

Describe lesions, color, anatomy visualized.

When would a physical exam of the nose be particularly important?

Physical exam of the sinusesFrontal:

Deeply palpate at eyebrow level

Observe for periorbital swelling, symmetry, warmth, redness, nasal or lacrimal discharge, abscess.

Children to do not develop front sinus until puberty. Palpate ethmoid sinus in between eyebrows instead.

Maxillary:

Deeply palpate medial to cheeks

Observe for mid-face swelling, symmetry, warmth, redness, nasal discharge, mouth pain, abscess (look into mouth).

Cranial Nerve I - Olfactory

Offer various scents for client to identify

Client occludes one nare while smelling scent

Use scent readily available and easy to identify (alcohol pad, toothpaste on gauze, coffee from tray).

Epistaxis

Acute Treatment

Sit up

Tilt head forward

Pinch nose 5 – 15 min.

Etiology

Dry mucous membranes.

Trauma

Lesion

Allergy

Physical Exam of the Mouth and Throat

External Structures

Inspect:

Breath: malodorous => systemic disease, poor oral hygiene

Lips: hydration, lesions, symmetry, injury, skin, color

Palpate:

Lips: lesions

Perioral area: lesions, swelling, warmth, symmetry

Physical Exam of the Mouth and Throat

Internal Structures (Oropharynx)

Inspect:

Tongue, buccal mucosa, gums, palates, tonsils, uvula, teeth

Describe color, symmetry, lesions, exudate, anatomical variations, dentation, swelling, bleeding

Use penlight or scope light. Use tongue blade or gauze pad to hold tongue. Wear gloves.

Palpate (with gloves):

Buccal mucosa and gums for lesions or tooth eruption (infants and children). Palpate palate for symmetry and cleft (infants).

Physical Exam of the Mouth and Throat

Grade Tonsils if Present

1+ normal

2+ half way btw pillars and uvula

3+ touching uvula

4+ touching each other

Note presence of exudate, stones, and describe color. Note if size is bi or uni lateral

Abnormal Findings

LeukoplakiaResponse to long term irritation and inflammation of muscosal membranes.Overwhelming majority are benign.Document location, size, and patient history of lesion.Also found in female genital muscosal tissue due to long term irritation.

Abnormal Findings

Candidiasis/Oral Thrush

Opportunistic fungal infection secondary to changes in normal flora. Normal flora is protective and can be disrupted by infection (bacterial or viral), diet, stress, medication, lifestyle, or environment/habits.

Painful, thick, white plague over tongue and mucosal surfaces that cannot be scraped off (leukoplakia is painless).

Presents in “satellite pattern” with small plaques radiating from larger central plaques.

Abnormal Findings

Xerostomia

Cracked, dry, reddened tongue indicative of severe dehydration. May also be caused by medication.

Other signs of dehydration will be present including chapped lips and tacky buccal mucosa.

Elderly and pediatric population vulnerable.

Abnormal Findings

Smooth Tongue

Vitamin and mineral deficiencies including B vitamins and iron (anemia)

Smooth burning tongue

History should corroborate finding (alcoholism, Celiac’s, poor nutrition, cystic fibrosis).

Abnormal FindingsChancre

syphilitic lesion (painless). It is typically found periorally or on lips. It is often ulcerated and can be large, but it is painless and remits on its own.

Canker Sore

inside the mouth on the mucosa. It will be painful, ulcerated, sensitive to heat, cold, and acid. The patient may have other GI complaints. Canker sores often recur.

Fever blister or cold sore

Caused by the Herpes Simplex Virus. It is typically found periorally or on the lips. It is a painful and gradually ulcerated lesion that begins invisibly as the sensation of tingling. The first instance of HSV infection may include fever, facial swelling, flu-like symptoms. HSV is chronic and lesions recur, though the use of ant-viral medications may reduce occurrence or prevent it, especially if used after first occurrence.

Abnormal Findings

Bruxsim

Chronic teeth grinding wears down surfaces of the teeth, making them vulnerable to decay and breakage. Can be caused by pathophysiologic states (like mandibular joint diseases), medications, lifestyle, stress, or patients may grind their teeth while sleeping and be unaware. Dentists can fit patients with appliances to prevent tooth wear.

Abnormal Findings

Hyperplasia

Overgrowth of gum tissue that may need surgical intervention

Dilantin

Pregnancy

Puberty

Leukemia

Abnormal Findings

Gingivitis

A bacterially mediated process that initiates an inflammatory process of the gingiva, causing loss of the gingiva tissues.

Documented and rated according to level of recession of gums away from insertion areas of teeth.

Interventions include mechanical removal of bacterial plaques (flossing, scraping), antimicrobials, and regular dental hygiene.

Physical Exam of the Cranial Nerves

Cranial Nerve XII

stick out tongue

side-to-side

strength

“la-la-la”

deviation to one side or weakness is abnormal

Palates and tonsils, CNs IX and X

Inspect palates for shape, color and lesions

Elevation of uvula when tongue blade is on middle third of tongue and patient says “ah” is normal.

Gag patient with blade on posterior 1/3 of tongue (very small percentage of population do not have gag reflex). Patient can swallow water instead of gagging.