Mosby items and derived items © 2005, 2001 by Mosby, Inc. HEAD ASSESSMENT.

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

HEAD ASSESSMENTHEAD ASSESSMENT


HEADHEAD

The skull is composed of The skull is composed of sevenseven bones that, in adulthood are fused bones that, in adulthood are fused (compound ) along structure lines. These bones include:-(compound ) along structure lines. These bones include:-

• Two frontalTwo frontal• Two parietalTwo parietal• Two temporalTwo temporal• One occipital One occipital

The movable (nonfused) lower jaw bone, or mandible and the fused bones The movable (nonfused) lower jaw bone, or mandible and the fused bones of face include:-of face include:-

• FrontalFrontal• NasalNasal• ZygomaticZygomatic• LacrimalLacrimal• SphenoidSphenoid• maxillamaxilla


FACEFACE

Eyes, noise, and mouth are generally Eyes, noise, and mouth are generally symmetric as are the ears. symmetric as are the ears.

Sensation is mediated by the trigeminal Sensation is mediated by the trigeminal nerve, cranial nerve which has three nerve, cranial nerve which has three sensory branches (1) ophthalmic (2) sensory branches (1) ophthalmic (2) maxillary and (3) mandibular. The maxillary and (3) mandibular. The muscle of facial expression enervated muscle of facial expression enervated the facial nervethe facial nerve

The major artery accessible on the face is The major artery accessible on the face is the temporal artery the temporal artery


I.I. Olfactory nerveOlfactory nerve

II.II. Optic nerveOptic nerve

III.III. Oculomotor nerveOculomotor nerve

IV.IV. Trochlear nerveTrochlear nerve

V.V. Trigeminal nerveTrigeminal nerve

VI.VI. Abducens nerveAbducens nerve

VII.VII. Facial nerveFacial nerve

VIII.VIII. Vestibulocochlear nerveVestibulocochlear nerve

IX.IX. Glossopharyngeal nerveGlossopharyngeal nerve

X.X. Vagus nerveVagus nerve

XI.XI. Accessory nerveAccessory nerve

XII.XII. Hypoglossal nerveHypoglossal nerve

The Cranial NervesThe Cranial Nerves


NECKNECK

• Muscles (sternoclodeiomastoid and trapezes) Muscles (sternoclodeiomastoid and trapezes)

• Thyroid glandThyroid gland

• Carotid artery and jugular veinCarotid artery and jugular vein

• TracheaTrachea

• cervical lymph nodscervical lymph nods

• Cervical vertebra Cervical vertebra

• Carotid arteries and jugular vein. Carotid arteries and jugular vein.


Thyroid GlandThyroid Gland

• Thyroid gland is butterfly shaped, with two lateral Thyroid gland is butterfly shaped, with two lateral lobes lying on either said of trachea.lobes lying on either said of trachea.

• It is the largest endocrine gland in the body and only It is the largest endocrine gland in the body and only one accessible to direct physical examination.one accessible to direct physical examination.

• Adult normal weight of thyroid gland is 15-20 gram Adult normal weight of thyroid gland is 15-20 gram male 20-25 gram femalemale 20-25 gram female

• The lobes are irregular and cone shaped each about The lobes are irregular and cone shaped each about 5cm long 3cm in diameter and 2cm thick 5cm long 3cm in diameter and 2cm thick


Thyroid GlandThyroid Gland

Inspection, palpation, percussion, and Inspection, palpation, percussion, and auscultation of the:auscultation of the:

• Posterior thoraxPosterior thorax

• Lateral thoraxLateral thorax

• Anterior thoraxAnterior thorax


Lymphatic SystemLymphatic System


Superficial Lymph Nodes by RegionSuperficial Lymph Nodes by Region

• Head Head • NeckNeck• Upper extremityUpper extremity• AxillaAxilla• BreastBreast• Lower extremityLower extremity


Upper extremityUpper extremity

The epitrochlear node is palpated above and The epitrochlear node is palpated above and post to the medical condoyle of the humorous.post to the medical condoyle of the humorous.

AxillaAxilla

Palpation of lymph nodes here done by gently Palpation of lymph nodes here done by gently rolling the soft tissue against the chest wall rolling the soft tissue against the chest wall and muscles. and muscles.

Lower extremityLower extremity

Palpation of inguinal and popliteal nodes while Palpation of inguinal and popliteal nodes while client is lying down with knee slightly flexed. client is lying down with knee slightly flexed.

Breast will be discussed later. Breast will be discussed later.


Assessment of the EyeAssessment of the Eye


GlobeGlobe

• ScleraSclera

Visible white layer of the eyeVisible white layer of the eye

• PupilPupil

Dark, central apertureDark, central aperture

Separates anterior from posterior chamberSeparates anterior from posterior chamber

• IrisIris

Pigmented contractile tissue controlling pupil sizePigmented contractile tissue controlling pupil size

• ConjunctivaConjunctiva

Mucous membrane lining globe, eyelids and socketMucous membrane lining globe, eyelids and socket

• CorneaCornea

Transparent anterior covering of eyeTransparent anterior covering of eye

Focuses light as it enters eyeFocuses light as it enters eye

• LensLens

Focuses light onto retina at back of eyeFocuses light onto retina at back of eye

Suspended by ligaments from ciliary bodySuspended by ligaments from ciliary body

• RetinaRetina

Rods/cones are photoreceptorsRods/cones are photoreceptors

Optic nerve transmits impulses to brainOptic nerve transmits impulses to brain


Equipment neededEquipment needed

Eye chart Eye chart (Snellen chart) (Snellen chart)

Near vision chart Near vision chart or newsprint.or newsprint.

Cover card.Cover card.

Penlight, Penlight, ophthalmoscope ophthalmoscope & ruler.& ruler.


Subjective Subjective DataData

Client should be seated comfortably in a Client should be seated comfortably in a well Lighted room that can be darkened well Lighted room that can be darkened for ophthalmic exam. for ophthalmic exam.

• History of prior eye surgery, trauma, History of prior eye surgery, trauma, use of corrective glasses or contact use of corrective glasses or contact lenses, blurred vision, Diplopia, lenses, blurred vision, Diplopia, strabismus.strabismus.

• Recent changes in vision. Date of Recent changes in vision. Date of previous vision test.previous vision test.

• Allergies, eye redness, frequent Allergies, eye redness, frequent watering discharge.watering discharge.


General Eye EvaluationGeneral Eye Evaluation

• HistoryHistory• InspectionInspection

– Periorbital regionPeriorbital region– EyebrowsEyebrows– EyelidsEyelids– Globe orientationGlobe orientation

• Orbital concernsOrbital concerns• PalpationPalpation

– Supraorbital ridgesSupraorbital ridges– Nasal, frontal, zygomatic bone/archNasal, frontal, zygomatic bone/arch


Eye PathologiesEye Pathologies• Orbital HematomaOrbital Hematoma• Orbital fractures (Blowout fracture)Orbital fractures (Blowout fracture)• Ruptured GlobeRuptured Globe• Corneal AbrasionCorneal Abrasion• Corneal LacerationCorneal Laceration• HyphemaHyphema• IriticIritic• Detached RetinaDetached Retina• ConjunctivitisConjunctivitis• HordeolumHordeolum• Periorbital LacerationsPeriorbital Lacerations• Foreign BodiesForeign Bodies• Contact Lens RemovalContact Lens Removal


Assessment of the EarAssessment of the Ear


Hearing CenterHearing Center


Deeper structure and middle Deeper structure and middle ear can be observed only by ear can be observed only by Otoscope.Otoscope.

Assessment of hearing acuity done Assessment of hearing acuity done simply by identification of voice tones, simply by identification of voice tones, with the client repeating testing words with the client repeating testing words spoken by the nurse. spoken by the nurse.


Subjective DataSubjective Data Ask about the followingAsk about the following

• History of prior ear surgery.History of prior ear surgery.• Trauma.Trauma.• Frequent infection. Frequent infection. • Ear pain.Ear pain.• Drainage. Drainage. • Hearing loss. Hearing loss. • Tinnitus. Tinnitus. • Vertigo. Vertigo. • Ototoxic medications. Ototoxic medications. • Last hearing examination. Last hearing examination.


Inspect and PalpateInspect and Palpate

The External Ear The External Ear

1).Size and shape :bilaterally equal size , no swelling , thickening1).Size and shape :bilaterally equal size , no swelling , thickening

2).Skin condition :intact , no lump or lesion2).Skin condition :intact , no lump or lesion

3).Tenderness : move the pinna and push the tragus3).Tenderness : move the pinna and push the tragus

4).The external auditory meatus : size / swelling / redness / 4).The external auditory meatus : size / swelling / redness /

dischargedischarge


USING AN OTOSCOPEUSING AN OTOSCOPE

• Adult : pull upwardAdult : pull upward

• Child: pull downward.Child: pull downward.

• Hearing loss is usually documented Hearing loss is usually documented under neuro as it generally results under neuro as it generally results from nerve damage.from nerve damage.

• Tuning fork: evaluates bone Tuning fork: evaluates bone conduction sound.conduction sound.


Hearing AcuityHearing Acuity

Voice TestVoice Test

. test one ear at a time. test one ear at a time

. 30 ~ 60 cm ; whisper slowly. 30 ~ 60 cm ; whisper slowly

• unable to hear whisper unable to hear whisper high tone loss high tone loss


Tuning Fork TestTuning Fork Test

Weber testWeber test : :

.place a vibrating tuning fork in the midline skull.place a vibrating tuning fork in the midline skull

.the same sound in both ears.the same sound in both ears

Rinne testRinne test : :

.compares air conduction ( AC ) and bone conduction( BC ).compares air conduction ( AC ) and bone conduction( BC )

.mastoid .mastoid near ear canal near ear canal

.AC : BC 2 : 1 or, AC > BC.AC : BC 2 : 1 or, AC > BC


Hearing lossHearing loss

Conductive loss Conductive loss

Sensorineural lossSensorineural loss

Webber test Webber test

Rinne testRinne test


Assessment of the NoseAssessment of the Nose


Functions of NoseFunctions of Nose

• Identify odors (upper 1/3 of septum) CN IIdentify odors (upper 1/3 of septum) CN I

• Air passageway (obligate in newborns)Air passageway (obligate in newborns)

• ““Air conditioning”Air conditioning”

– HumidifyHumidify

– Warms/cools airWarms/cools air

– Cleans and filters air of dust and most Cleans and filters air of dust and most bacteriabacteria

– Voice resonanceVoice resonance


N.BN.B

For client with NGT nurse For client with NGT nurse routinely checks for local routinely checks for local breakdown of skin breakdown of skin “Excoriation” of the naris “Excoriation” of the naris characterized by redness and characterized by redness and sloughing of the skin. sloughing of the skin.


Assessment of the sinusesAssessment of the sinuses


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

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

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

Assessment of the Sinuses Assessment of the Sinuses


Assessment of MouthAssessment of Mouth


Assessment of the MouthAssessment of the Mouth

Inspection (use good light source)Inspection (use good light source)

• Lips (color, moisture, cracking, lesions) – smile Lips (color, moisture, cracking, lesions) – smile for symmetry (CNVII)for symmetry (CNVII)

• Tongue (color, surface fissures, moisture) – stick Tongue (color, surface fissures, moisture) – stick out for deviation (CN VII)out for deviation (CN VII)

• Gums, buccal mucosa (check for pink color, Gums, buccal mucosa (check for pink color, bleeding, swelling)bleeding, swelling)

• Teeth (#, molars, color, cavities, dental repair) 32 Teeth (#, molars, color, cavities, dental repair) 32 adult – 20 children (3rd molars may be missing – adult – 20 children (3rd molars may be missing – wisdom teeth)wisdom teeth)


Mouth AssessmentMouth Assessment

InspectionInspection

• Hard palate & soft palateHard palate & soft palate

• Floor of mouth (Wharton’s duct/Submandibular Floor of mouth (Wharton’s duct/Submandibular gland, Sublingual gland)gland, Sublingual gland)

• Parotid gland (in cheek in front of ear) and Parotid gland (in cheek in front of ear) and Stensen’s duct (opposite 2nd molar)Stensen’s duct (opposite 2nd molar)

• Tongue (Lingual frenulum, lingual veins)Tongue (Lingual frenulum, lingual veins)


Mouth AssessmentMouth Assessment

PalpatePalpate

• Roof of mouth in infantsRoof of mouth in infants

• Lips, cheek, tongue, floor of mouthLips, cheek, tongue, floor of mouth

• Use gauze to hold tongueUse gauze to hold tongue

• Find Stensen’s duct (parotid salivary gland) opposite Find Stensen’s duct (parotid salivary gland) opposite upper second molarupper second molar

• Check temporomandibular joint (TMJ) – depression in Check temporomandibular joint (TMJ) – depression in front of tragus felt with fingers (slight pop can be front of tragus felt with fingers (slight pop can be normal; crepitus and masses are abnormal)normal; crepitus and masses are abnormal)



Normal findingsNormal findings

• Pink, moist lipsPink, moist lips

• Tongue midline, adequate movementTongue midline, adequate movement

• No lesionsNo lesions

• Tongue, gums, buccal mucosa are pink, moist, Tongue, gums, buccal mucosa are pink, moist, smoothsmooth

• No bleedingNo bleeding

• Smooth, white teeth, no dental cariesSmooth, white teeth, no dental caries



Abnormal findingsAbnormal findings

• Lesions, growthsLesions, growths

• Dry, cracked lipsDry, cracked lips

• Vesicles or blistersVesicles or blisters

• Red, tender, inflamed tongue, gums, buccal Red, tender, inflamed tongue, gums, buccal mucosamucosa

• ThrushThrush

• Coating on tongueCoating on tongue

• Bleeding gumsBleeding gums


THANK YOU FOR LISTENINGTHANK YOU FOR LISTENING

Mosby items and derived items © 2005, 2001 by Mosby, Inc. HEAD ASSESSMENT.

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Transcript of Mosby items and derived items © 2005, 2001 by Mosby, Inc. HEAD ASSESSMENT.