Upon assessment of the head, the nurse inspects and palpates simultaneously and also auscultate. The nurse will examine the skull, face, eyes, ears, nose, sinuses, mouth and pharynx.
There is a large range of normal shapes of skulls. The term normocephalic refers to a normal head size. Names of areas of the head are derived from names of the underlying bones: frontal, partietal, occipital, mastoid process, mandible, maxilla and zygomatic.
A. SKULL and FACE
- Recent trauma/neurological symptoms such as headache, dizziness, seizures, blurred vision or loss of consciousness.
- Patient’s occupation.
Inspection and palpation: (Skull)
- Inspect head, noting position, size, shape and contour.
- Head normally upright and in the mid-line of the trunk.
- Skull is generally round with prominence in the frontal area anteriorly and occipital area posteriorly.
- Palpate the skull for masses and tenderness.
- Inspect the facial features (e.g. symmetry of structures and of the distribution of hair).
- Inspect the eyes for edema and hollowness.
- Note symmetry of facial movements. Ask the client to elevate the eyebrows, frown or lower the eyebrows, close the eyes tightly, puff the cheeks and smile and show the teeth.
- Facial features should be symmetric or with slightly asymmetric facial features. Palpebral features equal in size. Symmetric nasolabial folds.
- Symmetric facial movements.
Vision is considered the most important sense because it allows people to interact freely with their environment and enjoy the beauty around them. To maintain optimum vision, people need to have their eyes examined regularly throughout life. It it recommended for people under 40 to have their eyes tested every 3 to 5 years or more frequently if there is a family history of diabetes, hypertension, blood dysrasia or eye disease (e.g. glaucoma). After age 40, an eye exam is recommended every 2 years to rule out the possibility of glaucoma.
It is a need to to add the eye assessment in every patient’s initial physical exam while periodic reassessments need to be made for clients in long-term care. Examination of the eyes includes assessment of visual acuity (the degree of detail the eye can discern in an image), ocular movement, visual fields (the area an individual can see when looking straight ahead), and external structures. Most eye assessment procedures involve inspection yet consideration is given to developmental changes and to individual hygienic practices if the patient wears contact lens or an artificial eye.
- Ask of eye diseases, eye trauma, diabetes or hypertension.
- Assess for common symptoms of eye disease.
- Review occupational history, use of eye glasses/contact lens and regular visits to an ophthalmologist/optometrist.
- Earliest way to assess – ask the patient to read printed materials over adequate lighting.
- Most accurate is the use of the Snellen chart.
- 20/20 normal vision, the larger the denominator, the poorer the vision.
- If patient can’t read, use the E-chart.
To assess visual fields, the nurse has the patient sit/stand 2-feet away facing the nurse at eye level. The patient gently closes/covers one eye (e.g. the left eye) and looks at the nurse’s eye directly opposite (e.g. patient’s left eye, nurse’s right eye).
EXTRA OCULAR MOVEMENTS
- Pertains to the 6 muscles that guides the movements of each eye.
- The patient sits/stands 2-feet away facing the nurse. The nurse holds a finger at a comfortable distance (6-12-in.) in front of the patient’s eyes. The patient keeps the head in a fixed position facing the nurse and follows the movement of the finger with eyes only.
- Pupils/eyes move in conjugate fashion with good papillary convergence.
EXTERNAL EYE STRUCTURES
Nurse stands in front of the patient at the eye level and asks the patient to look at the nurse’s face.
a. Position and Alignment
– Assess the position of the eyes inr elation to the other. They are normally parallel to each other.
– Abnormal conditions:
- Exopthalmus – bulging of the eyes which indicates hyperthyroidism.
- Strabismus – crossing of the eyes.
– Inspect for size, extension and hair texture.
– Ask the patient to raise and lower eyebrows. They should appear symmetrical.
– Inability to move eyebrows may indicate facial paralysis.
– Inspect for position, color, conduction and surface, condition and direction of lashes and the ability to close and blink.
– To inspect the surface of the upper lids, ask the client to close their eyes and then raise the eyebrows gently with thumb and index finger.
– Redness indicates inflammation or infection.
Ptosis – abnormal dropping of the eyelids over the pupils. Impairment of cranial nerve #3.
d. Lacrimal Appartaus
– Assess ability to close eyes.
– Tears are secreted from the lacrimal duct, it moistens the cornea and conjuctiva.
– The gland can be a site of tumor or infection.
– Look for evidence of excess tearing/edema in the inner canthus.
e. Conjuctiva and Sclera
- Cerebral conjuctiva – membranes covering the inside of the upper and lower eyelids.
- Bulbar conjuctiva – membranes covering the sclera.
- Sclera – assess for color, usually white, porcelain/light yellow in color.
– The transparent, colorless portion of the eye, covering the pupil and the iris.
– Assess for clarity and texture.
– Doesn’t contain blood vessels.
g. Pupils and Irises
– Inspect for the color of the iris.
– Inspect the pupils for shape, symmetry, size and reaction to light and accommodation (ability of the lens to adjust to objects at varying distances).
– Test for accommodation.
– PERRLA (Pupils Equally Round Reactive to Light and Accommodation)
– Test for papillary reaction, ideally in a dark room.
- Review of risk for hearing trauma.
- History of ear surgery/trauma.
- Determine if the patient has ear pain, itching, discharges, tinnitus vertigo (itching of the ears).
- Presence of hearing aide.
- Test each for gross hearing acuity using whispering words/watch. Cover the ear not being tested.
- Weber Test – test for lateralization of vibration by placing a tuning fork at the center of the scalp near the forehead.
- Rinne’s Test – test to compare air and bone conduction.
- Place vibrating tuning fork in the mastoid process behind the ear and patient tells you when the vibration stops.
- Then quickly hold the buzzing end of the tuning fork near the ear canal and ask if the patient can hear it.
- Air conduction is no longer than bone conduction.
- Assess exposure to dust, pollutants, allergies and trauma.
- History of nose bleeding (epistaxis).
- Test for patency of both nares.
- Test for acuity of sense of smell.
- Determine presence of dentures.
- Assess recent change in appetite/weight and dental hygiene practices.
- Assess for history of pain/lesions.
- History of tonsillectomy.
- Elicit gag reflex, assesses cranial nerve #10 glossopharyngeal.
- test the acuity of sense of taste.
- Test the strength of muscle for mastication.