Review Guide for Exam 2
50 multiple choice questions with both single choice answers and select all that apply answers. The latter
questions are labeled with: “Select all that apply”. Partial credit will be given for those parts of the
multiple answers that are correct. However, credit will be taken away for those answers that are incorrect,
so your final score for the question will be the answers you got correct minus the answers you got
incorrect. The level of learning for each question reflects either memory, understanding or application of
knowledge.
You will have 1 hour to complete the exam. The focus of the questions for each assigned chapter in
Wilson and Giddens Health Assessment for Nursing Practice (7th edition) is listed below. The number of
statements in the review below does not reflect the number of questions on the topics or the number of
questions on the exam.
Study to understand so that when situations are presented to you about the topic, you can figure out the
correct answer.
Chapter 9: Skin, Hair, & Nails
General Physical Signs

Bruises

Burns

Lacerations

Scars

Bony deformities

Alopecia (hair loss)

Retinal hemorrhages

Dental trauma

Head and abdominal injuries
Skin and Hair Abnormalities

These may be the most visible clues in detecting abuse or neglect.
Physical Signs of Abuse in Older Adults

Bruising

Burns

Abrasions

Areas of tenderness, particularly in hidden areas:
o
Axillae (armpits)
o
Inner thighs
o
Soles of feet
o
Palms
o
Abdomen
Physical Signs of Abuse in Infants and Children

Bruises, burns, lacerations, scars

Bony deformities

Alopecia

Retinal hemorrhages

Dental trauma

Head and abdominal injuries
Injury Patterns

When abuse is suspected, compare the injuries to the history and consider the development
level of the child.
Injuries to the Skin
1. Bruises (Ecchymosis)
o
Caused by blood seeping into tissues due to trauma.
o
Indicates superficial or deep injury (including muscle or abdominal organs).
o
Patterns: Bruises from abuse may show distinctive shapes, like loop patterns from being
hit with a cord.
2. Bites
o
Always intentional and common in abuse.
o
May or may not break the skin, often with bruising or a suck mark in the middle.
o
Size of bite mark can help determine the age of the perpetrator (child or adult).
o
Common locations in infants and children: Genitals and buttocks.
3. Burns
o
Immersion Burns: Recognizable by "glove" or "stocking" patterns (caused by scalding
water).

o
Locations: Hands, arms, feet, legs, buttocks.
Contact Burns: Caused by hot objects (e.g., cigarette, light bulb, lighter, or hot iron).

Intentional burns leave distinct "branded patterns."

Accidental burns typically leave nonuniform, glancing burn patterns.
Impetigo
Common, CONTAGIOUS superficial skin infection
Erythematosus, vascular rash, with yellow exudate
·
·
·
Impetigo mainly affects infants and children.
The main symptom is red sores that form around the nose and mouth. The sores rupture,
ooze for a few days, then form a yellow-brown crust.
Antibiotics shorten the infection and can help prevent spread to others.
Exanthem

A widespread rash on the skin that several things can cause
· A diffuse rash can have causes that aren't due to underlying disease.
· Examples include heat rash, insect bites, sunburn, or medication side effects.
Trichotillomania
AKA: Hair pulling- Loss of scalp hair that can be caused by physical manipulation
Keratoses
Skin growth that results from keratinocytes, thickening of the skin
General Overview of Skin Growths from Keratinocytes

Keratinocytes: The main cells in the epidermis responsible for producing keratin.

Results of Overproduction: Thickening of the skin, scaling, and the formation of growths such
as actinic keratosis (precancerous) and seborrheic keratosis (benign).
1. Hyperkeratosis- Aka a corn
o
Definition: Thickening of the outer layer of the skin due to overproduction of keratin.
o
Cause: Often in response to friction or pressure.
o
Manifestations: Localized scaling, roughness, calluses, or corns.
2. Squamous Cell Carcinoma (Confined to the Epidermis)
o
Definition: Skin cancer that originates from keratinocytes in the epidermis.
o
Example: Solar keratosis (Actinic keratosis).
3. Actinic Keratosis (Solar Keratosis)
o
Definition: A precancerous skin condition.
o
Appearance: Rough, scaly patch or bump.
o
Cause: Long-term sun exposure leading to skin damage.
o
Progression: May develop into squamous cell carcinoma.
4. Seborrheic Keratosis
o
Definition: A non-cancerous skin growth.
o
Appearance: Raised, waxy, or scaly lesion that is pigmented.
o
Common Locations: Face and trunk.
o
Characteristic: Warty and typically benign.
Petechiae
Description

Appearance: Tiny, flat, reddish-purple, non-blanchable spots less than 0.5 cm in diameter.

Size: Pinpoint to pinhead, approximately 1-3 mm.

Type: A form of macules (flat lesions).

Color:
o
Light skin: Lesions appear as small, reddish-purple pinpoints.
o
Dark skin: Difficult to detect, may be more visible in the buccal mucosa (inside the
mouth) or sclera (white part) of the eye.
Common Locations

Dependent surfaces of the body: Back and buttocks.

May also appear in the oral mucosa (inside the mouth) and conjunctiva (eye).
Causes

Minute hemorrhages due to fragile capillaries.

Underlying conditions:
o
Intravascular defects (blood vessel problems).
o
Infections.
o
Septicemia (blood infections).
o
Liver disease.
o
Deficiency in Vitamin C or K.
o
Anticoagulant therapy (blood thinners).
Symptoms of Other Conditions

Can be a symptom of stasis dermatitis.
Diagnostic Considerations

Difficult to detect in dark skin; look in the buccal mucosa or sclera.

Does not blanch when pressed (i.e., does not lose color).
Examples

Dermal petechiae: Small hemorrhages within the dermis or submucosa caused by capillary
fragility or underlying conditions.
Ecchymoses (AKA Bruise)
Description

Appearance: Flat, irregularly shaped reddish-purple lesion.

Size: Variable, does not have a specific size range.

Blanching: Non-blanchable (does not lose color when pressed).

Skin Tone Variations:
o
Light skin: Starts as a bluish-purple mark that changes to greenish-yellow as it heals.
o
Brown skin: Varies from blue to deep purple.
o
Black skin: Appears as a darkened area.
Causes

Release of blood from superficial vessels into the surrounding tissue.

Underlying causes:
o
Trauma or injury to blood vessels.
o
Hemophilia (a blood clotting disorder).
o
Liver disease.
o
Deficiency in Vitamin C or Vitamin K.
Localization/Distribution

Can occur anywhere on the body, typically at the site of trauma or pressure.
Example

Ecchymosis (commonly referred to as a bruise): A result of blood leakage from damaged vessels
into surrounding tissues.
Telangiectasias
Description

Definition: Permanent dilation of preexisting small blood vessels (capillaries, arterioles, or
venules) leading to superficial, fine, irregular red lines on the skin.

Appearance: Fine, irregular, red lines or webs on the surface of the skin.
Causes

Rosacea: A chronic skin condition that causes redness and visible blood vessels.

Collagen vascular disease: Conditions affecting the connective tissues, such as scleroderma.

Actinic damage: Skin damage caused by long-term sun exposure.

Increased estrogen levels: Often seen in pregnancy, hormonal therapies, or contraceptive use.
Examples

Essential telangiectasia: Occurs without an underlying systemic disease.

Hereditary hemorrhagic telangiectasia: A genetic disorder that causes abnormal blood vessel
formation.
Spider Veins
Description
 Appearance: Small central red area with radiating spider-like legs.
 Blanching: The lesion blanches with pressure.
 Color: May appear red, blue, or purple.
 Location: Most commonly found under the superficial layer of the skin.
Causes
 Can occur without underlying disease.
 May also be associated with:
o Pregnancy.- Spider veins already present will increase in size due to increased
blood flow to the hands and feet
o Liver disease.
o Vitamin B deficiency.
o Peripheral vasodilation and increased capillary formation.
o
Increased blood flow to areas such as the hands and feet.
Characteristics
 Type: A type of telangiectasia.
 Permanent dilation of preexisting small blood vessels (capillaries, arterioles, or
venules).
 Spider angioma is an example of spider veins.
Symptoms
 Typically harmless: No serious symptoms.
 However, there can be burning, itching, or discomfort in the legs.
Vascular Spiders
 Blood vessels spread out from a central point, giving a spider-like appearance.
 They may increase in size due to increased blood flow or vasodilation.
This summary organizes the characteristics, causes, and symptoms of spider angioma, a specific
type of telangiectasia, commonly seen in pregnancy and liver disease, and generally harmless.
Assessment of skin temperature
Using the dorsal surface of your hands
Normal Findings

Method: The skin temperature is best evaluated using the dorsal aspect of your hands.

Normal temperature: The skin should generally feel warm and consistent across the body.

Exceptions: The hands and feet may feel cooler, especially in a cool environment.
Abnormal Findings
1. Cool Skin
o
Generalized cool/cold skin:

o
Associated with shock or hypothermia.
Localized cool skin:

May indicate poor peripheral perfusion (poor blood flow to the extremities).
2. Hot Skin
o
Generalized hot skin:

o
May reflect hyperthermia, associated with fever, an increased metabolic rate
(hyperthyroidism), or exercise.
Localized hot skin:

May indicate inflammation, infection, traumatic injury, or thermal injury
(e.g., sunburn).
3. Asymmetrical Temperature (One Leg Hot, the Other Cold)
o
May be a sign of deep vein thrombosis (DVT) or cellulitis.
This organized structure details normal skin temperature assessment, using the dorsal aspect of the hand,
and highlights abnormal findings such as cool, hot, and asymmetrical temperatures, as well as potential
underlying causes.
Impact of age on skin, hair, nails and reason for changes
Infants


Skin:
o
Gentle pink color; darker-skinned babies may develop melanocytes after 2-3 months.
o
Common to see jaundice (yellow skin tint) and acrocyanosis (bluish discoloration of
hands and feet).
o
Vernix caseosa: A white, cheese-like substance covering the newborn’s skin.
o
Puffiness: Skin may appear puffy for 2-3 days after birth.
o
Flexion creases: Hands and feet should have discernible creases, related to gestational
age.
o
Milia: Normal tiny white papules on the face within the first 2-3 months.
o
Lack of subcutaneous fat and terminal hair; covered with lanugo (fine, downy hair).
o
Skin conditions: Cutis marmorata (mottling when exposed to cold), Erythema toxicum
(pink rash with vesicles), Mongolian spots (deep blue pigmentation), and salmon
patches (flat pink patches).
o
After birth: Skin may appear red initially but turns pink within a few hours.
Hair:
o
Covered with fine, downy lanugo over back and shoulders.
o
Infants do not have terminal hair.
Older Adults

Skin:
o
Becomes more transparent, paler, and develops pigment deposits like freckles,
hypopigmented patches, and solar lentigines (age spots).
o
Drier, flaky, and scaling skin due to decreased sebaceous and sweat gland activity.
o
Decreased subcutaneous tissue and muscle tone lead to looser skin, sagging under the
chin, eyes, earlobes, breasts, and scrotum.
o
Increased wrinkling, especially on sun-exposed or expressive areas.
o
May exhibit a variety of benign lesions:
o



Cherry angiomas: Tiny red papules.

Seborrheic keratoses: Pigmented, raised lesions.

Sebaceous hyperplasias: Flattened yellowish papules.

Cutaneous tags: Soft, small skin tags on chest or neck.

Cutaneous horns: Small, hard projections on the face.
Bruising and decreased turgor (elasticity) due to loss of collagen and elastic fibers.
Hair:
o
Gray hair: Due to a decrease in the number of functioning melanocytes.
o
Hair loss: Decreased hair production in axillary and pubic regions, often leading to ageassociated baldness (terminal hair transitions into vellus hair).
o
Opposite hair transition: In nares and ear tragus, vellus hair transitions to terminal
hair.
Nails:
o
Nails become thicker, brittle, and grow slower due to decreased peripheral
circulation.
o
Longitudinal ridges are expected and associated with aging.
Adolescents


Skin:
o
Increased oiliness due to higher sebum production, especially during puberty.
o
Prone to acne and increased perspiration from apocrine gland activity.
Hair:
o
Development of coarse terminal hair in axillary, pubic areas, and facial hair in males.
Additional Skin Conditions in Infants:

Erythema toxicum: Pink papular rash with vesicles.

Mongolian spots: Irregular blue pigmentation on sacral and gluteal areas.

Salmon patches: Flat, pink patches on the forehead, eyelids, upper lip, neck, and back.
Additional Hair and Nail Changes in Older Adults:

Axillary and pubic hair: Decline in hair growth due to reduced hormones.

Nail changes: Become thicker, brittle, and yellowish; growth slows with age.
This structure groups the information by age and organizes the skin, hair, and nail characteristics of
infants, older adults, and adolescents. It also highlights specific conditions and changes common to each
stage of life.
Test for and meaning of skin turgor
Altered if patient is dehydrated or edema is present (Done during palpation)
Pinch skin test: Skin is pinched springs back to previous state designates normal elastic skin turgor

Notes moisture
o
Normal Elastic Skin Turgor: Pinch skin, skin springs back to previous state
o
Poor/Abnormal Skin Turgor: stays pinches or tinted (dehydration)
ABCDE characteristics of malignant melanoma





A—Asymmetry (not round or oval)
B—Border (poorly defined or irregular border)
C—Color (uneven, variegated)
D—Diameter (usually greater than 6 mm)
E—Evolving (a skin lesion that looks different from others or is changing in size, shape, or color)
Skin cancer risks
•
•
•
•
•
•
•
•
•
•
•
Personal history of skin cancer
Family history of skin cancer
Older age
Exposure to ultraviolet (UV) radiation
Lifetime sun exposure (M)
Severe, blistering sunburns, especially at early age (M)
Indoor tanning (M)
Fair skin; blond or red hair
Blue or green eyes
Moles (large numbers of common moles or a dysplastic nevus)
Recommended counselling parents from 6 months-24 years to reduce cancer risks
Skin Cancer

Basal cell carcinoma
o

Squamous cell carcinoma
o

Most common form of skin cancer- easier to cure
Second most common skin cancer
Malignant melanoma
o
Very serious skin cancer- deadly
o
Lethal form of skin cancer that develops from melanocytes

Kaposi Sarcoma
o
Neoplasm of the endothelium and epithelial layer of the skin caused by kaposi sarcoma
herpesvirus 8
o
Commonly associated with Human Immunodeficiency virus (HIV) infection- aids
Macule
Description – Flat, nonpalpable change in skin color of the skin; less than 1 cm in diameter
Examples – Freckles, flat moles (nevi), petechiae (tiny spots of bleeding under the skin), measles, scarlet
fever
Papule
Elevated/Raised, firm, circumscribed area less than 1cm in diameter
Example: Wart, elevated moles, lichen, planus
Vesicle
With fluid, elevated, circumscribed, superficial, not into dermis, filled with serous fluid, less than 1cm
thick
Example: Varicella (chickenpox), herpes zoster (shingles), impetigo, acute eczema
Pustule
With pus (Purulent fluid), elevated, superficial lesion, similar to a vesicle but filled with purulent fluid
Example: Impetigo, acne, folliculitis, herpes simplex
=
Sebaceous glands and how they work

Function:
o



Secrete sebum, a lipid-rich substance that keeps the skin and hair lubricated, preventing
them from drying out.
Secretory Activity:
o
Stimulated by sex hormones (primarily testosterone).
o
Varies according to hormonal levels throughout the lifespan.
o
Increases in adolescents due to heightened hormone levels, particularly androgens.
o
Accelerates during pregnancy to dissipate excess heat from increased metabolism.
o
Decreases in adults, leading to drier skin and reduced perspiration.
Distribution:
o
Greatest concentration on the face and scalp.
o
Present in all areas of the body except the palms and soles.
Classification:
o
Considered an appendage and an accessory structure of the skin.
This organization provides a clear structure that highlights the functions, hormonal influences,
distribution, and classification of sebaceous gland
Normal hormone-related changes of adolescence



Activation and Function:
o
Apocrine glands enlarge and become active due to hormone stimulation at puberty.
o
Increased axillary sweating may occur, leading to body odor due to bacterial
decomposition of sweat.
o
Decomposition with bacteria
Sebum Production:
o
Increased sebum production is associated with rising hormone levels, primarily
androgens.
o
This heightened sebum secretion results in:

An oily appearance.

Increased susceptibility to acne.
Hair Changes:
o
o
Coarse terminal hair develops in:

Axillary and pubic areas of both male and female adolescents.

Facial area of males.
Functions of pubic hair:

Female pubic hair: Provides protection from bacteria.

Male pubic hair: Reduces friction during intercourse.
This organization clearly presents the key aspects of apocrine glands, including their activation, function,
changes in sebaceous activity, and hair development during puberty.
Jaundice

Definition: Jaundice is characterized by a yellow color in the skin, sclera (whites of the eyes),
fingernails, palms of the hands, and oral mucosa.

Appearance:
o
Light Skin:

Yellowish tint observed in:

Skin

Sclera of the eyes
o

Fingernails

Palms of hands

Oral mucosa
Dark Skin:

Yellowish-green tint most prominently seen in:

Sclera of the eyes (important to distinguish from yellow eye
pigmentation that may occur in dark-skinned patients)

Palms of hands

Soles of feet
This organization effectively outlines the definition of jaundice, along with the variations in appearance
based on skin tone
Cyanosis
Definition:
A bluish or purple discoloration of the skin or mucous membranes that occurs when there is less oxygen
in the blood.
Characteristics:

Common Areas: Most noticeable in the lips, nose, earlobes, and fingertips.

Color Changes:
o
Light Skin:

o
Grayish-blue tone, especially in:

Nail beds

Earlobes

Lips

Mucous membranes

Palms

Soles of feet
Dark Skin:

Ashen-gray color most easily seen in:

Conjunctiva of the eye

Oral mucous membranes

Nail beds

Lips
Erythema
Definition:
Redness of the skin or mucous membranes caused by hyperemia (increased blood flow) in superficial
capillaries, resulting in increased skin temperature secondary to inflammation.
Characteristics:

Light Skin:
o

Reddish tone with evidence of increased skin temperature secondary to inflammation.
Dark Skin:
o
Deeper brown or purple skin tone with evidence of increased skin temperature secondary
to inflammation.
Pallor
Definition:
An unhealthy pale appearance, characterized by a skin color that is almost white.
Characteristics:

Light Skin:
o

Pale skin color that may appear white.
Dark Skin:
o
Skin tone appears lighter than normal.
o
Light-skinned African Americans may have yellowish-brown skin.
o
Dark-skinned African Americans may appear ashen.
o
Specifically evident is a loss of the underlying healthy red tones of the skin.
Psoriasis
Definition:
A chronic and recurrent disease of keratin synthesis that typically manifests by age 20.
Characteristics:

Appearance:
o
Thickening of the skin in dry, silvery, scaly patches due to the overproduction of skin
cells.
o
Buildup of cells occurs faster than they can be shed.
o
Lesions are well-circumscribed, slightly raised, and erythematous with silvery scales on
the surface.

Common Locations:
o
Scalp
o
Elbows
o
Knees
o
Lower back
o
Perianal area
o
Buttocks
Triggers:

Emotional stress

Generally poor health
Symptoms:

Small bleeding points may appear if lesions are scratched.

Other symptoms include:
o
Pruritus (itching)
o
Burning sensation
o
Bleeding of lesions
o
Pitting of the fingernails
Disease Severity:

Can range from mild to severe.
Herpes simplex- Chicken pox is a type of herpes
Type 1: Associated with oral infection

Causes lesions on lips and oral mucosa
Type 2: Associated with genital infection

Causes lesions on penis, vagina, buttocks or arms
Outbreaks are triggered by a number of factors, including sun exposure, stress, and fever
Oral can transmit to genital and vise versa

Stays but breaks out when stressed/reaction to external stressors

Chronic viral infection

Lesions progress from vesicles to pustules and then crusts

Although lesions are often confined to oral mucosa or genitals, lesions from both types of herpes
can appear anywhere on body
Varicella (Chickenpox)
Overview:
 Also known as chickenpox.
 Acute, highly communicable viral infection, common in children and young adults.
Etiology:
 Caused by the varicella-zoster virus, a type of herpes organism.
 The virus remains dormant in the body and can later cause shingles (herpes zoster).
Transmission:
 Spread by respiratory droplets.
 Infectious period: From a few days before lesions appear until the last lesions have crusted, usually about
Vaccination:
 Live vaccine is administered at:
o 12 months of age
o 4-5 years of age
 A vaccine is also available for older adults to prevent shingles.
Clinical Findings:
 Lesions typically first appear on the trunk (main body) and then spread to the extremities (arms and legs)
 Lesion progression:
o Initially presents as macules (flat spots).
o Progresses to papules (raised bumps).
o Evolves into vesicles (fluid-filled blisters).
o Crusts form as vesicles heal.
 Lesions erupt in clusters over several days, leading to concurrent lesions at various stages.
General Characteristics:
 Highly communicable and can infect adults who did not have the infection as children.
 Generalized rash: Lesions may be scattered all over the body.
Contact dermatitis (Eczema)
Overview:
 Most common inflammatory skin disorder.
 Develops in response to irritants or allergens (e.g., metals, plants, chemicals, detergents).
 Affects people of all ages and ethnic groups.
Types:
1. Irritant Contact Dermatitis
o Caused by direct irritation of the skin from substances such as chemicals or
detergents.
2. Allergic Contact Dermatitis
o Triggered by an allergic reaction to substances that come into contact with the
skin.
3. Atopic Dermatitis
o A chronic inflammatory skin condition often associated with allergies and asthma.
Clinical Findings:
 Localized Erythema: Redness in the area exposed to the irritant or allergen.
 Associated Symptoms:
o Edema (swelling)
o Wheals (raised bumps)
o Scales
o Vesicles (fluid-filled blisters) that may weep, ooze, and become crusted.
 Pruritus: Common symptom, characterized by itching.
 Individual Variability: The inflammatory response can range from no reaction to
extreme reactions, highly individualized.
Characteristics of Lesions:
 Lesions can appear in a linear pattern (e.g., from poison ivy exposure).
 Lesions develop in areas directly exposed to the causative irritant or allergen.
Stages of Pressure Ulcers of Skin
Stage 1: Intact skin
Intact skin with non blanchable redness, usually over a bony prominence. The area may be painful, firm,
soft, warmer, or cooler compared to adjacent tissue. May be difficult to detect in individuals with dark
skin tones.
Stage 2: Involves epidermal skin layer and maybe dermis
Partial-thickness skin loss that appears as a shallow, open ulcer with pink wound bed
Shiny or dry shallow open ulcer with pink wound bed without slough or bruising
May look like open blister
Stage 3: Extends into subcutaneous tissue; muscle, fascia, and bone may be visible but not directly
involved
Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue. Subcutaneous fat may be
visible, but bone, tendon, or muscles are not exposed. Slough may be present; wound may include
undermining and tunneling. Depth of a stage III ulcer varies by anatomic location because of variation in
presence and depth of subcutaneous tissue.
Stage 4: Ulcer involves muscle and bone
Needs clean and sterile for cleanup
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present within
the wound bed. Undermining and tunneling often present. Depth of a stage IV ulcer varies by anatomic
location because of variation in presence and depth of subcutaneous tissue.
Unstageable Ulcer:

Full-thickness tissue loss where the true depth of the wound cannot be determined until slough
and/or eschar are removed to expose the base of the wound.
Suspected Deep Tissue Injury:

Localized area of discolored intact skin or a blood-filled blister caused by underlying soft tissue
damage resulting from pressure or shear.

May appear as an area of discolored (purple or maroon) intact skin or blood-filled blister.

This type of tissue wound may be difficult to detect in individuals with dark skin tones.
Stages of Edema
--- Emai
Edema scale
Swollen areas- decreased perfusion
Normal: No edema
Abnormal: Where is it? How bad is it?
1+ = 2mm indentation with pressure applied
2+ = 4mm indentation with pressure applied
3+ = 6mm indentation with pressure applied
4+= 8 mmindentation with pressure applied
Chapter 10: Head, Eyes, Ears, Nose, & Throat (HEENT)
Assessment of maxillary sinuses
1. Inspection

External Nose:
o

Nasal Mucosa and Septum:
o

Assess for shape, size, color, and nares.
Inspect for color, alignment, discharge, turbinates, and perforation.
Sinuses:
o
Inspect the frontal and maxillary sinus areas for swelling
2. Palpation

Nose:
o
Palpate the ridge and soft tissues of the nose for:

Tenderness


Displacement of cartilage and bone

Masses
Sinuses:
o
Palpate the frontal and maxillary sinuses for:

Tenderness or pain

Swelling
o
Note: Only the maxillary and frontal sinuses are accessible for physical examination.
o
Maxillary Sinuses:

o
Press over the sinus area above the cheekbones.
Frontal Sinuses:

Press upward on the frontal sinuses with the thumbs on the supraorbital ridge,
just below the eyebrows.

Be careful not to press directly over the eyeballs.
3. Transillumination

Perform if sinus tenderness is present or infection is suspected.

Procedure:
o
Darken the room and place a light source lateral to the nose, just beneath the medial
aspect of the eye.
o
Look through the patient’s open mouth for illumination of the hard palate.
o
Transilluminate the frontal sinuses by placing the light pen against the medial aspect of
each supraorbital rim.
4. Findings


Normal Findings:
o
Nose: No tenderness or pain with palpation over the sinuses.
o
Transillumination: A dim red glow is transmitted above the eyebrows.
Abnormal Findings:
o
Nose: Tenderness on palpation may indicate sinus congestion or infection.
o
Transillumination: Absence of a glow may indicate that one or more sinuses are
congested or filled with secretions.
5. Additional Notes

The paranasal sinuses develop as follows:

o
Maxillary Sinuses: Developed by 4 years of age.
o
Frontal Sinuses: Developed by 5 to 6 years of age.
Symptoms:
o

If the patient complains of sinus pain or shows signs of sinus congestion,
transillumination of the frontal and maxillary sinuses should be performed.
Sinus headaches may cause tenderness over the frontal or maxillary sinuses.
Head & neck lymph node assessment in healthy and ill individuals
Normal in adults: Soft, mobile, non-tender, and equal bilaterally
Infection or inflammation: Palpable, mobile, firm, tender
Malignancy: Hard, fixed, nontender, unilateral
Normal in children: 3mm, discreet, mobile, nontender,
Shotty: Describes a small, firm, mobile nodes that often remain after infection is gone
Indications for Palpation:

Suspected inflammatory process or malignancy

Patient reports pain
Regional Lymph Nodes Include:

Occipital

Preauricular

Postauricular

Anterior and posterior cervical chain

Parotid

Retropharyngeal (tonsillar)

Submental

Submandibular

Supraclavicular
Palpation Procedure:
1. Technique:
o
Use pads of the second, third, and fourth fingers.
o
Use both hands to compare findings on each side of the head and neck.
o
For submental nodes, palpating with one hand is easier.
2. Order of Palpation:
o
Preauricular
o
Parotid
o
Postauricular
o
Occipital
o
Retropharyngeal
o
Submandibular
o
Submental
3. Cervical Chain Palpation:
o
o
Anterior Chain:

Have the patient tilt their head toward the side being examined.

Palpate along the sides of the sternocleidomastoid muscle.
Posterior Chain:

Palpate the deep posterior cervical nodes near the anterior border of the trapezius
muscle.
4. Supraclavicular Nodes:
o
Ask the patient to hunch their shoulders forward and flex their chin toward the side being
examined.
o
Place fingers in the medial supraclavicular fossa.
o
Instruct the patient to take a deep breath while pressing deeply behind the clavicles to feel
for nodes.
Normal Findings:

Lymph nodes may or may not be palpable.

If palpable, nodes should be:
o
Soft
o
Mobile
o
Non-tender
o
Bilaterally equal
Abnormal Findings:

Enlarged, tender, firm but movable nodes may suggest:
o

Infection of the head or throat.
Hard, asymmetric, fixed, non-tender nodes may indicate:
o
Malignancy.
Head and Neck Inspection
Head:

Position Observation: Note any abnormalities.

Skull Inspection:


o
Size
o
Shape
o
Symmetry
Facial Features:
o
Symmetry
o
Shape
o
Color
Hair Distribution:
o
Color and texture

Salivary Glands: Observe for swelling or tenderness.

Tics and Spasms: Note any involuntary movements.
Neck:

Inspection:
o
Symmetry
o
Alignment of trachea
o
Fullness
o
Presence of skin folds, webbing, and masses
Nasal assessment
External Nose:


Inspection:
o
Nose: Shape, size, color
o
Nares: Check for flaring, narrowing, or discharge
Palpation:

o
Assess for displacement of bone or cartilage
o
Check for tenderness
o
Note any masses
Evaluate Patency of Nares
Nasal Cavity:



Nasal Mucosa Inspection:
o
Color: Normally pink
o
Discharge: Normally none or clear
o
Masses or Lesions: Normally none
o
Swelling of Turbinates: Normally not present
Nasal Septum Inspection:
o
Assess position, straightness, and thickness
o
Look for perforations, bleeding, or crusting
o
Note that cocaine abuse can cause holes in the septum
Sense of Smell:
o
Tested with recognition of different odors (Olfactory nerve CN I)
Sinuses:

Inspection:
o

Palpation:
o

Frontal and maxillary sinus areas for swelling
Frontal and maxillary sinuses for tenderness
Transillumination:
o
May be performed if sinus tenderness is present or infection is suspected
(Advanced Practice Nurse activity)
Special Considerations by Age Group:
Children:

Internal Nose Inspection:
o


Shine a light while tilting the nose tip upward with your thumb
Palpation of Paranasal Sinuses:
o
Maxillary sinuses after 4 years of age
o
Frontal sinuses by 5-6 years of age
Tenderness Assessment:
o
Note any tenderness indicating potential sinus infection, especially if an upper
respiratory infection has not improved after 10 days.
Older Adults:

Look for dry mucosa.

For men, note increased hair in the vestibule.
Infants:

Inspect for symmetry and positioning.

Assess nasal patency.

Paranasal sinuses are poorly developed; examination is generally unnecessary.
In pregnancy: Capillaries in nose, pharynx, and ears engorge causing nasal stuffiness and
fullness in ears. And deceased small and impaired hearing as well as epistaxis
Summary of Key Points:

External Nose: Assess shape, size, color, patency, symmetry, and tenderness.

Nasal Cavity: Inspect mucosa, septum, and sense of smell.

Sinuses: Inspect for swelling and tenderness; consider transillumination if needed.

Age Considerations: Tailor the examination approach based on the patient's age and
development stage.
Oral cancer risks

Tobacco use (M - Modifiable risk factor)

Alcohol use (M)

Age: Incidence is increased after age 55, with peak incidence between ages 64 and 74

Gender: There is a 2:1 male-to-female incidence

Human papillomavirus (HPV) infection of the mouth

Exposure to ultraviolet (UV): increased risk for lip cancers among those with prolonged exposure
to the sun (M).

Most prominent in African Americans

Immunosuppression increases risk.
Cluster headaches
Onset is sudden and associated with alcohol consumption, stress, or emotional distress
Most painful behind the EYE
Movement
Migraine headaches
Preceded by aura

“Warning”
o See double
o Smell something
o Seeing stars
Rest
Tension headaches
Pain usually steady, not throbbing
Most common, gradual
Palpation of head and neck: what it tells you, what you are looking for normal & abnormal
Head Palpation:

Assessment Areas:
o
Head and Scalp

Symmetry

Tenderness

Movement

Sutures/fontanels

Hair texture and distribution
o
Salivary Glands
o
Temporomandibular Joint Space
o
Skull

Symmetry

Smoothness
Neck Palpation:

Assessment Areas:
o
o
Trachea

Position

Tracheal tug
Movement

Hyoid bone and cartilage during swallowing
o
Lymph Nodes
o
Thyroid Gland
o

Size

Shape/configuration

Consistency

Tenderness

Nodules

Thrills
Neck Range of Motion
Expected Findings During Palpation
Head:

Symmetrical and smooth

Bones distinguishable

Ridge of sagittal fissure may be palpable

Hair is smooth and evenly distributed

Salivary glands without enlargement or tenderness

No thrill felt over temporal arteries

Auscultation Expectation: No bruits on temporal arteries
Neck:

Trachea in midline position

Hyoid, thyroid, and cricoid cartilage should be smooth and move during swallowing

Lymph nodes not palpable

Thyroid gland symmetrical with small lobes

Gland rises freely with swallowing

Right lobe may be up to 25% larger than left

Tissue firm and pliable

No palpable thrill over carotid arteries

Auscultation Expectation: No bruits on carotid arteries
Abnormal Findings During Palpation
Head:

Indentations or depressions

Elevations

Hair splitting, cracked ends, coarse, dry, brittle, or fine/silky

Thickening, hardness, tenderness, or thrill of temporal arteries

Salivary Glands:

o
Asymmetrical
o
Tender
o
Enlarged
o
Nodules
Auscultation Finding: Bruit over the temporal artery
Neck:

Trachea deviated to the right or left

Tenderness

Tracheal tug synchronous with pulse



Lymph Nodes:
o
Enlarged
o
Matted
o
Tender
o
Fixed
o
Warm
Thyroid Gland:
o
Asymmetry
o
Enlargement
o
Visible
o
Tender
o
Coarse tissue
o
Gritty sensation
Carotid Arteries:
o
Thrill palpated over carotid arteries
o
Auscultation Finding: Bruit over carotid arteries
Screening for head and neck abnormalities in neonate
1. Craniotabes

Definition: Softening of the outer table of the skull.

Characteristics:
o
Especially seen in the occipital region.
o
May result from conditions such as rickets, syphilis, or marasmus (emaciation).
2. Encephalocele

Definition: A neural tube defect characterized by protrusions of brain membranes through
openings in the skull.
3. Microcephaly

Definition: Circumference of the head is smaller than normal due to improper brain development
or cessation of growth.

Potential Causes: May occur in utero, e.g., infection by the Zika virus.
4. Craniosynostosis

Definition: Premature closure of one or more cranial sutures before complete brain growth.

Consequences:
o
Leads to a misshapen skull.
o
Prevents normal growth of brain tissue, with the shape depending on which sutures are
fused.
Not Really Abnormal Findings
5. Caput Succedaneum

Definition: Edema over the presenting part of the head during delivery.
6. Cephalohematoma

Definition: Collection of blood under the skin, confined by suture lines.
Other Observations


Fontanels: Should be flat and soft. Abnormal findings include:
o
Bulging: May indicate dehydration or crying.
o
Depressed: Considered abnormal.
Clavicle Check: Always check for fractures during the birthing process.
Potential Complications and Causes of Abnormalities

Birth Trauma

Tumors

Cranial Nerve Palsy: Can lead to unequal neck muscles.

Infection

Drug Ingestion
Torticollis
Definition

Also known as Wry Neck.

A condition that causes the head to tilt or rotate to one side.
Characteristics

Commonly seen in infants, often at birth.

The baby may favor one side of the neck.

Lack of full neck strength and range of motion (ROM).
Causes

Birth Trauma: Injuries sustained during delivery.

Tumors: Presence of growths affecting neck muscles or nerves.

Cranial Nerve Palsy: Weakness or paralysis of neck muscles leading to unequal neck muscle
development.

Infection: Conditions that can affect the neck or surrounding areas.

Drug Ingestion: Exposure to substances that may affect muscle control.
Management

In newborns, the condition may resolve itself over time without intervention.

Observation is typically recommended until resolution occurs.
Purpose of infant’s suture lines, & fontanels, and what their assessment can reveal about infant’s health
Cranial Bones

Soft and Flexible: Cranial bones are soft and separated by sutures, allowing for movement and
growth.
Sutures and Fontanels


Function:
o
Sutures and fontanels permit skull expansion to accommodate brain growth.
o
Suture lines and fontanels remain open to allow for ongoing brain development.
Closure Timeline:
o
Sutures: Begin to ossify between ages 6 to 18 years.
o
Fontanels:
o

Posterior Fontanel: Closes by 2 months.

Anterior Fontanel: Closes by 18 months.
Significance of Early Closure:

Normal Findings

Fontanels:
If fontanels close before birth, it may indicate that brain development has
stopped, which is a concern.

o
Should be flat and soft.
o
Bulging fontanels may indicate dehydration or crying.
Sutures:
o
Should not fully ossify until 6-18 years of age.
Skull Molding

During Birth:
o
Skull may mold as the baby passes through the vaginal canal, with bones shifting and
overlapping.
o
Normal shape and size are usually resumed within days after birth.
Temporal artery palpation: normal and abnormalities

Major Accessible Artery: The temporal artery is a significant artery located on the face.
Assessment Steps
1. Comparison:
o
Compare the right and left temporal arteries.
2. Palpation:
o
Palpate for:

Thickening

Hardness

Tenderness

Thrills
3. Auscultation:
o
Auscultate the temporal arteries for:

Bruit (an abnormal sound indicating turbulent blood flow, often due to plaque)

Note: A bruit may be heard if the artery has plaque.

Strong unequal pulses may indicate an issue.
Expected Findings

Normal:
o

The nurse may expect no bruits upon auscultation of the temporal arteries.
Abnormal:
o
An auscultated bruit over the temporal arteries is considered an abnormal finding.
Assessment of lymph nodes in adult and child: normal and abnormal
Technique

Palpation Method:
o

Use the pads of the second, third, and fourth fingers to palpate lymph nodes.
Order of Palpation:
o
Palpate lymph nodes in a specific order.
Lymph Nodes of the Head
1. Occipital Nodes
o
Location: Base of the skull
2. Postauricular Nodes
o
Location: Over the mastoid process
3. Preauricular Nodes
o
Location: Front of the ears
4. Parotid/Tonsillar Nodes
o
Location: At the angle of the mandible
5. Submandibular Nodes
o
Location: Between the angle and tip of the mandible
6. Submental Nodes
o
Location: Behind the tip of the mandible
Lymph Nodes of the Neck
1. Superficial Cervical Nodes
o
Location: At the sternocleidomastoid muscle
2. Posterior Cervical Nodes
o
Location: Along the anterior border of the trapezius muscle
3. Deep Cervical Nodes
o
Location: Deep to the sternocleidomastoid
4. Supraclavicular Areas
o
Location: Above the clavicle
Thyroid bruits
Normal Findings


Bruits:
o
Soft swishing sound detected during auscultation.
o
Common and considered normal in children up to 5 years of age due to faster heart rates
and arterial composition.
Thyroid Palpation:
o
The thyroid gland may or may not be palpable.
Bruits in Special Conditions

Pregnancy:
o
Bruits may be a continuous loud sound or systolic murmur that can be heard or felt over
the thyroid gland when a stethoscope is placed on it.
o
Common in pregnancy due to:

Hypermetabolic state.

Increased demand for thyroid hormones.

Increased blood volume and metabolism.
Abnormal Findings

General:
o
The presence of bruits is considered an abnormality unless in pregnant women.
Thrill
May be noticed over temporal artery

feeling for a vibration over a blood vessel or the precordium
o vibration
Thyroid hypertrophy
Definition:

Enlargement of the thyroid gland due to an increased size of thyroid cells.
Types of Thyroid Dysfunction:
1. Hypothyroidism:
o
Description: Underactive thyroid.
o
Symptoms:
o

Tiredness

Cold intolerance

Weight gain
Complications:

o
May lead to myxedema (skin and tissue disease).
Causes:

Can be caused by Hashimoto's disease.
2. Hyperthyroidism:
o
Description: Overactive thyroid.
o
Symptoms:
o

Heat intolerance

Symptoms resembling oppositional defiant disorder (ODD)

Weight loss (underweight or skinny)
Causes:

Can be caused by Graves’ disease.
Pregnancy Considerations:

Thyroid enlargement may be palpated for in pregnant women by advanced practice nurses
(APNs).

Increased metabolism during pregnancy may require more iodine and thyroid hormone
production to meet the body’s needs.
Clinical Assessment:

If the thyroid is enlarged, auscultate for bruits or vascular sounds.
Normal tympanic membrane characteristics
Composed if layers of skin, fibrous tissue, mucous membrane and is a shiny pearl gray.

It is translucent
Ototoxic medications
ototoxic medication such as the salicylates (aspirin is one) can cause decreased hearing – sensorineural

Aminoglycosides***, salicylates, furosemide
Weber test: normal and abnormal- understand how to test and what would make abnormal
Weber Test Overview

Purpose: The Weber test uses a tuning fork to assess hearing by evaluating sound lateralization.

Procedure:
1. Activate the tuning fork by holding it by the base stem and striking the prongs against the
base of the palm of the hand.
2. Immediately place the base of the fork on the midline of the patient’s skull.
3. Ask the patient to indicate in which ear the sound is heard louder.
Normal Clinical Findings

The patient should hear the tone equally in both ears.

However, studies indicate that up to 40% of normal-hearing individuals may perceive sound
lateralization to one side.
Abnormal Clinical Findings

Lateralization:
o
If the sound lateralizes to one side (the patient hears the tone better in one ear than the
other), the test is considered abnormal.
o
Conductive Hearing Loss: Lateralization of sound to the affected ear suggests
conductive hearing loss.
o
Sensorineural Hearing Loss: Lateralization of sound to the unaffected ear suggests
sensorineural hearing loss.
Specific Patient Responses

Conductive Loss: Patient reports sound heard only in the affected ear.

Sensorineural Loss: Patient reports sound heard only in the unaffected ear.

Whispered words should be repeated correctly, with the expected air conduction (AC) to bone
conduction (BC) ratio being 2:1.
This organization highlights the key aspects of the Weber test, including its purpose, procedure, expected
findings, and interpretations of the results.
Rinne Test

Rin Purpose: The Rinne test uses a tuning fork to assess hearing by comparing air conduction
(AC) to bone conduction (BC).
Procedure
1. Preparation:
o
Activate the tuning fork by holding it by the base stem and striking the prongs against the
base of the palm.
2. Testing Bone Conduction:
o
Place the base of the tuning fork directly on the patient’s mastoid process.
o
Use a watch with a second hand to time how long the patient can hear the tone.
o
Instruct the patient to indicate when they can no longer hear the tone.
3. Testing Air Conduction:
o
When the patient indicates the tone can no longer be heard, quickly remove the fork and
hold the vibrating prongs about 2.5 cm (1 inch) in front of the patient’s ear.
o
Begin timing again and instruct the patient to indicate when they can no longer hear the
tone.
4. Repeat:
o
Perform the test on the other ear.
Assessment of Findings
Normal Findings

The tone heard in front of the ear (AC) should last twice as long as the tone heard on the mastoid
process (BC).
o
Expected Response: AC > BC by a ratio of 2:1.
Abnormal Findings

Consider the test abnormal when:
o
Conductive Hearing Loss: The sound is heard longer by bone conduction than air
conduction (BC > AC). In this case, BC is longer in the affected ear.
o
Sensorineural Hearing Loss: The patient hears air conduction longer than bone
conduction (AC > BC) in the affected ear, but the ratio will be less than 2:1.
Summary of Clinical Findings

Normal:
o

AC > BC by a ratio of 2:1.
Abnormal:
o
BC > AC (conductive hearing loss).
o
AC > BC but less than a 2:1 ratio (sensorineural hearing loss).
Acute otitis media

Acute otitis media
o Inflammation in the middle ear, associated with a middle ear effusion that becomes
infected by bacterial organisms
Otoscopy of adult and child






Pull auricle down to view tympanic membrane
Pneumatic otoscope especially important for differentiation a red tympanic membrane caused by
crying (the membrane is mobile) from that resulting from disease (no mobility)
o Pneumatic bulb use paramount
Evaluate toddlers hearing by observing response to whispering, noise makers, and speech
Audiometric evaluation should be preformed in all young children begging at 3-4 y/o
External auditory canal shorter,
eustachian tube is wider, short and more horizontal
Presbycusis
Sensorineural hearing loss with aging. Rinne test AC>BC
Sensorineural hearing loss including assessment test results

Definition:
o

Hearing loss resulting from a disorder of the inner ear, damage to the acoustic nerve (CN
VIII), genetic disorders, systemic diseases, ototoxic medications, trauma, tumors,
prolonged exposure to loud noise, and aging.
Characteristics:
o
Frequency Progression:

o
o
Rinne Test:

Air conduction (AC) is greater than bone conduction (BC) (AC > BC).

Normal finding is a 2:1 ratio of AC > BC.
Weber Test:


Sound is heard in the unaffected ear.
Common Type:
o

First occurs with high-frequency sounds and then progresses to lower-frequency
tones.
Sensorineural hearing loss is the most common type of hearing loss.
Presbycusis:
o
Refers to hearing loss associated with aging.
This organized format succinctly summarizes the key points related to sensorineural hearing loss and its
assessment.
Conductive hearing loss including assessment test results
Definition:

Hearing loss resulting from reduced transmission of sound to the middle ear.
Characteristics:

Rinne Test:
o

Bone conduction (BC) is greater than air conduction (AC) (BC > AC).
Weber Test:
o
Sound is heard in the affected ear.
Causes:

Blockage:
o

Bone Fixation:
o

Thickening or hardening of the tympanic membrane.
Cerumen Impaction:
o

Excess deposition of bone cells along the ossicle chain, causing fixation of the stapes
in the oval window.
Sclerotic Tympanic Membrane:
o

Blockage of the external auditory canal with cerumen.
Sound will be heard best in the blocked canal.
Severity:
o
Can indicate more serious hearing loss.
Anatomy of adult, child, and infant’s ears (including auditory canal) & assessment adjustments for age
Assessing hearing through



Response to questions during history
Response to a whispered voice
Response to tuning fork for air and bone conduction
- Infants:





Inner ear developed in first trimester
External auditory canal in infants is shorter than adults
▪ Pull pinna down and back to see tympanic membrane
Eustachian tube is wide, shorter, and more horizontal than in adults
Assessment
o ▪ Pull pinna down and back
o Inspect auricles for full formation and flexibility
o Auditory canals should be examined in first few weeks of life
o Tympanic membrane becomes conical after first few months of life
o Evaluate infant hearing using sound stimuli
- Children




Pull pinna down view tympanic membrane
Use pneumatic otoscope to differentiate between a red tympanic membrane caused by crying or
from disease
Observing response to whispering, noisemakers, and speech for toddlers
Audiometric evaluation should be performed in all young children being at 3 – 4 years of age
- Older Adults:





If hearing aid is worn, inspect auditory canal for irritation
Inspect for coarse hair on auricle
Inspect tympanic membrane for sclerotic changes
Note presence of sensorineural (presbycusis) or conductive hearing loss
Inspect for cerumen impaction
Anatomy:
o

May show anatomical changes due to aging, including sclerotic changes in the tympanic
membrane and coarse hair in the auricle.
Assessment Adjustments:
o
Technique:

o
If a hearing aid is worn, inspect the auditory canal for irritation.
Inspection:

Inspect for coarse hair on the auricle.

Examine the tympanic membrane for sclerotic changes.

Note the presence of sensorineural (presbycusis) or conductive hearing loss.

Inspect for cerumen impaction.
Characteristic differences of dizziness and vertigo:
Vertigo




Definition:
o A false sense of motion, often described as an illusion of rotational movement, typically
due to a disorder of the inner ear.
Characteristics:
o Sensation of movement, usually in a rotational manner (whirling or spinning).
o Types:
 Subjective Vertigo: Sensation that one’s body is rotating in space.
 Objective Vertigo: Sensation that objects are spinning around the body.
Associated Conditions:
o Meniere disease (disorder leading to progressive hearing loss accompanied by severe
vertigo).
Assessment:
o Romberg Test: A positive result indicates unsteadiness or loss of balance.

Documentation:
o Time of onset and duration of attacks.
o Description of the attacks.
o Associated symptoms, including unsteadiness, loss of balance, or falling.
Dizziness


Definition:
o A general term used by patients to describe various sensations without a true sense of
motion.
Characteristics:
o Symptoms may include faintness, light-headedness, a sensation of spinning, or difficulty
maintaining balance while standing or seated.
Major parts of eye and purpose of each
External eye:


Eyelid
o
Distribute tears over eye surface
o
Limit amount of light entering the eye
o
Protect the eye from foreign bodies
Conjunctiva
o

Lacrimal gland
o

Move the eye

Bony skull orbit

Oculomotor nerve
o
Elevates and retracts the upper eyelid
o
Innervates all extraocular muscles except for superior oblique and lateral rectus
Trochlear nerve CN IV
o

Produces tears that moisten the eye
Eye muscles
o

Protects the eye from foreign bodies and desiccation
Innervates superior oblique
Abducens nerve CN VI
o
Innervates the lateral rectus
1. Sclera

Description: The white part of the eye.

Characteristics:
o
Avascular (lacks blood vessels).
o
Provides support for internal eye structures.
2. Cornea

Description: A clear, transparent layer at the front of the eye, continuous with the sclera.

Characteristics:
o
Major part of the eye's refractive power.
o
Contains sensory innervation for pain.
3. Iris

Description: The colored portion of the eye.

Characteristics:
o
Contains pigment cells that determine eye color.
o
Dilation and contraction control the amount of light entering the eye through the pupil.
4. Ciliary Body

Description: A muscle structure surrounding the lens.

Functions:
o
Produces aqueous humor.
o
Contains muscles that control accommodation (the eye's ability to focus on near and
distant objects).
5. Choroid

Description: A pigmented, richly vascular layer.

Function:
o
Supplies oxygen to the outer layer of the retina.
6. Lens

Description: A biconvex, transparent structure located behind the iris.

Characteristics:
o
Supported by fibers from the ciliary body.
o
Changes thickness based on ciliary body contraction to focus images at varying distances
on the retina.
7. Retina

Description: The sensory network of the eye.

Functions:
o
Transforms light impulses into electrical impulses.
o
Electrical impulses are transmitted through the optic nerve, optic tract, optic radiation,
and visual cortex, eventually reaching consciousness in the cerebral cortex.
o
Major Landmarks:

Optic Disc: The convergence point of the ventral retinal artery, central retinal
vein, and optic nerve.

Macula (Fovea): The central site of vision.
Major parts of ear and purpose of each
1. External Ear

Structures:
o
Auricle (Pinna): The outer visible part of the ear.
o
External Auditory Canal: The passage leading from the outside of the ear to the
tympanic membrane.


Note: The external auditory canal is shorter in infants than in adults.
Functions:
o
Protective: Shields the inner structures of the ear.
o
Sound Gathering: Helps gather and channel sound waves toward the tympanic
membrane.
2. Middle Ear

Overall Function: Amplification of sound waves.

Structures:
o
o
Ossicles:

Malleus: Hammer-shaped bone.

Incus: Anvil-shaped bone.

Stapes: Stirrup-shaped bone.
Tympanic Membrane (TM):


Functions:
Separates the middle ear from the external ear.
o
Sound Transmission: Ossicles transmit sound from the tympanic membrane to the inner
ear.
3. Inner Ear

Structures:
o
Vestibule: Responsible for balance and equilibrium.
o
Semicircular Canals: Also responsible for balance and equilibrium.
o
Cochlea: Contains the organ of Corti, which is responsible for hearing.

Function: Hair cells in the organ of Corti respond to sound waves, converting
them into electrical impulses that are transmitted through the cochlear branch to
the temporal lobe for interpretation.
This format provides a clear and structured overview of the auditory system, highlighting its functions,
anatomical parts, and methods of assessment.
Cranial nerves that innervate eye, ear, and face and what each does
Impact of pregnancy on vision







Hypersensitivity and changes are seen in the refractory power of the eye. So vision may
change temporarily due to pregnancy.
Probably don’t want to change contact or glasses prescription
Tears contain an increased level of lysozyme, resulting in a greasy sensation and perhaps
blurred vision for contact lens wearers.
Corneal edema/thickening occurs.
Diabetic retinopathy may worsen.
Intraocular pressure falls.
Subconjunctival hemorrhages may occur/resolve spontaneously.
Test for accommodation and purpose

Purpose: Assess pupil reaction to changes in focus (near and distant objects).

Procedure:

o
Test pupils for accommodation by observing their response when the patient focuses on a
near object.
o
Observation:

Pupils should constrict when focusing on a close object.

Pupils should dilate when focusing on a distant object.
Significance: Part of the PERRLA (Pupils Equal, Round, Reactive to Light, and
Accommodation) assessment.
Related Terms






Miosis:
o
Definition: Pupillary constriction less than 2 mm.
o
Clinical Use: Miotic eye drops are used for treating glaucoma.
Mydriasis:
o
Definition: Pupillary dilation more than 6 mm.
o
Clinical Use: Mydriatic drops are used for hypoxia in the eye.
Oval Pupil:
o
Definition: An irregularly shaped pupil.
o
Clinical Significance: Can occur with head injuries or intracranial hemorrhage.
Fixed Pupil:
o
Definition: A pupil that shows no reaction to light.
o
Clinical Significance: Often indicates increased intracranial pressure (ICP).
Anisocoria:
o
Definition: Unequal size of pupils.
o
Clinical Significance: May be congenital with normal reflexes.
Iridectomy:
o
Definition: Surgical excision of a portion of the iris, usually in the superior area.
Notes

Weakening of Accommodation: This condition is commonly observed in older age, affecting the
eye's ability to adjust focus between near and distant objects.
Test for peripheral vision and purpose
Peripheral Vision


General Information
o Peripheral vision is fully developed at birth.
o It is part of the measure for visual acuity.
Testing Methods
o Confrontation Test:
 Generally used for estimating peripheral vision.
 Procedure:
 Patient covers one eye while the nurse covers the opposite eye.
 Both look into each other’s eyes.


The nurse fully extends their arm and moves their hand centrally,
asking the patient to report when the fingers are first seen.
o Instrumentation:
 Accurate measurement of peripheral vision requires specialized
equipment.
Areas Tested:
o Nasal field
o Temporal field
o Superior field
o Inferior field
2 TYPES: Temporal and nasal field
Test for cardinal fields of gaze and purpose

Tests for nystagmus
o
Often normal for presence when looking up and down
o
Often abnormal for presence when looking side to side

Note lid lag

Note exposure of sclera above iris
CN 1V is trochlear
Abducens going out on sides
Retinal hemorrhage and possible causes
Retinal hemorrhages in infancy

Occurs in infant victims of shaken-baby syndrome
Periorbital edema
Refers to swollen, puffy lids; occurs when crying, infection trauma, and systematic problems including
kidney failure, heart failure and allergy
Ptosis
Ptosis- drooping of eyelid due to nerve damage
Nystagmus
Check for nystagmus
Associated with lazy eye
Often normal for presence with looking up and down
Often abnormal for presence when looking side to side
Exophthalmos
Bulging of eye anteriorly out of orbit
Interpretation of visual acuity rating

Visual acuity
Decrease in central vision, distortion of central vision, use of dim or bright light to
increase visual acuity, complaints of glare, difficulty in performing near work without
lenses
Measure visual acuity, noting the following:
o Near vision
o Distant vision
o Peripheral vision
o

Visual testing





Use Snellen chart.
Test each eye individually.
Test with and without corrective lenses.
If vision less than 20/20, conduct pinhole test.
o This maneuver permits light to enter only central portion of lens
o Should result in an improvement in visual acuity by at least one line on the chart if
refractive error is responsible for the diminished acuity
Visual acuity tested with Snellen E game at 3 years of age; younger children by observing
activities
Snellen Results






Normal- 20/20.
Larger the denominator, the poorer the vision
20/30- can read at 20 feet what normal vision can read at 30 feet.
Poorer than 20/30 or unable to distinguish colors needs referral
20/200-legally blind with this as best corrected visual acuity
Presbyopia- needs to hold further away to read; loss of lens elasticity with age
Glossopharyngeal and vagus- Gag reflex
Facial and trigeminal- Face movement
Eye movement- Oculomotor (All except lateral rectus and superior oblique)
Lateral rectus- Abducens
Superior oblique- Trochlear
Oculomotor- Moves the eyelid