Nancy Sanderson MSN, RN
Lecture 4
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Feature concept: Sensory perception
◦ Ability to understand and interact through senses:
 Sight
 Hearing
 Smell
 Taste
 Touch
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Recent head trauma?
Loss of consciousness?
Headaches? I.e.: Sinus, migraines,
neurological
Use of a helmet when appropriate? I.e.:
occupation, contact sports, cycling, and
skateboarding.
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Head and neck contain multiple structures:
◦ Skull encloses brain.
◦ Facial structures include eyes, ears, nose, and
mouth.
◦ Neck structures include:
 Upper portion of spine
 Esophagus
 Trachea
 Thyroid gland
 Arteries
 Veins
 Lymph nodes
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Elsevier Inc.
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Skull is a bony structure that protects brain and
upper spinal cord:
◦ Contains special senses of vision, hearing, smell,
taste.
◦ Comprises six bones fused at sutures.
◦ Covered by scalp tissue typically covered with hair.
Face comprises 14 bones:
◦ Mandible articulates with temporal bone to form
temporomandibular joint.
◦ Facial muscles innervated by cranial nerves
V (trigeminal) and VII (facial).
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Mosby, an imprint of
Elsevier Inc.
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Copyright © 2013 by
Mosby, an imprint of
Elsevier Inc.
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Inspect and palpate:
Inspect the head for size shape and skin
characteristics. I.e.: Head in relation to neck
and shoulders for size and shape.
Normocephalic term designating that the
skull is symmetric and appropriately
proportioned for the size of the body. Versus
microcephaly and macrocephaly.
Inspect facial features for size, symmetry,
movement, skin characteristics, and facial
features.
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All facial features should appear symmetric with
a calm facial expression. Facial bones should be
symmetric and proportional to the size of the
head.
Palpate the structures of the skull for contour
and, tenderness and intactness. Palpation takes
place when there is suspected injury, observed
irregularity or abnormality or reported pain. The
skull should be symmetric, and feel firm without
tenderness.
Palpate the bony structures of the face, jaw, and
movement of the jaw, temporal arteries for:
tenderness, jaw pain, clicking, pulsation of
artery.
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External ocular structures:
◦ External eye is composed of eyebrows, upper and
lower eyelids, eyelashes, conjunctivae, and lacrimal
glands.
◦ Palpebral fissure is opening between eyelids.
◦ Conjunctivae are two thin, transparent mucous
membranes, between eyelids and eyeball.
 Bulbar conjunctiva covers scleral surface of
eyeball.
 Palpebral conjunctiva lines eyelids and contains
blood vessels, nerves, hair follicles, and
sebaceous glands.
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Inspect the conjunctiva of the eye for color,
drainage and lesions. This is done by gently
pulling done the lower eye lid. No drainage,
redness or swelling should be noted.
Inspecting the sclera of the eye commonly
referred to as the whites of the eye for
erythema, jaundice, or lesions. Sclera should
be white and clear although in darker
pigmented individuals the sclera may have a
slight yellowing to the sclera.
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Snellen Chart distance vision cranial nerve II
Patient sits or stands twenty feet from the
chart. Patient reads the line of the smallest
letters that are possible for them to read.
Test the other eye in the same manner then
both eyes. Document findings according to
the fraction printed on the Snellen chart. You
must also document if the patient is wearing
corrective lenses or contacts at the time.
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Pupils for size, shape, reaction to light,
accommodation and consensual reaction.
Determine the pupil size with a pupil gauge
Using a pen light approaching from the side
and shining the light directly into the pupil
observing for a reaction of the pupil to the
light. Consensual reaction the constriction of
the iris and the pupil of one eye when a light
is shown in the opposite eye.
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Accommodation ask the patient to fix her
gaze on an pen light or finger, observe the
eyes as you move the object in and away from
the face. The pupils will dilate and constrict
when focusing on objects near and far as a
simultaneous response, consensual response.
PERRLA- pupils equal round reacts to light
and accommodating.
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Six muscles attaching the eyeball to the orbit
of the eye. These muscles are stimulated by
three cranial nerves.
CNVI-abducens- innervates the lateral rectus
muscle for lateral movement. Abducts the
eye.
CNVI-trochlear- innervates the superior
oblique muscles moving the eye down and in.
CNIII- ocular motor- innervates all the rest of
the eye moving superior, inferior, medial,
rectus and the inferior oblique muscles.
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Extra ocular muscles function test: EOMhence extraocular movement. The patient to
move or follow the eyes keeping head still
through the six cardinal positions of gaze.
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Stand 15 inches away from the patient and
off to the side of the patient, shine the light
beam on the pupil and look for the orange
glow in the pupil. Normally: light reflex.
Abnormal: absent light reflex (may be due
to opacity of the lens, i.e. cataract)
Red reflex present bilaterally.
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Ear is a sensory organ for hearing and maintaining
equilibrium
Divided into three sections:
◦ External ear
◦ Middle ear
◦ Inner ear
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
External ear
◦ Auricle or pinna and external auditory ear canal
composed of cartilage and skin.
 Helix is prominent outer rim.
 Concha is deep cavity in front of external
auditory meatus.
 Lobule is bottom portion of ear.
◦ Auricle serves three main functions:
 Collection and focus of sound waves.
 Location and direction of sound.
 Protection of external ear from water and dirt.
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Mosby, an imprint of
Elsevier Inc.
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Copyright © 2013 by
Mosby, an imprint of
Elsevier Inc.
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Copyright © 2013 by
Mosby, an imprint of
Elsevier Inc.
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Sound waves strike the tympanic
membrane
Vibrations transmit through the auditory
ossicles (malleus, incus, stapes) to oval
window (Conductive hearing loss to this
point)
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Vibrations travel to cochlea and then to the
round window (Sensory hearing loss at this
point)
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CN VIII (acoustic)
Nerve sends message to brain
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How is your hearing?
◦ Use of hearing aid?
◦ Taking ototoxic drugs?
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Have you had any trouble with your ears or
balance?
◦ Are you having any vertigo? (feeling as if the room
is spinning, different from dizzy)
◦ Are you having any tinnitus? (musical ringing in the
ear)
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Does anyone smoke in your household?
◦ Increased risk of otitis media in children
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Use an otoscope with the largest ear
speculum that the canal will accommodate
Position the patient’s head so that you can
see through the scope
Straighten the ear canal be grasping the
auricle firmly and pull it upward, backward
and slightly away from the head
Brace your hand against the patient’s face
Insert the speculum gently into the ear
canal, directing it somewhat down and
forward
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Use an otoscope with the largest ear
speculum that the canal will accommodate
Position the patient’s head so that you can
see through the scope
Straighten the ear canal be grasping the
auricle firmly and pull it upward, backward
and slightly away from the head
Brace your hand against the patient’s face
Insert the speculum gently into the ear
canal, directing it somewhat down and
forward
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Identify the handle of the malleus
Identify the short process of the malleus
Inspect the pars flaccida and Pars tensa
Normal
◦ Shiny, transparent, pearly gray, slight concave,
non-bulging, no perforation
TM gray and intact bilaterally
without erythema, bulging,
or retraction.
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Estimating Hearing
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Occlude one ear of your patient
Stand 1-2 feet behind patient
Whisper a word (i.e. 88)
Repeat with other ear
Gross hearing intact by whisper test.
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Weber Test
◦ Tap against palm and
place midline vertex of
head
◦ Normal: Hears equally in
both ears
◦ Conductive hearing lossbest in impaired ear
◦ Sensorineural hearing
loss- only in normal ear
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Rinne Test
◦ Tap against palm and place on mastoid process. When no
longer hears place 1-2 cm from ear until no longer hears
◦ Sensorineural hearing loss- heard longer thru air, but less
than 2:1 ratio
◦ Normal air conduction (ac) is 2 times longer than bone
conduction (bc)
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Allergic Rhinitis
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Itching
Swelling
Rhinorrhea
Sneezing
Tearing eyes
◦ Later- stuffy nose, coughing, decreased smell, sore
throat, dark circles under eyes
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Inspect the anterior and inferior surfaces of
the nose
◦ Note any asymmetry or deformity
◦ Inspect for discharge
◦ Test patency
 Press on each nostril one at a time and have the
patient breath in
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Palpate for any masses, lesions or tenderness
Nose symmetrical midline. No deformities or skin
lesions. Nares patent bilaterally.
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Inspect the inside of the nose
◦ Inspect vestibule, septum and
turbinates
 Color of nasal mucosa
 Foreign body
 Discharge (note color: clear, yellow, green, bloody)
 Masses, lesions, polyps
 Septum: deviation, perforation, bleeding
 Turbinates: color, swelling, exudate, polyps
Normally no swelling, mucoid drainage; redder than oral
mucosa
Septum without deviation, perforation, or bleeding.
Turbinates pink, without dc, edema, exudate, or polyp.
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Palpate for sinus tenderness
◦ Press up on the frontal sinuses from under the
bony brows (avoid pressure on the eyes)
◦ Press up on the maxillary sinuses
◦ Normal: pt will feel pressure but no pain with
palpation
Frontal and maxillary
sinuses nontender
to palpation
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ROS:
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Sore throat
Sore tongue
Bleeding from the gums
Tooth pain
Hoarseness
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Inspect lips
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Color
Moisture
Lumps
Ulcers
Cracking
Symmetry
Swelling (edema)
Inspect oral mucosa (inside of mouth)
◦ With good light and a tongue blade, inspect for
color, ulcers, white patches, and nodules.
Lips pink and moist without cracking or lesions.
Buccal mucosa pink without nodules or lesions.
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Teeth/Gums
◦ Inspect for missing teeth, caries, conditions,
discoloration
◦ Note the color of the gums
◦ Normal
 Pink
 Margins without swelling
 No bleeding
Teeth white, straight, evenly spaced, clean and free of
decay. Gums pink without swelling or bleeding.
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Pharynx
◦ With the patient’s mouth open, have the patient say “ah”
 As the patient says “ah” check the rise of the soft palate (CN X)
◦ Gag reflex (CN IX , X)
◦ If needed press a tongue blade firmly down upon the
midpoint of the arched tongue
◦ Inspect the soft palate, anterior and posterior pillars, uvula,
tonsils and pharynx
◦ Note color, swelling, ulceration
◦ Tonsillar enlargement
◦ Exudate
◦ Breath odor (halitosis)
Soft palpate pink, rises midline. Tonsils pink without
enlargement or exudate. Pharyngeal wall pink without
exudate or lesions. No halitosis noted.
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ROS
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Neck pain?
Lumps or swelling?
History of neck surgery?
History of neck trauma?
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Inspect for:
Head position
Neck muscle symmetry
Masses or scars
Abnormal pulsations
Neck supple & symmetrical
Without masses, scars, or
abnormal pulsations
 Inspect
Should be midline
 Palpate
For tracheal shift
 Place finger in sternal
notch and slip to each
side.
Trachea midline.
Palpate the lymph nodes
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Use the pads of your index and
middle fingers with a gentle rotary
motion.
Preauricular
Posterior auricular
Occipital
Tonsilar
Submandibular
Submental
Superficial cervical
Posterior cervical
Deep cervical chain
supraclavicular
 Note location, size, shape,
delimitation, mobility,
consistency and tenderness.
 Lymph nodes normally
nonpalpable in healthy adults
 Small, soft, mobile, discrete,
non-tender nodes (shotty)
may be found in normal
persons.
 Enlarged (>1cm) firm, tender,
and freely moveable often
indicates infection.
 Hard, non-tender, and fixed
often indicates malignancy.
 Enlarged supraclavicular node,
especially on left, suggests
possible metastasis from
thorax or abdomen
No lymphadenopathy noted or
lymph nodes nonpalpable.
Inspect first then
palpate
 Assess for:
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Enlargement
 Goiter
Consistency
Symmetry
Nodules
Movement
Thyroid nonpalpable
Goiter
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PERRLA
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Hearing (equal sound –whisper test; finger rubbing;
(pupils are equal round and react to light and
accommodation)
Weber's best)
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Nose
(normal appearance; symmetry; no discolored
drainage)
Mouth (check for malocclusion; tonsils; dental caries)
Throat (Range of motion; palpate [use care] sides &
midline all should be midline & nontender)