Islamic University of Gaza
Faculty of Nursing
Chapter 6
Head Assessment
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Head assessment
• inspects for size, shape, and contour of
head.
• The skull is generally round with anterior &
posterior prominences.
• Large infant's head may be hydrocephalus.
• Large adult's head & facial bones resulting
from acromegaly.
• palpates the skull for nodules or masses
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Assessment of the eye
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Eye chart (Snellen chart)
Chart or newsprint.
Cover card.
Penlight, ophthalmoscope
Ask your client about:
History of previous eye surgery, trauma, use of
corrective glasses or contact lenses, blurred
vision, Diplopia, strabismus.
• Recent changes in vision. Date of previous
vision test.
• Allergies, eye redness, frequent watering
discharge
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Assessment of the eye cont..
• Assess:
- external eye structures, pupils, and iris, visual
acuity, ocular movements, Peripheral vision.
- internal eye structures e.g. iris , retina, macula etc
• ** Consider the following Factors:
• age use of corrective lens, artificial eye, allergies,
pain, visual disturbances, and health related
factors such increase Blood Pressure, or Diabetes
mellitus
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• Assessment of external eye structures:
position and alignment of eyes, eye brow,
eye lids, eye lashes, lacrimal glands, pupils
and iris.
• ** Assessment of pupils done by using
penlight which produce constriction of
pupils.
• ** Assessment must do for accommodation
and convergence of pupils.
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• Assess Visual Acuity:
- done by placing the client 20 feet from the
snellen eye chart and testing each eye alone.
• ** Assess extra ocular movements:
- by asking client to hold his head and follow
movements of your forefinger.
• *Assess peripheral vision: “Visual fields”
• - Hemianopsia: blindness of 1/2 field in one or
both eyes.
• - Quadrantanopsia: blindness of 1/4 of visual
field in one or both eyes.
• - Ascotoma: Island like blindness in visual field
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Eye Pathologies
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Orbital Hematoma
Orbital fractures (Blowout fracture)
Ruptured Globe
Corneal Abrasion
Corneal Laceration
Hyphema
Iritic
Detached Retina
Conjunctivitis
Hordeolum
Periorbital Lacerations
Foreign Bodies
Contact Lens Removal
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Ear Assessment
• Ask about :-History of ear surgery, trauma, frequent
infection, ear pain, drainage, hearing loss,
tinnitus, vertigo, ototoxic medications, last
hearing examination
• Assess client in sitting position & inspects the
auricle’s placement, size, symmetry, and color.
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Color of ears must be the same as of the face.
Redness: sign of inflammation or fever.
Pallor: indicate frost bite.
palpate the auricles for texture, tenderness, and
skin lesion.
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Ear assessment cont…
• If client complains of pain: pull the auricle and
press on the tragus and behind the ear over the
mastoid process if pain increase, means external
ear infection, if pain is not increase, means middle
ear infection may be present.
• Inspection of ear canal for size and discharge.
• Assessment of cerumen if it is yellow or green may
indicate infection.
• Assessment of hearing acuity: done simply by
identification of voice tones, with the client
repeating testing words spoken by the nurse
• **N.B: deeper structure and middle ear can be
observed only by otodscope.
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The Otoscope Examination
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Using the Otoscope :
choose the largest speculum
head toward the opposite shoulder
pull adult ear : pinna upper and back
pull infant and child ( <3 age ) : pinna down
hold the otoscope : upside down
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The Otoscope Examination cont..
• The External Canal :
redness / swelling / lesion / foreign body /
discharge
• Tympanic Membrane :
color / character / perforation
shiny , translucent , pearl-gray color
Cone-shaped light reflex
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Assessment of the nose
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Functions of the nose
Identify odors (upper 1/3 of septum)
Air passageway (obligate in newborns)
“Air conditioning”
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Humidify
Warms/cools air
Cleans and filters air of dust and most bacteria
Voice resonance
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Inspect and Palpate
Eternal Nose
1).symmetric , in the midline , skin lesion , pain
2).nostril patency :
each time test one side
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Assessment of the Nose cont..
• inspect & observe symmetry, inflammation, & deformity.
• In case of swelling or deformities of nose, the nose is
palpated gently for tenderness, swelling and underlying
deviations.
• * Normally the external nose is symmetrical, strait, non
tender, and without discharge.
• Assess mucosa which is normally pink in color.
• Yellowish or greenish discharge – means sinus infection.
• Pale mucosa with clear discharge – means allergy.
• N.B: For client with NGT nurse routinely checks for local
breakdown of skin “Excoriation” of the naris characterized
by redness and sloughing of the skin
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Assessment of the sinuses
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Palpate sinuses
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Transillumination-Frontal& Maxillary Sinuses
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Palpation for the sinus areas
frontal sinus below the eyebrow
maxillary sinus  below cheekbones
• Transillumination sinusitis:
1).frontal sinus  under the superior orbital
2).maxillary sinus  inside the mouth on the hard palate
normal  light up symmetrically
Transillumination is the transmission of light through tissues of the body. A
common example is the transmission of a flash of light through fingers,
producing a red glow. This is because red blood cells absorbed other
colors of the beam and transmitted only the red component
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Assessment of the sinuses
• Frontal and maxillary sinuses are examined for
pain and edema.
• - palpate sinuses (both frontal and maxillary
for tenderness, which verbalized by client
during exam.
• - Percuss sinuses for resonance which is
normally hollow tone, and noting abnormality
e.g. flat, dull tone elicited or expresses pain on
percussion.
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Assessment of Mouth and pharynx
Anatomy of the mouth
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• Assessment of oral cavity can be made during
administration of oral hygiene.
• Lips – inspected for color, texture, hydration,
contour, and lesions.
• Inner and buccal mucosa, Gums and teeth
inspected for color, hydration, texture and
lesions e.g. ulcers, abrasions or crusts.
• Tongue and floor of mouth can carefully
inspect.
• Assessment of palate “soft and hard” by
extending client’s backward, assessment for
color, shape, texture, and extra bony
prominences or defects
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Assessment of Pharynx
Assessment for pharynx done: by using
tongue depressors.
• Pharyngeal tissues are normally pink and
smooth.
• Edema, ulceration, or inflammation
indicates infections or abnormal lesions.
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Assessment of Neck
• Client in sitting position: assessment done
by inspection and palpation.
• Assess neck muscles, trachea, thyroid
gland, carotid arteries and jugular veins,
cervical lymph nodes and cervical
vertebrae.
• Assess neck size and position of trachea and
thyroid
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• Assess range of motion by asking the client
to tilt the head backward and side to side
• Assess lymph nodes and venous distention.
• Neck should be symmetrical with full range
of motion.
• No neck vein distention should be visible.
• Inspect and palpate cervical vertebrae On the
posterior aspects of the neck for symmetry,
tenderness, masses or swelling.
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• Thyroid gland is assessed by palpation,
observation and auscultation.
• Normal thyroid gland not palpable.
• - Palpation – for gland itself.
• - If enlargement of thyroid gland is
detected, the area over the gland is
auscultated for a bruit
• Bruit: vibrations& sound of blood flow through
arteries In enlarged gland, heard with the bell of
stethoscope
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Thyroid dysfunction
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changes in sleep pattern e.g. fatigue,
drowsiness, lethargy, or insomnia.
Emotional disturbances: e.g. mood changes,
irritability, nervousness.
hair loss brittleness of nails.
Altered sensitivity to heat or cold.
dyspnea on exertion , tachy cardia.
changes in appetite: weight loss, abnormal
bowel habits...etc.
changes in menstruation.
hoarseness , difficulty swallowing ….etc.
History of radiation for to head or neck.
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Trachea
• Trachea normally centered; (at the
supra-sternal notch)
• The cartilages should be smooth, non
tender and move easily under examiner’s
fingers when the client swallow.
• * Palpation done by placing the thump
and forefinger on each side of the trachea
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Assessment of the lymphatic system
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Functions of lymphatic system
Movement and transportation of lymphocytes
Production of lymphocytes.
Production of antibodies.
Phagocytosis
Absorption of fat and fat soluble substances.
Enlargement of lymph node: provides early
indication of infection or malignancy.
Lymphatic System consists of a network of
collecting ducts, lymph fluids e.g. spleen,
thymus, tonsils, adenoids--- etc
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• Examination of lymphatic System : 2 steps
- firstly inspection for enlarged lymph nodes, skin
lesions, edema, erythematic, and red streaks on
the skin.
- Secondly palpating gently the lymph nodes areas
using pads of "2, 3, 4" fingers in gentle circular
motion.
• Press lightly and then increasing pressure
gradually.
• Move skin lightly over the under lying tissues
&not moving the examining fingers over the skin.
NB. Large nodes due to malignancy are generally not
tender vary in size, hard, asymmetrical
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some Areas of lymph nodes
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Pre auricular: in front of the ear.
Mastoid or posterior auricular – behind the
ear. Above the mastoid process.
Occipital – at the base of skull posterior.
Parotid – near the angle of the jaw.
Sub-mandibular – midway between angle of
jaw and the tip of the mandible.
Sub mental – in the midline posterior to the
tip of the mandible.
Anterior superficial nodes – in the anterior
triangle of the neck.
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some Areas of lymph nodes cont..
• Posterior cervical nodes – in the
posterior triangle of the neck.
• Deep cervical nodes – very deep and
difficult to be examine.
• Supra clavicular or scalene nodes – In
the angle formed by clavicle and
Sternocleidomastoid muscle.
• ** Axilla, breast &Lower extremity
(inguinal and popliteal nodes)
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The end
Thank you
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