Islamic University of Gaza Faculty of Nursing

1. Islamic University of GazaFaculty of Nursing Chapter 6Head Assessment

2. 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 (Acromegaly is a condition in which there is too much growth hormone and the body tissues get larger over time). • Palpates the skull for nodules or masses.

3. Assessment of the eye

4. Assessment of the eye • 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.

5. Assessment of the eye cont.. • Assess: • external eye structures, pupils, and iris (قزحية), visual acuity, ocular movements, peripheral vision. • 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.

6. Assessment of external eye structures: -Position and alignment of eyes, eye brow, eye lids, eye lashes, lacrimal glands, pupils and iris. • Assessment of pupils: -Use penlight to produce constriction of pupils. -Must be done for accommodation and convergence of pupils.

7. Assessment of visual acuity: -Place the client 20 feet from the snellen eye chart and test each eye alone. • Assessment of extra ocular movements: -Ask client to hold his head and follow movements of your forefinger. • Assessment of 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.

9. Eye Pathologies • 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

10. Assessment of the Ear • 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 & inspect the auricle’s placement, size, symmetry, and color. • Color of ears must be the same as of the face. • Redness: sign of inflammation or fever. • Pallor: indicates frost bite. • Palpate the auricles for texture, tenderness, and skin lesion.

11. 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 increases, means external ear infection, if pain does not increase, means middle ear infection may be present. • Inspect ear canal for size and discharge. • Assess cerumen if it is yellow or green (may indicate infection). • Assess hearing acuity: 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 otoscope.

13. The Otoscope Examination 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.

14. The Otoscope Examination cont.. • The External Canal: -Assess for redness, swelling, lesion, foreign body, discharge. • Tympanic Membrane: -Assess for color, character, perforation: shiny, translucent, pearl-gray color, Cone-shaped light reflex.

15. Assessment of the nose Functions of the nose • Identifying odors (upper 1/3 of septum) • Air passageway (obligate in newborns) • Air conditioning: -Humidifying -Warming/cooling air -Cleaning and filtering air of dust and most bacteria • Voice resonance

16. Inspect and palpate Eternal Nose 1)Symmetric , in the midline , skin lesion , pain. 2)Nostril patency: each time test one side.

17. 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

18. Assessment of the sinuses

19. Palpate sinuses

20. Transillumination-Frontal& Maxillary Sinuses

21. 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

22. Transilluminationis 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.

23. 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.

24. Assessment of mouth and pharynx

25. 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 should be carefully inspected. • Assessment of palate “soft and hard” by extending client’s backward, assessment for color, shape, texture, and extra bony prominences or defects

26. 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.

27. 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

28. 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.

29. 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

30. Thyroid dysfunction • Changes in sleeppattern: e.g. fatigue, drowsiness, lethargy, or insomnia. • Emotional disturbances: e.g. mood changes, irritability, nervousness. • Hair loss, brittleness (fragility) of nails. • Altered sensitivity to heat or cold. • dyspnea on exertion, tachycardia. • Changes in appetite: weight loss, abnormal bowel habits...etc. • Changes in menstruation. • Hoarseness , difficulty swallowing ….etc. • History of radiation for to head or neck.

31. 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.

32. Assessment of the lymphatic system 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

33. Examination of lymphatic System: 2 steps 1- Inspection for enlarged lymph nodes, skin lesions, edema, erythematic, and red streaks (lines) on the skin. 2- 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 underlying tissues & not moving the examining fingers over the skin. **NB: Large nodes due to malignancy are generally not tender, vary in size, hard, asymmetrical.

34. Some areas of lymph nodes • 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.

35. 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 examined. • 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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