ASSESSMENT TOOL FOR EVERY SYSTEM

SKIN, HAIR AND NAILS

 How to examine your own skin

 Braden scale for predicting pressure sore risk
 PUSH TOOL to measure pressure ulcer healing

EYES

 Test near visual acuity

 Confrontation test
 Corneal Light Reflex test
 Cover test
 Cardinal field of gauze test
 Sneelen test

EARS

 Whisper test
 Rinne test
 Webber test
 Romberg Test

BREAST AND LYMPHATICS

 Breast self-examination (BSE)

PHIREPHERAL VASCULAR

 Allen test
 Ankle-brachial test
 Trendelenburg test

MUSCKOSKELETAL

 Phalen test
 Test for tinel sign
 Test Range Of Motion
 Bulge test
 Ballottement test

NEUROLOGIC

 Standard neurologic classification of spinal cord injury

MALE GENETALIA

 Testicular self-examination

SKIN, HAIR AND NAILS

SKIN -The skin is the largest organ of the body. It is a physical barrier that protects the
underlying tissues and organs from microorganisms, physical trauma, ultraviolet
radiation (UVR), and dehydration.

SUBCUTANEOUS TISSUE- beneath the dermis which contains varying amounts of fat, connects the skin
to underlying structures.

EPIDERMIS- the outer layer of skin, is composed of four distinct

layers: the stratum corneum, stratum lucidum, stratum granulosum, and
stratum germinativum. The outermost layer consists of dead, keratinized cells that
render the skin waterproof.

DERMIS- The inner layer of skin.

SEBACIOUS GLAND - They secrete anoily substance called sebum that waterproofs the hair and skin

HAIR- consists of layers of keratinized cells, found over much of the body except for
the lips, nipples, soles of the feet, palms of the hands, labia minora, and penis.
HAIR FOLLICLE- Hair develops within a sheath of epidermal cell

2 TYPES OF HAIR:

1. Vellus hair (peachfuzz) is short, pale, fine, and present over much of the body.
2. Terminal hair
(particularly scalp and eyebrows) is longer, generally darker, and coarser than vellus
hair. Puberty initiates the growth of additional terminal hair in both sexes on the
axillae, perineum, and legs

CUTICLE-The nails, located on the distal phalanges of fingers and toes, are hard, transparent
plates of keratinized epidermal cells that grow

NAIL BODY- extends over the entire nail bed and has a pink tinge as a result of bloodvessels underneath.

LUNULA- s a crescent-shaped area located at the base of thenail.

ABNORMAL FINDINGS:

ASSESSMENT PROCEDURE ABNORMAL FINDINGS

SKIN PALLOR (loss of color) is
seen in arterial
insufficiency, decreased
blood supply, and anemia.
Pallid tones vary from pale
to ashen without
underlying pink.
CYANOSIS
may cause white skin to
appear blue-tinged,
especially in the perioral,
 nail bed, and conjunctival
areas. Dark skin may
appear blue, dull, and
lifeless in the same areas.

JAUNDICE is characterized by yellow

skin tones, ranging from
pale to pumpkin,
particularly of the sclera,
oral mucosa, palms, and
soles.
ACANTHOSIS NIGRICANS is velvety
darkening of skin in body
folds and creases,
especially the neck,

Inspect for color variation BUTTERFLY RASH (also called

malar rash) across the
bridge of the nose and
cheeks characteristic of systemic
lupus erythematosus

ERYTHEMA
Skin redness
and warmth is seen in
inflammation, allergic
reactions, or trauma.

COMMON SKIN VARIATIONS:

-Freckles
-Vitiligo depigmentation of the skin
-Striae(sometimes called stretch marks)
-Scar
-Mole
-Seborrheic Keratosis, warty or crusty
pigmented lesion.
-Cutaneous horn
-Cutaneous tag, a raised papule with
depressed center
- Cherry Angiomas, small raised spots
typically seen with aging

PAPULE AND PLAQUE

Elevated, palpable, solid mass. Papules have a
circumscribed border and are less than 0.5
cm; plaques are greater than 0.5 cm.
NODULE AND TUMOR
Elevated, solid, palpable mass that extends
deeper into dermis than a papulealesced papules
with a flat top.
VESICLE AND BULLA
Circumscribed elevated, palpable mass
containing serous fluid
WHEAL
Elevated mass with transient borders that are
PUSTULE
Pus-filled vesicle or bulla. Examples include acne
(pictured below), impetigo, furuncles,
and carbuncles.ten irregular.
CYST
Encapsulated fluid-filled or semisolid mass that is
located in the subcutaneous tissue or
dermis. Examples include sebaceous cyst and
epidermoid cyst

SECONDARY SKIN LESIONS

EROSION
Loss of superficial epidermis that does not extend
to the dermis.
ULCER
Skin loss extending past epidermis, with necrotic
tissue loss.

SCAR (CICATRIX)
Skin mark left after healing of wound or lesion
that represents replacement by connective
tissue of the injured tissue.
FISSURE
Linear crack in the skin that may extend to the
dermis and may be painful

VASCULAR SKIN LESIONS:

PETECHIA (PL. PETECHIAE)

Round red or purple macule that is 1 to 2 mm
in size.
ECCHYMOSIS (PL. ECCHYMOSES)
Round or irregular macular lesion that is larger
than petechial lesion
HEMATOMA
A localized collection of blood creating an
elevated ecchymosis
CHERRY ANGIOMA
Papular and round, red or purple lesion found on
the trunk or extremities
SPIDER ANGIOMA
 Red arteriole lesion with a central body with
radiating branches.
TELANGIECTASIS (VENOUS STAR)
Bluish or red lesion with varying shape (spider-
like or linear) found on the legs and anterior
chest. It does not blanch when pressure is
applied.

CONFIGURATION OF SKIN LESIONS:

LINEARCONFIGURATION- Straight line, as in a

scratch or streak

ANNULAR
CONFIGURATION- Circular lesions. An example
is tinea corporis

CLUSTERED
CONFIGURATION-Lesions grouped together.

DISCRETE
CONFIGURATION-Individual and distinct
lesions.
NUMMULAR
CONFIGURATION- Coin-shaped lesions

ONFLUENT
CONFIGURATION
Smaller lesions run together to
form larger lesion

SCALP AND HAIR Pustules with hair loss in

patches are seen in tinea
capitis, a contagious
fungal disease (ringworm,

Infections of the hair

follicle (folliculitis) appear
as pustules surrounded by
erythema

TRACTION ALOPECIA
- Acquired hair loss results from
prolonged or repetitive tension of the
scalp hair.

ALOPECIA TOTALIS
-complete hair loss of the scalp
NAILS Pale or cyanotic nails may
indicate hypoxia or
anemia. Splinter
hemorrhages may be
caused by trauma.

Early clubbing (180-

degree angle with spongy
sensation) and late
clubbing (greater than
180-degree angle) can
occur from hypoxia.

Thickened nails
(especially toenails) may
be caused by decreased
circulation and are also
seen in onychomycosis.

Paronychia (inflammation)
indicates local infection.

Detachment of nail plate

from nail bed
(onycholysis) is seen in
infections or trauma.

COMMON NAIL DISORDER:

KOILONYCHIA
Spoon-shaped nails that may
be seen with trauma to
cuticles or nail folds or in iron
deficiency anemia, or
endocrine or cardiac disease

YELLOW NAIL
SYNDROME
Yellow nails grow slow and
are curved.

PARONYCHIA
Local infection.

LONGITUDINAL
RIDGING
Parallel ridges running
lengthwise
 HALF-AND-HALF NAILS
Nails that are white on the
upper proximal half and pink
on the distal half.

PITTING
Seen with psoriasis.

SKIN CANCER CHARACTERISTICS:

Asymmetry, Borders, Color, Diameter, Elevated

Most commonly detected cancer: Basal Cell Carcinoma(BCC), Squamos Cell Carcinoma( SCC), Melanoma

SELECTIVE COLLABORATIVE PROBLEMS:

RC: Allergic reaction

RC: Skin rash
RC: Insect/animal bite
RC: Septicemia
RC: Hypovolemic shock
RC: Skin infection
RC: Skin lesion
RC: Ischemic skin ulcers
RC: Graft rejection
RC: Hemorrhage

HEAD AND NECK

The framework of the head is the skull, which can be divided into two subsections:
the cranium and the face

CRANIUM The cranium houses and protects the brain and major sensory organs. It consists of
eight bones:
Frontal (1)
Parietal (2)
Temporal (2)
Occipital (1)
Ethmoid (1)
Sphenoid (1)
In the adult client, the cranial bones are joined together by immovable sutures:
the sagittal, coronal, squamosal, and lambdoid sutures.

FACE

Facial bones give shape to the face. The face consists of 14 bones

Maxilla (2)
Zygomatic (cheek) (2)
Inferior conchae (2)
Nasal (2)
Lacrimal (2)
Palatine (2)
Vomer (1)
Mandible (jaw) (1)

TEMPORAL ARTERY- major artery, is located between the eye and the top of the ear.

PAROTID GLANDS -are located on each side of the face, anterior and inferior to the ears, and behind the
mandible.

SUBMANDIBULAR GLANDS-are located inferior to the mandible, underneath the base of the tongue.

NECK

The structure of the neck is composed of muscles, ligaments, and the cervical
vertebrae.

The sternomastoid (sternocleidomastoid) and trapezius muscles are two of the paired
muscles that allow movement and provide support to the head and neck

The internal jugular veins and carotid arteries are located bilaterally, parallel and
anterior to the sternomastoid muscles

THYROID GLAND The thyroid gland is the largest endocrine gland in the body.

LYMPH NODES
Are located in the head and neck. filter lymph, a clear substance composed mostly of excess tissue fluid,
after the lymphatic vessels collect it but before it returns to the vascular system
The most common head and neck lymph nodes are referred to as follows:

Preauricular
Postauricular
Tonsillar
Occipital
Submandibular
Submental
Superficial cervical
Posterior cervical
Deep cervical
Supraclavicula

ABNORMAL FINDINGS
Head and Face MICROCEPHALY
An abnormal small head

ACROMEGALY
The skull and facial bones are larger
and thicker
PAGET DISEASE OF THE BONE
A corn-shaped enlarged skull bones

Drooping, weakness, or
paralysis on one side of
the face may result from a
stroke (cerebrovascular
accident, CVA) and
usually is seen with
paralysis or weakness of
other parts on that side of
the body.

A “mask-like” face marks

Parkinson disease;

a“sunken” face with

depressed eyes and
hollow cheeks is typical of
cachexia (emaciation or
wasting);

and a pale,
swollen face may result
from nephrotic syndrome.

the trachea may be

pulled to the affected side
 in cases of large
atelectasis, fibrosis, or
pleural adhesions. The
trachea is pushed to the
unaffected side in case of a tumor, enlarged
thyroid lobe, pneumothorax, or
with an aortic aneurysm

In cases of diffuse
enlargement, such as HYPERTHYROIDISM
Myxedema (severe hypothyroidism) is
characterized by a dull, puffy face; edema
around the eyes; and dry, course, and sparse
hair

CRUSHING SYNDROME
Cushing syndrome may present with a moon-
shaped face with reddened cheeks and
increased facial hair.

Graves disease, or
an endemic goiter, the
thyroid gland may be
palpated. An enlarged,
tender gland may result
from thyroiditis.

BELL PALSY
Bell palsy usually begins suddenly and
reaches a peak within 48 hours. Symptoms
may include twitching, weakness, paralysis,
drooping eyelid or corner of the mouth,
drooling, dry eye, dry mouth, decreased
ability to taste, eye tearing, and facial
distortion.

SCLERODERMA
A tightened, hard face with thinning facial skin is
seen in scleroderma.

SIMPLE GOITER
A simple (nontoxic) goiter is any
enlargement of the thyroid gland not caused
by inflammation or neoplasm

SELECTIVE COLLABORATIVE PROBLEMS:

RC: Hypercalcemia
RC: Corneal abrasion (associated with inability to close eyelids secondary to
exophthalmos)
RC: Thyroid crisis
RC: Thyroid dysfunction
RC: Cerebral vascular accident
RC: Seizures
RC: Cranial nerve impairment (fifth trigeminal, seventh facial, eleventh spinal
accessory)
RC: Increased intracranial pressure

TYPES OF HEADACHES:

1. SINUS HEADACHE deep, constant, throbbing pain: pressure like pain in one specific area of face
or head. Occur in one area of pain
2. CLUSTER HEADACHE stabbing pain: may be accompanied by tearing, eyelid drooping, reddened
eye or runny nose. Occur in localized eye and orbit and radiating to the facial and temporal
regions.
3. TENSION HEADACHE dull, tight, diffuse. Located in frontal, temporal, and occipital region.
4. MIGRAINE HEADACHE accompanied by nausea, vomiting and sensitivity to noise or light.
Located around the eyes, cheeks pr forehead.
5. TUMOR-REALTED HEADACHE aching steady. Varies with location of the tumor.

ASSESSING EYES
EXTERNAL EYE STRUCTURE:
The eyelids (upper and lower) are two movable structures composed of skin and two
types of muscle: striated and smooth. Their purpose is to protect the eye from
foreign bodies and limit the amount of light entering the eye.
The eyelids join at two points: the lateral (outer) canthus and medial (inner)
canthus. The medial canthus contains the puncta, two small openings that allow
drainage of tears into the lacrimal system, and the caruncle, a small, fleshy mass
that contains sebaceous glands.

The white space between open eyelids is called the

palpebral fissure.

Eyelashes are projections of stiff hair curving outward along the margins of the
eyelids that filter dust and dirt from air entering the eye.

The conjunctiva is a thin, transparent, continuous membrane that is divided into

two portions: a palpebral and a bulbar portion

The lacrimal apparatus consists of glands and ducts that lubricate the eye.

The lacrimal gland, located in the upper outer corner of the orbital cavity just
above the eye, produces tears

Tears empty into the lacrimal canals and are then channeled into the
nasolacrimal sac through the nasolacrimal duct.

The extraocular muscles are the six muscles attached to the outer surface of each
eyeball

INTERNAL STRUCTURE OF THE EYE:

The sclera is a dense, protective, white
covering that physically supports the internal structures of the eye.

The cornea permits

the entrance of light, which passes through the lens to the retina.

The ciliary body

consists of muscle tissue that controls the thickness of the lens, which must be
adapted to focus on objects near and far away

The iris is a circular disc of muscle containing pigments that determine eye
color.

The central aperture of the iris is called the pupil

The lens is a biconvex, transparent, avascular, encapsulated structure located

immediately posterior to the iris.

The choroid layer contains the vascularity necessary to provide nourishment to

the inner aspect of the eye and prevents light from reflecting internally.

The innermost layer, the retina, extends only to the ciliary body anteriorly
The optic disc is a cream-colored, circular area located on the retina toward the
medial or nasal side of the eye.

VISION
Visual Fields and Visual Pathways
A visual field refers to what a person sees with one eye.

Visual perception occurs as light rays strike the retina, where they are
transformed into nerve impulses, conducted to the brain through the optic nerve, and
interpreted

VISUAL REFLEXES
The pupillary light reflex causes pupils to constrict immediately when exposed to
bright light.

This can be seen as a direct reflex, in which constriction occurs in the

eye exposed to the light, or as an indirect or consensual reflex, in which exposure to
light in one eye results in constriction of the pupil in the opposite eye

Accommodation is a functional reflex allowing the eyes to focus on near objects

External eye ABNORMAL FINDINGS

Test distant visual activity Myopia (impaired far
vision) is present when
the second number in the
test result is larger than
the first (20/40)

Test near visual activity Presbyopia ( impaired near vision)

indicated when
the client moves the chart
away from the eyes to
focus on the print. It is
caused by decreased
accommodation and is common condition in
client’s over 45 years of age.

Test visual fields for A delayed or absent

gross peripheral vision perception of the
examiner’s finger
indicates reduced
peripheral vision

Perform corneal light Asymmetric position of the

reflex test. light reflex indicates
deviated alignment of the
 eyes

Perform cover test Phoria is a term used to

describe misalignment
that occurs only when
fusion reflex is blocked.

Strabismus is constant
malalignment of the eyes.

Tropia is a specific type of

misalignment: esotropia is
an inward turn of the eye,
and exotropia is an
outward turn of the eye
Perform the cardinal Failure of eyes to follow
fields of gaze test movement symmetrically
in any or all directions
indicates a weakness in
one or more extraocular muscle

Nystagmus—an oscillating
(shaking) movement of
the eye—may be
associated with an inner
ear disorder, multiple
sclerosis, brain lesions, or
narcotics use.
Inspect the eyelids and Drooping of the upper lid,
eyelashes. called ptosis (formal term
blepharoptosis), may be
attributed to oculomotor
nerve damage,
myasthenia gravis

An inverted lower lid is a

condition called an
entropion, which may
cause pain and injure the cornea as the
eyelash
brushes against the
conjunctiva and cornea

Ectropion, an everted
lower eyelid, results in
exposure and drying of
the conjunctiva
Hordeolum (stye), a hair
follicle infection, causes
local redness, swelling,
 and pain.
A chalazion, an
infection of the meibomian
gland (located in the
eyelid), may produce
extreme swelling of the lid,
moderate redness, but
minimal pain
Observe the position Protrusion of the eyeballs
and alignment of the accompanied by retracted
eyeball in the eye eyelid margins is termed
socket exophthalmos

Inspect the bulbar Generalized redness of

conjunctiva and sclera the conjunctiva suggests
conjunctivitis (pink eye).
Areas of dryness are
associated with allergies
or trauma.

Episcleritis is a local,
noninfectious
inflammation of the sclera.

Bright red areas on the

sclera indicate a
subconjunctival
hemorrhage. These are
often caused by sneezing,
coughing, or vomiting,
which may break a blood
vessel
Inspect the palpebral Cyanosis of the lower lid
conjunctiva suggests a heart or lung
disorder
Test pupillary reaction Monocular blindness can
to light. be detected when light
directed to the blind eye
results in no response in
either pupil. When light is
directed into the
unaffected eye, both
pupils constrict

Pupils do not react at all to

direct and consensual
pupillary testing

Pupils do not constrict;

eyes do not converge
 ABNORMAL FINDINGS ON EXTRAOCULAR
MUSCLE
(CORNEAL LIGHT REFLEX)
Pseudostrabismus
Normal in young children, the pupils will appear
at the inner canthus (due to the epicanthic
fold
Strabismus (or Tropia)
A constant malalignment of the eye axis,
strabismus is defined according to the direction
toward which the eye drifts and may cause
amblyopia
Exotropia (eyes turns outward)
Esotropia (eyes turns inwaRD

(COVER TEST)
Phoria (Mild Weakness)
Noticeable only with the cover test, phoria is less
likely to cause amblyopia than strabismus.
Esophoria is an inward drift and exophoria an
outward drift of the eye

(POST TEST)
Paralytic Strabismus
Noticeable with the positions test, paralytic
strabismus is usually the result of weakness or
paralysis of one or more extraocular muscles

3RD nerve paralysis: looks straight ahead.

4th nerve paralysis: The eye cannot look down
when turned inward
6th nerve paralysis: The eye cannot look to the
outer side
INTERNAL EYE Abnormalities of the red
reflex most often result
from cataracts. These
usually appear as black
spots against the
background of the red
light reflex. Two types of
age-related cataracts are
nuclear cataracts and
peripheral cataract

Papilledema, or swelling
of the optic disc, appears
as a swollen disc with
blurred margin

Optic atrophy is evidenced

by the disc being white in
color and a lack of disc
vessels

Hyphema occurs when

injury causes red blood
cells to collect in the lower
half of the anterior
chamber

Hypopyon usually results

from an inflammatory
response in which white
blood cells accumulate in
the anterior chamber and
produce clou

(Corneal abnormalities)
A corneal scar, which appears grayish white, may
be due to inflammation or an old injury.

Early pterygium, a thickening of the bulbar

conjunctiva that extends across the nasal side.

(LENS ABNORMALITIES)
Nuclear cataracts appear gray when seen with a
flashlight; they appear as a black spot
against the red reflex when seen through an
ophthalmoscope

Peripheral cataracts look like gray spokes that

point inward when seen with a flashlight;
they look like black spokes that point inward
against the red reflex when seen through an
ophthalmoscope

(ABNORMALITIRES OF THE IRIS)

IRREGULARLY-SHAPED IRIS
An irregularly-shaped iris causes a shallow
anterior chamber, which may increase the risk
for narrow-angle (closed-angle) glaucoma.

(ABNORMALITIES OF THE PUPIL)

Miosis
Also known as pinpoint pupils, miosis is
characterized by constricted and fixed pupils—
possibly a result of narcotic drugs or brain
damage

Anisocoria
Anisocoria is pupils of unequal size. In some
cases, the condition is normal; in other cases,
it is abnormal

Mydriasis
Dilated and fixed pupils, typically resulting from
central nervous system injury, circulatory
collapse, or deep anesthesia

(ABNORMALITIES OF THE OTIC DISCS)

PAPILLEDEMA
Swollen optic disc
Blurred margins
Hyperemic appearance from accumulation of
excess blood
Visible and numerous disc vessels
Lack of visible physiologic cup

GLAUCOMA
Enlarged physiologic cup occupying more than
half of the disc’s diameter
Pale base of enlarged physiologic cup
Obscured and/or displaced retinal vessel

OPTIC ATROPHY
White optic disc
Lack of disc vessels

(ABNORMALITIES OF THE RETINAL VESSELS

AND BACKGROUND)
CONSTRICTED ARTERIOLE
Narrowing of the arteriole
Occurs with hypertension
COPPER WIRE ARTERIOLE
Widening of the light reflex and a coppery color
Occurs with hypertension

SILVER WIRE ARTERIOLE

Opaque or silver appearance caused by
thickening of arteriole wall
Occurs with long-standing hypertension
ARTERIOVENOUS NICKING
AV crossing abnormality characterized by vein
appearing to stop short on either side of
arteriole
Caused by loss of arteriole wall transparency
from hypertension

ARTERIOVENOUS TAPERING
AV crossing abnormality characterized by vein
appearing to taper to a point on either
side of the arteriole
Caused by loss of arteriole wall transparency
from hypertension

ARTERIOVENOUS BANKING
AV crossing abnormality characterized by twisting
of the vein on the arteriole’s distal
side and formation of a dark, knuckle-like
structure

COTTON WOOL PATCHES

Also known as soft exudates, cotton wool patches
have a fluffy cotton ball appearance,
with irregular edges

HARD EXUDATE
Solid, smooth surface and well-defined edges
Creamy yellow-white, small, round spots typically
clustered in circular, linear, or star
pattern
Associated with diabetes mellitus and
hypertension

SUPERFICIAL (FLAME-SHAPED) RETINAL

HEMORRHAGES
Appear as small, flame-shaped, linear red streaks
on retinal background
Hypertension and papilledema are common
causes

DEEP (DOT-SHAPED) RETINAL HEMORRHAGES

Appear as small, irregular red spots with blurred
edges on retinal background
Lie deeper in retina than superficial retinal
hemorrhages
Associated with diabetes mellitus
 MICROANEURYSMS
Round, tiny red dots with smooth edges on
retinal background
Localized dilatations of small vessels in retina, but
vessels are too small to see
Associated with diabetic retinopathy

Abnormalities of the External

Eye Ptosis (drooping eye)

Ectropion (outwardly turned

lower lid)
Conjunctivitis (generalized
inflammation of the

ENTROPION
(inwardly turned lower
eyelid)

BLEPHARITIS
(staphylococcal infection of
the eyelid)

DIFFUSE EPISCLERITIS
(inflammation of the sclera

EXOPHTHALMOS
(protruding eyeballs and
retracted eyelids)

CHALAZION
(infected meibomian gland)

HORDEOLUM
(stye)
SUBCONJUNCTIVAL
HEMORRHAGE
(bright red areas of the sclera)

SCLERAL JAUNDICE

SELECTIVE COLLABORATIVE PROBLEMS:

Increased IOP
Corneal ulceration or abrasion

ASSSESSING EARS
External Ear
Inspect the auricle, Ears are smaller than 4
tragus, and lobule cm or larger than 10 cm

Macrotia is a congenital
excessive enlargement of
the external ear

Some abnormal findings

suggest various disorders,
including:
Enlarged preauricular
and postauricular
lymph nodes—infection

Tophi (nontender, hard,

cream-colored nodules
on the helix or antihelix,
containing uric acid
crystals)—gout

Blocked sebaceous
glands—postauricular
cysts
Ulcerated, crusted
nodules that bleed—
skin cancer (most often
seen on the helix due
to skin exposure)

Redness, swelling,
scaling, or itching—
otitis externa

Pale blue ear color—

frostbite

Move the pinna and A painful auricle or tragus

press on the tragus. is associated with otitis
Then palpate the externa or a postauricular
mastoid process. cyst.

Tenderness over the

mastoid process suggests
mastoiditis.

Tenderness behind the ear may occur with

Otitis media.
INTERNAL EAR: otoscopic Abnormal findings
associated with specific
examination disorders include:

Inspect the external Foul-smelling, sticky,

auditory canal yellow discharge—otitis
externa

or impacted
foreign body
Bloody, purulent
discharge—otitis media
with ruptured tympanic
membrane (TM)
Blood or watery
drainage (cerebrospinal
fluid)—skull trauma
(refer client to physician
immediately)
Impacted cerumen
blocking the view of the
external ear canal—
conductive hearing loss

Abnormal findings in the

ear canal may include:

Reddened, swollen
canals—otitis externa

Exostoses
(nonmalignant nodular
swellings)

Polyps may block the

view of the eardrum
Inspect the TM Abnormal findings in the
(eardrum) TM may include:

Red, bulging eardrum

and distorted,
 diminished, or absent
light reflex—acute otitis
media

Yellowish, bulging
membrane with
bubbles behind—
serous otitis media
Bluish or dark red color
—blood behind the
eardrum from skull
trauma

White spots—scarring
from infection
Perforations—trauma
from infection
Prominent landmarks—
eardrum retraction from
negative ear pressure
resulting from an
obstructed eustachian
tube
Obscured or absent
landmarks—eardrum
thickening from chronic
otitis media

With otitis media, the

membrane does not move
or flutter when the bulb is
inflated.
Perform the whisper test For whisper test, unable to
by asking the client to repeat the two-syllable
gently occlude the ear not word after two tries
being tested and rub the indicates hearing loss and
tragus with a finger in a requires follow-up testing
circular motion. Start with by an audiologist
testing the better hearing
ear and then the poorer
one. With your head 2 ft
behind the client (so that
the client cannot see your
lips move), whisper a two
syllable word such as
popcorn” or “football.” Ask
the client to repeat it back
to you. If the response is
incorrect the first time,
whisper the word one
more time. Identifying
three of six whispered
words is considered
passing the test. The
whisper test has been
studied in both pediatric
and adult clients to
evaluate hearing acuity
and has been found to
have a high sensitivity and
specificity
Perform the Weber test With conductive hearing
loss, the client reports
if the client reports
lateralization of sound to
diminished or lost
the poor ear—that is, the
hearing in one ear
client “hears” the sound in
the poor ear. The good
This
ear is distracted by
test helps evaluate the
background noise and
conduction of sound
conducted air, which the
waves through bone to
poor ear has trouble
help distinguish between
hearing. Thus, the poor
conductive hearing (sound
ear receives most of the
waves transmitted by the
sound conducted by bone
external and middle ear)
vibration
and sensorineural hearing
(sound waves transmitted
by the inner ear). Strike a With sensorineural
tuning fork softly with the hearing loss, the client
back of your hand and reports lateralization of
place it at the center of the sound to the good ear.
client’s head or forehead. Centering is This is because of limited
the important part. Ask perception of the sound
whether the client hears due to nerve damage in
the sound better in one the bad ear, making
ear or the same in both sound seem louder in the
ears. unaffected ear.
Perform the Romberg Client moves feet apart to
prevent falls or starts to
test. fall from loss of balance.
This tests the client’s This may indicate a
equilibrium. Ask the client vestibular disorder.
to stand with feet together,
arms at sides, and eyes
open, then with the eyes
closed.

Perform the Rinne test. With conductive hearing

The Rinne test compares loss, BC sound is heard
longer than or equally as
air and bone conduction long as AC sound (BC ≥
(AC and BC, respectively) AC). Conductive hearing loss
sounds occurs when sound is not
Although AC > BC in conducted through the
normal hearing, the Rinne outer ear canal to the
test is used to determine eardrum and ossicles of
the cause of the hearing the middle ear. Possible
loss (conduction or causes include fluid in
sensorineural) once it is middle ear, middle ear
determined that there is a infection (otitis media),
hearing loss allergies (serous otitis
media), eustachian tube
dysfunction, perforated
eardrum, benign tumors,
impacted cerumen,
infection in the ear canal
(external otitis), or the
presence of a foreign
bod

If the cause is
sensorineural, the finding
will also be AC > BC.
Sensorineural hearing loss occurs with
damage
to the inner ear (cochlea),
or to the nerve pathways
between the inner ear and
brain. This is the most
common type of
permanent hearing loss. It
decreases one’s ability to
hear faint sounds. Even
loud speech may be
muffled. Causes include a
virus, ototoxic drugs,
genetic hearing loss,
aging, head trauma,
abrupt changes in air
pressure, malformation of
the inner ear, loud noise
exposure, Meniere
disease, and autoimmune
inner ear disease

Abnormalities of the Tympanic ACUTE OTITIS MEDIA

Membrane Note the red, bulging
 membrane; decreased or
absent light reflex.

BLUE/DARK RED
TYMPANIC MEMBRANE
Indicates blood behind
eardrum due to trauma.

PERFORATED
TYMPANIC MEMBRANE
Perforation results from
rupture caused by increased
pressure, usually from
untreated infection or trauma.

SEROUS OTITIS MEDIA

Note the yellowish, bulging
membrane with bubbles
behind it.

SCARRED TYMPANIC
MEMBRANE
White spots and streaks
indicate scarring from
infections.

RETRACTED TYMPANIC
MEMBRANE
Prominent landmarks are
caused by negative ear
pressure due to obstructed
eustachian tube or chronic
otitis media

CHRONIC SUPPURATIVE OTITIS MEDIA WITH

CHOLESTEATOMA

TYMPANIC MEMBRANE WITH TYMPANOSTOMY

TUBE IN PLACE

SELECTIVE COLLABORATIVE PROBLEMS:

Otitis media (acute, chronic, or serous)

Otitis externa, Perforated tympanic membrane

ASSESSING MOUTH, THROAT, NOES AND SINUSES
LIPS ABNORMAL FINDINGS
Inspect the lips. Dry, cracked lips are seen
with dehydration. Lesions
or ulcers of the lips are
seen with viral infections.
Lip cancer can occur
anywhere but is most
common on lower lip. Most lip cancers
are
squamous cell
carcinomas.

Pallor around
the lips (circumoral pallor)
is seen in anemia and
shock.

Bluish (cyanotic)
lips may result from cold
or hypoxia.

Reddish lips
are seen in clients with
ketoacidosis, carbon
monoxide poisoning, and
chronic obstructive
pulmonary disease
(COPD) with
polycythemia.

Swelling of
the lips (edema) is
common in local or
systemic allergic or
anaphylactic reaction
Inspect the teeth
Receding gums.

Red, swollen gums that

bleed easily are seen in
gingivitis, scurvy (vitamin
C deficiency), and
leukemia.

Receding red
 gums with loss of teeth
are seen in periodontitis.

Enlarged, reddened gums

(hyperplasia) that may
cover some of the
normally exposed teeth
may be seen in
pregnancy, puberty,
leukemia, and with use of
some medications, such
as phenytoin.

A bluish-
black or gray-white line
along the gum line (Burton
line) is seen in lead poisoning
MOUTH
Inspect the buccal Leukoplakia (chalky white
mucosa raised patches) may be
seen in chronic irritation,
heavy smoking, and
alcohol use. These are
precancerous lesions and
should be referred to the
client’s primary health
care provider for further
assessment.

Whitish, curd-like patches

that scrape off over
reddened mucosa and
bleed easily indicate
“thrush” (Candida
albicans) infection.

Koplik spots (tiny whitish spots that lie over

reddened mucosa) are an
early sign of measles

Brown patches may

appear inside the cheeks
of clients with Addison
disease (chronic
adrenocortical
insufficiency)
Inspect Stensen ducts Reddened opening of
/parotid ducts Stensen ducts is seen
with mumps
Inspect and palpate the Abnormalities include the
tongue following:
-Smokers may also
have a yellow brown Dry; nodules, ulcers
coating on the tongue, present; papillae or
which is not leukoplakia.
fissures absent;
asymmetrical. Deep
longitudinal fissures are
seen in dehydration; black
hairy tongue seen with
conditions causing
hyposalivation, heavy
smoking, alcohol intake,
use of antibiotics that
inhibit normal bacteria
leading to fungus, use of
mouthwashes; also seen
with bismuth intake

Raised whitish feathery

areas on sides of tongue
that cannot be scraped off
suggest hairy leukoplakias
seen in HIV infection and
AIDS.
A smooth, reddish, shiny
tongue without papillae is
indicative of niacin or
vitamin B12 deficiencies,
certain anemias, and
antineoplastic therapy

An enlarged tongue
suggests hypothyroidism,
acromegaly, or Down
syndrome, and
angioneurotic edema of
anaphylaxis.

A very small
tongue suggests
malnutrition.

An atrophied
tongue or fasciculations
point to cranial nerve
(hypoglossal, cranial
nerve XII) damage.
Assess the ventral
surface of the tongue. Leukoplakia, persistent
lesions, ulcers, or nodules
may indicate cancer and
should be referred.
Induration increases the
likelihood of cancer
Palpate
The area if you see lesions, if the client is The underneath the tongue
over age 50, is the most common site
or if the client uses of oral cancer.
tobacco or alcohol. Note
any induration. Check also
for a short frenulum that
limits tongue motion (the
origin of “tongue-tied”

-The older client may

have varicose veins on
the ventral surface of the
tongue
Inspect for Wharton Abnormal findings include
ducts—openings from the lesions, ulcers, nodules,
submandibular salivary or hypertrophied duct
glands—located on either openings on either side of
side of the frenulum on the frenulum
floor of the mouth.

Observe the sides of the Canker sores may be

tongue. seen on the sides of the
tongue in clients receiving
certain kinds of
chemotherapy.

Leukoplakia, persistent
lesions, ulcers, or nodules
may indicate cancer and
should be further
evaluated medically.
Check the strength of Decreased tongue
the tongue strength may occur with a
defect of cranial nerve XII
—hypoglossal—or with a
shortened frenulum that
limits motion
Check the anterior Loss of taste
tongue’s ability to taste discrimination occurs with
trauma, viral infections,
sinusitis and polyposis,
 increasing age, neurologic
illnesses such as
Parkinson or Alzheimer
and zinc deficiency, or use
of certain medications that
affect smell threshold
Inspect the hard A candidal infection may
(anterior) and soft appear as thick white
(posterior) palates and plaques on the hard
uvula palate. Deep purple,
raised, or flat lesions may
indicate a Kaposi sarcoma

A yellow tint to the hard

palate may indicate
jaundice because bilirubin
adheres to elastic tissue
(collagen). An opening in
the hard palate is known
as a cleft palate
Note odor
Fruity or acetone breath is
associated with diabetic
ketoacidosis.
An ammonia
odor is often associated
with kidney disease.

Foul odors may indicate an oral

or respiratory infection, or
tooth decay.
Alcohol or
tobacco use may be
identified by breath odor.
Fecal breath odor occurs
in bowel obstruction;

S
ulfur odor (fetor
hepaticus) occurs in end-
stage liver disease
Assess the uvula Asymmetric movement or
loss of movement may
occur after a
cerebrovascular accident
(stroke). Palate fails to
rise and uvula deviates to
normal side with cranial
 nerve X (vagus) paralysis
Inspect the tonsils. Tonsils are red, enlarged
(to 2+, 3+, or 4+), and
covered with exudate in
tonsillitis. They also may
be indurated with patches
of white or yellow exudate

Grading of tonsils in
tonsillitis is depicted in
Inspect the posterior A bright red throat with
pharyngeal wall. white or yellow exudate
indicates pharyngitis.

NOSE NASAL POLYP – are small, pale, round, firm over

Inspect the internal growths or masses on mucosa.
nose
PERFORATED SEPTUM
It opens a path from one side of your nose to
the other. Symptoms are
bleeding (epistaxis) or
crusting may be noted on
the lower anterior part of
the nasal septum with
local irritation.

Ulcers of
the nasal mucosa or a
perforated septum may be
seen with use of cocaine,
trauma, chronic infection,
or chronic nose picking

Nasal mucosa is red and swollen with upper

respiratory tract infection.

Purulent discharge is seen with acute

bacterial rhinosinusitis.
SINUSES Frontal or maxillary
Palpate the sinuses sinuses are tender to
palpation in clients with
allergies or acute bacterial
rhinosinusitis. If the client
has a large amount of
exudate, you may feel
crepitus upon palpation
over the maxillary sinuses.
This may also be present
 with a viral URI
Percuss the sinuses. The frontal and maxillary
sinuses are tender upon
percussion in clients with
allergies or sinus infection.
HERPES SIMPLEX TYPE
I (COLD SORES)
Clear vesicles surrounded by
red indurated base

CHEILOSIS OF LIPS
Scaling painful fissures at
corner of lips

CARCINOMA OF LIP
Round, indurated lesion
becomes crusted and ulcerated
with elevated border

SMOOTH, REDDISH,
SHINY TONGUE
WITHOUT PAPILLAE
DUE TO VITAMIN B12
DEFICIENCY

BLACK HAIRY TONGUE

Not hair, but elongated
filiform papillae seen with
use of antibiotics that inhibit
normal bacteria

CARCINOMA OF
TONGUE
Round indurated lesion
becomes crusty and ulcerated
with elevated border

CANKER SORE
Painful small ulcers inside mouth; do not occur
on lip surface; noncontagious

ACUTE TONSILLITIS
Acute tonsillitis secondary to infectious
mononucleosis.
Note the marked tonsillar enlargement with
erythema and
the large white-gray patches
 STREPTOCOCCAL PHARYNGITIS
Characterized by an erythematous posterior
pharynx (A), palatal petechiae (B), and a white
strawberry tongue (C)

GINGIVITIS
Red swollen gums that easily
bleed

RECEDING GUMS
Gum tissue surrounding tooth
pulls back, exposing more of
tooth or root of tooth

KAPOSI SARCOMA
LESIONS
Advanced lesions seen in HIV

LEUKOPLAKIA
(VENTRAL SURFACE)
Thick raised patch does not
scrape off; seen in heavy
tobacco or alcohol use

HAIRY LEUKOPLAKIA (LATERAL SURFACE)

CANDIDA ALBICANS NFECTION (THRUSH)

Curd-like patches easily
scrape off, leaving a reddened
area
SELECTIVE COLLABORATIVE
PROBLEMS RC: Nosebleed
RC: Sinusitis (bacterial)
RC: Stomatitis
RC: Gum infection (gingivitis, periodontitis)
RC: Oral lesions
RC: Laryngeal edema

ASSESSING HEART AND NECK VESSELS

,