22.5: Summary
22.1 Head and Neck
The head contains the skull, brain, and face. Common functions of the head include eating, breathing, and communication. The head houses the brain and sensory organs responsible for vision, hearing, smell, taste, and touch. The neck contains muscles, vertebrae, blood vessels , the thyroid gland, and lymph node s. The neck is a vital region of the body that supports head movement, breathing, swallowing, communication, circulation, and immune responses.
Nursing assessment of the head and neck includes inspecting and palpating structures of the head, face, and neck. Subjective data collected from the patient and objective data collected through the assessment should be verified and documented appropriately.
Abnormalities of the head and neck include conditions such as headache, concussion, head injury , acromegaly, Cushing syndrome, scleroderma, Bell palsy, myxedema, and simple goiters.
22.2 Eyes
External structures of the eye include the eyebrows, eyelids, eyelashes, conjunctiva, cornea, sclera, iris, pupil, lacrimal gland, and lacrimal ducts. Internal structures of the eye include the lens, ciliary muscle, vitreous humor, retina, cones, rods, macula, optic nerve, and optic disc. The primary function of the eyes is to enable vision. Key elements of vision include visual fields, visual pathways , and visual reflexes.
The nursing assessment includes inspecting the eyes by assessing the pupils, visual acuity, extraocular movements, and peripheral vision. Objective and subjective findings should be validated to ensure accuracy prior to documenting the findings.
Abnormalities of the external eye include conditions such as conjunctivitis, stye, chalazion, ptosis, ectropion, and exophthalmos. Abnormalities of the internal eye include conditions such as pterygium, corneal abrasions and scars, cataracts, irregularly shaped iris, mydriasis, anisocoria, miosis, papilledema, glaucoma, optic atrophy, and macular degeneration. Visual abnormalities include conditions such as myopia, hyperopia, astigmatism, presbyopia, color blindness, amblyopia, strabismus, diplopia, floaters, flashes, photophobia, night blindness, and halos.
22.3 Ears
The ear consists of three main parts: the outer ear, the middle ear, and the inner ear. The external ear is composed of the pinna (auricle) and the external auditory canal. The middle ear is composed of the eardrum ( tympanic membrane ), ossicles , and eustachian tube. The inner ear is composed of the cochlea and the vestibular system . The ear functions to enable hearing and maintain balance.
Nursing assessment of the ear involves collecting subjective and objective data. Subjective data can be obtained by asking the patient about factors such as symptoms, hearing changes, ear pain, medications, occupational and recreational exposures, and personal habits. Objective data can be obtained by inspecting and palpating the external ear, inspecting the ear canal and tympanic membrane, conducting hearing tests, as well as performing balance and equilibrium assessments.
Abnormalities of the ear can often lead to hearing loss, tinnitus, and vertigo. Abnormalities of the external ear and canal include conditions such as microtia , macrotia , Stahl ear, cauliflower ear, otitis externa , earwax impaction, foreign bodies in the ear canal, and ear tags. Abnormalities of the middle ear include conditions such as perforated eardrum s, tympanosclerosis , tympanic membrane retraction , myringitis , otitis media , and foreign bodies in the ear. Abnormalities of the inner ear include conditions such as sensorineural hearing loss , Ménière disease, labyrinthitis, and inner ear trauma.
22.4 Mouth, Throat, Nose, and Sinuses
The mouth is located at the opening of the digestive and respiratory tracts and is composed of lips, teeth, jaws, tongue, palate, uvula, and salivary glands. Functions of the mouth include eating, tasting, speaking, initiating digestion, and speech.
The throat is a muscular tube that connects the nasal cavity and mouth to the larynx and the esophagus. Functions of the throat include breathing, swallowing, speech production, and protection of the airway.
The nose is composed of the nasal bridge, nostrils, nasal cavities, nasal septum , and turbinates . Functions of the nose include facilitating breathing, detecting smells, influencing speech, contributing to immune defense, and aiding in temperature regulation.
Sinuses are a group of air-filled spaces within the bones of the face and skull, located around the nose and above the eyes, that connect to the nasal cavity. Functions of the sinuses include insulating the skill, adding warmth and humidity to the air that is breathed in, producing mucus, and adding voice resonance.
Nursing assessment of the mouth, throat, nose, and sinuses involves collecting subjective data through a series of questions, as well as objective data by performing a nursing assessment using inspection and palpation methods. Comparing subjective and objective data helps to ensure data collected and documented are reliable and accurate.
Abnormalities of the mouth may include conditions such as oral ulcers , leukoplakia , erythroplakia , thrush, oral cancer , cleft lip , cleft palate , halitosis , tooth decay , gum disease , dry mouth , tooth mobility , toothache, and discolored teeth . Abnormalities of the throat may include conditions such as enlarged tonsils , tonsillar exudate , pharyngitis , laryngitis , epiglottitis , GERD, throat cancer , and dysphagia . Abnormalities of the nose and sinuses may include conditions such as epistaxis , deviated septum , sinusitis , nasal polyp s, rhinitis , fracture, congestion, obstruction, discharge, and nose deformities.