Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
Department of Nursing

Lucinda Campus, Brgy. Ungot, TarlacCityPhilippines 2300

Tel.no.: (045) 493-1865 Fax: (045) 982-0110 website: www.tsu.edu.ph
Awarded Level 2 Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines Inc
(AACCUP)

TOPIC: ASSESSMENT OF THE EYES, EARS, NOSE, MOUTH AND OROPHARYNX

HEALTH ASSESSMENT is an evaluation of the health status of an individual by performing the

two most important parts of assessment that includes:
● 1.PHYSICAL EXAMINATION
● 2. Obtaining HEALTH HISTORY

TYPES OF DATA
● SUBJECTIVE DATA are information from the client’s point of view (“symptoms”),
including feelings, perceptions, and concerns obtained through interviews.
● OBJECTIVE DATA are observable and measurable data (“signs”) obtained through
observation, physical examination, and laboratory and diagnostic testing.

ASSESSMENT TECHNIQUES
1. Inspection
The examiner will look at, or "inspect" specific areas of the body for normal color, shape
and consistency. Certain findings on "inspection" may alert the healthcare provider to focus
other parts of the physical exam on certain areas of the body. This technique uses the sense of
sight

For example, your legs may have redness and swelling. Your healthcare provider will then
pay special attention to the common things that cause swelling, such as extra fluid, and then
use this information to help them make a diagnosis

2. Palpation
This is when the examiner uses their hands to feel for abnormalities during a health
assessment. This technique uses the sense of touch. Things that are commonly palpated
during an exam include your lymph nodes, chest wall (to see if your heart is beating harder
than normal), and your abdomen. You will use palpation to see if there are any masses or
lumps, anywhere in the body.

1
 3. Percussion
This is when the examiner uses their hands to "tap" on an area of the patient’s body.
The "tapping" produces different sounds. Sounds depends on the kind of sounds that are
produced over the abdomen, on the back or chest wall. Healthcare provider may determine
anything from fluid in the lungs, or a mass in the stomach. This will provide further clues to a
possible diagnosis.

4. Auscultation
This is an important physical examination technique used by the healthcare provider, where he
or she will listen to the heart, lungs, neck or abdomen. This is to identify if any problems are
present. Auscultation is often performed by using a STETHOSCOPE.

The stethoscope will amplify sounds heard in the area that is being listened to. If there is an
abnormal finding on the examination, further testing may be suggested.

CONTENT:

ASSESSMENT OF THE EYES, EARS, NOSE, MOUTH, AND OROPHARYNX

A. Assessment of the Eyes

It is recommended that people under age 40 have their eyes tested every 3 to 5 years, or
more frequently if there is a family history of diabetes, hypertension, blood dyscrasia, or eye
disease (e.g., glaucoma). After age 40, an eye examination is recommended every 2 years.
Assessment includes:
• External Eye Structure
• Internal Eye Structure
• Peripheral Vision
• Extraocular Movements
• Visual Acuity

2
Eye Structures

Eye Structures Assessment

Area Normal Findings Abnormal Findings
Eye Brows • Hair evenly distributed; • Loss of hair; scaling and
skin intact flakiness of skin
• Eyebrows symmetrically • Unequal alignment and
aligned; equal movement movement of eyebrows
Eye Lashes • Equally distributed; • Turned inward
curled slightly outward
Eye Lids • Skin intact; no discharge; • Redness, swelling,
no discoloration flaking, crusting, plaques,
• Lids close symmetrically discharge, nodules,
• Approximately 15 to 20 lesions
involuntary blinks per • Lids close
minute; bilateral blinking asymmetrically,
• When lids open, no incompletely, or
visible sclera above painfully
corneas, and upper and • Rapid, monocular,
lower borders of cornea absent, or infrequent
are slightly covered blinking
• Ptosis, ectropion, or
entropion; rim of sclera
visible between lid and
iris
Sclera • Transparent; capillaries • Jaundiced sclera (e.g., in
sometimes evident; sclera liver disease);
appears white (darker or excessively pale sclera
yellowish and with small (e.g., in anemia);
brown macules in dark- reddened sclera
skinned clients) (marijuana use,
rheumatoid disease);
lesions or nodules (may
indicate damage by
mechanical, chemical,
allergenic, or bacterial
agents)
Lacrimal Gland • Lacrimal gland is • Presence of edema and
normally non palpable pain
• No tenderness on
palpation

3
 • No regurgitation from the
nasolacrimal duct
Cornea • Transparent, shiny, and • Opaque; surface not
smooth; details of the iris smooth (may be the result
are visible of trauma or abrasion)
• In older people, a thin, • Arcus senilis in clients
grayish white ring around under age 40
the margin, called arcus
senilis, may be evident
Pupils • Black in color; equal in • Cloudiness, mydriasis,
size; normally 3 to 7 mm miosis, anisocoria;
in diameter; round, • bulging of iris toward
smooth border, iris flat cornea
and round

Anisocoria

Area Normal Findings Abnormal Findings

Pupils (cont’d) • Illuminated pupil • Neither pupil constricts
constricts (direct • Unequal responses
response) • Response is sluggish
• Nonilluminated pupil • Absent responses
constricts (consensual • One or both pupils fail to
response) constrict, dilate, or
• Response is brisk converge
• Pupils constrict when
looking at near object;

4
 pupils dilate when
looking at far object
• Pupils converge when
near object is moved
toward nose.

Visual Fields Assessment

Area Normal Findings Abnormal Findings
Peripheral Visual Fields • When looking straight • Visual field smaller than
ahead, client can see normal (possible
objects in the periphery glaucoma); one-half
vision in one or both eyes
(possible nerve damage)

Extra Ocular Muscle Test

Area Normal Findings Abnormal Findings
Six Ocular Movements • Both eyes coordinated, • Eye movements not
move in unison, with coordinated or parallel;
parallel alignment one or both eyes fail to
follow a penlight in
specific directions, e.g.,
strabismus (cross-eye)
• Nystagmus (rapid
involuntary rhythmic eye
movement) other than at
end point may indicate
neurologic impairment

5
Strabismus and Nystagmus

Area Normal Findings Abnormal Findings

Hirschberg test • Light falls symmetrically • Light falls off center on
(e.g., at “6 o’clock” on one eye
both pupils)
Cover Test • Uncovered eye does not • If misalignment is
move present, when dominant
eye is covered, the
uncovered eye will move
to focus on object

Visual Acuity Test

Area Normal Findings Abnormal Findings
Near Vision • Able to read newsprint • Difficulty reading
newsprint unless due to
aging process
Distance Vision • 20/20 vision on Snellen- • Denominator of 40 or
type chart more on Snellen-type
chart with corrective
lenses

6
 Three Types of Eye Charts
Lifespan Considerations
Infants
• Infants 4 weeks of age should gaze at and follow objects.
• Ability to focus with both eyes should be present by 6 months of age.
• Infants do not have tears until about 3 months of age.
• Visual acuity is about 20/300 at 4 months and progressively improves.
Children
• Epicanthal folds, common in individuals of Asian cultures, may cover the medial canthus
and cause eyes to appear misaligned.
• Epicanthal folds may also be seen in young children of any race before the bridge of the
nose begins to elevate.
• Preschool children’s acuity can be checked with picture cards or the Snellen E chart. Acuity
should approach 20/20 by 6 years of age.
• A cover test and the corneal light reflex (Hirschberg) test should be conducted on young
children to detect misalignment early and prevent amblyopia.
• Always perform the acuity test with glasses on if a child has prescription lenses.
• Children should be tested for color vision deficit. From 8% to 10% of Caucasian males and
from 0.5% to 1% of Caucasian females have this deficit.
Older Adults
• Visual acuity decreases as the lens of the eye ages and becomes Accommodation to far
objects often improves, but accommodation to near objects decreases.
• Color vision declines; older people are less able to perceive purple colors and to
discriminate pastel colors.
• Many older adults wear corrective lenses; they are most likely to have hyperopia. Visual
changes are due to loss of elasticity (presbyopia) and transparency of the lens opaquer and
loses elasticity.
• The ability of the iris to accommodate to darkness and dim light diminishes.

7
 • Peripheral vision diminishes.
• The adaptation to light (glare) and dark decreases.

B. Assessment of the Ears

Assessment of the ear includes direct inspection and palpation of the external ear,
inspection of the internal parts of the ear by an otoscope, and determination of auditory acuity.
The ear is usually assessed during an initial physical examination; periodic reassessments
may be necessary for long-term clients or those with hearing problems.
Types of Hearing Loss
• Conductive hearing loss is the result of interrupted transmission of sound waves through
the outer and middle ear structures. Possible causes are a tear in the tympanic membrane
or an obstruction, due to swelling or other causes, in the auditory canal.
• Sensorineural hearing loss is the result of damage to the inner ear, the auditory nerve, or
the hearing center in the brain.
• Mixed hearing loss is a combination of conduction and sensorineural loss.
Ear Structure

Assessment of the Auricles

Area Normal Findings Abnormal Findings
Auricles • Color same as facial skin • Bluish color of earlobes
• Symmetrical (e.g., cyanosis); pallor
• Auricle aligned with (e.g., frostbite); excessive
outer canthus of eye, redness (inflammation or
about 10°, from vertical fever)
• Asymmetry
• Low-set ears (associated
with a congenital
abnormality, such as
Down syndrome)

8
 Area Normal Findings Abnormal Findings
Auricles (cont’d) • Mobile, firm, and not • Lesions (e.g., cysts);
tender; pinna recoils after flaky, scaly skin (e.g.,
it is folded seborrhea); tenderness
when moved or pressed
(may indicate
inflammation or infection
of external ear)

External Ear Canal and Tympanic Membrane Assessment

Area Normal Findings Abnormal Findings
External Ear Canal • Distal third contains hair • Redness and discharge
follicles and glands • Scaling
• Dry cerumen, grayish-tan • Excessive cerumen
color; or sticky, wet obstructing canal
cerumen in various shades
of brown
Tympanic Membrane • Pearly gray color, • Yellow-amber
semitransparent Pink to • White
red, some opacity • Blue or deep red
• Dull surface

Visualize the tympanic membrane using an otoscope.

9
 Inserting an Otoscope
Gross Hearing Acuity Tests
Area Normal Findings Abnormal Findings
Response to Normal Voice • Normal voice tones • Normal voice tones not
Tones audible audible (e.g., requests
nurse to repeat words or
statements, leans toward
the speaker, turns the
head, cups the ears, or
speaks in loud tone of
voice)
Whisper Test • Able to repeat the phrases • Unable to repeat the
correctly in both ears phrases in one or both
ears
Webber Test • Sound is heard in both • Sound is heard better in
ears or is localized at the impaired ear, indicating a
center of the head (Weber bone-conductive hearing
negative) loss; or sound is heard
better in ear without a
problem, indicating a
sensorineural disturbance
(Weber positive)

Webber Test Rinne Test Romberg Test

10
 Area Normal Findings Abnormal Findings
Rinne Test • Air-conducted (AC) • Bone conduction time is
hearing is greater than equal to or longer than
bone-conducted (BC) the air conduction time,
hearing, i.e., AC > BC i.e., BC > AC or BC =
(positive Rinne) AC (negative Rinne;
indicates a conductive
hearing loss)
Romberg Test • Balance is maintained • Presence of tendency to
even when eyes are sway, fall, or loss of
closed balance

Lifespan Considerations
Infants
• To assess gross hearing, ring a bell from behind the infant or have the parent call the child’s
name to check for a response.
• Newborns will quiet to the sound and may open their eyes wider. By 3 to 4 months of age,
the child will turn head and eyes toward the sound.
• All newborns should be assessed for hearing prior to discharge from the hospital.
Children
• To inspect the external canal and tympanic membrane in children less than 3 years old, pull
the pinna down and back. Insert the speculum only 0.6 to 1.25 cm (0.25 to 0.5 in).
• Perform routine hearing checks and follow up on abnormal results. In addition to
congenital or infection-related causes of hearing loss, noise-induced hearing loss is
becoming more common in adolescents and young adults as a result of exposure to loud
music and prolonged use of headsets at extremely loud volumes.
Older Adults
• The skin of the ear may appear dry and be less resilient because of the loss of connective
tissue.
• Increased coarse and wire like hair growth occurs along the helix, antihelix, and tragus.
• The pinna increases in both width and length, and the earlobe elongates.
• Earwax is drier.
• The tympanic membrane is more translucent and less flexible. The intensity of the light
reflex may diminish slightly.
• Sensorineural hearing loss occurs.
• Generalized hearing loss (presbycusis) occurs in all frequencies, although the first
symptom is the loss of high-frequency sounds: the f, s, sh, and ph sounds.

11
 C. Assessment of the Nose and Sinuses
A nurse can inspect the nasal passages very simply with a flashlight. However, a nasal
speculum and a penlight or an otoscope with a nasal attachment facilitates examination of the nasal
cavity.
Assessment of the nose includes inspection and palpation of the external nose (the upper
third of the nose is bone; the remainder is cartilage); patency of the nasal cavities; and inspection
of the nasal cavities.
Facial Sinuses

Assessment of the Nose

Area Normal Findings Abnormal Findings

External Nose • Symmetric and straight • Asymmetric
• No discharge or flaring • Discharge from nares
• Uniform color • Localized areas of
• Not tender; no lesions redness or presence of
skin lesions
• Tenderness on palpation;
presence of lesions
Patency of Nasal Cavities • Air moves freely as the • Air movement is
client breathes through restricted in one or both
the nares nares
Inspection of the Nasal • Mucosa pink • Mucosa red, edematous
Cavity • Clear, watery discharge • Abnormal discharge (e.g.,
• No lesions pus)
• Presence of lesions (e.g.,
polyps)

12
 Nasal Septum • Nasal septum intact and • Septum deviated to the
in midline right or to the left

Assessment of the Facial Sinuses

Area Normal Findings Abnormal Findings
Maxillary and Frontal • Not tender • Tenderness in one or
Sinuses more sinuses

Percussion of the Frontal and Maxillary Sinuses

Transillumination of the Frontal and Maxillary Sinuses

Lifespan Considerations
Infants
• A speculum is usually not necessary to examine the septum, turbinates, and vestibule.
Instead, push the tip of the nose upward with the thumb and shine a light into the nares.

13
 • Ethmoid and maxillary sinuses are present at birth; frontal sinuses begin to develop by 1
to 2 years of age; and sphenoid sinuses develop later in childhood. Infants and young
children have fewer sinus problems than older children and adolescents.
Children
• A speculum is usually not necessary to examine the septum, turbinates, and vestibule. It
might cause the child to be apprehensive. Instead, push the tip of the nose upward with
the thumb and shine a light into the nares.
• Ethmoid sinuses continue to develop until age 12.
• Cough and runny nose are the most common signs of sinusitis in preadolescent children.
• Adolescents may have headaches, facial tenderness, and swelling, similar to the signs
seen in adults.
Older Adults
• The sense of smell markedly diminishes because of a decrease in the number of olfactory
nerve fibers and atrophy of the remaining fibers. Older adults are less able to identify and
discriminate odors.
• Nosebleeds may result from hypertensive disease or other arterial vessel changes.

D. Assessment of the Mouth and Oropharynx

The mouth and oropharynx are composed of a number of structures: lips, oral mucosa,
the tongue and floor of the mouth, teeth and gums, hard and soft palate, uvula, salivary glands,
tonsillar pillars, and tonsils.
Structures of the Mouth and Oropharynx

Assessment of the Lips and Buccal Mucosa

Area Normal Findings Abnormal Findings
Outer Lips • Uniform pink color • Pallor; cyanosis
(darker, e.g., bluish hue, • Blisters; generalized or
in Mediterranean groups localized swelling;
and dark-skinned clients) fissures, crusts, or scales
• Soft, moist, smooth (may result from
texture excessive moisture,
• Symmetry of contour

14
 • Ability to purse lips nutritional deficiency, or
fluid deficit)
• Inability to purse lips
(may indicate facial nerve
damage)
Inner Lips • Uniform pink color • Pallor; leukoplakia (white
(freckled brown patches), red, bleeding
pigmentation in dark-
skinned clients)
Mouth • Moist, smooth, soft, • Excessive dryness
glistening, and elastic • Mucosal cysts; irritations
texture (drier oral mucosa from dentures; abrasions,
in older clients due to ulcerations; nodules
decreased salivation)

Assessment of the Teeth and Gums

Area Normal Findings Abnormal Findings
Teeth and Gums • 32 adult teeth • Missing teeth; ill-fitting
• Smooth, white, shiny dentures
tooth enamel • Brown or black
• Pink gums (bluish or discoloration of the
brown patches in dark- enamel (may indicate
skinned clients) staining or the presence
• Moist, firm texture to of caries)
gums • Excessively red gums
• No retraction of gums • Spongy texture; bleeding;
tenderness (may indicate
periodontal disease)
• Receding, atrophied
gums; swelling that

Inspecting the Buccal Mucosa and Teeth

15
 Area Normal Findings Abnormal Findings
Dentures • Smooth, intact dentures • Ill-fitting dentures;
irritated and excoriated
area under dentures

Assessment of the Tongue/Floor of the Mouth

Area Normal Findings Abnormal Findings
Tongue • Central position • Deviated from center
• Pink color (some brown (may indicate damage to
pigmentation on tongue hypoglossal [12th cranial]
borders in dark-skinned nerve); excessive
clients); moist; slightly trembling
rough; thin whitish • Smooth red tongue (may
coating indicate iron, vitamin
• Smooth, lateral margins; B12, or vitamin B3
no lesions deficiency)
• Raised papillae (taste • Dry, furry tongue
buds) (associated with fluid
deficit), white coating
(may be oral yeast
infection)
• Nodes, ulcerations,
discolorations (white or
red areas); areas of
tenderness
Tongue (cont’d) • Moves freely; no • Restricted mobility
tenderness
• Smooth tongue base with • Swelling, ulceration
prominent veins

Assessment of the Palates and Uvula

Area Normal Findings Abnormal Findings
Hard and Soft Palate • Light pink, smooth, soft • Discoloration (e.g.,
palate jaundice or pallor)
• Lighter pink hard palate, • Palates the same color
more irregular texture • Irritations
• Exostoses (bony growths)
growing from the hard
palate

16
 Uvula • Positioned in midline of • Deviation to one side
soft palate, rises during from tumor or trauma;
vocalization immobility (may indicate
damage to trigeminal [5th
cranial] nerve or vagus
[10th cranial] nerve)

Assessment of the Oropharynx and Tonsils

Area Normal Findings Abnormal Findings
Oropharynx • Pink and smooth • Reddened or edematous;
posterior wall presence of lesions,
plaques, or drainage
Tonsils • Pink and smooth • Inflamed
• No discharge • Presence of discharge
• Of normal size or not • Swollen
visible • Grade 2: The tonsils are
• Grade 1 (normal): The between the pillars and
tonsils are behind the the uvula.
tonsillar pillars (the soft • Grade 3: The tonsils
structures supporting the touch the uvula.
soft palate). • Grade 4: One or both
tonsils extend to the
midline of the
oropharynx.

Lifespan Considerations
Infants
• Inspect the palate and uvula for a cleft. A bifid (forked) uvula may indicate an
unsuspected cleft palate (i.e., a cleft in the cartilage that is covered by skin).
• Newborns may have a pearly white nodule on their gums, which resolves without
treatment.
• The first teeth erupt at about 6 to 7 months of age. Assess for dental hygiene; parents
should cleanse the infant’s teeth daily with a soft cloth or soft toothbrush.
• Fluoride supplements should be given by 6 months if the child’s drinking water contains
less than 0.3 parts per million (ppm) fluoride.
• Children should see a dentist by 1 year of age.
Children
• Tooth development should be appropriate for age.
• White spots on the teeth may indicate excessive fluoride ingestion.
• Drooling is common up to 2 years of age.
• The tonsils are normally larger in children than in adults and commonly extend beyond
the palatine arch until the age of 11 or 12 years.
Older Adults
• The oral mucosa may be drier than that of younger people because of decreased salivary
gland activity. Decreased salivation occurs in older people taking prescribed medications
17
 such as antidepressants, antihistamines, decongestants, diuretics, antihypertensives,
tranquilizers, antispasmodics, and antineoplastics. Extreme dryness is associated with
dehydration.
• Some receding of the gums occurs, giving an appearance of increased toothiness.
• Taste sensations diminish. Sweet and salty tastes are lost first. Older people may add
more salt and sugar to food than they did when they were younger. Diminished taste
sensation is due to atrophy of the taste buds and a decreased sense of smell. It indicates
diminished function of the fifth and seventh cranial nerves.
• Tiny purple or bluish black swollen areas (varicosities) under the tongue, known as caviar
spots, are not uncommon.
• The teeth may show signs of staining, erosion, chipping, and abrasions due to loss of
dentin. Medicare does not cover dental cleanings or treatments. Older adults with limited
incomes may delay or avoid professional dental care.
• Tooth loss occurs as a result of dental disease but is preventable with good dental
hygiene.
• Check that full or removable partial dentures fit properly. Bone loss and weight loss or
gain can change the way these prosthetics fit.
• The gag response may be slightly sluggish.
• Older adults who are homebound or are in long-term care facilities often have teeth or
dentures in need of repair, due to the difficulty of obtaining dental care in these
situations. Do a thorough assessment of missing teeth and those in need of repair,
whether they are natural teeth or dentures.

18