NUR2180: Physical Assessment - HEENT ASSESSMENT
Knock, Hello, my name . I’m going to be your nurse today.
I’m going to wash my hands.
Can I check your wrist band? Can you please tell me your complete name and birthdate? Do
you know where you are? Do you know what day it is ?
Thank you, Today I’m going to do a head, eye, ear, nose and throat exam.
Do you have any questions or concerns b4 we get started?
I’m going to close your privacy curtain.
** The first thing I’m going to do is to examine your head, the overall shape, contour, masses
lesions or swelling. . Do you have any headaches or have you had any head injuries?
I’m going to palpate your head and check your hair for distribution and parasites
When I palpate your head, let me know if you have any pain or tenderness.
(I see your hair is evenly distributed with no parasites) your head is rounded and normocephalic
(nor-mo-cephal-ic) and symmetrical with no tenderness or masses or lesions
NEXT, I’m going to check your EYES:
Do you wear glasses or contact lenses? Can I have you remove your glasses while I inspect your
eyes? You can put them back on for the eye test. Do you have any eye pain or eye issues I
should know about?
I’m going to check your eyes for overall shape, contour, discharge, redness, and swelling. I’m
going to check your eyebrows and eyelashes as well.
I can see that the sclera on both eyes is white. I’m going to pull down your lower lid on both
eyes and check your conjunctiva.
Your conjunctiva is pink and moist. I don’t see any drainage, redness, swelling, or foreign
bodies.
I’m going to shine a light into your eyes to look for constriction and consensual contraction of
the other pupil that is present.
** Shine light from the side into each eye)
Next, I’m going to check for accommodation. If I can have you focus on my penlight as I bring
it closer to your nose and back out again. Your pupils are equal, round, reactive to light, and
accommodation.
PERRLA is present.
I have my penlight and I’m going to move my penlight in the 6 cardinal directions. Keep your
head still and use your eyes to focus and follow the penlight as I move it.
, I don’t see any extraocular movement.
I’m going to have you read the snelling chart from 20 feet away. I’m going to have you cover
one eye and read the last row. Now, cover the other eye and do the same thing,
EARS
Next, I’m going to move on to your ears. Do you have any hearing problems or any issues I
need to know about?
I’m going to check your hearing and check for shape, size, position, and see if any drainage is
present. As I palpate your ears, let me know if you have any pain or tenderness.
I’m going to palpate the pinna and Targus. Do you feel any pain or tenderness? I’m going to
look inside your ear with my penlight. I don’t see any drainage, earwax, redness, or lesions.
Next, I’m going to check your hearing. I’m going to stand behind you and ask you to close your
eyes. I’m going to make a sound with my fingers and, you let me know which side you hear the
sound from.
NOSE
Next, I’m going to check your nose. Do you have any allergies or sinus pressure?
I'm going to check your nasal septum to make sure it is midline and there is no deviation. I’m
going to check your nares bilaterally for patency and check for any drainage, redness, or
swelling.
Knock, Hello, my name . I’m going to be your nurse today.
I’m going to wash my hands.
Can I check your wrist band? Can you please tell me your complete name and birthdate? Do
you know where you are? Do you know what day it is ?
Thank you, Today I’m going to do a head, eye, ear, nose and throat exam.
Do you have any questions or concerns b4 we get started?
I’m going to close your privacy curtain.
** The first thing I’m going to do is to examine your head, the overall shape, contour, masses
lesions or swelling. . Do you have any headaches or have you had any head injuries?
I’m going to palpate your head and check your hair for distribution and parasites
When I palpate your head, let me know if you have any pain or tenderness.
(I see your hair is evenly distributed with no parasites) your head is rounded and normocephalic
(nor-mo-cephal-ic) and symmetrical with no tenderness or masses or lesions
NEXT, I’m going to check your EYES:
Do you wear glasses or contact lenses? Can I have you remove your glasses while I inspect your
eyes? You can put them back on for the eye test. Do you have any eye pain or eye issues I
should know about?
I’m going to check your eyes for overall shape, contour, discharge, redness, and swelling. I’m
going to check your eyebrows and eyelashes as well.
I can see that the sclera on both eyes is white. I’m going to pull down your lower lid on both
eyes and check your conjunctiva.
Your conjunctiva is pink and moist. I don’t see any drainage, redness, swelling, or foreign
bodies.
I’m going to shine a light into your eyes to look for constriction and consensual contraction of
the other pupil that is present.
** Shine light from the side into each eye)
Next, I’m going to check for accommodation. If I can have you focus on my penlight as I bring
it closer to your nose and back out again. Your pupils are equal, round, reactive to light, and
accommodation.
PERRLA is present.
I have my penlight and I’m going to move my penlight in the 6 cardinal directions. Keep your
head still and use your eyes to focus and follow the penlight as I move it.
, I don’t see any extraocular movement.
I’m going to have you read the snelling chart from 20 feet away. I’m going to have you cover
one eye and read the last row. Now, cover the other eye and do the same thing,
EARS
Next, I’m going to move on to your ears. Do you have any hearing problems or any issues I
need to know about?
I’m going to check your hearing and check for shape, size, position, and see if any drainage is
present. As I palpate your ears, let me know if you have any pain or tenderness.
I’m going to palpate the pinna and Targus. Do you feel any pain or tenderness? I’m going to
look inside your ear with my penlight. I don’t see any drainage, earwax, redness, or lesions.
Next, I’m going to check your hearing. I’m going to stand behind you and ask you to close your
eyes. I’m going to make a sound with my fingers and, you let me know which side you hear the
sound from.
NOSE
Next, I’m going to check your nose. Do you have any allergies or sinus pressure?
I'm going to check your nasal septum to make sure it is midline and there is no deviation. I’m
going to check your nares bilaterally for patency and check for any drainage, redness, or
swelling.
