Last Updated:Wednesday, September 04, 2002

Ears, Nose, Throat,
Mouth and Sinus Assessment
Unit 3

Overview

• Developmental focus throughout
• Nursing Diagnoses
• Health Teaching

ENT History - Present Health status

• pain or discomfort
• hearing loss
• pediatric- pulling or tugging at ears
• drainage from ears or nose
• ear wax build up and care
• drainage from ears or nose
• òability to smell

ENT - Past Health History

• Injury to ears, nose, mouth or teeth
• Environmental hazards
• History of ear, throat infections
• Use of ototoxic drugs
• History of allergies frequent use nasal sprays
• Ringing in the ears (tinnitus)
• Dizziness
• History of frequent nosebleeds
• Previous surgery tubes, tonsillectomy

ENT - Family History

• of hearing loss

Ear

• Developmental factors
• Structure
• History
• Assessment:

• loud noise - startle reflex (Moro)
• 3-4 months- head turns > noise

• > incidence middle ear infections

• speech development reflects hearing acuity;

• degenerative hearing loss
• social and safety implications

• Exposure to loud noises
• occupation
• recreation
• use of protective devices
• Exposure to fumes or dust

• Assessment important at any age

Structure

auricle

1. Gross hearing

conversation
whisper (occlude one ear)

2. bone and air conduction (if hearing is diminished)

Tuning forks

• lateralization of sound (Weber)
• compare AC to BC (Rinne)
• Auditory Functioning
  • Weber test

• Normal- sound equal in both ears
• Conduction loss - sound to defective ear
• Sensorineural loss- sound to better ear

Rinne Test

Tests for air conduction vs bone conduction

• Normal
• AC > BC 2:1

3. With Otoscope

Otoscopic Exam

Inspect  

cerumen
appearance
            erythema, edema
            narrowing
            foreign body
            discharge
? Tenderness
            inspect with care

2. Tympanic membrane

Common ear problems

• Otitis external

Nose

• Problem with smell
• Rhinitis
• Discharge (character)
• Epistaxis
  predisposing factors
  alleviating factors
• Allergies (nasal crease)
• Cocaine use

• shape
• symmetry
• discharge
• nasolabial folds
• masses, tenderness

Inspection/palpation (continued)

• nares (with head tipped back)
  • Color - mucous membrane
    • should appear pink
    • in presence of allergies - bluish gray or pale
    • in presence of infection- red
      
  • Patency

Nose/Sinuses

• Palpation
  • Sinuses
    • Frontal
    • Maxillary
      
  • Transillumination

Nose

• Cranial nerve 1
  • Olfactory
  • When is this tested?

Mouth

• Last dental exam
• Regularity of dental exam
• Pain associated with food or stress
• Problems
• Ask client to open and close mouth
• Mobility of mandible and occlusion of teeth
• Mouth opened wide and closed,

• tenderness
• crepitus
• deviation

• Lips
• Inside lips/Gums
• uniform color, inflammation, edema

• teeth
• infants
• toddler
• school age
• adult
• elderly

• Buccal mucosa
• glands and ducts
• Parotid
• Submaxillary/sublingual
• Palate
• hard
• soft

Inspection and palpation

• Tongue
• fit
• color
• position
• moist
• slightly rough
• Cranial Nerve VII (facial) S & M & XII (hypoglossal) M

Throat/Pharynx (oropharynx)

• One side at a time
• Mucous membranes
• Uvula
• arches
• tonsils

• oropharynx
• equipment
• ask client to say "ah" or yawn
• Look for: rise of soft palate (CN 9 & 10)
• Check color
• Evidence of exudate, edema, ulceration
• Tonsillar enlargement
• Palpation
  • Gag reflex
  • Performed on unconscious or if suspect impaired swallowing

Mouth

• Developmental considerations
• Infants
• sense of taste and smell not fully developed
• React to acid, bitter, salt & sweet
• Prone to sore throats as they get older
• Elderly
• Decreased sense of taste and smell
• # of taste buds decreases

Nursing Diagnoses

• Knowledge deficit
• Self-care deficit, oral hygiene
• Altered oral mucous membrane
• Altered dentition
• Impaired swallowing
• Risk for aspiration
• Sensory perceptual alteration: auditory/visual
• Pain