02.05 EENT Assessment

Join NURSING.com to watch the full lesson now.

Included In This Lesson

Study Tools

Outline

Overview

  1. Areas to be assessed:
    1. Eyes
    2. Ears
    3. Nose
    4. Mouth
    5. Throat

Nursing Points

General

  1. Supplies needed
    1. Ophthalmoscope
    2. Otoscope
    3. Tuning fork
    4. Pen light
    5. Tongue blade
    6. Alcohol pad

Assessment

    1. Eyes
      1. External inspection
        1. Sclera – should be white with minimal vessels visible
        2. Conjunctiva – pull lower eyelid down to inspect
          1. Should be pink, moist with minimal clear drainage
        3. Drainage – minimal clear drainage, if any (tears)
        4. Symmetry
          1. Eyebrows
          2. Eyelids
          3. Eye opening
        5. Eyelids and lashes
          1. Look for redness, swelling, discharge, or lesions
        6. Shape/placement
          1. Protrusion
          2. Sunkenness
      2. Internal inspection
        1. Ophthalmoscope
          1. Inspect optic disc, retinal vessels, and color
            1. Optic disc should be medial
          2. Look for red reflex
      3. Vision/Function assessment

        1. PERRLA – Pupils should be equal, round, and reactive to light and accommodation
          1. See Neuro assessment
        2. EOM – extraocular movements to 6 cardinal directions should be smooth and coordinated
        3. Visual acuity – use Snellen chart 20 ft away to test acuity
        4. Peripheral vision
          1. Have patient look straight ahead
          2. Wiggle fingers from behind head moving forward until patient can see them
    2. Ears
      1. External
        1. Inspect
          1. Pinna – symmetry, lesions, swelling
          2. External meatus – drainage, redness, cerumen
        2. Palpate
          1. Pinna – tenderness, masses
          2. Mastoid process – tenderness
      2. Internal inspection
        1. Pull pinna up and back for adults
        2. Pull pinna down and back for children
        3. Otoscope
          1. Redness
          2. Swelling
          3. Drainage
          4. Cerumen
          5. Foreign bodies
          6. Tympanic membrane
            1. Should be pearly gray and translucent
            2. Intact
      3. Hearing/Function assessment
        1. Whisper test
          1. Stand 2 feet away
          2. Whisper a 2-syllable word
          3. Ask patient to repeat
        2. Weber test for bone conduction
          1. Strike tuning fork
          2. Place on the top of the pt’s head
          3. Sound should be equal bilaterally
        3. Rinne test to compare air/bone conduction
          1. Strike tuning fork
          2. Place end on mastoid process
          3. Ask patient to state when they can no longer hear the sound
          4. Without touching the forks, move to just outside the ear
          5. Ask patient to state when they can no longer hear the sound
          6. Air conduction should be 2x bone conduction
          7. *Perform bilaterally
    3. Nose
      1. External
        1. Inspect
          1. Symmetrical
          2. Midline
          3. Nostrils symmetrical
          4. Deformities or lesions
        2. Palpate
          1. Frontal and maxillary sinuses
            1. Should be nontender
      2. Internal inspection
        1. Pen light OR otoscope
        2. Color of mucosa
        3. Hair
        4. Drainage
        5. Septum midline
        6. Turbinates – beefy red
        7. Polyps
      3. Smell/Function assessment
        1. Occlude one nostril at a time to assess patency
        2. Assess sense of smell
          1. Ask patient to close eyes and identify a common scent (alcohol, lemon, cinnamon, coffee)
    4. Mouth
      1. Inspect
        1. Lips/mouth
          1. Color
          2. Moisture
          3. Lesions
        2. Teeth/gums
          1. Bleeding or swelling
          2. Dentition
            1. Spacing
            2. Loose or missing
            3. Dentures
        3. Tongue/cheeks
          1. Tongue midline
          2. Ulcerations or white patches
          3. Pink/moist and smooth
          4. Lift tongue to look for swollen salivary glands
        4. Palate
          1. Hard palate should be firm with rugae
          2. Soft palate should be pink/moist and rise with uvula when patient says “Ah”
        5. Jaw alignment/TMJ
          1. Have patient bite down/clench
          2. Look at alignment
          3. Palpate masseter muscles
          4. Palpate TMJ for clicking or tenderness
    5. Throat
      1. Ask
        1. Difficulty swallowing
        2. Pain or tenderness
      2. Inspect
        1. Should be pink/moist
        2. Look for redness/swelling
        3. Look for exudate or lesions
        4. Tonsils – grade
          1. 0 = not visible
          2. 1 = visible
          3. 2 = halfway between pillars and uvula
          4. 3 = touching uvula
          5. 4 = touching each other
      3. Cranial nerves IX, X, and XII
        1. Have patient stick out their tongue – should be midline with no deviation
        2. Use tongue blade to elicit/test gag reflex
          1. Could also assess swallow

Nursing Concepts

  1. A patient who can safely swallow without coughing, gagging, or clearing their throat will most likely have an intact gag reflex.
    1. When in doubt, specifically test it
  2. Tonsils grade 3 and 4 could cause aspiration or airway risk
    1. Make sure the provider is aware
    2. If possibility of intubation – have difficult airway box ready

Patient Education

  1. Be sure to ask the patient if they have any history of lesions or ulcers or herpes simplex virus

Transcript

In this video we’re going to talk about the EENT assessment – that includes eyes, ears, nose, mouth, and throat assessments. In terms of supplies, you’re going to need an alcohol pad, an ophthalmoscope, an otoscope, a tuning fork, a pen light, and a tongue blade. If you don’t have access to the scopes, you can use a pen light, and if you don’t have a tuning fork, you’ll just skip those tests.

We’ll start with the eyes, and as always, we start with inspection. You want to look externally first – are the eyes and eyelids symmetrical? Is there any drooping? Do you see any drainage, redness, or lesions? Are the eyes protruding or sunken in?
Look at the sclera – they should be white and smooth with minimal blood vessels visible. Then, Use your thumbs to gently pull down on the lower eyelid and check the conjunctiva. They should be pink and moist with minimal clear drainage, if any.
Next we’ll check vision and pupil function. You should use a Snellen chart placed 20 feet away from the patient and have them close one eye at a time and read the chart – this tests for visual acuity.
Then we’ll test for peripheral vision – have the patient look directly at your nose. Put your hands about a foot away from their head and a little behind and start wiggling your fingers. Move your hands slowly forward and have the patient let you know when they can see the wiggling. It should be straight sideways, about 180 degrees.
Now we’ll look at pupils and extraocular movements. This is the same test you’ll see in the neurologic exam. Shine your pen light into each eye one at a time looking for the pupils to constrict. They should be round, constrict briskly, and equally on both sides.
Then, have the patient follow your finger with just their eyes and test the 6 cardinal movements. The movements should be smooth and coordinated on both sides.
Now, you’ll want to grab your ophthalmoscope, turn the light on, and check inside the eyes. You’re looking at the retina and the optic disk, which is on the medial side. The retina should be orangey-red with some blood vessels visible. You should also be able to see the red reflex when you shine the light toward the pupils.
Now we’re going to move on to the ears. As always, start with inspection externally. You’re looking at the pinna – they should be symmetrical with no lesions or swelling. You also want to look at the external meatus looking for drainage, swelling, redness, or any cerumen buildup.
Go ahead and palpate externally as well – the pinna should be smooth with no masses or tenderness. You also want to palpate the mastoid process – it should be firm and nontender.
Now, before you start your internal exam, let’s do the hearing tests, and I’ll explain why in a second. First test is the whisper test. Stand 2 feet away from the patient and whisper a 2-syllable word and have them repeat it. My favorite is “bacon”, they usually get excited about that! Just make sure you repeat it on the other side with a different word! Like… cheesecake!
Next you’ll move on to the Weber and Rinne tests. For that, you need a tuning fork. The Weber test tests bone conduction for hearing – so how well the sound moves through bone. You’ll strike the tuning fork with the heel of your hand or on the table, then place it on the top of their head. Ask the patient if it sounds the same on both sides.
Next you’ll do the Rinne test. This is to compare air conduction and bone conduction. You’ll strike the tuning fork again – a pro tip here is to just use your hand, if you hit it too hard it vibrates forever and takes a long time. So you strike the tuning fork and place it on the patient’s mastoid process and start counting.
Have the patient tell you when they can no longer hear the sound and note how many seconds it was. Then … WITHOUT touching the tuning fork, move it to just outside of their ear and start counting again. Again, have them tell you when they can’t hear it anymore.
The second time, which is the air conduction, should be about twice as long as the first one, the bone conduction. It’s not about the exact number of seconds, just make sure your counting is consistent.
NOW I want you to grab your otoscope to look inside. For adults, pull the pinna up and back, for kids, pull it back and down. Make sure your probe cover is the right size and look inside the meatus. You’re looking for any redness or swelling, discharge, or cerumen buildup. You also want to look at the tympanic membrane, or eardrum – it should be pearly gray and translucent. Make sure you check out the images attached to this lesson because we’ve provided some examples of what this should look like.
Now – here’s why we did that part last, we’re actually going to hang onto the otoscope and move right on to inspecting the inside of the nose! All about efficiency! You want to look for discharge, hair distribution, and polyps. You should also look to see that the septum is midline and that the turbinates are beefy red.
You can also use this time to quickly inspect inside the patient’s mouth. You’re looking at the mucous membranes, they should be pink and moist with no lesions or ulcerations. Look for any white patches that could indicate thrush.

Now you can put the otoscope away and inspect externally. The nose should be midline and symmetrical, the nares should be equal on both sides. Make note of any deformities or lesions.
You should also palpate the frontal and maxillary sinuses – any tenderness there could indicate an infection.
Then we’ll quickly test function. Occlude one nostril at a time and have the patient sniff, that tests for patency. Then have them close their eyes and identify a common scent like an alcohol pad to make sure their smeller is working!
Now we can move on to the mouth and throat. This is where you’ll need your pen light. First, inspect the outside of the lips and mouth looking for any cracking or lesions,
Look at the roof of their mouth. The hard palate should be hard and pink with rugae or ridges. Then have them say “Ah!” Their soft palate and uvula should both rise midline when they do that.
Look at their tongue and under their tongue – it should be midline, dark pink with no swelling or lesions. And there shouldn’t be any swelling in the salivary glands under the tongue.
You will also want to look at their teeth and gums – is there any bleeding or plaque? Are any teeth broken, or loose, or missing? Do they have dentures? When they bite down are their teeth in alignment?
Look at the back of their throat for any redness or swelling of the tonsils.
Lastly – use your tongue blade to elicit a gag reflex to make sure the cranial nerves are intact and that the patient should be able to safely swallow.

Remember that any swelling in the throat, tongue, or tonsils could cause an aspiration or airway risk – so make sure you’re aware if that’s the case for your patient.

And that’s it for the EENT assessment. I know it’s a lot, but for each one you inspect internally and externally, palpate for any abnormalities, and assess function.

We hope that helps. Now, go out and be your best selves today. And, as always, happy nursing!