ASSESSMENT OF THE NAILS  Transverse linear depression

Equipment needed: (associated with an acute, severe

 Acetone illness)
 Cotton ball  Bilateral (usually)
Assessment:  Due to temporary disruption of
1. Inspect fingernail plate shape proximal nail growth (systemic
 Determine its curvature and angle illness)
2. Inspect fingernail and toenail textures  Timing of illness may be
3. Inspect fingernail and toenail color, lesions, estimated by measuring distance
and obvious deformities from line to the nailbed
Nail Grooming Koilonychia
Normal  Spoon-shaped nails
 Clean, manicured  Loss of convexity
Abnormal  Consider iron-deficiency anemia
 Dirty, jagged, or broken (poor hygiene Mee’s lines
or related to client’s occupation)  Transverse lines similar to the lunula
Nail Color (crosses the nail)
Normal  Occur following an acute or severe
 pink with longitudinal ridging illness
Abnormal  Vary in width
 Pale or cyanotic (hypoxia or anemia)  Moves distally as nail grows out
 Yellow discoloration (fungal infection or  Arsenic poisoning
psoriasis)  Heart failure
Nail Shape  Hodgkin’s disease
Schamroth’s technique  Chemotherapy
 Put ring fingernails together  Carbon monoxide poisoning
 Locate diamond-shaped space in  Leprosy
between the fingernails (normal finding) Onycholysis
 No diamond shape (clubbing of the  Painless separation of the nail plate from
fingers) the pinker nailbed
Nail Texture  Starts distally, progresses proximally
 Present and smooth (normal) (enlarges free edge of the nail)
 May be thickened and yellowish due to  Local (trauma from excess manicuring,
decreased circulation (elderly) psoriasis, fungal infection, and allergy to
 Excessive thickness due to hypoxia cosmetics)
(clubbing)  Sytemic (diabetes, anemia,
 Beau’s lines photosensitive drug reactions,
 hyperthyroidism, peripheral ischemia,  Bands across nails  protein deficiency
bronchiectasis, and syphilis)  White spots  zinc deficiency
Paronychia  Spoon-shaped nails  iron-deficiency
 Indicates local inflammation of proximal
and lateral nail folds (superficial
infection)
ASSESSMENT OF THE SKULL AND FACE
 Nail folds are red, swollen, and tender
1. Inspect skull for shape and symmetry
 May create a felon (painful abscess on
2. Inspect facial features
fingertip) if extends into pulp space of
3. Inspect eyes for edema and hollowness
finger
4. Inspect facial symmetry and movements
 Most common infection of the hand
 Elevate eyebrows
(Staph and Strep spp)
 Frown/lower eyebrows
 May spread until completely surrounds
 Close eyes tightly
nail plate
 Puff cheeks
 Local trauma (nail biting, manicuring, or
 Smile
frequent hand immersion in water)
 Show teeth
REMEMBER:
5. Palpate the skull for nodules, masses, or
 Perform blanch or capillary refill test
depression
 2-3 seconds (normal)
 Include the fontanels for pediatric
 Always document your findings
patients
Skull Assessment
Lifespan Considerations
 Assess for the size, shape, and symmetry of
Neonate/Newborn
the skull
 Nails grow quickly, extremely thin, and
Normal:
tear easily
 rounded, smooth (normocephalic)
Children
Abnormal:
 Bent, bruised, or ingrown nails (shoes
 enlarged (hydrocephalus)
too tight)
 lack symmetry
 Nail-biting should be discussed with
 increased size with prominent nose and
family member
forehead
Elderly
Assessing Facial Features
 Nails grow slower and thicker
Normal:
 Nails tend to split
 Symmetrical facial features (round, oval,
 Toenail fungus is more common and
square, elongated)
difficult to eliminate (not necessarily
 Palpebral fissures equal
dangerous to health)
 Symmetric nasolabial folds
 Longitudinal bands commonly develop
Abnormal:
  Asymmetrical facial features  Depends on the type of delivery (vaginal
 Prominent facial hair (hypertrichosis or vs caesarian section)
werewolf syndrome) Vaginal delivery:
 Exophthalmia  Can sometimes lead to elongated,
 Facies (a distinctive facial expression molded heads
associated with a clinical condition)  normal shape of the head becomes
 Bird facies more rounded after 1-2 weeks (molding)
Assessment of the Eyes Cesarean Section
 Inspect the eyes for edema and  Tend to have smooth, rounded heads
hollowness Head movement:
 Normally, there should be none  Can slightly lift their heads and move
Abnormal: side to side
 Periorbital edema  Voluntary control is established at
 Eye bags approximately 4-6 month
 Hollow eyes Anatomy of the Ear
Assessing Facial Symmetry Outer ear
Ask patient to:  Direct soundwaves to the auditory canal
1. Elevate eyebrows Middle ear
2. Frown  Air-filled
3. Lower eyebrows Contains:
4. Close lids tightly  Tympanic membrane
5. Puff the cheeks  Ossicles
6. Smile  Malleus
7. Show teeth  Incus
 Stapes
Other assessments of the face Inner ear
 Palpate for any nodules, masses, or  Fluid-filled
depressions  Has two (2) labyrinths:
Normal: • Bony (semicircular canals,
 Smooth, uniform, no nodules/masses cochlea, and vestibule)
noted • Membranous (series of ducts)
Abnormal: Types of Fluid:
 Indicate which area has abnormalities  Perilymph (outside the ducts)
such as a depression from local trauma  Endolymph (inside the ducts)
Lifespan Considerations Cerumen
Neonates/Newborns  Also known as earwax
Shape of the head can be different  Produced by the outer ear
 Has lubricant (prevents dessication) and  Fold pinna forward (normally mobile, firm,
antibacterial properties and recoils)
 Antibacterial properties:  Lesions and tenderness (may indicate
 Acidic inflammation/infection of the external ear)
 Contains lysozyme  Fold pinna forward (normally mobile, firm,
 Antibodies and recoils)
Wet:  Lesions and tenderness (may indicate
 honey-brown, or dark orange inflammation/infection of the external ear)
 Moist (50% lipid) 3. Inspect external canal of ear:
 Common in Africans and Europeans  Distal 3rd with hair follicles and glands
Dry:  Wet/dry cerumen
 Gray, and possibly flaky  4 years or older (up and back)
 Not moist (20% lipid)  3 years or below (down and back)
 Common in East Asians and Native Tympanic Membrane
Americans Normal:
Physiology of Hearing  Pearly gray
Neural Pathways  Semitransparent
 Afferent fibers in the auditory division of Abnormal:
acoustic nerve (CN VIII) end in the dorsal  Pink, red, yellow, white, blue, or dull
and ventral cochlear nuclei. surface
 Auditory impulses then go to inferior Hearing Loss
colliculi (centers for auditory reflexes),  Complete or partial
medial geniculate body of the thalamus,  Permanent or temporary
and into the auditory cortex May involve reception of frequency tones:
Assessing the Ear  Low
1. Inspect the auricles for:  Middle
 Color, symmetry of size, and position  High
 Level of superior aspect of auricle in Classified as:
relation to the eye  Conductive
 Cyanosis (earlobes)  Sensorineural
 Pallor  Mixed
 Erythema (inflammation, or fever)  Functional
 Color is same as facial skin Conductive Hearing Loss
2. Palpate the auricles for:  Results from external or middle ear
 Texture disorders (block sound transmission)
 Elasticity  Responds to medical or surgical
 Tenderness intervention (or both)
 This means (characteristics):
  Abnormal Weber test results  Unable to repeat 50% of numbers
 Negative Rinne test results mentioned (abnormal)
 Improved hearing in noisy areas Watch Tick Test
 Normal ability to discriminate sounds • Pocket watch held near patient’s ear
 Difficulty hearing when chewing • Patient told to listen to the watch tick
 A quiet speaking voice • Slowly moved away
Sensorineural Hearing Loss • Distance heard:
 Results from disorders of the inner ear or • ≥20 inches (normal)
CN VIII • <10 inches (hearing loss)
 This means (characteristics): Weber Test
 Positive Rinne test  Tests for lateralization of vibration (bone
 Poor hearing in noisy areas conduction)
 Difficulty hearing high-frequency sound  Place tuning fork at midline of the head
 Complains that others mumble or shout (scalp/forehead), after striking it on a hard
 Tinnitus surface
Mixed Hearing Loss  Ask the patient to state on which side is
 Combines aspects of conductive and louder:
sensorineural hearing loss • Left
Functional Hearing Loss • Right
 Results from psychological factors other • Midline (equal)
than organic damage Normal:
Assessment of Hearing Acuity  Equal sounds in both ears
 Use normal tone of voice  Localized at center of the head
 If there is difficulty, then other tests may  Classify as “negative”
be used: Abnormal:
– Watch tick  Lateralization to the affected ear
– Whispered word (conductive hearing loss)  obstruction of
 Other tests using the tuning fork: ossicles
– Weber test  Lateralization to the unaffected ear
– Rinne test (sensorineural hearing loss)  nerve or
Whispered Word Test inner ear damage
1. At 30-60 cm (1-2 feet) from the patient, let Remember:
him press on his tragus with one finger  If the sound is heard equally on both ears
2. Whisper non-consecutive numbers  Person may have normal hearing or equal
3. Let client repeat the mentioned numbers degrees of hearing loss in both ears
4. Results:
 Able to repeat words/numbers (normal)
Rinne Test
 Compares air against bone conduction
 Place on mastoid process after striking
tuning fork on a hard surface
 Let patient tell you when it stops
 Quickly hold buzzing end near ear canal,
then ask if patient can hear it
 Patient then should tell you if the tone
sounds louder with the fork on the mastoid
or just outside the ear canal
Normal:
 Air>Bone conduction
 Tone should be louder outside the
ear canal
 Classify as “positive”
Remember:
 Patients with conductive hearing loss will
perceive the sound as louder on the
mastoid
 Classify as “negative”
Ear Signs
Earlobe crease
 Visible crease extending at least 1/3 of
distance from tragus to posterior pinna
 Associated with possible coronary heart
disease
Earlobe nodule (gouty tophus)
Gouty tophus
 Long-standing accumulation of sodium
urate crystals in the helix and anti-helix
 Painless, hard, and irregular
 May have discharges (chalky)
Darwin tubercle
 Developmental eminence in upper third of
posterior helix
 Harmless
 Must be distinguished from acquired
nodules (gouty tophus)
Hematoma (Trauma)
Traumatic or hemostatic defect
 Leads to blood accumulation between
cartilage and perichondrium
 Tender, blue, doughy mass (usually painless)
 Prompt incision and drainage prevents
suppuration of cauliflower ear
Cauliflower ear:
 Untreated hematomas heal as nodular
and bulbous irregularities of the helix
and anti-helix
 Results from the necrosis of underlying
cartilage from blunt trauma of previous
injury
Otorrhea (Otorrhagia)
 Bloody (otorrhagia)
 Purulent
 Clear
 Serosanguinous
Characteristic:
 Melted cerumen (yellow)
 Eczema in meatal wall or early ruptured
acute otitis media (serous)
 Temporal bone fracture (bloody)
 Purulent (polyps, chronic external otitis)
Cerumen (Impaction)
May be due to:
 Excessive production of earwax
 Narrow meatus
Obstruction leads to partial deafness plus:
– Tinnitus
– Dizziness
Bulging tympanic membrane
Seen in:
 Acute suppurative otitis media
 More conical
 Loss of bony landmarks
 Distorted light reflex
• Lop (Bat ear) • Feeling of fullness of blockage
• Pinna protrudes at right angle • Deep, or boring
• May be due to shortage of: • Intermittent, sudden, or gradual
• Skin • Possible causes:
• Cartilage • Trauma
• Both • Hematoma
Microtia • Gout
 Unusually small ears • Insect bites
Macrotia • May be a referred pain from:
 Unusually large ears • Unerupted lower third molar or
• Perforation (tympanic membrane) caries
• Foreign body • Trigeminal neuralgia
Ear Symptoms • Temporomandibular joint arthritis
 Tinnitus Dizziness (and Vertigo)
 Temporary altered hearing • Persistent stimulation of the semicircular
 Earache (otalgia) canals or vestibular nucleus when head is
 Dizziness (and vertigo) at rest
 Ringing in the ears • Gives hallucination of motion
 Sufficiently distressing to seek consult • When eyes are opened, patient’s
 May be the first symptom of an acoustic surroundings seem to be spinning or
neuroma (if unilateral) whirling
Temporary Altered Hearing • When eyes are closed, patient continues to
 May be experienced during swallowing or feel as if in motion
yawning (popping sound) • Possible causes:
 On otoscope: • Migraine
• Retracted eardrum/tympanic • Cerebellar hemorrhage
membrane • Intracranial abscess
• May be caused by Eustachian tube • Temporal bone fracture
dysfunction: • Otitis media (with effusion)
• Mild, intermittent pain Lifespan Considerations
• Feeling of fullness in the ear Neonate/Newborn
• Altered hearing • All newborns should be assessed for
Ear Pain/Otagia hearing prior to discharge
• Arises from inflammation of structure in – Uses auditory brain response
the ear (or referred from other sites testing
including the thyroid) • To assess gross hearing:
• • Ring a bell from behind infant (or have
• Characteristics of pain may be: parent call child’s name for response)
 • Newborns tend to quiet to the sound • Sensorineural type
(and may open their eyes wider) Generalized hearing loss (presbycusis) occurs in
Infant all frequencies:
To assess gross hearing: • Loss of high-frequency sounds (first
• Ring a bell from behind infant (or have symptom)
parent call child’s name for response) • F, S, Sh, and Ph
• Child should be able to turn head and eyes If affected by presbycusis:
toward the sound (approximately 3-4 • Conversation may be distorted and result
months old) in what appears to be inappropriate or
To inspect external canal and tympanic confused behavior
membrane in below 3 years old (18 months):
The Nose
• Pull pinna down and back
• Insert speculum approximately ¼ to ½ inch • Consists of:

only – External nose

Adolescents and Young Adults – Nasal cavity

Hearing loss is become more common in • Both are divided by a septum into the
right and left halves
adolescents and young adults; probably due to:
• Exposure to loud music • Has two (2) elliptical orificies (nostrils)

• Prolonged use of headsets at loud • Lateral margin is rounded and mobile (ala
nasi)
volumes
External Nose

Elderly Framework:

• Skin on ear may appear dry and less  Above (nasal bones, frontal processes of

resilient (due to loss of connective tissue) maxillae, and nasal part of frontal bone)

• Pinna increases in both width and length  Below (plates of hyaline cartilage)

• Earlobe elongates Purpose:

• Earwax is drier • Humidify air (passing through the

• Increased coarse and wire-like hair growth turbninates and septum)

along: • Filters air (fine and coarse hair in the nasal

• Helix vestibule)

• Antihelix • Lined by respiratory epithelium

• Tragus • Has surface secretory cells

Tympanic membrane: • Produce immunoglobulins, inflammatory

• More translucent mediators, and interferons

• Less flexible The Sinuses

• Diminished intensity of light reflex Main Functions:

(only slightly) – Produce mucus for the nose

Hearing loss occurs: – Voice resonance

Additional Functions:
– Lighten the skull  valuable in
upright posture
– Protect the brain from trauma
Four Pairs:
• Frontal (protects the brain)
• Ethmoidal, Maxillary (protect the eyes)
• Sphenoidal (surgical approach to the
pituitary gland)
Remember that all:
– Open into the nasal cavity
– Lined by respiratory mucosa (ciliated
and secrete mucus)
– Innervated by branches of the
trigeminal nerve
The Process of Smell
Receptor cells
– Located in the olfactory epithelium
– True neurons that conduct action
potentials into the CNS
– Basal cells of the olfactory epithelium
are undifferentiated stem cells that
continuously turn over (and replace
themselves)
Olfactory nerve (CN I)
• Carries information from the olfactory
receptor cells to the olfactory bulb
• Olfactory epithelium are also innervated by
the trigeminal nerve (CN V) to detect
noxious or painful stimuli (e.g. ammonia)
• Olfactory nerves also pass through
cribriform plate on their way to the
olfactory bulb
• Mitral cells (in the olfactory bulb)
– form the olfactory tract (projects into
prepiriform cortex)
Assessing the Nose and Sinuses
The Procedure
1. Inspect external nose for any deviations in
shape, size, color, flaring, or discharge from
nares.
2. Lightly palpate external nose to identify any
areas of tenderness, masses, and
displacements of bone and cartilage.
3. Determine patency of both nasal cavities.
 Ask patient to close mouth, exert
pressure on one naris, and breathe
through the opposite naris. Repeat on
other side.
Normal:
 Uniform color, symmetrical, no nasal
flaring, nasal septum at midline, and no
perforation
 Non-tender, no lesions noted
 Air moves freely as client breathes
through the nares
4. Tip head back, with speculum held in non-
dominant hand, and little finger at side of
nose to stabilize
 Dominant hand (used to position
head/hold light)
Observe for:
– Redness
– Swelling
– Growths
– Discharges
5. Check the nasal septum
– Intact and at midline (normal)
– Deviated (abnormal)
6. Palpate maxillary and frontal sinuses using
both thumbs
Frontal
Direct manual pressure upward towards the
wall of the sinus
Maxillary
Pressure upward over the lower edge of the • May be accompanied by:
maxillary bone – Perceived change in taste of food
Findings: (bland and unpalatable)
– No tenderness (normal) – Ageusia (loss of sense of taste)
– Tenderness (abnormal) • May be:
Signs – Temporary
Epistaxis – Permanent
May be: • Results from conditions that:
– Spontaneous vs induced – Irritate and cause swelling of
– Front vs back nasal mucosa
Source of bleeding: – Obstruct olfactory area in the
 Anterior (Kiesselback plexus) nose
 Posterior (Woodruff’s area  posterior • Such as:
3rd of inferior meatus) – Heavy smoking
Local causes: – Rhinitis
– Coughing – Sinusitis
– Sneezing Permanent Anosmia
– Nose picking • Due to destruction of:
– Fracture – olfactory neuroepithelium
– Foreign bodies – any part of olfactory nerve
Generalized Cause: • Due to:
• Vascular (hemophilia, – Cocaine or acid fumes (paralyze
thrombocytopenia) nasal cilia)
• Infectious (typhoid fever, dengue fever, – Head trauma
diphtheria, syphilis) Rhinorrhea
• Drugs (anticoagulants, ASA) • Free discharge of thin nasal mucus
Forein Body • Common (rarely serious)
Nasal Septum Deviation • Discharge may be:
Nasal Septum Perforation • Clear
• Hole in the nasal septum • Purulent
• Common causes: • Bloody
– Chronic infection • Serosanguinous
– Nasal surgery • Unilateral:
– Repeated trauma • Foreign body (foul discharge)
– Cocaine abuse • Neoplasm (bloody discharge)
Symptoms • Head injury/surgery
Anosmia (cerebrospinal fluid)
• Loss of smell • Bilateral:
 • Allergic – Lacrimation
• Infectious (upper respiratory – Sneezing
tract) – Headache (common)
Nasal Obstruction Vasomotor Rhinitis
• May be caused by: • Non-allergic mucosal edema and
– Allergic rhinorrhea
– Inflammatory • Associated with:
– Neoplastic • Vasodilatation of nasal vessels
– Endocrine • Mucosal edema
– Mechanical obstruction • Increased mucus production
– Traumatic injury • Due to chronic environmental irritants:
• Dust
• Smoke
Nasal Syndromes • Strong odors
Acute Rhinitis • Cold air
• Infectious disease (common cold) Suppurative Paranasal Sinusitis
– Rhinoviruses infect mucous • Due to:
membranes of nose and sinuses – Streptococcus pneumoniae
(lead to inflammation and – Haemophilus influenzae
increased nasal secretions) • Severe pain in the face (7-14 days after
• Presentation: acute URTI)
– Watery nasal discharge and • Pain and pressure without fever
sneezing – sinus obstruction 
– Discharge becomes purulent decongestants
– Associated with fever and body Cavernous Sinus Thrombosis
malaise • Most feared complication of nasal
• Usually lasts 3-10 days infections
• Presence of severe local pain suggests a • May cause:
complication • Blindness
– Bacterial sinusitis • Death
Allergic Rhinosinusitis • Spread of Infection:
• May be seasonal or perennial Nose  angular veins  cavernous sinus 
• Caused by allergens: septic thrombosis
– Pollens, molds, house dust, mites, • Bilateral involvement of the eyes:
cockroach, and animal dander – Deep pain
• Presentation: – Immobilization of globes
– Itching (nose and eyes) – Periorbital edema
– Rhinorrhea
 – Chemosis (swelling of Elders
conjunctivae) • Diminished sense of smell:
• May involve CN 3, 4, and 6 – Decreased number of olfactory
• Manifestation: nerve fibers
– Sudden chills, high fever, – Atrophy of remaining fibers
prostrated, comatose • Less able to identify and discriminate
– Death within 2-3 days between odors (in effect)
Lifespan Considerations – hyposmia
Infants • Nosebleeds (epistaxis) occurs usually
• A speculum is not usually necessary to due to hypertensive disease or arterial
assess septum, turbinates, and vestibules vessel changes
• Instead:
• Push tip of nose upward (using
thumb)
• Shine a light into the nares
• Sinuses:
• Ethmoid and maxillary (present at
birth)
• Frontal (1-2 years old)
• Sphenoid (later in childhood)
Children
• Assessing septum, turbinates, and
vestible, similar to infant (no use of
speculum usually necessary)
• Ethmoid sinuses (fully developed by 6
years old)
• Rare to have sinus problems at
this age
Preadolescent
• Most common signs of sinusitis in this
age?
– Cough
– Runny nose (rhinorrhea)
Adolescent
• May have (similar to adults):
– Headaches
– Face tenderness
– Swelling