- NCM 203 LEC: HEALTH ASSESSMENT

- TOPIC: GENERAL SURVEY

- 2ND SEMESTER | S.Y 2021-2022
- CLINICAL INSTRUCTOR: MR. ALDRIN ANTONE

REVIEW: PHYSICAL ASSESSMENT PHYSICAL ASSESSMENTS

- a systematic, comprehensive, continuous
collection, validation and communication of
client’s data using a variety of methods
ASSESSING APPEARANCE AND MENTAL STATUS
- Explain the procedure to the patient.
- Do handwashing.
- Provide privacy.
→ when the patient enters, greet them
with a → Syndrome – collection of signs and
handshake to convey that you care. This allows
you to assess muscle strength, hydration, skin
temperature and texture
MENTAL STATUS
 Observe body built, height and weight in
relation to the client’s age, lifestyle and
health.
→ It is because naay times na makita
jud ang difference between patients’ data
and the patients’ façade, this could be
because of the disease present
 Height should be proportionate to arm span.
If not, consider Marfan’s syndrome
symptoms
ABNORMALITIES
- A condition or irregularity
A. TOO TALL: MARFAN SYNDROME

- A patient orientation
- How a patient respond to a particular question/s
of a healthcare worker.
→ If the patient cannot answer your
questions, it means he/she is disoriented or
there is a problem with the level of
consciousness of the patient
→ Lethargic – Compromised level of
consciousness

SAMPLE QUESTIONS
A. Patient’s name - hereditary disorder that
B. Patient’s birthdate affects the body’s connective tissues, long limbs
C. Patient’s current location in proportion to the trunk of the patient
D. Patient’s current location status - eye problems, long arm and fingers
→ (1) ask the current president of the
country (2) ask if he/she is aware of the MARFAN SYNDROME: SIGNS AND SYMPTOMS
pandemic
E. Current Time  Disproportionately long legs
 Extreme tall and slender build
 Long, narrow face
 High arched neck and crowded teeth
 Indented or protruding sternum
 Dislocated lenses of the eyes
 High pressure in the eye
 Cystic changes in the lungs
 Flexible joints
 Flat feet
 Curved spine
 Abnormal heart sounds
B. TURNER’S SYNDROME (X-)
- chromosomal anomaly
female births
- missing an X chromosome on the 23rd pair
- check and observe for the physique of the
patient
TURNER’S SYNDROME: SIGNS AND SYMPTOMS
 Short stature
 Characteristic facial features
 Low hairline
 Fold of skin
 Constriction of aorta
 Shield-shaped thorax
 Poor breast development
 Widely spaced nipples
 Elbow deformity
 Shortened metacarpal IV
 Rudimentary ovaries, Gonadal streak
(underdeveloped gonadal structures)
 Brown spots
 No menstruations
C. TOO TALL: GIGANTISM
- increase activity of anterior pituitary gland
- problem in the growth hormone
MARFAN SYNDROME VS GIGANTISM
 Marfan syndrome
- Disorder of connective tissues
in - Has heart abnormalities (which means
there is also a pulmonary problem)
- Inherited gene defects in fibrilin
 Gigantism
- Enlarged soft tissue and late closure of
the growth/epiphyseal plates (which
means continuous growth)
→ Epiphyseal Line - closed na ang
plate /stopped growing
CONCEPT OF DWARFISM
 Essentially a person with short stature
 May be caused by:
- Gonadal dysgenesis (XO = Turner
Syndrome)
- Bone & Metabolic diseases
- Idiopathic - no known cause or
constitutional delayed growth
  Abuse & neglect (independent of BODY TYPES (HABITUS)
nutrition)
→ Kaspar Hauser syndrome
 Genetic Mutations

ACHONDROPLASIA AND DWARFISM

 Achondroplasia
- Most common form of dwarfism
- When growth plate chondrocytes inhibit
→ There are people na ganun ang
from functioning & proliferating
built ng katawan and it is because
→ Early closure of the epiphyseal
genetics siya
plate.
- Stunts growth (but have average size of
STHENIC
torso)
 Average height
TYPES OF DWARFISM  Well-developed musculature
 Wide shoulders
 Flat abdomen
 Oval face
 Muscular
 Thick-set individual
 Broad chest
 High diaphragm
 Stomach tends to lie transversely
 Gallbladder is high in the abdomen (away
from midline)
 Proportionate  Transverse colon is also high
- Same size all over
E.g. hypothyroidism HYPERSTHENIC
 Short
 Disproportionate  Stocky
- May have some average-size parts  May be obese
 Broader chest
 Thicker abdominal wall
 Rectangular-shaped face
 Very muscular
 Thick-set individual
 Broad chest
 High diaphragm
 Stomach tends to lie transversely
 Gallbladder is horizontal high in the
abdomen (away from the midline) B. DEBILITATED

ASTHENIC
 Long
 Thin-chested lean individual
 Lower positioned organs (diaphragm,
stomach, gallbladder, and transverse colon)
 Stomach and transverse colon descended  Weak
into pelvis (dring erect position)  Feeble
 Exaggeration of the hyposthenic type  Lack of strength
 With weaknesses and loss of energy
HYPOSTHENIC
 Tall C. KWASHIORKOR
 Willowy  Patients that has a problem with their
 Poorly developed musculature protein ingestion
 Long, flat chest  Protein ingested are not enough
 Abdomen may sag  Malnutrition
 Long neck → Protein lang ang wala or kulang
 Triangular face
 Similar to asthenic but features mentioned D. MARASMUS
are not as marked  Old man’s face
→ Aside from protein, lahat talaga ng
nutrition kay wala

E. FAILURE TO THRIVE

BODY TYPES (OTHER CONDITIONS)

A. CACHECTIC (CACHEXIA)
→ he or she is not able to thrive in the
environment because there’s a lot of factors
like poverty (no money = no food)
- physical and developmental delay or
retardation in infants and children
 Profound and marked malnutrition - seen in children with illness but more in those
 Wasting with psychosocial or maternal deprivation
 Ill health
 → MATERNAL DEPRIVATION - wala na  Remember:
alagaan sa mama, no breast feeding 2.2lbs -> 1kg
1inch -> 2.54cm
BODY TYPES (ACCORDING TO BUILD AND WEIGHT) 100cm -> 1meter

 Most frequently used:

- Weight in kilograms
- divided by height in meters squared

𝑾𝒆𝒊𝒈𝒉𝒕 (𝒌𝒈)
𝑯𝒆𝒊𝒈𝒉𝒕 (𝒎𝟐 )

 Some use “703” instead of “700” but

ENDOOMORPH difference is scientifically negligible
- Stocky build, with prominent - Weight in pounds multiplied to 700.
abdomen - Divide by height in inches
- And divide again by height in inches.
ECTOMORPH
- Physiological type that is tall with 𝑾𝒆𝒊𝒈𝒉𝒕 (𝒍𝒃𝒔) × 𝟕𝟎𝟎∗
long and lean limbs 𝑯𝒆𝒊𝒈𝒉𝒕 (𝒊𝒏𝒄𝒉𝒆𝒔)
𝑯𝒆𝒊𝒈𝒉𝒕 (𝒊𝒏𝒄𝒉𝒆𝒔)
MESOMORPH
- Husky and muscular body

→People in categories above overweight are

→ Identify which body type patient’s body
more prone to heart problems, pulmonary
belongs to, compute for the BMI if ever patient is
problems, coronary artery disease
underweight, overweight or normal.

ANOTHER WAY OF MEASURING OBESITY

ASSESSING HEIGHT AND WEIGHT
 Determining waist circumference
 BODY MASS INDEX (BMI)
Male:  102cm (40 inches)
- Ratio of your weight and height
- There are two formulas Female:  88cm (35 inches)
AbN: anything beyond the measurements
 → Waist is slightly above our navel
OBESITY
 Remember that obesity can be caused by a
variety of factors, including:
- Poor diet (high in fat and calories)
- Sedentary lifestyle
→ inactive lifestyle
- Not enough sleep → hormonal changes
lead to increased hunger and craving of
high-calorie food)
- Genetics (rate of metabolism)
- Increasing age (decreases muscle mass,
slows metabolic rate → easier to gain
weight)
- Pregnancy (post-pregnancy weight may
be difficult to
lose)
TYPES OF OBESITY (DISTRIBUTION)
Android (Male)
- Fats are located mainly on the waist
- Central type of obesity
- Increases risk for certain diseases (diabetes
mellitus II, high cholesterol and triglycerides,
hypertension, and heart disease)
→ LDL and HDL – bad cholesterol
→ LDL – increases chance of atherosclerosis
→ plaque formation in blood vessels.
Thus, blockage in the circulation)
→ O2,  tissue perfusion - leads to tissue
necrosis (tissue death)
→ Apoptosis – cell death
Gynecoid/Gynoid (Female)
- Fats are located on the hips and thighs
- Peripheral type of obesity
OTHER WEIGHT CONDITIONS
● Cushing Syndrome
- Due to excess cortisol in the body ( from
medications or pituitary gland tumor )
- Example of medication - PREDNISONE
- Truncal fat
- Moon face (bibilog ang mukha)
- Thin limbs
● Unexplained weight loss
- Cancer
- Diabetes mellitus (problem with insulin)
(your body can produce insulin however,
there is tissue resistance where they reject
the insulin )
- Hyperthyroidism (increase in your
metabolism = increase ang temp, hr, pr, bp
= papayat ka )
 Unexplained weight loss
- Diabetes mellitus
- tissue/cellular resistance to insulin insulin will
not metabolize the glucose in the cells
hyperglycemia
- high levels of glucose in the bloodstream
circulation of the blood will go lower  the body
will compensate by increasing the bp. The reason
patients with diabetes has high bp.
- when the body cannot utilize glucose it will
metabolize the fat in the body. This is why
patients with diabetes lose weight.
 - Movement disorder
- Hyperthyroidism
- Depression ANTALGIC/LIMPING GAIT
- Diuresis  Murag nagtakiang
- patients with kidney failure  kidneys cannot
do the excretion of bodily waste which resulted
to: edema (panghupong), pleural effusion (water
on the lungs), etc.
- the body has overly excreting of fluids
payatot
- no excretion of wastes in the kidneys  tataba

POSTURE AND GAIT

SHUFFLING GAIT
ASSESSMENT OF POSTURE AND GAIT
 Example: Patients with Parkinson’s Disease
 Standing position
- Let patient stand against the wall (with
shoulders lying flat)
- Let patient sit on a chair with backrest
- Let him/her walk towards you

 Walking has 8 phases

WIDE (BROAD) BASE GAIT

 Only one side of the lower limbs are only
affected
 Example: patients with Polio
 In this gif, the right leg has the problem
 Normal - evenly distributed weight
- able to stand on heels and toes
- toe pointed straight ahead (equal both sides)
- posture erect, movements coordinated and
rhythmic, arms swing in opposition, stand
length is appropriate
 Abnormalities
- Limping/discomfort
- Shuffling
- Wide/Broad base gait FEAR OF FALLING GAIT (PSYCHOGENIC)
- Fear of falling
 Something has to do with
- Loss of balance
psychology/thinking of the person
  They feel that they’re falling.  Lateral curvature in the normally straight
vertical line of the spine
 You can assess it by leaning back against the wall
and check the symmetry of your shoulders.
 Scoliosis can affect children i.e., yung mga heavy
bag na gina carry ng mga students

LOSS OF BALANCE
 Cerebellum is for gait and coordination.
 When the cerebellum is compromised, the
patients will not keep his balance.
LORDOSIS
 The abdomen is protruding
 Excessive inward curve of the spine
 Exaggerated lumbar concavity

ATAXIC GAIT (MOVEMENT DISORDER)

 NEUROMUSCULAR DISORDER
 TREMORS
- ABNORMALITIES IN SPINE CURVATURE
KYPHOSIS
 Increased forward curvature of the spine
 Causes hunching of the back
Bones:
 Cervical - 5
 Thoracic – 12
 Lumbar – 7

SCOLIOSIS
 “s” formation
 ADAMS FORWARD BEND TEST CLINICAL MANIFESTATIONS OF COPD
 Instruct the patient to bend forward and TRIPOD POSITION
observe the shoulder blades if it is protruding.  Patient may sit upright with arms supported on
a fixed surface. This optimizes the function of
pectoral muscles to expand the thoracic cavity
 Obstructions in respiration (inhalation,
exhalation)
 problem associated with the output for
inhalation and exhalation.
- ; now naga increase ang levels of CO2 and and
decreasing levels of O2
 To answer that question why carbon dioxide is
OTHER POSITION TENDENCIES building up is that while we are still alive our
cells keeps on metabolizing, and as it continues
to metabolize the byproducts of that is the
carbon dioxide.
 Take note that in order for the cells to
metabolize they need glucose and oxygen
(aerobic respiration) = by product is CO2
 With that, as it continues to produce CO2 that
is one of the sole reason why there is a build up
of CO2 of patients with COPD.
 Bluish-red color of skin
- Polycythemia and cyanosis (cyanotic)
- Physiologic polycythemia (normal)
- Polycythemia vera (abnormal)
 Hemoptysis
- yung sputum may kasamang blood
 CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(COPD) – always tend to lean forward and
DEPRESSION
braces selves with arms
 Slumped posture

TENSED/ANXIOUS
 Shoulders elevated
 Stiff
 Restless
 Di mapakali
 Stuttering
 BODY AND BREATH ODOR
BREATH ODORS  Stare of Hyperthyroidism:
- Eyelid Retraction
 Alcohol breath – drinking alcohol (exophthalmos)
 Halitosis – abnormal
- Bad breath caused by food particles, and protrusion of
bacteria, etc. eyeball)
 Acetone breath (diabetes mellitus) - Grave’s
- Same smell as the one used in nail polish Disease
 Sweet and fruity breath indicates diabetic
ketoacidosis

BODY ODORS
 Note presence or absence (bromhidrosis-
excessive odor) OBVIOUS SIGNS OF HEALTH AND ILLNESSES
 Asians and Native Americans have fewer POOR NUTRITIONAL STATUS
sweat glands - Listlessness/ Apathy
- Less obvious body odor (than Caucasians - Poor Muscle Tone
and Black Africans) - Hair: thin/sparse
- Cheilosis (fissure at mouth angles)
SIGNS OF DISTRESS IN POSTURE OR FACIAL - Glossitis (inflammation of tongue)
EXPRESSION - Acute/Chronically ill
DISTRESS (POSTURE OR FACIAL EXPRESSION) - Frail/Feeble

 Observe at rest or
during conversation
- Note degree of
eye contact
(natural,
sustained, and
unblinking/averted)
 Smiles and frowns appropriately (Poor Muscle Tone)
 Immobile face/expressionless
 Flat/sad with poor eye contact (depression)
 Drooping (ptosis) or gross asymmetric in
neurologic disorders or injury:
- could be stroke /CVA
(Cerebrovascular Accident) or Bell’s
palsy.

(Thin/Sparse hair)

(Cheilosis → fissures at mouth angles)
(Glossitis → inflammation of the tongue)
(Acute/Chronically Ill)
(Frail/Feeble)
(Listlessness/Apathy)
CLIENT’S ATTITUDE
 Cooperative/Willing
 Unresponsive/Unwilling
 Anxious
AFFECT AND MOOD
(APPROPRIATE RESPONSES)
Emotional Variations and Responses
 Facial features are symmetric, good eye contact,
and frowns appropriately
 Facial expression appropriate to question being
answered
 Appropriate Response:
- Who, What, When and Where
 Affect
- Behavior expression of mood
 Mood
- Psychological state
 NCM 203 LEC: HEALTH ASSESSMENT
TOPIC: SPEECH, SKIN AND HAIR
2ND SEMESTER | S.Y 2021-2022
CLINICAL INSTRUCTOR: MR. ALDRIN ANTONE
Patient: “They’re destroying too
SPEECH many cattle and oil just to make soap. If we
ASSESSMENT OF SPEECH need soap when you can jump into a pool of
 Listen to quality, quantity, organization of water, and then when you go to buy your
speech gasoline, my folks always thought they
- Able to answer in organized manner should get pop, but the best thing to get is
(and with appropriate words) motor oil, and money. May as well go there
 Abnormality: and trade in some pop caps and, uh, tires,
- Disorganized speech and tractors to car garages, so they can pull
- Consistent (non-stop) speech cars away from wrecks, is what I believed in.”
- Long periods of silence → the response of the patient does
 Do: consider neurologic/psychiatric not address the interviewers’ question.
disorders Jumping from one topic to another.
→ Neurologic Disorder
– refers to disease process NEVER FORGET
and anything that has something to  Document everything
do with the deterioration of your → you can assume, BUT, do not
brain pathologically diagnose
– E.g. CVA (Cardiovascular
Accident) LIFESPAN CONSIDERATIONS
→ Psychiatric Disorder – A. INFANTS
– refers to mental illness
Observation of behavior provides important data for
RELEVANCE AND ORGANIZATION OF THOUGHTS
general survey:
THOUGHTS
 Must have relevance and organization in Physical Neuromuscular Social and
answer to questions (evident) Development Function interaction
 Abnormality: skills
- Disorganized speech → are they able → assess with → they
→ more on subjective cues because to speak MMDST (Metro interact
you’re trying to listen to the verbalization of already? Manila through
the patient Developmental crying
→ Slurred speech Screening Test)
- Word salad
E.g. of Word Salad
Interviewer: “What do you think  May be helpful:
about current political issues like energy - Have parents hold their infants or
crisis?” very young children for some parts of
the assessment
 - TRUST VS MISTRUST
E.g. a baby crying
→ Trust - able to attend the
baby immediately
→ Mistrust - unable to attend
the baby immediately
B. CHILDREN
 Preschool, school-age, and adolescent
→ consider how they think and
answer
 Weigh children without shoes and with as
little clothing as possible (patient’s gown)
 Anxiety in preschool children may be
decreased.
- Let them handle and be familiar
with examination equipment
 School-age children may be very modest and
shy about exposing their body parts
→ they are allowed to be
accompanied by their parents
 Adolescents should be examined without
parents’ present
C. ELDERLY
 Allow extra time for answering questions
 Adapt questioning techniques appropriately
(for hearing and visual limitations
→ gradually increase your voice for
elders who have a hearing problem
 Elders with osteoporosis may lose several
inches in height
- Document and assess awareness
of this loss of height
→ because of their curved
spine
 Be specific when asking about weight loss
(amount and timeframe)
Nurse: “Have you lost more than 5lbs
in the last 2 months?”
SKIN & HAIR
ANATOMY OF THE SKIN
 Skin
- First line of defense
- Single heaviest single organ in the body
o 16% of total body weight
o 1.2-2.3 square meters in area
- Functions:
o keep body in homeostasis
o Synthesizes vitamin D
o Body temperature modulation
- Protects underlying tissue against
microorganisms, harmful substances,
radiation.
- Provides boundaries for fluids
LAYERS OF THE SKIN
SKIN & HA
 There are three layers of the skin:
- Epidermis (outer)
- Dermis (Middle)
- Subcutaneous tissue or hypodermis
(below)
 Epidermis
- Most superficial layer
- Does not contain blood vessels
- Gets nourishment through diffusion
from the dermis
- Cell migration takes approx 1 month
(inner to outer)
Has two layers:
- Outer Keratinized Layer
- Keratinocytes produces
keratin
- Keratin makes skin immune
to abrasions (hardens the
skin)
- Inner Cellular Layer
- site of melanin and keratin
formulation

 Dermis
- Rich in blood vessels (blood supply)
- Merges with the subcutaneous layer
below
- Contains:
- Connective tissue
- Sebaceous Glands
- Sweat Glands
- Hair follicles
 Subcutaneous Tissue or Hypodermis
- Deepest layer of the skin
- Consists mostly of fats and
connective tissues
- Protect the internal organs and
muscles from shock and changes in
temperature
SKIN COLOR
- Pigment affects the skin color
- Relies on four pigments:
o Melanin
o Carotene
o Hemoglobin (Oxyhemoglobin
Deoxyhemoglobin forms)
SKIN COLOR
 Relies on four pigments:
 Pigments: affects the color of our skin
MELANIN
 Produced by melanocytes
 Amount is genetically determined
 Increased by exposure to sunlight
- Note: we all have equal number of melanocytes
in our body
→ kaya lang may mas maitim satin, ang sa
mga sobra ka itim, very active ang kanilang
melanocytes in producing melanin
CAROTENE
 Produced by Carotinocydes
 Golden-yellow pigment
 Found in:
- subcutaneous fat
- heavily keratinized areas (palms and
soles)
→ color of the patient high in
carotene level is yellow, orange
→ never assume right away that
patient has liver problems
HEMOGLOBIN (OXYHEMOGLOBIN AND
DEOXYHEMOGLOBIN FORMS)
 Found in our blood
COMPONENTS OF BLOOD
1. PLASMA
- 90% water
- And other solutes
2. FORMED ELEMENTS
A. White Blood Cells (Leukocytes)
B. Red Blood Cell (Erythrocytes)
- contains our hemoglobin
C. Platelets (Thrombocytes)
 Carries our oxygen and carbon dioxide
and
- both oxygen and carbon dioxide has high
affinity or attracted to our iron
 Contains: Iron and Heme
→ Heme - Protein
→ Iron - binding of our oxygen and carbon
dioxide
 Circulates in the red blood cells and carries
oxygen of the blood
→ due to your iron, RBC consists of 90%
hemoglobin
 Exists in two (2) forms
A. Oxyhemoglobin
B. Deoxyhemoglobin
→ Most of the time deoxyhemoglobin oxygen
unbonded because oxygen is being transferred to
another tissue, once the molecules of your tissue are
getting smaller that’s the time wherein carbon
dioxide will have a higher affinity to bind to your
iron.
IRON DEFICIENCY ANEMIA
 Common to female because of their
menstruation
 Can assess on the palms and conjunctiva
 Cyanotic – paleness
– pertains to cyanosis
 Cyanosis – bluish discoloration
DEOXYHEMOGLOBIN
 no oxygen; when hemoglobin releases
oxygen
 Darker and bluer pigment
 Produced when oxyhemoglobin passes
through capillaries and loses its oxygen
 Increased concentration in the tissue leads
to a bluish cast -> cyanosis
PROPENSITY OF SKIN TO TAN AND BURN
FITZPATRICK SCALE

CARBAMINOHEMOGLOBIN
 When carbon dioxide binds to hemoglobin

OXYHEMOGLOBIN
 Contains oxygen
 When oxygen binds to hemoglobin
 Bright red pigment
 Arteries and capillaries (concentrated)
→ Veins are not included because in
carries deoxygenated blood.
→ Pulmonary veins are the only veins HAIR
that carry oxygenated blood.  Adults have 2 types of hair
 Increased blood flow reddens skin 1. Vellus Hair
 Decreased blood flow produces pallor o Short
(paleness) o Fine
o Inconspicuous
LIGHTER-SKINNED PEOPLE o Unpigmented (relatively)
 Some areas are normally redder on:
- Palms
- Soles
- Face
→ Melanin causes hair color to be
red, brunette, blonde, also depends on
the genetic make-up of the individual
→ We produce white hair as we grow
-Neck
older because of decrease in melanin
-Upper chest
production
→ Redness can be triggered by
2. Terminal
alcohol intoxication, allergic attack
o Coarser
o Thicker
 o More conspicuous
o More pigmented
o Scalp and eyebrows
→ Pubic hair is curly because it gets
squished in the underwear, same with
underarm hair

HAIR (SPLIT END)

SEBACEOUS GLANDS
NAILS  Produce a fatty substance secreted onto skin
surface (through hair follicles)
 Protect the distal ends of fingers and toes  Secretes oil and sebum
 Fingernails frown 0.1mm daily  Not found on:
- Toenails are slower - Palms (Sweat glands)
 Parts: - Soles
a) Lunula → whitish moon
b) Nail plate → firm, rectangular, and
curving; site of attachment of nail bed
c) Cuticle → extends from nail fold,
functions as a seal, protects space
between fold and plate from external
moisture)
d) Lateral nail fold → covers sides of nail
plate
e) Proximal nail fold → covers ¼ of the nail
plate [nail root])
f) Free edge → 0.1 mm day or slower if
toenails)
→ Hangnails – dehydration/H20 deficit
→ Kung pangit ka’g nails, you are
malnourished ECCRINE
 Widely distributed
 Open directly onto skin surface
 Helps control body temperature (sweat)

APOCRINE
 Axillary and genital regions
 Open into hair follicles
 Stimulated by emotional stress
 Responsible for body odor (bacterial
decomposition of apocrine sweat)
→ that’s why our armpits sweat when we’re
nervous
 Palpate skin temperature (compare
both sides)
→ using the dorsal part of your hand
 Note skin turgor
→ elasticity of skin, general
hydration of the body; expect poor
skin turgor for elderly
 Document location of skin lesions on
body surface diagram
→ skin lesions – birth marks, chicken
pox marks, pimple, lumps

4. Inspect for the uniformity of the skin color

 Pallor → paleness

-Decreased redness in the skin

(anemia)
- Inspected in the areas:
a) Fingertips
b) Lips
c) Mucosa
 Cyanosis
- → bluish discoloration of the skin
- low oxygen, iron deficiency
(anemic), cardio-pulmonary
conditions (blood, heart, blood
vessels)
- Types:
ASSESSMENT OF THE SKIN
- Central
1. Assemble equipment and supplies
- Peripheral
- Ruler with cm markings
- Examination gloves
- Magnifying glass
2. Do proper medical handwashing
3. Provide privacy
 Central Cyanosis  Jaundice

- Decreased level of oxygen in the - Yellowish color of the skin

blood - Found in the areas:
- Conditions a) Sclera
- Chronic Obstructive
Pulmonary Disease (COPD)
- Congenital Heart Disease
(e.g. tetralogy of fallot)
→ present at birth
 Peripheral Cyanosis
→ yellow coloration -
icteric
→ no yellow
coloration – anicteric
→ May be due to:
- Liver disease
- Hemolysis of
red blood cells
- Occurs when oxygen (100-120 days)
levels are normal → Hemo – blood
- When blood flow → Lysis - breakdown
decreases and slows, b) Palpebral Conjunctivae
tissues are able to c) Skin
extract more oxygen
than usual from the JAUNDICE
blood (venous
obstruction  May be due to :
- May be natural response to: - Liver disease
- Anxiety - Hemolysis (breakdown of blood) of red
- Cold environment blood cells
 CAFE-AU-LAIT SPOTS VITILIGO

 Chalk-white lesions
 Due to autoimmune
destruction of
melanocytes (by t cells)

ERYTHEMA
 Increased redness
 Slightly but uniformly pigmented macule (or and warmth of the
patch) skin
 Somewhat irregular border  May be due to :
 0.5-1.5 cm - Inflammation
 Benign - Allergic reactions
 If> 6 spots, consider neurofibromatosis (may - Trauma (physical
problema sa nerves ng ating skin ) trauma)
- Increased blood flow – vasodilation
ACANTHOSIS NIGRICANS
EDEMA
 makikita sa ASSESSING FOR EDEMA
mga obese,  Problem with kidney ➡ regulation of fluids
DM,
 Roughening 1. Let patient sit with legs dangling
and darkening 2. Palpate skin over tibia, pressing the skin
of the skin in between thumb and index finger (30-60
localized areas seconds)
 Found in the posterior neck - pa akyat dapat ang pag assess ng edema
para alam mo kung hanggang saan na ang
ALBINISM edema
3. Run finger pads over area pressed and note
 may problem sa melanocytes (absence or low indentation
production of melanin) 4. If (+), repeat the test by moving up
 Generalized loss of pigmentation extremities
 Total lack or decreased tyrosinase enzyme
5. Note point wherein swelling is not noted
activity
anymore
 Extraordinary vulnerability to damage from
sunlight  When to note when the patient is getting
better: indentation goes lower
 The pull of gravity and pressure causes
edema to start at the foot.
 Measurement – amount of indentation
 Duration – time when the skin will go back regression, trauma, or other extraneous
to its normal position factors
- can become secondary lesions
TYPES OF PRIMARY LESIONS
Macule
Patch
Papule
Plaque
Nodule
Wheal
Cyst
Vesicle
Bullae
Pustule
PRIMARY LESION: MACULE
 Flat
- may have a little protrusion
 Variable size and shape
 Differs from surrounding skin (color)
 <1 cm
 Example: Freckles and Petechiae (Dengue
Fever)
PITTING
 Skin takes very slowly to go back to its
normal position

- Petechiae - caused by BP cuff or after

tourniquet test
SKIN LESIONS - having 20-30 petechial rashes after the
ASSESSMENT OF SKIN LESIONS tourniquet test means positive on dengue
 Inspect, palpate, and describe skin lesions fever
 Use gloves as needed

PRIMARY LESIONS
- original lesions which may have continued
to full development, or modified by
 - The bigger ones are the vesicle – filled with
fluid.

PRIMARY LESION: PATCH

 Very large macule
 Coalescence of macules
 ≥1 cm

2. Psoriasis (guttate type)

\\

Examples of Patch are: Pityriasis rosea and Vitiligo PRIMARY LESION: PLAQUE
 Vitiligo - caused by autoimmune - Broad based papule
- Occupies relatively on
 Pityriasis rosea - caused by fungu
large surface area (in
comparison to its height
above skin level)

- Pityriasis
rosea Vitiligo
Examples of Plaque are:
roseaPRIMARY LESION: PAPULE 1. Psoriasis
 Small
 Solid
 Elevated
 ≤ 1cm

Examples of papule are;

1. Chickenpox (varicella)
- The small ones are the papules
2. Ringworm
- Caused by fungal and microbial infections PRIMARY LESION: WHEAL
- Irregular
- Transient (relatively)
- Superficial – for it is situated in the dermal
layer
- Localized edema
- Flat-topped papule
- Most common example; pag nakagat ng
lamok then the red bumps it leaves is what
you call a wheal.
PRIMARY LESION: NODULE

- PALPABLE
- Usually palpated in
the back of the head,
and axilla
- Firmer and deeper
than the papule
- Round to spheroid
shape (marble-like)
- Center may be at the
dermis or to the subcutaneous tissue Examples of wheal are:
1. Mosquito bites
Examples of nodule are:
1. Surfer’s nodule
- Usually natatamaan ang foot sa surf board
of surfers kaya nag develop into these
bumps

2. Skin test (e.g., Mantoux test)

- Mantoux test – for tuberculosis
- Skin test are facilitated to check if the
patient is allergic to a particular antibiotic
or drug medications.
2. Boxer’s knuckle pads
- Due to trauma or arthritis PRIMARY LESION: CYST
- Epithelial cell-lined sac
- Contains liquid or semi-solid material (fluid,
cells, and cell products)
 1. Shingles (varicella zoster)

Examples of cysts are: 2. Bullous pemphigoid

1. Sebaceous cyst

PRIMARY LESION: BULLAE

2. Ganglion cyst
- Larger than vesicle (≥ 1cm)

TO REMOVE THESE: incision is made to incise the

cyst and remove the underlying sac. Examples of bullae are;
1. Bullae over foot
PRIMARY LESION: VESICLE
- Filled with serous fluid
- Elevated
- ≤ 1cm

Examples of vesicles are:

 2. Burn (2nd degree) SECONDARY LESIONS
- The tissues are compressed - Secondary Lesions are mas grabe at mas
malaki (e.g. a wound becomes a scab)

TYPES OF SECONDARY LESIONS

Scales
Crusts
Excoriations
Fissures
Erosions
PRIMARY LESION: PUSTULE Ulcers
- Elevated Scars
- Filled with pus (exudate)
SECONDARY LESION: SCALES
- THIN EXFOLIATED EPIDERMIS
- pagbabalat

Examples of pustule are:

1. Acne (severe pustular)
Examples of scales are:
1. Dandruff

2. Psoriasis (pustular)
2. Psoriasis (scalp)
 SECONDARY LESION: CRUST (SCAB)
- Dried residue;
 Serum
 Pus
 Blood
- May be mixed with epithelial and bacterial
debris

Examples of Excoriation are:

1. Linear

Examples of crust are:

2. Punctuate
1. Cutaneous anthrax

2. Impetigo SECONDARY LESION: FISSURES

- Line crack of the skin

Examples of fissures are:

SECONDARY LESION: EXCORIATION
- Superficial excavations of epidermis
- May be linear or punctuate
- Results from scratching
Examples are; 2. Wound (post- debridement)
1. Athlete’s foot

2. Fissure-in ano (anal fissure)

SECONDARY LESION: ULCER
 Deeper loss of
epidermis and
dermis
 May bleed and
scar

Examples of ulcer are:

SECONDARY LESION: EROSION 1. Pressure ulcer (bed sore)
- Loss of superficial epidermis  injuries to the
- Surface is moist (but does not bleed) skin and
underlying
tissue,
primarily
caused by
prolonged
pressure on
the skin
2. Venous Insufficiency
Examples erosion are:  problem with the
1. Chickenpox (varicella) veins
- \
-
-
-
 SECONDARY LESION: SCAR - Hyperthyroidism – mabilis ang
metabolism or ang basal metabolic rate
(BMR)
- Pag mataas ang metabolism there will be
increase in your temperature
 Hyperhidrosis – excessive sweating

SKIN INTEGRITY
 New connective tissue (fibrous) that has
replaced lost substance (in the dermis or
 Assess skin over pressure point areas
deeper)
(sacrum, hips, and elbows) – prone to
 Results from injury or disease
decubitus ulcers/bed sores
 Part of normal reparative process
 When we say pressure points these are the
points where in your bones are actually
Examples of scar are:
applying pressure
Normal: intact, no redness
1. Hypertrophic
Abnormal: (+) skin breakdown (open
 a thickened, wide,
wound), redness, warmer than other body
often raised scar that
parts
develops where skin
is injured
SKIN TEXTURE

 Note any rough, flaky, or dry skin

(hypothyroidism)
2. Keloid
 Obese clients may report dry, or itchy skin
 The patient possibly
- Pag obese ka mas mababa ang iyong
underwent heart surgery
water content sa body (50%)

SKIN THICKNESS

 Note for presence/absence of calluses

- Magkaroon ka ng calluses pag any part
of your body is exposed to frequent
SKIN CONDITION
friction
SKIN MOISTURE
- Rough, thickened sections of epidermis
 Dryness
- Commonly seen in parts exposed to
- Consider hypothyroidism or dehydration
constant pressure
 Oiliness (prone to acne)
Normal: Thin skin without calluses (normal)
 Sweating (degree)
Abnormal: Very thin skin (arterial
- Consider hyperthermia or
insufficiency/steroids therapy – abnormal) –
hyperthyroidism – because your body is
madali na lang magkaroon ng skin breakage
trying to compensate for the increasing
of your temperature
 SKIN TEMPERATURE
 Compare hands and feet bilaterally (using
dorsal aspect of hand)
Normal:
- uniform and within normal range
Abnormal:
- generalized hyperthermia (fever)
- generalized hypothermia (shock)
- localized hyperthermia (infection)
- localized hypothermia (arteriosclerosis)
 Fever – caused by pyrogens (endotoxins that
are being released by your pathologic
microorganisms or pathogenic
 Hyperthermia (also called heat stroke) –
usually cause by external environment
 There is a problem in the circulation sa blood
pag walang bilateral uniformity
WHICH PARTS OF THE HAND TO USE?
SKIN TURGOR
 Refers to the skin’s elasticity
- and how quickly it returns to its original
shape after being pinched
 Refers to skin mobility
- for bigger patients it is difficult to assess so
we need to pinch other areas such as the frontal
lobe, forehead
 Assessed By:
- Lifting fold of skin
- Note its ease with which it lifts up
 Where:
- Child/Adult: forehead, chest, abdomen,
and extremities
- Elderly: Chest and abdomen only
 Findings:
- Pinched easily and immediately returns to its
original position (NORMAL)
- Older patients – decrease elasticity and
collagen fibers (sagging/wrinkled skin in the
face, breasts, and scrotal area)
- Decreased mobility = edema
- Decreased turgor (or>30seconds) =
dehydration

1. Finger pads
- Fine discrimination (pulses, texture, size,
and crepitus)
2. Ulnar and Palmar surfaces
- Vibrations/ Thrills/ Fremitus
3. Dorsal surface
- Temperature
(Poor Skin Turgor)
 DOCUMENTATION FOR SKIN FINDINGS
DIAGRAM

- Draw the location, size, and describe skin lesions

on the body surface diagram


 Unconjugated bilirubin – a toxic waste
product of hemoglobin (RBC) breakdown
that has to be excreted
→ Unconverted unconjugated bilirubin is
difficult to excrete. It will just go around the body
and cause yellow coloration.

 Conjugated Bilirubin – the kidneys have

LIFESPAN CONSIDERATIONS the ability to excrete the conjugated
 Neonates/Newborns bilirubin
 Infants  No liver problem - can convert
 Elderly unconjugated bilirubin to conjugated
bilirubin
NEWBORNS/NEONATES  Has liver problem - cannot convert the
 Physiologic jaundice may manifest at 2-3 unconjugated bilirubin
days after birth - Liver cirrhosis → frequent
→ a normal process alcohol consumption
→ usually lasts 1 week tapos mawala
na NEONATES/NEWBORNS: BUILD UP
 Pathologic jaundice appears within 24 OF BILIRUBIN
hours after birth
→ there’s a problem in the baby’s EXTRAUTERINE LIFE
organs  Life outside the uterus
→ it usually lasts more than 8 days,  The baby is already delivered
mawala lang siya if there is medical When babies are born:
management a. Organs are still underdeveloped
b. Immune system is also underdeveloped
ADULTS: BUILD UP OF BILIRUBIN
↑Level of Bilirubin = heart or brain REASON WHY THERE IS PHYSIOLOGIC JAUNDICE
complication 1. Liver is underdeveloped
 Can only process a certain amount of
bilirubin
LIVER 2. Placenta is no longer present
 Processes our bilirubin from unconjugated 3. Mas underdeveloped pa ang liver
to conjugated so that it can be excreted
already A. NEWBORNS/NEONATES
- Newborns, they have a high number or has  Note for presence of:
fast number of blood specifically the red blood - Milia (whiteheads)
cell - Small nodules over the nose & face
- Vernix caseosa-white, cheesy, and greasy
- Increase in rate of hemolysis (while the liver is material
still underdeveloped) → it cannot process the
amount of bilirubin that is brought about by If premature:
the destruction of our red blood cell LANUGO
→ Thus, there will be a buildup of our  Fine, downy hair over the shoulders and
bilirubin kaya 2-3 days pa bago lalabas back
If dark-skinned:
RED BLOOD CELL HYPERPIGMENTATION
 Will undergo hemolysis  Bruise-like/hematoma-like found on the
back (sacral area)
INTRAUTERINE LIFE
 Life inside the uterus B. INFANTS
 The baby has liver that is underdeveloped  Note for presence/absence:
- Diaper rash (diaper dermatitis)
PLACENTA - Inquire about details of immunization
 Is the one responsible for assisting in the history
excretion of bilirubin  Also assess skin turgor (abdomen)
 Assists the processing of the unconjugated
bilirubin to be excreted C. CHILDREN
→ Kaya pag labas ng bata, di pa siya  Usually have minor skin lesions like bruising
yellow (physiologic jaundice) within 24 and abrasions on arms and legs
hours. But after 2-3 days, there will be an → From being playful
increased rate in the hemolysis of the RBC.  Lesions on other parts of the body may be
- Increase in hemolysis = increase in bilirubin signs of disease or abuse
- And since the liver is underdeveloped, it → Take thorough history, e.g. glove/stocking
cannot process all the unconjugated bilirubin injury, cigarette burns)

PHOTOTHERAPY OR BILI LIGHT

→ Gina coveran ang mata and reproductive
organs ng baby para di masunog

PATHOLOGIC JAUNDICE: REASONS WHY THE BABY

WILL TURN YELLOW AFTER 24 HOURS
1. The baby is still premature

 Secondary Lesions
may occur
frequently as
children scratch or
expose a primary
lesion to microbes
(staph, spp)
→ Brought about by primary lesions (scratching
due to itchiness)
 Oil glands may
become more
productive and
consequently
develop acne
(puberty)
D. ELDERLY
● Changes in fairer skin occur earlier than
dark-skinned individuals
● Wrinkles first appear on skin of face and
neck (abundant in collagen elastic fibers)
→ As you grow older the collagen level
depletes
● Skin appears thin and translucent due to
loss of dermis and subcutaneous tissue.
● Skin may be dry and flaky (less active
sebaceous and sweat glands)
→ More prominent over extremities
● Decreased skin turgor
→ Assess for hydration instead over
sternum or clavicle
● Senile lentigines (melanotic freckles)
→ Flat, tan-brown, macules appear on
areas exposed to the sun (apparent on back
of hand and other skin areas)
→ May be as large as 1-2cm
ASSESSMENT OF THE HAIR AND SCALP
ASSESSING THE HAIR
Assess for:
- Growth
- Texture
- Oiliness
- Infection → caused by microorganisms
- Infestation → caused by pests
1. Wear gloves
2. Inspect hair (natural color)
3. Inspect evenness of growth over the scalp
4. Inspect hair texture and oiliness
5. Note presence of infections or infestation
(part the hair in several areas and check
behind the ears, along the hairline, and
neck)
6. Inspect amount of body hair
Normal: characteristic hair distribution on
body (biologic sex and physiologic function)
Abnormal: excessive hairiness in females
(may be due to imbalance in adrenals)
7. Note presence of infection/infestation by
parting the hair
Normal: scalp free from flaking
No signs of nits or lice
Abnormal: excessive scaliness
(DERMATITIS – inflammation of dermal
layer)
RAISED LESIONS (tumor/inflammation)
EXCESSIVE HAIR LOSS MAY BE CAUSE BY:
- Infection
- Nutritional deficiencies
- Hormonal disorders
- Thyroid or liver disease
- Drug toxicity (chemotherapy)
→ Note: A common misconception is that all  More common in children (in settings of
cancer patients experience hair loss. The family or
reason why there is hair loss is due to the psychosocial
chemotherapy drugs. Chemotherapy drugs is stress)
non-selective meaning it does not have the
ability to select cancer cells. Chemotherapeutic
drugs attack cells whether they are healthy or
cancer cells.
- Hepatic or renal failure  Occasionally may lead to hair being
- Radiation or chemotherapy consumed

HAIR CONDITION  Ringworm:

ALOPECIA - Tinea
 Loss of hair capitis
 Male-pattern hair loss (normally)
 Loss of hair which may be:
a. Diffuse
b. Patchy
NUTRITIONAL DEFECIENCIES (KWASHIORKOR)
c. Total
- Babies and children do not get enough
ALOPECIA AREATA
protein or other essential nutrients

 Flag sign

 Copper-red
 Clearly demarcated round or oval patches
of hair loss
 Usually affects children and young adults
 No visible scarring or inflammation

TRICHOTILLOMANIA
CANCER TREATMENT
 Hair loss due to
pulling, plucking  Radiotherapy
or twisting hair (localized)
→ associated to those
with mental illness

 Chemotherapy (total)
 CHILDREN
ADRENAL IMBALANCE
- Axillary and pubic
- (HIRSUTISM) hair begin to appear
- Hirsutism can be caused by: Polycystic ovary as puberty
syndrome. This most common cause of approaches
hirsutism is caused by an imbalance of sex - Measured by Tanner
hormones that can result in irregular periods, scale/staging
obesity, infertility and sometimes multiple cysts
on your ovaries
- TANNER STAGING
-
-
-
-
-
-
-
-

THYROID DISORDERS

● Hyperthyroidism
- Fine, silky hair (maninipis)
● Hypothyroidism
- Sparse hair

LIFESPAN CONSIDERATION

● Neonates/Newborns (and Infants)

● Children
● Elderly
ELDERLY
NEONATES/NEWBORNS (and infants)
- Possible loss of scalp, pubic, and axillary hair
- Normal to have very little or a great deal of - Hair on eyebrows, ears, and nostrils may
body and scalp hair become bristle-like, and coarse
 NCM 203 LEC: HEALTH ASSESSMENT
TOPIC: SKULL & FACE, NAILS, EYES, EARS, NOSE, MOUTH & NECK
2ND SEMESTER | S.Y 2021-2022
CLINICAL INSTRUCTOR: MR. ALDRIN ANTONE
THE ANATOMY OF THE SKULL AND FACE
ASSESSMENT OF THE SKULL AND FACE

1. Inspect skull for shape and symmetry - The Frontal, Temporal, Parietal, and Occipital
2. inspect facial features Regions of the Skull.
3. Inspect eyes for edema and hollowness - Lacrimal bones consist of small bones.
4. Inspect facial symmetry and movements - In newborns, always assess their sutures if
a. elevate eyebrows they’re fused already.
b. frown/ lower eyebrows - As the infant grows older, the sutures will fuse
c. close eyes tightly to each other.
d. puff cheeks - During infancy, the sutures are movable. As
e. smile development occurs, the sutures will fuse and
become immovable.
5. Palpate the skull for nodules, masses, or
depression ASSESSMENT OF THE SKULL
Include the fontanels for pediatric patients.  Assess for the size, shape, and symmetry of
- check for closure and depression the skull
(pagkalubong) of the skull  Normal:
- depression of the fontanels  the patient - rounded, smooth (normocephalic)
is dehydrated  fluid volume deficit → Cephal means head
- nagburot/nibukol ang ulo  fluid volume  Abnormal
overload - enlarged (hydrocephalus)
- Hydrocephalus
→ Hydrocephalus is a problem on the
pathway of the CSF.
 VP SHUNT

→ The CSF cannot get out and will just

circulate around the ventricles (chambers)
of the head. Since di makalabas and CSF
and the fontanelle (fetal skull) is still open,
it will build up in the head and will
abnormally grow.
→ Kayang maagapan kung may early
management.
- Ventriculoperitoneal (VP) Shunt
- catheter is connected from the abdomen up
to the ventricles. Wherein the CSF will be
drained.
- A VP shunt is a small plastic tube that helps
drain extra cerebrospinal fluid from the
brain. Most VP shunts are placed to treat
hydrocephalus.
 Abnormal:
- Lack symmetry
- Increased size with prominent nose and
forehead
Hydrocephalus – there is a buildup of pressure on
the chambers of the brain’s ventricles causing the
patient to be lethargic which affects their level of
consciousness.
→ the buildup of fluid in the cavities
(ventricles) deep within the brain. The
excess fluid increases the size of the
ventricles and puts pressure on the brain.
Cerebrospinal fluid normally flows through
the ventricles and bathes the brain and
spinal column.
 ASSESSMENT OF FACIAL FEATURES
 Normal:
- Symmetrical facial features (round, oval,
square, elongated)
- Palpebral fissures equal
- Symmetric nasolabial folds
 Abnormal:
- Asymmetrical facial features
- Prominent facial hair (hypertrichosis or
werewolf syndrome)
LEONINE FACIES (LEPROSY/HANSEN’S DISEASE
Exophthalmia - hyperthyroidism
- Facies (a distinctive
facial expression
associated with a
clinical condition)
- Bird facies
MOON FACIES (CUSHINGOID SYNDROME)
- CUSHING – increased levels of cortisol; or
patients who underwent corticosteroid
treatments which results the swelling of
their face.
→ Cushing’s syndrome is a disorder that occurs
when your body makes too much of
the hormone cortisol over a long period of time.
Cortisol is sometimes called the “stress
hormone” because it helps your body respond to
stress.
- Mycobacterium leprae is a bacterium that
causes leprosy, also known as "Hansen's
disease", which is a chronic infectious
 disease that damages the peripheral nerves
and targets the skin, eyes, nose, and muscles.

ASSESSMENT OF THE EYES

 Inspect the eyes for edema and hollowness
Edema – if you have head injury/trauma
(black eye)
Hollowness – stress, dehydrated, sunken
eyelids, sunken periorbital area ASSESSMENT OF FACIAL SYMMETRY
 Normally, there should be NONE  Ask patient to:
 Abnormal: 1. Elevate eyebrows
1. Periorbital edema 2. Frown
→ there are times that it is also called 3. Lower eyebrows
blepharitis 4. Close lids tightly
→ hubag ang eyelids 5. Puff the cheeks
→ grabe ang pag secrete ng lacrimal 6. Smile
ducts 7. Show teeth
 Trying to check for your cranial nerve
number (5 or 7)

OTHER ASSESSMENTS OF THE FACE

 Palpate for any nodules, masses, or
depressions
 Normal:
- Smooth uniform, no nodules/masses
2. Eye bags noted
→ cause by stress
 Abnormal:
- Fractures
- Indicate which area has abnormalities
such as a depression from local trauma

LE FORT FRACTURES

3. Hollow eyes
→ sunken eyes, malnutrition,
dehydration
 FACIAL FRACTURE (LE FORT III)

LIFESPAN CONSIDERATIONS
NEONATES/NEWBORNS

- Shape of head
can be different HEAD MOVEMENT
(Shape is due to - Can slightly move lift their heads and move side
pressure applied to side
by the pelvic area - Voluntary controls are established at
up to the vagina, approximately 4-6 months
but it will be Strabismus - a condition in which the eyes do not line
molded naturally. up with one another, involuntary to new born, cross-
eyed)
- Depends on
the type of delivery (vaginal vs. cesarean NAILS
section)  Assist in grasping objects
 Protect the distal ends of fingers and toes
VAGINAL DELIVERY (from trauma)
- Can sometimes lead to elongated,  Fingernails grow 0.1 mm/day
molded heads - Toenails are slower
- normal shape of head becomes more  Complete replacement of nail plate:
round after 1-2 weeks (molding) - Finger (4-6 months)
(Can be observed at the occipital/parietal - Toe (12-18 months)
area)
CESAREAN SECTION
- Tend to have more smooth,
round heads (because there
is no pressure applied)
 PARTS OF THE NAILS NAIL GROOMING, COLOR, MARKINGS AND SHAPE
A. NAIL GROOMING
 Lunula –
whitish moon  Normal
 Nail plate – - Clean,
firm, manicured
rectangular,
and curving site
of attachment - Pink with some
of nail bed longitudinal
 Cuticle – riding
extends from - May have
nail fold, functions as a seal, protects space
between fold and plate from external freckles/pigments (dark-skinned)
moisture
 Lateral nail fold – covers sides of nail plate  Abnormal
 Proximal nail fold – covers ¼ of the nail - Dirty, jagged,
plate (nail root) or broken
 Free edge – 0.1 mm/day or slower if toenails (poor hygiene
→ it’s not attached to anything; grows from or related to
the finger and toes client’s
occupation)
ASSESSMENT OF THE NAILS - Jagged or broken
- to determine problem in nutrition, nail edge →
oxygenation, cardio-pulmonary
 Equipment needed:
- Acetone
- Cotton ball B. NAIL COLOR
Normal:
1. Inspect fingernail plate shape - Pink with some longitudinal ridging
- Determine its curvature and angle - May have freckles/dark-skinned
2. Inspect fingernail and toenail textures pigments
3. Inspect fingernail and toenail color, lesions Abnormal:
and obvious deformities 1. PALE OR CYANOTIC (HYPOXIA OR ANEMIA)
Assess through: HYPOXIA
1. SCHAMROTH’S TECHNIQUE  Decreased O2
2. CAPILLARY REFILL TEST  There is a problem with the distribution of
- To assess the blood flow. A quick test oxygen to the different tissues
performed on the nail beds ANEMIA (IRON DEFICIENCY)
 There is problem with the oxygen
IRON
  Has high affinity to our oxygen and carbon c. >180° (late clubbing)
dioxide
→ If there is transferring of oxygen to our
tissues, lumiliit ang binding ng oxygen kaya
nag ba-bind na kaagad ang carbon dioxide

2. SPLINTER HEMORRHAGES (TRAUMA)

D. NAIL TEXTURE
 Present and smooth
 May be thickened and yellowish due to
decreased circulation (elderly)
3. YELLOW DISCOLORATION (FUNGAL INFECTION
 Excessive thickness due to hypoxia
OR PSORIASIS)
(clubbing)

NAIL TEXTURE: BEAU’S LINE

 Transverse
linear
depression
(associated
with an
C. NAIL SHAPE
acute, severe illness)
 SCHAMROTH’S TECHNIQUE
 Bilateral (usually)
 Due to temporary disruption of proximal
nail growth (systemic illness)

NAIL TEXTURE: KOILONYCHIYA

 Spoon-shaped
- We can know it the patient is poorly nails
oxygenated and if they have problem  Loss of convexity
either cardio or pulmonary system  Consider iron-
1. Put ring fingernails together deficiency anemia
2. Locate diamond-shapes space in
between the fingernails (normal finding) NAIL TEXTURE: MEES’ LINE
→ If not found = problem with oxygenation
→ Mostly seen with patients with Chronic
Obstructive Pulmonary Disease(COPD)
Angles:
a. 160° (normal)
b. 180° (Early Clubbing + Spongy Sensation)
→ Can also be brought about by drugs
 Transverse lines similar to the lunula which causes Myocardial infarction (heart
(crosses the nail) attack) and CVA
 Follow an acute/severe illness
 Vary in width NAIL TEXTURE: PARONYCHIA
 Moves distally as the nail grows
 Arsenic poisoning
 Heart failure
 Hodgkin’s disease
 Chemotherapy
 Carbon monoxide poisoning
→ Sleeping inside a burning house will cause
you to lose consciousness due to carbon  Indicates local inflammation of proximal
monoxide poisoning or toxicity and lateral nail folds (superficial infection)
 Leprosy → Superficial meaning the infection is on
→ Also known as Hansen’s disease the skin
 Nail folds are red, swollen, and tender
NAIL TEXTURE: ONYCHOLYSIS  Most common infection of the hand (staph
and strep spp)
 May spread until completely surrounds nail
plate if it is not addressed
 Local trauma (nail biting, manicuring, or
frequent hand immersion in water)

 Painless separation of the nail plate from the

pinker nailbed
→ Usually happens due to traumas
 Starts distally, progresses proximally
(enlarges free edge of the nail)
 Local (trauma from excess manicuring, ● May create a felon (painful abscess on
psoriasis, fungal infection, and allergy to fingertip) if extends into pulp space of
cosmetics) finger
 Systemic (diabetes, anemia, photosensitive → Abscess meaning there is already presence
drug reactions, hyperthyroidism, peripheral of infection
ischemia, bronchiectasis, and syphilis) → There are times wherein the affected area
→ Healing process of patients with is needed to be amputated
diabetes is slow due to viscosity of blood
which slows down the circulation then
slows down the oxygen distribution.
→ If hypoxia (decrease in oxygen levels) is
not addressed it will progress into ischemia,
REMEMBER:  Nail-biting (psychological) should be
● Also inspect the surrounding tissue: discussed with family member
 Normal: Intact epidermis ELDERLY
 Abnormal: Presence of hangnails  Nails grow slower and thicker
→ Do not pull but use nail cutter  Nails tend to split
 Toenail fungus is more common and
- Perform difficult to eliminate (not necessarily
blanch or dangerous to health)
capillary  Longitudinal bands commonly develop
refill test a. Bands across nails → protein
→ 2-3 deficiency
seconds b. White spots
(normal) → zinc deficiency
c. Spoon-shaped nails
→ iron-deficiency
Note: Abnormalities are signs of illness
but it needs further diagnosis by the
physician
→ LEUKONYCHIA – harmless, white spots in
the fingernails

EYES
ANATOMY OF THE EYES

 Always document your findings → Palpebral Fissure – check the symmetry

of the left and right eye's palpebral fissure.
LIFESPAN CONSIDERATIONS → Pupil – assess the constriction and
NEONATE/NEWBORN dilation of the eye with the use of a penlight
 Nails grown quickly, extremely thin, and
tear easily
→ Note: the proper cutting of nails should be
straight across
CHILDREN
 Bent, bruised, or ingrown nails (shoes too
tight)
 THE ORBITS
 Quadrilateral pyramids
- Bases face anteriorly
- Apices pointing backward
medially
- Medial sides are parallel
(TOP VIEW) - NOSE
- EYES
 Formed by 7 bones:
a. Orbital roof - frontal bone and
lesser wing of sphenoid
b. Medial wall - ethmoid, maxillary,
lacrimal and sphenoid
THE EYELIDS
 Palpebral fissure
- Area between opened upper and
lower eyelids
- Has 2 angles/canthi:
a. Lateral or outer canthus
(temporal)
b. Medial or inner canthus
(nasal)
 Medial canthus:
- Caruncle ( small protuberance of modified
skin )
- Plica semilunaris (tissue fold behind the
and caruncle )
 Each lid has a punctum at the nasal aspect
 Skin overlying the eyelids is the thinnest of the
body
 Supplied by facial nerve (CN VII) and
oculomotor nerve (CN III)
 Sclera
- Outer protective layer of the eyeball
- Modified anteriorly to become the cornea
 Cornea
- Transparent area/ passage where light rays
enter the eye
CHOROID
- Found inside the SCLERA
- Highly vascular layer that nourishes the
structures in the eyeball
RETINA
- Lines the posterior ⅔ of the choroid
- Neural tissue (contains the receptor cells)
RECEPTOR CELLS
- Day vision (cones)
- Night vision (rods ➡ more
sensitive to light)
 CRYSTALLINE LENS - Primary visual receiving area
- Transparent structure (Brodmann’s area 17 or V1) is located
- Held in place by the zonule on sides of calcarine fissue)

ZONULE ASSESSMENT OF THE EYES

- Holds the lens in place (attached to the ciliary EYEBROWS
body)  Inspect eyebrows for:
- Also known as the lens suspensory ligament - Hair distribution (is it evenly distributed?)
alignment
CILIARY BODY  Let the patient raise and lower eyebrows (check
- Thickened anterior part of the choroid the movement)
- contains circular and longitudinal muscle fibers  Normal findings:
that attach near the corneoscleral junction. - symmetrical, equal eyebrow hair and
movement
IRIS  Abnormal:
- Pigment (colored) and opaque - Scaling (seborrheic dermatitis -
- Contains circular muscle fibers (constrict) and inflammation of your skin)
radial fibers (dilate) that control pupil size - Lateral sparseness (outer 3rd)
- Asymmetry (movement of distribution)
PHYSIOLOGY OF VISION - Consider:
NEURAL PATHWAYS  Hypothyrodism – Sign of Hertoghe
 Atopic Dermatitis

 Light stimulus is detected by the receptor
cells (rods or cones)
 This goes to the optic tract, and ends in the
lateral geniculate body (thalamus)
 Fiber from nasal half and temporal half of
the other eye synapse on the cells whose
axons from the geniculocalcarine tract
 Geniculocalcarine tract passes to occipital
lobe of the cerebral cortex
EYELASHES
 Inspect for evenness and curl direction
 Normal:
- even distribution and outward
 Inspect for surface characteristics
- elevate brows with thumb and index fingers,
then let patient close eyes
 Normal:
- Skin intact no discharge/ discoloration
- 15-20 blinks per minute
EYES
 Normal findings:
- Palpebral fissures  equal in size when open
- equal in size = the distance of upper and
lower lid is equal
  Ectropion  outward turning of lower lid
(exposed palpebral conjunctivae, puncta of
lower lid also outward, leads to tearing
- Upper lid  covers small portion of iris and
cornea
- Lower lid  margin just below junction of
cornea and sclera
- Lid margins  clear
- Lacrimal duct openings  evident at nasal
side of eyelids

 Abnormal:
BULBAR/PALPEBRAL CONJUNCTIVAE
 Lower palpebral
- Ask patient to look up
- Depress lower lids using thumbs

- Rapid, monocular, infrequent, or absent of

blinking
- Ptosis - drooping of the eyes/eyelids (may
due to myasthenia gravis, damage to
oculomotor nerve, or senile ptosis)
- Myasthenia gravis-neurologic problem
- Senile-pagkatanda, old patients’ eyelid/s
have a huge tendency of droopy eyelids.
 Bulbar
 Entropion  inward turning of lid margin - Rest thumb and finger on bones of the
(elderly) cheek and brow; spread the lids.
- being highlighted (red line), papasok na - Let patient to look each side and down.
yung lower lid
  Abnormal:
 Upper palpebral - dilated red blood vessels (bloodshot
- Ask patient to look down, and relax the eyes)
eyes → bloodshot eyes are common with
- Raise upper lid slightly (eyelashes will trauma patients, pag stress at puyat ka.
protrude) → also common if you’re using
- Pull gently forward and down marijuana. (pero dili ingani kapula gud)
- Place small stick (applicator/tongue blade)
1 cm above lid margin.
- Push down stick as you raise edge of lid
then evert.

 Palpebral  should be pink and clear

 Abnormal:
- inflamed
conjunctival
surface
(conjunctivitis)

- Secure upper lashes against eyebrow with

thumb
- Inspect palpebral conjunctivae LACRIMAL GLANDS AND DUCTS
- After: grasp upper lashes and pull forward
gently
- Ask patient to look up, lid will return to
normal position

 Bulbar  cover of sclerae

→ Sclerae - the white part
 Normal:  Use tip of index finger to palpate lacrimal duct
- Transparent with red blood vessels (inner canthus) then gland (outer canthus)

 Normal:
- evident at nasal ends of upper and
lower lid
- no edema/tenderness noted
→ tenderness means eliciting pain
and/or palpating some masses. Dapat
walang tenderness para normal.
  Abnormal:
- Opaque, not smooth (corneal opacity)
- Discharges in the inner canthus
- Arcus juvenilis (arcus senilis in the young
may mean high cholesterol levels in the
blood)

 Abnormal:
- Inflammation due to obstruction
(dacryocystitis) PUPILS
 Normal
- Inspect for color, shape symmetry, and
responses.
- PERRLA – (P)pupils (E)equally (R)round,
(R)reactive to (L)light and
(A) accommodation.
- Constricts with light, round, and isocoric
(normal finding)

 Abnormal:
CORNEA
- Anisocoria - is when your eye's pupils are
 Normal:
not the same size.
- Shiny, smooth
- Assess by measuring the size of the pupils –
- Arcus senilis (grayish-white ring at the
part of the NVS or neurovital signs
corneal periphery). It may look abnormal but
that gray halo surrounding the cornea is
normal to people as they become old.
→ Now it becomes abnormal if it occurs to
people at young age.

CHECKING FOR DIRECT AND CONSENSUAL

REACTION TO LIGHT
1. Darken room and tell client to look straight
ahead
2. Penlight should enter field of vision from the
temporal side
 3. Observe;
I. Direct: pupils constrict in the same
eye
II. Consensual: pupil constricts in
opposite eye
 Accommodation:
1. Hold object (pencil) about 10cm (4inches)
from the bridge of the nose.
2. Ask the patient to look at top of the object
then distant object behind the penlight.
3. Alternate gaze from near to far.
→ ang ginagawa sa accommodation ay gina
observe ang reaction sa pupil.
- Remember that when the patient looks at a
far object their pupil dilates. →
Normal: - response to near -> constrict
- response to far -> dilate
ASSESSMENT OF VISUAL FIELDS
VISUAL FIELDS
 Nurse stands 2 feet away from patient
(facing each other)
 Nurse hold object and tests peripheral
vision
 Temporal – 90 degrees to central point
 Upward – 50 degrees (due to orbital ridge)
 Downward – 70 degrees (due to cheekbone)
 Nasal – 50 degrees (left arm periphery)
ASSESSMENT OF THE EXTRAOCULAR MUSCLES
- Ask patient to follow finger or pencil as it is
 You are trying to check for the movement of
the eyes of the patient
 Cranial nerves: III, IV, VI (ang gina assess for
your extraocular movement)
 Oblique – diagonal movement of the eyes,
either going to the right or going to the left
 Assess in patients at least 6 months’ old
1. Stand directly in front of the patient
2. Hold penlight at 60 cm (2 feet)
→ pag below 6 months old meron pa
silang normal nystagmus
→ Nystagmus – if the infant is too
young, you will notice na hindi coordinated
ang movement ng eyes
→ If may ma notice pang nystagmus
pag 6 months old and older it means you are
already suspecting that there is a problem
with your cranial nerves specifically your III,
IV, VI
3. Ask to hold head in fixed position and
follow penlight using eyes only
→ We have to let the parents hold
their infant most of the time during
the assessment
 Normal:
- movement of eyes in conjugate
fashion (except when converging on
object moving closer)
 Convergence
- ability of eyes to turn inward and
focus on very close objects
 Abnormal:
- there are times where in during the
test of convergence, one side of the
eye either the left or the right is not
moving or it is fixed while the other
one has the ability to move inward
EXTRAOCULAR MUSCLE
moved toward the bridge of the nose.

 Normal:
- converging eyes follow object within 5-8 cm of
the nose
 Abnormal:
- eye movement not coordinated/parallel
(nystagmus)
- rapid lateral/horizontal movement of the eye
- normal for infants below 6 months old.
ASSESSMENT OF VISUAL ACUITY
VISUAL ACUITY
 Degree to which detail and contours of the
objects are perceived
(right image: if you see this you might have
nearsightedness or farsightedness)
- Usually defined by the shortest distance two
lines can be separated and still be perceived as
two lines
(Snellen Chart)
- for correctional glasses and contact lenses, it is
always worn during the test
- Individual is placed 20 feet (6 meters) away
from Snellen chart
- client read aloud the smallest line
distinguishable to him
- D E F P O T E C (default letters)
- Since patient tend to memorize, you need to point
out which letter to be read.
 Equipment:
- Snellen’s chart
 Child must have 20/20 vision by 6 years’ old
TESTING NEAR VISION (MYOPIA)
(Rosenbaum Chart)
 If with glasses, must be used during test
 Reading material should be at least 14 inches
away from patient
 Normal:
- Able to read fine print
TESTING DISTANCE VISION (HYPEROPIA)
 Let patient sit/stand 6 meters (20 feet) from
the chart (cover the eye not being tested, use
cover card)
- if using hands, cup hands and do not apply
pressure, just enough to cover the eye)
 Take three readings for both eyes to validate
further
 Record readings
- Smallest line where the patients were able to
read at least half of all the letters
 - Abnormal Vision
 Presbyopia
- Age related vision (reading a newspaper at
arm’s length) → Can be observed sa mga lola and
lolo natin pag naga basa, ilayo nila ang ginabasa
ganon.

ASSESSMENT OF FUNCTIONAL VISION

FUNCTIONAL VISION
A. COUNTING FINGERS (CF)
(20/200, legally blind)
- A normal person can see the woman at 200 ft.,
but the patient needs to be at 20ft to see the
person)

TESTING DISTANCE VISION

→ one of the alternatives of the Snellen chart

 Result:
- C/F @ 1 foot (12 inches)
→ how many fingers can the patient
identify at 1 foot (12 inches)?

B. HAND MOVEMENT (HM)

 Top line of the
chart is 20/200
 Numerator
- always 20 (distance of patient from chart)
 Denominator
- greatest distance a person with normal vision
can read the smallest line

VISUAL ACUITY RESULTS  How:

 20/40 – 2cc - Hold hand @ 30 cm (12 inches) from
- means 2 letters were misread by patient client’s face
wearing corrective lenses - Move slowly back and forth, stopping
periodically
TERMS IN VISION TESTING - Ask client to tell when hand stops moving
 Emmetropia  Result:
- Normal Vision - H/M @ 1 foot (12 inches) from face
 Ametropia
 - NH/M (no hand movement) @ 1 foot (12 CONJUCTIVA SIGNS
inches) from face Pterygium Pinguecula

C. LIGHT PERCEPTION (LP)

→ instruct the patient

to look from side to side

LENS SIGNS
 How: Cataract – cloudiness Subluxation (Ectopia
- Penlight is shone from lateral position → ECCE – procedure Lentis → in Marfan’s
(outer canthus) and turned off for cataract extraction Syndrome)
- Ask the patient to tell you when the
light is on/off
 Result:
- LP (positive light perception)
- NLP (no light perception)

OTHER EYE SIGNS (CONDITIONS)

EYELID SIGNS → AFTER
External Hordeolum Internal Hordeolum PROCEDURE: (1) avoid
(Stye) lifting heavy objects
(2) eat a high-fiber
diet— to prevent
constipation

LIFESPAN CONSIDERATIONS
A. INFANTS

Layman’s term → 4 weeks of age can gaze at and follow

Bugingit objects
3 months Should start manifesting
tears
4 months Visual acuity is at
20/300 and
progressively improves
6 months Can focus with both
eyes
  Grasp the upper eyelashes between your
 Hirschberg test thumb and forefinger
- Cover test + corneal light reflex  Place a wetted applicator on the surface of
- Should be conducted for early detection the eyelid at the top of the tarsal plate
and management of amblyopia (lazy  Flip the eyelid up over the applicator
eye)  Remove the applicator as you hold the
everted eyelid in place with your other hand
 Examine the pretarsal surface for foreign
body
 If you found one, remove it with a gentle
rolling motion of the applicator
 Remove your hand from the eyelid
COVER TEST  And tell the patient to look up
ESOTROPIA  Left eye is  The eyelid will flip back to its normal position
deviated
inward B. CHILDREN
 As the right eye
is covered, the
left eye moves
outward to pick
up fixation

EXOTROPIA ● Left eye is

deviated
outward
 Epicanthal folds
● As the right eye
- Common in Asian Ethnicities
is covered, the
- May cover the medial canthus
left eye moves
- May cause the eyes to appear misaligned
inward to pick
- May be present in other races before the
up fixation
bridge of the nose begins to elevate
HYPERTROPIA ● Left eye is
 Pre-school child’s acuity
deviated
- May be checked with picture cards or E
upward
chart
● As the fixating
- Should be 20/60 (6 years of age)
eye is covered,
- Perform acuity test with glasses on if
the deviated
child has prescription to wear lenses
left eye moves
- Consider conducting Hirschberg Test
(source: google) downward to
pick up fixation
EVERTING THE UPPER EYELID
 Ask the patient to look down
HOW TO CHECK THE VISUAL ACUITY OF THE
CHILDREN
FEATURES
 Skin around orbit
may darken
 Eyeball may
appear sunken
(decreased
orbital fat)
 Skin fold of upper
eyelids may
seem more
→ We ask the patient to identify the prominent
object  Sagging of the
C. ELDERLY lower lid
 Visual acuity decreases as the lens of the eye  May appear dry
ages (becomes more opaque and losses and lusterless
elasticity) (decreased tear
 Ability of the iris to accommodate darkness production of
and dim light diminishes lacrimal glands)
 Diminishing peripheral vision
 Decreased ability to adapt to light (glare) and
dark ARCUS SENILIS
 Decreased accommodation for near objects  Grayish-
but possible improvement in far vision white arc or ring
 Near point of vision around cornea
- 9 cm (10 yrs old)  Could be
- Reading and close work become more sign of diabetes (if
difficult (40-45 yrs old) not on elderly)
- 83 cm (60 years old) → leads to eventual  Accumulation of lipid substance on the cornea
hyperopia  Iris may appear pale with brown discolorations
 Many elderly wear corrective lenses (convex (due to pigmentation degeneration)
shape) because of a further near point of
vision CORNEA
- Visual changes due to loss of elasticity  Tends to cloud with
(prebyopia) and transparency of the lens age
 Conjunctivae may
appear paler than
younger adults and
become slightly yellow
due to fat deposits
→ Due to sclerotic(hardening) changes in the iris
  Pupillary b. Ossicles
reaction to light INNER EAR
accommodation
may be less brisk
 Pupils can
appear smaller in
size, unequal and
irregular in shape.

EARS
ANATOMY OF THE EARS
OUTER EAR

 Has two labyrinths:

- Bony (semicircular canals.cochlea,
and vestibule)
- Membranous tissues (series of
ducts)
 Types of fluid:
 Direct sound waves to the auditory canal - Perilymph (outside the ducts)
MIDDLE EAR - Endolymph (inside the ducts)
→ If ever you are riding a car and the road is stiff, the
body can sense that it is being tilted due to the fluids
inside your ear will be tilting as well.

CERUMEN
- A.K.A Earwax
- Produced by the outer ear
- Has lubricant (prevents desiccation) and
antibacterial properties
→ it is advised not to clean your ears
 Tympanic Membrane = Eardrums (pearly white
every day
 Ossicles (Bones)
 Antibacterial properties:
- Stapes (smallest bone in the body)
- Acidic
- Incus
- Contains lysozyme (→ are enzymes that can
- Malleus
cause lysis)
 Air- filled
- Antibodies
Contains:
a. Tympanic membrane
 TYPES OF CERUMEN
A. WET
- Honey-brown, or dark
orange
- Moist (50% lipid)
- Common in Africans and
Europeans

B. DRY
- Gray, and possibly flaky
- Not moist (20% lipid)
- Common in East Asians ASSESSMENT OF THE EAR
and Native Americans

PHYSIOLOGY OF HEARING
NEURAL PATHWAYS

1. Inspect the auricles for:

 Afferent fibers in the auditory division of
acoustic nerve (CN VIII) end in the dorsal and
ventral cochlear nuclei
 Auditory impulses then go to inferior colliculi
(centers for auditory reflexes), medial
geniculate body of the thalamus, and into
the auditory cortex
→ Always remember reflex arc, everything starts
with a stimulus received by sensory receptors.
The sensory neurons convert the stimulus into
impulses and then analyze it in the brain. Motor
neurons send impulses to the effector, producing
a response.
- Color, symmetry of size, and position
- Level of superior aspect of auricle in
relation to the eye
- Cyanosis (earlobes)
→ Auricle should not be lower than the
lines of our eyes because this might indicate
that the patient has chromosomal disorder
- Pallor
- Erythema (inflammation, or fever)
→ Erythema might be a sign of external
ear infection
- Color is same as facial skin
2. Palpate the auricles for:
- Texture
- Elasticity
- Tenderness
 - Fold pinna forward (normally mobile,
firm and recoils)
- Lesions and tenderness (may indicate
inflammation/infection of the external
ear)
3. Inspect external canal of ear:
- Distal 3rd with hair follicles and glands
- Wet/dry cerumen
- 4 years or older (up and back)
- 3 years or below (down and back)
TYMPANIC MEMBRANE
LEFT AND RIGHT
d. Functional
A. CONDUCTIVE HEARING LOSS
 Results from external
or middle ear disorders
(block sound
transmission)
- Ear disorder 
ear infection 
inflammation
 Responds to medical or surgical intervention
(or both)
 This means (characteristics):
- Abnormal Weber test results
- Negative Rinne test results
- Improved hearing in noisy areas
- Normal ability to discriminate sounds
- Difficulty hearing when chewing
- A quiet speaking voice

B. SENSORINEURAL HEARING LOSS

 Results from
 Normal: disorders of the
- Pearly gray inner ear or CN VIII
- Semi- transparent (Vestibulocochlear)
 This means
 Abnormal: (characteristics):
- Pink, red, yellow, white, blue or dull - Positive Rinne
surface test
- Poor hearing in
HEARING LOSS noisy areas
 May be: - Difficulty hearing
- Complete or partial high-frequency
- Permanent or temporary sound
 May involve reception of frequency tones: - Complains that others mumble or shout
- Low - Tinnitus
- Middle → No problems of the sound wave coming
- High inside the ear but there is problem on how
 Classified as: the organs receive the stimulus. How they
a. Conductive transmit these impulses to the auditory
b. Sensorineural cortex to be analyzed.
c. Mixed (both conductive and
sensorineural)
 C. MIXED HEARING LOSS
 Combines aspects of conductive and
sensorineural hearing loss
D. FUNCTIONAL HEARING LOSS
 Results from psychological factors other
than organic damage
ASSESSMENT OF HEARING ACUITY
 Use normal tone of voice
 If there is difficulty, then other tests may be
used:
a. WATCH TICK
b. WHISPERED WORD
 Other tests using tuning fork:
a. WEBER TEST
b. RINNE TEST
WISPERED WORD TEST
1. At 30-60 cm (1-2 feet) from the patient, let
him press in his tragus with one finger
2. Whisper non-consecutive numbers
3. Let client repeat the mentioned numbers
→ Any word that has only little syllables
→Word/s should be simple
→Word/s said on the other ear should not be
repeated on the other
RESULTS:
1. Able to repeat words/numbers (normal)
2. Unable to repeat 50% of numbers
mentioned (abnormal)
WATCH TICK TEST
1. Pocket watch held near patient’s ear
2. Patient told to listen to the watch tick
3. Slowly move away
4. Then identify the distance where the patient
can no longer hear the tick
→ Make sure that the environment is
quiet
5. Distance heard:
 Normal:
- ≥20inches
 Hearing loss:
- <10 inches (hearing loss)
WEBER TEST
● Test for lateralization of vibration (BONE
CONDUCTION)
1. Place vibrating tuning fork in the middle of
forehead or on top of the patient’s head
2. Ask patient to state on which side is louder:
a. left,
b. right
c. midline (equal)
● Normal:
- equal sounds in both ears
- Localized at center of the head
- classify as “negative”
● Abnormal:
- Conductive loss: shifting of sounds to poorer
hearing ear (heard better in impaired ear)
due to obstruction of ossicle
- Sensorineural loss: shifting of sounds to
better ear due to nerve or inner ear damage
● Remember:
- If the sound is heard equally on both ears:
Person may have normal hearing or equal
degrees of hearing loss in both ears
RINNE TEST
● Compares air and bone conduction
1. Place the vibrating tuning fork on the mastoid
process
 2. Let patient tell you when it stops or could no EARLOBE CREASE
longer hear the tuning fork  Visible earlobe
→ Air conduction > bone conduction crease extending at
3. immediately bring vibrating tuning fork in front least 1/3 of distance
of the ear and ask if patient can hear it from tragus to
4. Patient then should tell if the tone sounds posterior pinna
louder with the fork on the mastoid or just
outside the ear canal  Associated with
 Normal: possible coronary
- Air Conduction > Bone Conduction heart disease
- Tone should be louder outside the ear canal
- Classify as positive EARLOBE NODULE
 Gouty tophus/tophi
REMEMBER: (result of gouty
- Patients with conductive hearing loss will arthritis)
perceive the sound as louder on the mastoid  Long standing
- classify as “negative” accumulation of
sodiumurate crystal in
→ Rinne Test – We are checking for the air and bone the helix and anti-helix
conductivity  there is a buildup of
- when talking about sound, checking if uric acid from metabolism problems or
patient has any hearing loss, the air conduction must excretion problems, which will affect the
be heard longer compared to bone conduction, joints; if the buildup is too large it will
which is the “normal”. accumulate in the ears.
 Painless, hard, and irregular
EAR SIGNS
 Earlobe crease DARWIN TUBERCLE
 Earlobe nodule (gouty tophus)  Developmental eminence
 Darwin tubercle in upper third or posterior
 Hematoma (Trauma) helix
 Otorrhea (Otorrhagia)  Harmless
 Cerumen (Impaction)  Must be distinguished by
 Bulging Tympanic Membrane acquired nodules (gouty
 Lop (Bat ear) tophus)

EAR HEMATOMA
 Traumatic (physical) or
hemostatic (statis of blood)
defect
 Leads to blood
accumulation between
cartilage and perichondrium
 Tender, bluey, doughy mass (usually painless)  Characteristic:
 Prompt incision and drainage prevent - Melted cerumen
suppuration of cauliflower ear (yellow)
 May have conductive hearing loss due to - Eczema in meatal
blockage of orifice of ear. wall or early
EAR HEMATOMA: CAULIFLOWER EAR ruptured acute
 Untreated otitis media
hematomas heal as (serous) –
nodular and inflammation of the middle ear.
bulbous - Temporal bone fracture (bloody)
irregularities of the - Purulent (polyps, chronic, external otitis)
helix and anti-helix
 Result from the → Side note: if ever na nagka head injury ang
necrosis of patient, there are times that it is associated with
underlying cartilage from blunt trauma of leakage in the ears.
previous injury
 if there are trauma causing deaths of tissues, → And how do we know if the leakage is caused
it should be treated and dead tissues should by the head injury? If it leaks CSF (cerebrospinal
be removed or it will develop into gangrene. fluid)

EAR TRAUMA CERUMENT (IMPACTION)

 May be due to:
- Excessive
production of
earwax
- NARROW
MEAUTUS
- Obstruction leads to partial deafness
OTTORRHEA (EAR DISCHARGES)
plus: tinnitus (ringing sound in the ear –
 May be:
only assessed by the patient) and
- bloody (otorrhagia)
dizziness
- purulent
 Painless, hard, and irregular
- clear
- serosanguinous
BULGING TYMPANIC MEMBRANE
 those mentioned above are
the classification of  Seen in:
discharges. - acute suppurative otitis media
 When we try to note the discharges, we need - tympanic membrane is shiny due to the
describe its characteristics smoothness of its surface (normal)
- more conical
- loss of bony landmarks
- distorted light reflex
 → it should be flat and smooth but in this case PERFORATED TYMPANIC MEMBRANE
its bulging.
NORMAL TYMPANIC OTITIS MEDIA
MEMBRANE

 Perforated – may butas

 Also called perforated ear drum
LOP (BAT EAR)
 Caused by cleaning of your ears if it is too
deep already
 Dapat intact ang tympanic membrane to be
able to resonate vibrations or sound waves

FOREIGN BODY (INSECT)

 Pinna protrudes at right angle
 May be due to shortage of:
- Skin
- Cartilage
- Both
MICTROIA

 Unusually small ears EAR SYMPTOMS

A. TINNITUS
 Ringing in the ears
 Sufficiently distressing to seek consult
 May be the first symptom of an acoustic
 Surgical
neuroma (if unilateral)
reconstruction
 Nagkakaroon tayo ng ringing of the ears for
of the microtia
example if may explosion just like you are near
the firecrackers
MACROTIA
 Unusually large ears B. TEMPORARY ALTERED HEARING
 May be experienced during swallowing or
yawning (popping sound)
 On otoscope:
- Retracted eardrum/tympanic membrane
 NORMAL TYMPANIC RETRACTED TYMPANIC  Cochlear – organ of hearing
MEMBRANE MEMBRANE  Vestibule – organ for your balance
 Gives hallucination of motion
 When eyes are opened, patient’s
surroundings seem to be spinning or whirling
 When eyes are closed, patient continues to
feel as if in motion
 May be caused by → For example, kanang gikan kamo nag
Eustachian tube swimming tas pag uli nimo feel mo while gahigda
dysfunction: ka kay murag galutaw ka gihapon sa tubig
- Mild,  Possible causes:
intermittent - Migraine
pain - Cerebral hemorrhage
- Feeling of - Intracranial abscess → (abscess meaning
fullness in the meron ng infection)
ear - Temporal bone fracture
- Altered hearing - Otitis media (with effusion)

C. EARACHE/EARPAIN (OTALGIA)
 Arises from inflammation of structure in the
ear (or referred from other sites including the
thyroid)
 Characteristics of pain may be:
- Feeling of fullness of blockage
- Deep, or boring
- Intermittent, sudden, or gradual
LIFESPAN CONSIDERATIONS
NEONATE/NEWBORN
 All newborns should be assessed for
hearing prior to discharge
- Uses auditory brain response testing
→ May naka attach sa ears ng patient and if

 Possible causes: they are going to play a sound or an audio

- Trauma file/audio stimulation kay may reaction after, it
- Hematoma will send waves doon sa monitor wherein there
- Gout is a brain activity
→ Pag comatose ang patient or if the patient
- Insect bites
- Unerupted lower third molar or caries doesn’t have any brain activity it means that the
(toothache) patient is brain dead already
- Trigeminal neuralgia
- Temporomandibular joint arthritis  To assess gross hearing:
- Ring a bell from behind infant (or have
parent call child’s name for response)
D. DIZZINESSS AND VERTIGO → There are times wherein ito yung one of the
reflex to check the hearing of the baby for
 Persistent stimulation of the semicircular
example pag mag clap ka tas makuratan ang
canals or vestibular nucleus when head is at
baby (startle reflex)
rest
 - Newborns tend to quiet to the sound (and → Lipid contents are now lesser compared to
may open their eyes wider) when younger.
INFANT
 To assess gross hearing:
- Child should be able to turn head and eyes
toward the sound (approximately 3-4
months old)
→ MMDST (Metro Manila Developmental
Screening Test) is being used to assess the
development of the child.
 To inspect external canal and tympanic  Increase coarse and wire-like hair growth along
membrane below 3 years old (18 months): the:
- Pull pinna down and back - Helix
- Insert speculum approximately ¼ to ½ inch - Antihelix
only - Tragus
 Tympanic membrane:
ADOLESCENTS AND YOUNG ADULTS - More translucent
 Hearing loss is more common in adolescents and - Less flexible
young adults; probably due to: - Diminished intensity of light reflex (only
- Exposure to loud music slightly)
- Prolonged use of headsets and loud  Hearing loss occurs:
volumes - Sensorineural type
 Generalized hearing loss (presbycusis) occurs in
COMPARISON OF SOUND LOUDNESS all frequencies:
- Loss of high-frequency sounds (first
symptom)
- F, S, Sh, and Ph sounds
→ gradually increase the voice and dapat di
mabilis ang convo when talking to the elderly.
 If affected by presbycusis:
- Conversation may be distorted and result in
what appears to be inappropriate or
confused behavior.

ELDERLY THE NOSE

 Skin on ear may appear dry and less resilient CONSISTS OF:
(due to loss of connective tissue) 1. External nose
 Pinna increases in both width and length 2. Nasal cavity
 Earlobe elongates - → hollow area
 Earwax is drier, flakier 3. Septum
- a wall that divides the nose into
right and left halves
 - → can also be found in any
organ that has a chamber or
separated by a wall (e.g. heart)

4. Has two Elliptical Orificies a.k.a

Nostrils or Nares

FRAMEWORK OF THE EXTERNAL NOSE

 Above Area
1. Nasal bones
 Blockage of the nose or the inflammation
2. Frontal processes of maxillae
of the Sinuses – caused by Sinusitis
3. Nasal part of frontal bone
→ a.k.a nose bridge, a part that can be
THE PURPOSE OF THE NOSE
palpated

 Below Area
1. Plates of Hyaline Cartilage

NASAL STRUCTURE

 Humidify air
- Passing through the turbinates’
and septum
 Filters air
- Fine and coarse hair in the nasal
vestibule
 Lined by respiratory epithelium
 Has surface secretory cells
 Frontal bone and Nasal bone – forms the
- Produce immunoglobulins,
nose bridge
inflammatory mediators, and
interferons → part of the
immune system’s second and
third line of defense
- Internal first line of defense →
mucous membrane
- External first line of defense →
skin
 THE SINUSES - Ciliated and secrete mucus
→ when there is an inflammation of your sinuses,
palpate starting from your forehead down to
your sphenoid, ethmoid and maxillary sinuses

MAIN FUNCTIONS OF THE SINUSES

 Produce mucus for the nose
 Voice resonance
→ pag nagka sinusitis, naga lahi ang quality
sa atoang voice
 Lighten the skull
→ Ciliated – tiny hair-like structures
- valuable in upright posture
that does move particles away
→ the sinuses function like
 Remember that all are innervated/supplied
airbags, it pushes the skull up, to
by branches of the trigeminal nerve
lighten the skull
 Protect the brain from trauma
PHYSIOLOGY OF SMELL
THE PROCESS OF SMELL
FOUR PAIRS OF THE SINUSES
→ when we talk about the process of smell, it
involves senses and receptor cells that (1)
receives the stimulus, (2) passes through the
sensory neurons, (3) and make the stimulus as
impulses (4) impulses will be sent off to the
brain to create a response
 Receptor cells
- Located in the olfactory epithelium
(CN-1)
- True neurons that conduct action
1. Frontal potentials into the CNS
- Protects the brain - Basal cells of the olfactory
2. Ethmoid epithelium are undifferentiated stem
- Protects the eyes cells that continuously turn over and
3. Maxillary replace themselves
- Protects the eyes  Olfactory nerve (CN I)
4. Sphenoidal - carries information from the
- Surgical approach to the pituitary olfactory receptor cells to the
gland olfactory bulb
- Olfactory nerves also pass through
THINGS TO REMEMBER ABOUT THE SINUSES cribriform plate on their way to the
 Remember that all open into the nasal olfactory bulb
cavity - Olfactory Epithelium are innervated
 Remember that all are lined by respiratory by the trigeminal nerve (CN V) to
mucosa
 detect noxious or painful stimuli (e.g.
ammonia)
 Cranial Nerve I (CN I) and Cranial Nerve V
(CN V)
- Cranial Nerve I → sense of smell
- Cranial Nerve V → sense of touch  OBSERVE FOR:
 Mitral cells (in the olfactory bulb)
- Form the olfactory tract (projects
into prepiriform cortex)
4. Tip head back, with speculum held in non-
dominant hand, and little finger as side of
nose to stabilize
- Dominant hand (used to position
head/hold light)
a. Redness

ASSESSMENT OF THE NOSE AND SINUSES

THE PROCEDURE
1. Inspect external nose for any deviations in b. Swelling
shape, size, color, flaring, or discharge from
nares
NASAL FLARING
→ Ga laki ang butas ng ilong kung ga hinga
→ Occurs when there is difficulty breathing
or mad
2. Lightly palpate external nose to identify any
areas of tenderness, masses, and
displacements of bone and cartilage c. Growths
3. Determine the patency of both nasal cavities
- Ask patient to close mouth, exert
pressure on one naris, and breathe
through the opposite naris. Repeat on
the other side
→ Ex: pag may sipon. Sa left, maka hinga
ka tapos sa right hindi. Tas after ilang
hours/minutes sa left ka naman hindi d. Discharges
maka hinga and sa right maka hinga 5. Check the nasal septum
- Intact and at midline (normal)
 NORMAL: - Deviated (abnormal)
- Uniform color, symmetrical, no nasal flaring, 6. Palpate maxillary and frontal sinuses using
nasal septum at midline, and no perforation both thumbs
- Non-tender, no lesions noted
- Air moves freely as client breathes through
the nares
 → Thrombocytopenia – low
 FRONTAL blood platelet count
- Direct manual pressure upward towards the → range which can also lead to
wall of the sinus bleeding tendencies
 MAXILLARY - Infectious (typhoid fever, dengue fever,
- Pressure upward over the lower edge of diphtheria, syphilis)
the maxillary bone - Drugs (anticoagulants, ASA)
 FINDINGS:  Anticoagulants – no
- No tenderness (normal) coagulation process on
- Tenderness (abnormal) the blood
 ASA - Aspirin
SIGNS HOW TO STOP NOSEBLEED
A. EPISTAXIS (Nosebleed)  Don’t let the patient tilt their head, because
- Spontaneous (trauma) vs induced (on there is a
purpose / gituyo / sinadya) possibility
- Front vs back that the blood
 Source of bleeding: would cause
- Anterior (Kiesselbach plexus) aspiration →
- Posterior (Woodruff’s area -> posterior (matuk an sa
3rd of inferior meatus) sariling dugo)

 Instead, let the patient lean forward with his

 Local causes: head down and then at the same time apply
- Coughing - because of pressure pressure on the nose bridge, you can also
- Sneezing - from blowing / allergic rhinitis provide the patient with a cold washcloth or
- Nose picking ice bag and apply it on the nose bridge, this
- Fracture – from trauma will decrease the flow of blood due to
- Foreign bodies vasoconstriction.

 Generalized cause:  If you are

- Vascular (hemophilia, going to assess the
thrombocytopenia) - blood vessels patency of your
→ Hemophilia - problem clotting nares (nostrils),
factor because of domino effect which pinch or apply
increases chances of bleeding pressure on this
tendencies part
 B. FOREIGN BODY

SYMPTOMS
A. ANOSMIA
NASAL SEPTUM DEVIATION

- Loss of smell
 May be accompanied
by:
- Perceived
change in taste
of food (bland
 There are times wherein the patient is cleft lip and unpalatable
the nasal folds disappear - Ageusia (loss of sense of taste)
 May be:
 TEMPORARY → COVID
 PERMANENT → damaged nerves
 Results from conditions that:
- irritate and cause swelling of nasal
mucosa
- obstruct olfactory area in the nose
 Such as:
C. NASAL SEPTUM PERFORATION - Heavy smoking
- Rhinitis
- Sinusitis

PERMANENT ANOSMIA
 Due to destruction of:
- Olfactory neuroepithelium
- Hole in the nasal septum - Any part of olfactory nerve
 Common causes: - Cocaine or acid fumes (paralyze nasal
- Chronic infection cilia)
- Nasal surgery - Head trauma
- Repeated trauma
- Cocaine abuse RHINORRHEA
 Free discharge of thin nasal mucus
  Common (rarely serious) ACUTE RHINITIS
 Discharge may be:
- Clear → (in cases of your rhinitis)
- Purulent → (if ever it is caused by viral or
bacterial infection)
- Bloody → (damage in the blood vessels of the
nose)
- Serosanguinous
 Unilateral:
- Foreign body (foul discharge)  Infectious disease (common cold)
- Neoplasm (bloody discharge - Rhinoviruses infect mucous membranes of nose
- Head injury/surgery (cerebrospinal fluid) and sinuses (lead to inflammation and increased
 Bilateral: nasal secretions)
- Allergic →There is swelling, redness, and pain
- Infectious (upper respiratory tract) → It can also lead to blockage

RHINORRHEA  Presentation:
 May be caused by: - Watery nasal discharge and sneezing
- Allergic Reaction (when there is an allergic - Discharge becomes purulent
reaction, it follows the inflammatory process. - Associated with fever and body malaise
One of the cardinal signs is swelling. Thus, there - Usually lasts 3-10 days
will be an obstruction in the nasal passageway.) - Presence of severe local pain suggests a
 Inflammatory complication
 Neoplastic → (“new growth”) - Bacterial sinusitis
 Endocrine ALLERGIC RHINOSINUSITIS
 Mechanical Obstruction  May be seasonal or perennial
 Traumatic Injury  Caused by allergens:
- Pollens, molds, house dust, mites, cockroach,
NASAL SYNDROMES and animal dander
 Acute Rhinitis
 Allergic Rhinosinusitis
 Vasomotor Rhinitis
 Suppurative Paranasal Sinusitis
 Cavernous Sinus Thrombosis

 Presentation:
- Itching (nose and eyes)
- Rhinorrhea
- Lacrimation (teary-eyed)
- Sneezing CAVERNOUS SINUS THROMBOSIS
- Headache (common)
→ Note: you have to palpate to elicit tenderness
VASOMOTOR RHINITIS

 Thrombus: Blocks our blood vessel

 Most feared complication of nasal infection

 May cause:
 Non-allergic mucosal edema and rhinorrhea - Blindness
 Associated with: - Death
- Vasodilation of nasal vessels  Spread of Infection:
- Mucosal edema - Nose > Angular veins > Septic Thrombosis
- Increased mucous production  Bilateral involvement of the eyes:
 Due to chronic environmental irritants: - Deep pain
- Dust - Immobilization of globe
- Smoke - Periorbital edema
- Strong odors - Chemosis (swelling of conjunctivae.
- Cold air  May involve CN # 3, 4, and 6 MOTOR
SUPPURATIVE PARANASAL SINUSITIS Manifestation:
- Sudden chills, high fever, prostrate,
comatose.
- Death within 2-3 days

 Due to:
- Streptococcus pneumoniae → (there is
bacterial infection. Filled with discharges)
- Haemophilus influenzae
 Severe pain in the face (7-14 days after acute
URTI)
 Pain and pressure without fever
- Sinus obstruction  decongestants (ex.
Neozep)
 LIFESPAN CONSIDERATION - Hyposmia
INFANTS - Nosebleeds (epistaxis) may result from
hypertensive disease or other arterial vessel
- A speculum is usually not necessary to examine the changes
septum, turbinates and vestibules
- Instead, push the tip of the nose upward with the ANATOMY OF THE ORAL CAVITY AND
thumb and shine a light into the nares OROPHARYNX
- 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

- Assessing septum, turbinates, and vestibule,

similar to infant (no use of speculum usually
necessary)
- Ethmoid sinuses fully develop by 6 years of age.
Sinus problems in children under this age are rare.
Cough and runny nose are the most common signs
of sinusitis in preadolescent children
THE ORAL CAVITY
PREADOLESCENT
 Separated into 2 regions:
- Most common signs of sinusitis in this age? - Oral vestibule
a. Cough - Oral cavity proper
b. Runny nose (rhinorrhea)
The Oral Cavity
ADOLESCENT  Separated in two (2) regions:
- Oral vestibule
- May have headaches, face tenderness, and - Oral cavity proper
swelling similar to the signs seen in adults  Inferior to the nasal Canal

ELDERS

● Diminished sense of smell:

- Decreased number of olfactory nerve fibers
- Atrophy (lumiliit) of remaining fibers

● Less able to identify and discriminate between

odors (in effect)
 - breathing (opens into the pharynx, which is
common pathway for food and air)

ASSESSING THE ORAL CAVITY AND OROPHARYNX

Lips

 epiglottis (square red outline below
tongue)
- closes and opens during swallowing, so that
any food won’t go down in its pathway, and
should go down the esophagus path.
 Has a roof, floor, and lateral walls.
 open onto the face through the oral fissure
 continuous with the cavity of the oropharynx
Lips or Labia
 Inspect outer lips for symmetry of contour,
color, and texture. (rough lips are cause by
dehydration) (cheilosis – swelling and fissuring
of mouth) overextending mouth.
 Ask purse lips as if to whistle, purse lips
breathing (inhale with the nose and exhale using
the mouth, exhalation tend to be longer) – in
purse lips is trying to assess the muscular
movement or integrity of the muscle of lips to
purse.
Normal:
- uniform, pink color, soft, moist, and smooth

Parts:
 roof – hard and soft palates
 floor – muscular diaphragm and tongue
 lateral walls – (cheeks) which merge
anteriorly to form the lips (and oral fissure)

Posterior Aperture:
- oropharyngeal isthmus

Purpose:
- inlet (entry) for digestive system (involved Abnormal:
with initial processing of food, aided by - chapped, dry, pale lips
secretions from salivary glands)
- (when eating food containing starch,
breakdown of food has already begun in the
mouth due to salivary glands)
- manipulates sound produce by the larynx
(and one outcome of this is speech-the
ability to talk)
 Buccal Mucosa  NORMAL:
- The buccal mucosa
is the lining of the
cheeks and the
back of the lips,
inside the mouth
where they touch
the teeth.
- Entire oral cavity
should be pink
 Also check for the Parotid papilla with opening without ulcers.
of the parotid ducts  ABNORMAL:
 Wear gloves – for you or the patient to not - Linea alba,
contaminate each other. Fordyce's granules
 Check for: and
- color, moisture, presence of lesions leukoedema are
how: common atypical
- Grasp lips on each side between thumb and findings on the
index finger buccal mucosa.
- pull lip outward, away from teeth You may feel small
- Palpate for lesions, and check front teeth papules within the
and gums tissues usually
indicative of
sclerotic or fibrotic
minor salivary
glands.
- Deep red color,
lesions, palpable
SUB-SUB TOPIC masses or swelling.

- also checking for moth ulcers or stomatitis

to inspect the inside of cheeks, use padded tongue
depressor.

(Dissected View)
TONGUE  NORMAL:
 Palpate - Smooth
tongue and - No palpable
floor of mouth nodules/lesions
for:  Remove
- Nodules gloves
- Lumps
Nodules are
masses that is
why we check for
the two first. ASSESS NOW THE TEETH, GUMS, AND DENTURES
- Excoriated areas  Inspect teeth, gums, while examining the
inner lips, and mucosa.
 Use piece of  Include assessing dentures, if any (ask to
gauze to grasp remove it and check the condition.
tongue tip
- We don’t use ASSESSING THE TONGUE
gloves in grasping  Inspect the surface of the tongue for position,
the tongue color, and texture, by asking the client to
because it slips. protrude the tongue. -
And so, using a (instructions; ilabas ang dila sir, turn it into
gauze adds sides, etc.)
additional grip to
check the sides of
the tongue.
 NORMAL:
 Use index - Pink moist, slightly
finger of other rough, thin, and
hand to whitish coating.
palpate the
tongues;
i. Back
ii. Borders  ABNORMAL:
iii. base - Deviation/tremors
(Cranial Nerve
(CN) XII damage) –
motor damage
- Red tongue
(anemia)
 INNERVATION OF THE TONGUE  Geographic Tongue
- Inflammation, dehydration processes.

 Inspect the tongue movement by asking the

patient to:
 Roll tongue upward and move side to side

 NORMAL:
- No tenderness, able to move freely

 ABNORMAL:
- Restricted mobility of the tongue

MOTOR – movement
SENSORY – taste, reflex, texture, temperature

 HAIRY TONGUE (Poor oral hygiene)

 Inspect base of the tongue

along with flow of the mouth,
and frenulum.
 NORMAL:
- Smooth tongue base
- Prominent veins
 Abnormal:
- Swellings  Wharton’s duct (Submandibular gland):
- Ulcerations (singaw/luas) - Beside the base of the frenulum of the
 Inspect duct openings: tongue
- Parotid (Stensen’s duct) – malapit sa
tonsil
 Submandibular (Wharton’s duct) –
mandibles
- Sublingual (Bartholin’s duct) – under the
tongue

THE SALIVARY GLANDS

 Bartholin’s duct (Sublingual gland):

- Bartholin’s gland – located at the
female reproductive organ para if ever
once it is stimulated it will release
substances that would make the vaginal
opening slippery (vaginal orifice)
- Crest of sublingual fold
Note: the ducts of Rivinus drain the
sublingual gland, but the largest of
these is the Bartholin’s duct
 Stensen’s duct (Parotid gland):
- Beside the crown of the second upper
molar
 Makita mo ito if you are going to stretch your
cheeks, if you are going to check the insides
of the patient’s cheeks

 Normal:
- Same color as the buccal mucosa
 THE PALATES  Normal:
- Midline of soft palate
- Immobile

 Normal:
- Light, pink, smooth (soft palate)  Abnormal:
- Lighter in color (hard palate) - Deviation to 1 side (damage to CN V and
X)
- Tumor/Trauma – reddened or may
gasgas
- Swelling (Uvulitis) – inflammation

 Uvulitis

 Abnormal:
- Bony growth from hard palate
(exostosis)

THE UVULA
 Bifid Uvula (mild cleft)
 INNERVATION OF THE UVULA TARTAR

 Unchecked plaque
OTHER CONDITIONS OF THE MOUTH AND  Visible, hard deposit of plaque and dead
OROPHARYNX bacteria at gum line
CARIES

GINGIVITIS
 Multifunctional microbial infectious disease
 Characterized by demineralization of
inorganic and destruction of organic
substance of the tooth

PLAQUE

 Inflammation of your gums

 Red ang adjacent tissues doon sa
connection ng teeth
 Red, swollen gingiva

 Invisible, soft film of enamel which may be

bacteria, saliva, or epithelial cells (mga kiki
nato sa ngipon)
 GLOSSITIS
 Inflammation of the tongue
STOMATITIS
 singaw/luas
 inflammation of the oral mucosa (mouth
ulcer)
PAROTITIS
 bayook
 if ever you are a male, it can cause male
sterility that means that if ever you are
going to have sex hindi ka na magkakaanak
because you are already sterile kasi yung
mumps natin due to the intense
temperature parang naluluto yung sperm
pero naa gihapon magawas na semen pero
di na siya viable
 Inflammation of the parotid gland
SORDES
 Accumulation of foul matter like food,
microorganisms, and epithelial cells in the
mouth that can cause your halitosis or your
bad breath
 Associated with chronic debilitating disease
(protracted fever)
LIFESPAN CONSIDERATIONS
NEONATES/NEWBORNS
 May have a pearly white nodule on their
gums (Epstein pearls)
 May resolve without treatment
 Inspect the palate and uvula for cleft
- Bifid uvula may suggest an unsuspected
cleft palate (i.e., a cleft in the cartilage
that is covered by skin)
 INFANT
 Inspect the palate and uvula for cleft. Same
as neonate
 First teeth erupt at about 6-7 months of age
 Assess for dental hygiene
 Parents should be taught to clean infant’s
teeth with a soft cloth or soft-bristled
toothbrush
 Fluoride supplements should be given by 6
months (if child’s drinking water contains
less than o.3 parts per million [ppm] of
fluoride)
 Should see a dentist at 12 months (1 year
old)
CHILDREN
 Tooth development should be appropriate
for age
 White spots on teeth may indicate fluoride
ingestion
 Drooling may be common up to 2 years old.
 Tonsils are normally larger in children than in
adults
 -Commonly extend beyond the palatine arch
until 11-12 years old
 Rounded protuberances (usually 3) found on
cutting edge of incisors upon first eruption.
 Common in children
ELDERLY
 Oral mucosa may be drier (due to decreased
salivary gland activity)
 Decreased salivation may occur due to some
medications being taken
 -Diuretics – pampaihi na gamut
- Antihypertensives
 Extreme dryness be associated with
dehydration
 Some receding of gums occurs (gives
appearance of increased toothiness)
- Increased toothiness - lumaki ang ngipin
 Diminished taste sensation (atrophy of taste
buds and decreased sense of smell)
- Sweet and salty taste (lost first)
- Tend to add more salt and sugar to food
compared to their younger selves
- Suggests diminished function of CN V and
CN VII
- CN VII- for sensory senses
 Tiny purplish or bluish-black swollen areas
(varicosities) under the tongue are common
(caviar spots)
 Teeth may show signs of staining, erosion,
chipping, and abrasions, due to loss of dentin
 Teeth loss due to dental disease but
preventable with good dental hygiene
 Slightly sluggish gag reflex
aspiration
 Those in long-term care facilities often have
dentures in need of repair
- Due to difficulty of access to dental care
in these situations
- Do thorough assessment of missing teeth
and those in need of repair (natural or
dentures)
 B. Posterior/Vertebral - cervical vertebrae, spinal
cord, cervical nerves, and muscles of vertebral
column
THE NECK
C. Lateral/Vascular (2 compartments) - major
ANATOMY OF THE NECK
blood vessels and vagus nerve
→ Vascular – mga blood vessels

 Ventricular Tachycardia – mabilis ang pag

tibok ng puso kung may problema sa ventricles
ng heart
→ Tachycardia – increase/above the
normal na heart rate
Intervention:
a. Do a carotid massage
→ when you’re going to massage or
apply pressure continuously, you’re now
going to stimulate the vagus nerve. Pag
sinabi natin na vagus nurse, “vavagal ang
pag tibok ng puso” (term na ginagamit para
mas maintindihan)
→ Naay times na mahilo na.
- ARTERY
- VEIN Remember, if your heart beats slower or mag
baba ang heart rate mo, ang blood flow
going to your brain will also decrease
D. Root of the neck – area immediately superior to
the superior thoracic aperture and axillary inlets
 Tube providing continuity from head to
- Superior margins of clavicle (anterior)
trunk
and scapula (posterior)
 Extends anteriorly from lower border of
→ Thorax – sa chest part na
mandible to upper surface of manubrium
of sternum
 Extends posteriorly from superior nuchal  Lymph Nodes:
line of → “Lusay”
occipital bone to the intervertebral disk → belongs to Lymphatic System
between C7 and T1 vertebrae (Immune System)
→ If ever naay infection, ma papalpate
ang mga lymph nodes
HAS FOUR COMPONENTS
A. Anterior/Visceral - parts of digestive and
respiratory tracts, and several endocrine glands
→ Thyroid gland – located sa neck

a) Level I (submental and
submandibular)
b) Level II (upper jugular)
c) Level III (middle jugular)
d) Level IV (lower jugular)
e) Level V (posterior triangle)
f) Level VI (anterior triangle)
g) Level VII (superior mediastinal)
→ Green dots – for palpation of your lymph
nodes
 Palpation Process:
1. Start sa preauricular which means
“pre” before the ear. When
palpating for the lymph nodes, use
the pads of two to three fingers. Do
it in a circular motion.
2. Proceed to the postauricular
“behind”
3. Moving down to the tonsillar
4. Submandibular
5. Submental
6. Right below the chin
7. Anterior cervical
8. Posterior cervical - located behind
the sternocleidomastoid muscle
9. Most of the time, you can’t really
feel the deep cervical because it is
“deep” during the process, ang
patient mag lingi sa left side tapos
right side na pud. Press the external
sternocleidomastoid muscle.
10. Supraclavicular “supra” means
above
11. Infraclavicular
12. Occipital – behind the neck
→ Before palpating, instruct the patient “Sir
igna ko kung sakit ha”
→ i-check pud ang tenderness
 If you’re going to palpate, instruct the
patient to:
A. Flex the neck “pataas” huwag
ipa-hyperflex
THE THYROID GLAND
 FINDING THE THYROID GLAND
- Left and right lobes are at the anterior
triangle in the lower neck at either side of the
airway
→ma palpate ang trachea tapos
mararamdaman mo ang triangle (triangle –
color yellow sa picture) tapos you go lower
and palpate the sides as well
- Inferior to the position of the oblique line of
the thyroid cartilage
- Sternothyroid muscles prevents lobes from
moving to upper neck
- Locate the thyroid prominence and arch of
the cricoid cartilage and then feeling
posterolateral to the larynx
→ dapat you’re also aware of the
terminologies (e.g. supraclavicular,
infraclavicular)
FUNCTIONS OF THE THYROID GLAND
- Regulate metabolic activity through
hormones (thyroxine “T4” and
triiodothyronine “T3”)
→ Iodine – common ng thyroxine and
triiodothyronine. Kailangan ito to be able to
produce the perfect thyroid hormones.
→ Kung may hyper secretion ng T4 and T3,
tataas ang temperature and heart rate ng
patient
→ TSH (Thyroid Stimulating Hormone) – a
hormone that regulates T4 and T3
→ Anterior Pituitary Gland – responsible for
the release of TSH, nasa utak ito siya.
→ Paano malaman kung may problem sa
thyroid gland? Kung merong enlargement sa thyroid
gland.
→ Goiter – enlargement of thyroid gland
→Hyperthyroidism and Hypothyroidism –
another disease that causes goiter. (Ang mga
payatot maski daghan gina kaon tapos wala naga
gain ug weight basin naay problem sa thyroid gland)
→ Patients with Hyperthyroidism – heat
intolerance
→ Patients with Hypothyroidism – cold
intolerance
- Parafollicular cells produce the hormone
thyrocalcitonin that lowers blood calcium
→ Parathyroid gland – regulates calcium
levels. PTH ang naga pa ba ba sa calcium
levels
ASSESSING THE NECK
1. Ask the client to hold the neck erect
→ “Sir mag lingkod ta ug tarong, thank you
sir”
2. Inspect the muscles of the neck
(sternocleidomastoid and trapezius “trapal”)
for abnormal swelling or masses
→ Trapezius – name of a muscle derived from
its shape
 Normal:
- Muscles equal in size
- Head centered
 Abnormal:
- Unilateral swelling of the neck
- Head tilted to one side
 Consider masses, injury,
muscle weakness,
shortening of the
sternocleidomastoid, or
scar
→ Contractures – complication or scarring from an
injury or burn

ASSESSING HEAD MOVEMENT
1. Observe for head movement
→ “Sir, look right/left”
 Normal:
- Coordinated, smooth movement with
no discomfort
 Abnormal:
- Muscle tremors, tourette, spasms, or
stiffness
2. Ask the patient to move chin to the chest
 Normal:
- Head flexes at 45 degrees
 Abnormal:
- Limited range of motion, painful
movements, involuntary movements
→ Nuchal rigidity – neck stiffness
3. Ask the patient to move head back to chin
points upward
 Normal:
- Head hyperextends at 60 degrees
 Abnormal:
- Limited range of motion at less than 60
degrees
4. Ask the patient to move head so that ear is
moved towards the shoulder on each side
 Normal:
- Head laterally flexes at 40 degrees
 Abnormal:
- Head laterally flexes at less than 40
degrees
5. Ask the patient to turn head to the right and
left
 Normal:
- Head laterally rotates 70 degrees
 Abnormal:
- Head laterally rotates less than 70
degrees
ASSESSING MUSCLE STRENGTH
- Applies pressure
1. Ask the patient to turn head to one side
against resistance provided by your hand.
Then repeat at the other side
→ “Sir, lingi ta sa left side, mag apply ko
ug pressure sir, i-try ug pigil sir ha”
→ tama2 na pressure lang i-apply
 Normal:
- Equal strength
 Abnormal:
- Unequal strength
2. Ask the patient to shrug shoulders against
resistance of your hands
→ you’re going to hold down the patient’s
shoulder, “Sir mag butang ko ug pressure ha,
isaka daw imong shoulder sir”
 Normal:
- Equal strength
 Abnormal:
- Unequal strength
→ Similarities of assessing the head movement and
assessing the muscle strength: both instructs the
patient to move the neck
ASSESSING THE THYROID GLAND
1. Enlargement
- Goiter
2. Patient complains of fullness of mass in
the neck
3. Evaluation includes description of the
gland and functional assessment
GOITER
 Question Answer
In assessing the tympanic Otoscope
→ I-assess ang swallowing reflex sa patient.
membrane, what equipment
There are times na ang thyroid gland dili
are you going to use?
swollen pero ang neck muscles swollen. Pag
How do you pull the helix of an Pull the helix
mag swallow ang patient i-observe kung ang adult patient? up and back
mass mag saka or stable lang
→ Pag mag palpate ka tapos naga saka pud You will know that tympanic Pearly gray
ang mass, that means sa thyroid gland na membrane is normal when the and semi
color is: transparent
siya pero pag neck mass, dili na siya naga
saka
Which of the following is/are - Normal Tone
Hypothyroidism - Iodine deficiency done to the patient to check of Voice
hearing acuity? - Watch Tick
→ pag kulang ang gina secrete sa thyroid Test
gland, ma stimulate ang anterior pituitary - Whisper Test
gland to secrete TSH. TSH will act on your In performing the whisper test, False
thyroid gland to produce T3 and T4 the patient should cover the
ear that is being tested
→ naga produce si thyroid gland ug T3 and T4
In performing the whisper test False
pero incomplete/not enough you will utter the same word
→ ang thyroid gland naga overcompensate on both ears
pag gina pa sige2 ug produce siya sa TSH. How would you identify if the Patient
Even if sige siya ug produce ug thyroid patient heard what you repeats the
whispered? word he/she
hormones pero kulang, mag overcompensate
heard
na siya. Pag naga overcompensate kay very
What type of test being Weber Test
active ang thyroid gland that is why naga
performed?
dako ang thyroid gland.
- ↑ TSH = ↓ T3 and T4
Hyperthyroidism
- ↓ TSH = ↑ T3 and T4
→ since taas na ang thyroid hormones, What is being tested? Test for
kailangan less ang pag release ug lateralization
thyroid stimulating hormone of vibration
Hyposecretion
→ walay problema sa iodine
In performing rinne test, where On the
would you place the vibrating mastoid
tuning fork first? process

Bone conduction should be False

greater than air conduction
How far should you place the As close as
watch from the ear during possible
watch tick test
How would you know if the Shifting of
patient has sensorineural loss sounds to
after performing weber’s test better ear
to the patient?
All newborns should be True
assessed for hearing using
auditory brain response testing
prior to discharge from the
hospital