Health Assessment Discussion Paper

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Health Assessment Discussion Paper

Prior to class, and after reading/viewing the module assignment, select one of the following and conduct an assessment.

  • Eyes
  • Ears
  • Nose
  • Mouth

You may conduct the assessment on a fellow student, friend, or family member. Remember to secure their permission.

Collect both subjective and objective data using the process described in the textbook. Health Assessment Discussion Paper

Then, document your findings and bring them to class.

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Your instructor may ask that you submit your documentation. If so,

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.)

ASSESSMENT AND HISTORY OF THE EYES, EARS, NOSE, MOUTH, AND THROAT
FACULTY: This is for the review and discussion of history and assessment of eyes, ears, nose, mouth, and
throat. This is also the format the students should follow later in the class when they are assessing the eyes,
ears, nose, mouth, and throat on their partner. Note, however, the portions that are part of the General Head
to Toe Assessment. The remainder of the assessments are for more comprehensive assessments and should
be used based on findings from the review of systems. The “other tests” may be discussed if time is available.
For your health history/review of systems, remember to use the following prompts:
• Have you ever experienced…
• Do you have a history of…
• Do you have a family history of…
I. Eyes
a. History (from Review of Systems):
i. Decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering
or discharge, glaucoma, cataracts
ii. Wears glasses or contacts, last eye exam or glaucoma test, how coping with loss of
vision if any
b. Inspection: Health Assessment Discussion Paper
i. Eyebrows, eyelids, and eyelashes for abnormalities
ii. Sclera and conjunctiva for color, swelling, or lesions
iii. Pupils (equal, round, reactive to light and accommodation)*
iv. Eye movement (extraocular muscles)*
c. Other tests:
i. Snellen eye chart
ii. Confrontation test (peripheral vision)
II. Ears
a. History (from Review of Systems):
i. Earaches, infections, discharge and characteristics, tinnitus, vertigo
ii. Hearing loss, hearing aid use, how hearing loss affects daily life
b. Inspection:
i. Size and shape
ii. External auditory meatus for size, swelling, redness, or discharge
c. Palpation:
i. Pinna and tragus for tenderness
d. Other tests:
i. Whispered voice test
III. Nose and Sinuses
a. History (from Review of Systems): Health Assessment Discussion Paper
i. Discharge (characteristics), unusually frequent or severe colds, sinus pain, nasal
obstruction, nosebleeds, allergies or hay fever, change in sense of smell
b. Inspection:
i. Symmetry and deformity
c. Palpation:
i. Nasal patency
ii. Frontal and maxillary sinuses for tenderness
Rev. 01/2017 Page 5 of 11
IV. Mouth and Throat
a. History (from Review of Systems):

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i. Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or on
tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste
ii. Pattern of daily dental care, use of dentures, bridges, last dental checkup
b. Inspection:
i. Lips for color, moisture, cracking, or lesions
ii. Teeth and gums for abnormalities
iii. Tongue for color, surface characteristics, look under tongue for lesions, and assess
moisture
iv. Using a wooden tongue blade and a good light source, inspect the inside of the patients
mouth including the buccal folds and under the tongue. Note any ulcers, white patches
(leucoplakia), or other lesions. If abnormalities are discovered, use a gloved finger to
palpate the anterior structures and floor of the mouth.
v. Inspect the posterior oropharynx by depressing the tongue and asking the patient to say
“Ah.” Note any tonsilar enlargement, redness, or discharge.
vi. Buccal mucosa for color, moisture, nodules, and lesions*
vii. Tonsils for size, color, and surface characteristics
c. Palpation:
i. Instruct the students to don gloves, take a gauze pad and ask the partner to stick out
their tongue. As the student holds the tongue with the gauze pad they palpate (by
sliding their finger) along the sides of the tongue for any signs of cancer-lesions. They
should also do a finger sweep of the oral mucosa assessing for any papules Health Assessment Discussion Paper