Overview
Clinical Meaning
The head, eyes, ears, nose, throat (HEENT), and skin assessment is a foundational component of the comprehensive nursing assessment that evaluates structures critical to sensory...
The head, eyes, ears, nose, throat (HEENT), and skin assessment is a foundational component of the comprehensive nursing assessment that evaluates structures critical to sensory function, airway patency, neurological integrity, and protective barrier function. The head assessment includes evaluation of the skull for symmetry, tenderness, and lesions, as well as assessment of the temporal arteries and temporomandibular joint (TMJ). The twelve cranial nerves originate from the brainstem and provide motor and sensory innervation to the head and neck structures; the practical nurse must be able to perform a basic cranial nerve screening, particularly nerves II (optic, visual acuity), III, IV, VI (oculomotor, trochlear, abducens -- extraocular movements), V (trigeminal, facial sensation and mastication), VII (facial, facial expression and taste), VIII (vestibulocochlear, hearing and balance), IX and X (glossopharyngeal and vagus, swallowing and gag reflex), XI (accessory, shoulder shrug and head turning), and XII (hypoglossal, tongue movement). Eye assessment includes evaluation of visual acuity using a Snellen chart (normal vision is 20/20), visual fields by confrontation testing, pupil assessment using the PERRLA documentation system (Pupils Equal, Round, Reactive to Light and...