RN First Call Certified Practice

Adult Decision Support Tools: EAR, NOSE AND THROAT ASSESSMENT

This assessment is based on best practice as of September 2009. For more information or to provide feedback on this or any other decision support tools, e-mail certifiedpractice@crnbc.ca

Ear, Nose and Throat Assessment

The following assessment must be completed and documented.

ASSESSMENT
History of Present Illness and Review of System
General The following characteristics of each symptom should be elicited and explored: Onset (sudden or gradual) Chronology Current situation (improving or deteriorating) Location Radiation Quality Timing (frequency, duration) Severity Precipitating and aggravating factors Relieving factors Associated symptoms Effects on daily activities Previous diagnosis of similar episodes Previous treatments Efficacy of previous treatments Cardinal Signs and Symptoms In addition to the general characteristics outlined above, additional characteristics of specific symptoms should be elicited, as follows: Ears Recent changes in hearing Compliance with and effectiveness of hearing aid Itching Earache Discharge Tinnitus Vertigo Ear trauma Q-tip use

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

CRNBC Oct 09/Pub. 706

RN First Call Certified Practice

Adult Decision Support Tools: EAR, NOSE AND THROAT ASSESSMENT

Nose Nasal discharge or postnasal drip Epistaxis Obstruction of airflow Sinus pain Itching Anosmia Nasal trauma Mouth and Throat Voice change Dental status Oral lesions Bleeding gums Sore throat Uvula midline Dysphagia (difficulty swallowing) Hoarseness or recent voice change Neck Pain Swelling Enlarged glands Other Associated Symptoms Fever Malaise Nausea or vomiting Medical History (Specific to ENT) Frequent ear or throat infections Sinusitis Trauma to the head or ENT area ENT surgery Audiometric screening results indicating hearing loss Allergies Medications currently used (prescription and OTC) Herbal preparations Smoking Personal and Social History (Specific to ENT) Others at home with similar symptoms Seasonal allergies Asthma Hearing loss Menires disease ENT cancer Frequent exposure to water (swimmers ear)

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

CRNBC Oct 09/Pub. 706

RN First Call Certified Practice

Adult Decision Support Tools: EAR, NOSE AND THROAT ASSESSMENT

Use of foreign object to clean ear Use of ear protection Crowded living conditions Dental hygiene habits Exposure to smoke or other respiratory toxins Recent air travel Occupational exposure to toxins or loud noises

PHYSICAL ASSESSMENT OF THE EARS, NOSE AND THROAT

General Appearance
Apparent state of health Degree of comfort or distress Color (flushed or pale) Nutritional status (obese or emaciated) Match between appearance and stated age Difficulty with gait or balance

Ears Inspection Pinna: look for lesions, abnormal appearance or position Canal: discharge, swelling, redness, wax, foreign bodies Tympanic membrane: colour, light reflex, landmarks, bulging or retraction, perforation, scarring, air bubbles, fluid level Estimate hearing with watch or whisper test Perform Weber and Rinne tests Palpation Tenderness over tragus or mastoid process Tenderness on manipulation of the pinna Pre- or post-auricular nodes Assess occipital nodes for tenderness and swelling Nose Inspection External: inflammation, deformity, discharge or bleeding Internal: colour, of mucosa, oedema, deviated or perforated septum, polyps, bleeding Trans-illuminate the sinuses for dulling of light reflex Observe nasal versus mouth breathing Palpation Sinus and nasal tenderness Percussion Sinus and nasal tenderness

points

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

CRNBC Oct 09/Pub. 706

RN First Call Certified Practice

Adult Decision Support Tools: EAR, NOSE AND THROAT ASSESSMENT

Mouth and Throat Inspection Lips: color, lesions, symmetry Oral cavity: breath odour, color, lesions of buccal mucosa Teeth and gums: redness, swelling, caries Tongue: colour, texture, lesions, tenderness of floor of mouth Throat: colour, tonsillar symmetry and enlargement, exudate Uvula midline Neck Inspection Symmetry Swelling Masses Redness Active range of motion Thyroid enlargement Palpation Tenderness, enlargement, mobility, contour and consistency of nodes and masses Lymph nodes of the head and neck Thyroid: size, consistency, contour, position, tenderness Pre-post auricular nodes Anterior and posterior cervical nodes Tonsillar Submaxillary Submandibular Occipital

CLINICAL REASONING AND CLINICAL JUDGMENT

The first step is to differentiate between major or serious causes of an ENT presentation from a minor one. The following signs and symptoms require referral to a physician or nurse practitioner: Pain and fever with mastoid tenderness Positive Brudzinsky sign (chin to chest) Treatment failure for otitis media, strep throat or peritonsillar abscess Hoarseness without fever or illness Unexplained vertigo Pain out of proportion to clinical findings (consider epiglottitis)

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

CRNBC Oct 09/Pub. 706