Assessment of the HEENT

Nurses often practice in clinical environments where medical providers are not present.
In these cases, the health history and physical assessment can be important. Nurses will often
have to organize and present this information to medical providers over the telephone in order to
receive proper orders for care and treatment of the patient. A review of multiple systems may be
necessary in these cases (Mayo et al., 2012). For instance, a patient presenting for a problem
related to the ear may need an entire head, eyes, ears, nose, and throat (HEENT) examination
because all of the areas are interconnected. The purpose of this paper is to present a case related
to a HEENT examination completed on a patient to include the health history, a physical
examination of the systems, and the interventions completed to ensure adequate care delivery.
Health History
A forty-eight year old male patient presented to the clinic with complaint of right ear
pain. His subjective report was that for the past three days he had been having sharp and aching
right ear pain that radiated into the jaw. He recently had an upper respiratory infection with a
sore throat and cough the week prior, but all symptoms had improved. The earache occurred
without notice. The first time that anything was noted to be abnormal was two nights prior. He
described that he wore a headband and two nights prior he had woken in the morning and noted
blood and drainage on the headband. The next day the pain became so severe that he could not
sleep. He had been taking over the counter ibuprofen which had been relieving the constant
pain. He had no medication allergies that he was aware of. He felt that he needed to make an
appointment at the clinic today for treatment and subsequent care. A HEENT examination was
started on the patient.
Physical Examination
head. The head had no visual abnormalities and was normocephalic. The patients face
had good symmetry and facial muscle function was intact. Facial expression was appropriate to

behavior and mood. No abnormal facial structures, expothalmos, or abnormal swelling was
noted. His skin had good color and pigmentation. Head position was center and midline in
relation to the neck. Accessory neck muscles were symmetrical. Full range of motion to the neck
could be completed without limitations. The patient was able to turn his head to the right and left
without difficulty. He was also able to touch his chin to his chest without difficulty. His
accessory cranial nerve function was intact. His cervical lymph nodes were soft and non-tender
to palpation. No enlargements were present. No obvious pulsations involving the arteries were
found near the neck (Jarvis, 2012, p. 261).
eyes. No visual abnormalities were reported from the patient or were identified in the
examination. The patient denied any eye pain. His eyes did not water or contain redness,
swelling, or discharge. He denied any past history of ocular problems. The patient did not wear
corrective eye wear. Nystagmus was not present upon examination. The patients pupils were
round, reactive to light and accommodation. Eyebrows were symmetrical and did not contain
scaling or lesions. His eyelids did not droop and had an adequate amount of eyelashes. Eyeballs
were aligned normally without protrusion or sunken appearance. Sclera was white and not
icteric. Red reflex was present and within normal limits. Visual acuity was normal for age.
Oculomotor and ocular cranial nerves were intact (Jarvis, 2012, p. 298).
ears. No abnormalities were noted to the external ear structures. An otoscope was used
to visualize the middle ears. The left ear canal was found to be without redness, swelling, or
drainage. The tympanic membrane was pearly gray and intact. The right ear canal was painful
upon insertion of the ear probe. The ear canal was swollen, ulcerated, and contained purulent
yellow-green drainage. The drainage did not have a foul odor. The patient denied any hearing
issues to either ear. He denied any use of medications or treatments to clean or treat the ears
(Jarvis, 2012, p. 332).

nose. Nasal structures were found to be symmetrical. The nasal cavities did not contain
any discharge. The facial sinuses did not elicit pain upon palpation. The nasal cavities were lined
with pink, health tissue and no obstructions were visualized. The patient reported no issues with
the nose (Jarvis, 2012, p. 361).
throat. No sores or lesions were noted to the patients mouth, tongue, or gums. The
patient denied any tenderness or soreness to the throat. Tissues of the inner throat were intact,
healthy, and without redness or swelling. No hoarseness was noted upon patient speech. The
patient denied any difficulty swallowing or alteration to taste. The tonsils are visible and were
not inflamed. The patient had good oral hygiene and no halitosis was noted. The
glossopharyngeal cranial nerve was intact (Jarvis, 2012, p. 366).
Interventions
consultation. The patients main problem was an ulcerated, red, swollen ear canal with
purulent yellow-green drainage. This problem was the identified cause of significant pain to the
right ear. All other system assessments were normal. The clinic did not have a medical provider
at the time, but a physician was working at another clinic location that day. A telephone call was
made to this medical provider for consultation and medication orders. The patients main
problem was relayed to the physician along with the patients chief complaint, medical history,
and medication allergies. The physician wished to start the patient on antibiotic therapy, a course
of medication that would be taken for ten days. It was also recommended that the patient could
continue to take the over the counter ibuprofen for acute pain.
education. The patient was given the prescription for the medication and was educated
on taking the prescription exactly as prescribed, twice daily for the next ten days. He was
advised to take the entire prescription even if his ear started to feel better. The medication should
ideally be started as soon as possible after obtaining the prescription to promote healing. Each
dose of antibiotic medication should be taken with a full glass of water. When taking ibuprofen

it is recommended to take this medication with food to prevent stomach upset. The patient was
educated on how many tablets of antibiotic medication and ibuprofen would need to be taken as
a single dose. The patient verbalized understanding of the instructions and repeated back those
instructions to the nurse. A follow up appointment was made for two weeks to assess the
efficacy of the antibiotic therapy.
follow up. The patient arrived at the follow up appointment and had reported that he had
taken the entire antibiotic prescription and that his ear was doing much better. He had taken the
ibuprofen which had helped the pain. After several days on antibiotic therapy, the pain subsided
and he did not require analgesia. A reassessment was completed and the right ear canal was
completely healed. There were no other complaints or abnormalities noted. He was discharged
from the clinic and was advised to follow up as needed for health issues.
In situations where a medical provider is not available, nurses may act as the eyes and
ears of these providers in portraying an accurate account of the patients status. The proper
assessment and report can provide medical providers the information that they require to give
further orders for care and treatment. In this case, a complete HEENT examination was
completed in order to identify important details related to a patients complaint of ear pain. Due
to this accurate assessment, the medical provider was able to provide orders medical to treat the
patients condition. The patient was also given adequate education during the encounter and this
resulted in good compliance by the patient. Nurses are key players in patient care. Adequate
assessment skills coupled with good reporting skills can make a difference in the care of patients.

References
Jarvis, C. (2012). Physical examination & health assessment (6th ed.). St. Louis, MO: Elsevier
Mayo, A. M., Chang, B. L., & Omery, A. (2012). Use of protocols and guidelines by telephone
nurses. Clinical Nursing Research, 11(2), 204-19. Retrieved from
http://search.proquest.com/docview/197185533?accountid=34574