Head, Neck, and Neurological Assessment (UNRS 220, HealthAssess)

When should gloves be worn during head, neck, and neurological assessment?

Gloves should be worn when assessing the eyes, mouth, nose, or ears if there is any drainage or contact with mucous membranes

When are gloves not necessary?

Gloves are not required when inspecting intact skin such as the skull or face, as long as there is no risk of contact with body fluids

When should dentures, glasses, or hearing aids be removed for assessment?

Remove them when inspecting the mouth, nose, or ears; they do not need to be removed when testing vision, hearing acuity, or facial symmetry

Mandible

The jawbone

Frontal bone

Forms the front of the skull

Occipital bone

Forms the back of the skull

Maxillary bone

Facial bone forming the upper jaw

Lacrimal apparatus

Produces tears and keeps the eyes moist and lubricated

Bulbar conjunctivae

The bulbar conjunctiva lines the eyeball

Palpebral conjunctivae

The palpebral conjunctiva lines the inside of the eyelids

Sclera

The white protective outer layer of the eye

Iris

Colored portion of the eye that regulates the amount of light entering through the pupil

Pupil

The round opening in the iris that changes size to control light entry

Why the pupil constricts and dilates

Constricts in bright light and for near vision; dilates in dim light or for far vision

How the pupil constricts and dilates

Muscles controlled by CN III constrict and dilate the pupil

Lens and how it works

Transparent structure that bends light rays to focus on the retina

Cranial nerves for eye movement

Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens)

Cranial nerve for vision

Cranial nerve II (optic nerve) transmits visual information to the brain

Tympanic membrane

The eardrum, seen by using the otoscope, normally pearly gray

Cerumen

Waxy ear secretion

Auricle, aka pinna

External part of the ear made of cartilage and skin

Vestibulocochlear apparatus and CN VIII

• inner ear maintains both balance (vestibule and semicircular canals) and hearing (cochlea)

  • both send signals through the same cranial nerve (vestibulocochlear nerve, CN VIII)

  • why hearing and balance issues may present together as part of one problem; if a patient presents with a hearing problem, they should also be assessed for balance issues, and vice versa

Middle ear

Cavity behind the tympanic membrane, transmits vibrations to the inner ear

Eustachian tube

Connects the middle ear and nasopharynx; equalizes pressure and explains why ear infections can follow respiratory infections

Nasal cavity

Warms, moistens, and filters inhaled air

Nasal septum

Divides the nasal cavity into two passages

Nares

Oval openings of the nose for air entry; lined with hair to filter debris

Hard palate

Bony anterior portion of the roof of the mouth

Soft palate

Muscular posterior part of the roof of the mouth

Uvula

Tissue hanging from the soft palate

Tonsils

Lymphoid tissue in the posterior pharynx that helps protect against infection

Posterior pharynx

The area behind the mouth and nose, can be seen through the mouth

Gingiva

Technical term for the gums

Tongue appearance, top and bottom

Top: rough with papillae; bottom: smooth with visible veins.

Oropharynx

Visible portion of the throat behind the mouth

Lymphoid tissue variation in younger people

Tonsils and lymph nodes are naturally larger in younger people, so they may appear prominent as a normal finding

Thyroid gland

Endocrine gland in front of the trachea

Migraine headaches

stand out for their associated symptoms

• wide range of unusual features, such as temporary vision loss

• family history (strong genetic component)

Halos around lights

Can indicate angle-closure glaucoma, which is an emergency

Hearing loss in older adults

A common age-related change is that high-frequency sounds will become harder to hear

Tinnitus

Ringing or buzzing in the ears without any external source, sometimes results from exposure to loud noises or as an adverse effect of medications

The connection between the common cold and hearing

The Eustachian tube connects the nasal cavity to the middle ear, so if one catches a cold, the nasal congestion may travel up the Eustachian tube into the middle ear, causing temporary partial hearing loss

Ear drainage

• Purulent drainage is a sign of infection

• bloody drainage is a sign of trauma

Sinuses

air-filled cavities within skull bones (part of the nasal cavity)

Tobacco and the mouth assessment

Asking about tobacco use is important since it increases the risk for various mouth problems

Facial assessment findings from stroke

A stroke often causes one-sided facial weakness or paralysis

Mask-like facial appearance

May indicate neurological disorder affecting facial muscle control

Risks for patients with stroke

• risk of aspiration → pneumonia (keep NPO)

• risk for falling (d/t weakness)

The significance of abnormal pupils

Pupils that behave abnormally, such as acting asymmetrically, not responding, or having an unusual size, may indicate neurological problems like brain damage

The significance of the onset of an orientation deficit

• a new deficit in orientation is a medical emergency

• an old one may reflect a chronic neurologic disease, which may be typical for that patient

Head assessment, characteristics to assess

Assess skull shape, size, contour, facial symmetry, and hair distribution

Palpebral fissures

Openings between the eyelids; should be symmetrical

Nasolabial folds

Creases from the nose to the corners of the mouth; should appear symmetrical

Involuntary facial movements

Twitching may indicate neurological disorder

What to look for when palpating the skull

Use fingertips to feel for nodules or masses along the scalp and sides of the head

Expected skull protrusions

Normal prominences at various parts along the skull, which is not normally perfectly round

The significance of mild facial asymmetry

A small degree of asymmetry is a common expected variation

Aging and dryness

In general, as people reach old age, every part of the body that has any degree of fluid becomes drier, including the hair, skin, and mucous membranes; some degree of dryness is therefore expected, but you should still be looking for excessive dryness, which is abnormal

Aging and drooping

In general, as people reach old age, every part of the body that has any degree of elasticity becomes droopier, including the skin around the face and the eyelids; some degree of sagging is therefore expected, but you should still be looking for sagging that is either excessive or has some kind of abnormal feature, such as entropion or ectropion, which is considered abnormal

Aging and sensory changes

In general, as people reach old age, every form of sensation becomes less effective, including vision, hearing, and tasting; some degree of deficit is therefore expected, but you should still be looking for deficits that are either excessive or has some kind of abnormal feature, such as sudden changes in visual acuity or seeing halos around lights

Abnormal head assessment findings resulting from trauma

Lumps, sunken areas, bruising

Hair loss causes

May result from medical issues, medication side effects, stress, or genetics

Periorbital edema

Swelling around the eyes; an important early sign

Hirsutism

Excess coarse hair growth in a male pattern on women

Head lice

The eggs (called nits) appear as white ovals on hair shafts; the lice themselves are small, making them much harder to see

Bell's palsy vs stroke

Both cause unilateral facial weakness, but stroke usually spares the forehead (upper face)

Testing facial expression symmetry

Ask the client to smile and show teeth; observe for equal movement and presence of nasolabial folds

Puffing cheeks test

Have the client puff out cheeks; press gently, air should escape equally from both sides

The significance of forehead wrinkles

When client raises their eyebrows check for equal forehead wrinkles; an asymmetry may indicate an asymmetry in facial muscle strength

Speech and facial muscles

Slurred or unclear speech may reflect facial or cranial nerve weakness

Instructing the client for the eyes inspection

Ask client to look at your eyes; this will help to assess for symmetry

Inspecting lower eyelids

Retract skin below lids as client looks upward; this will help reveal the conjunctivae

Pupil assessment

Assess size, shape, equality, reactivity to light and accommodation

What is the first step in the pupillary light reaction technique?

Begin with the patient gazing into the distance; this will help the pupils dilate, so that the reflex is more noticeable

How should the light be shone during the pupillary light reaction test?

Shine a light from the side, one eye at a time

What should happen to both pupils when light is directed at only one eye during the pupillary light reaction test?

Both pupils should constrict equally

Accommodation test

Begin with the patient gazing into the distance, place your finger inches from the patient's face, then ask them to look at your finger; the pupils should constrict and the eyes should converge onto your finger

Normal conjunctivae

The conjunctivae are clear, so the color will appear pink over the inner eyelid and white over the eye

Normal pupil size

Black, round, equal, and 3-5 mm in normal lighting

Exophthalmos (proptosis)

bulging eyes

Strabismus

Misalignment of the eyes; one eye is turned abnormally inward or outward

Redness around eyes

Redness of the tissue around the eyes, such as the eyelids or conjunctiva, is a sign of inflammation, which may be from infection

Ptosis

Technical term for drooping eyelid, can be caused by nerve damage or edema

Inability to fully close eyelids

May occur with facial muscle paralysis (the muscles are too weak to fully close the eyelids) or bulging eyes (eyes are too bulging for the lids to fit over them)

Subconjunctival hemorrhage

Localized bleeding in the eye under the conjunctiva, often after coughing or trauma; usually resolves on its own with time

Conjunctivitis

Inflammation of the conjunctivae causing redness and drainage, from infection or irritation (this is what is commonly called "pink eye")

Cloudy pupils

The pupils are covered by the lens, which is normally clear; commonly, in older people, as a result of accumulated damage over time, the lens will become cloudy, a condition called cataracts

Ask how quickly vision changes occurred

Determine if vision changed suddenly or gradually; sudden changes are urgent, whereas a gradual decline over years is expected

Headache with vision changes

A headache with visual changes may indicate that the headache is a migraine

Sudden throbbing pain and eye changes

Sudden throbbing eye pain and redness can mean angle-closure glaucoma

Is cerumen a normal finding?

Some cerumen in the external auditory canal is normal

The significance of crusts or scaling on the auricles

A common sign of eczema

Subtle cues of a potential hearing deficit

• client is leaning forward

• turning ear toward speaker

• watching your lips closely

• frequently asking for repetition

• misunderstanding questions

Otitis externa

Infection of the external ear canal

• causes redness, swelling, and drainage visible in the outer ear

Mastoid process

Bony prominence behind the ear; palpate for tenderness or swelling

How to palpate frontal sinuses

Press thumbs upward just below eyebrows; expect the patient to feel pressure, not pain

How to palpate maxillary sinuses

Press thumbs upward below cheekbones; expect the patient to feel pressure, not pain

Normal sinus finding

If the client feels mild pressure, this is normal

Abnormal sinus finding

Pain or tenderness suggests inflammation or infection

Significance of pale nasal mucosa

Indicates allergies