🧠 HEAD, EYES, EARS, NOSE, MOUTH & NECK

Purpose of Head & Neurological Assessment

To detect stroke, head injury, cranial nerve dysfunction, and changes in mental status.

Key Tools for Head & Neurological Assessment

Penlight and gloves (if contact with mouth/fluids).

Subjective Questions in Head Assessment

Ask about headache, dizziness, head injuries, vision changes, confusion, and difficulty speaking or swallowing.

Objective Measures in Head Assessment

Inspect facial symmetry, speech clarity, pupil response, eye tracking, hand grip strength, and orientation.

Expected Findings in Head Assessment

Symmetrical facial movement, clear speech, equal reactive pupils, strong grips, and alertness with full orientation.

Red Flags in Head Assessment

Facial drooping, unequal pupils, slurred speech, one-sided weakness, and new confusion or drowsiness.

Definition of Stroke

Loss of blood flow to a part of the brain or bleeding in the brain, causing sudden weakness, facial droop, speech issues, or confusion.

Definition of Bell’s Palsy

Temporary weakness or paralysis of one side of the face caused by inflammation of the facial nerve.

Definition of Orientation Deficit

Confusion about person, place, time, or situation, often caused by infection, low oxygen, dehydration, or medication effects.

Definition of Head Trauma

Injury to the head or brain that can cause headache, nausea, confusion, or vision changes.

Safety Action related to neurological assessment

Initiate fall precautions and keep the patient NPO if swallowing is impaired.

Purpose of Eye Assessment

To detect neurological injury, infection, vision impairment, and liver disease.

Key Tools for Eye Assessment

Penlight and gloves.

Subjective Questions in Eye Assessment

Ask about vision changes, eye pain, discharge, itching, or dryness.

Objective Measures in Eye Assessment

Inspect eyebrows, lids, lashes, sclera, conjunctiva, check eye alignment, test PERRLA, assess fields of gaze.

Expected Findings in Eye Assessment

White, moist sclera; pink, moist conjunctiva; pupils equal and reactive; aligned eyes that track smoothly.

Red Flags in Eye Assessment

Unequal pupils, yellow sclera, sudden vision loss, bulging eyes, and drooping eyelids.

Definition of Conjunctivitis

Inflammation of the eye’s lining causing redness, itching, and drainage.

Definition of Cataracts

Clouding of the eye’s lens leading to blurry or foggy vision.

Definition of Strabismus

Eyes that do not align properly, which can result in one eye turning in, out, up, or down.

Definition of Subconjunctival Hemorrhage

A broken blood vessel under the surface of the eye that appears as a bright red patch.

Definition of Ptosis

Drooping of the upper eyelid that may partially cover the eye.

Definition of Jaundice

Yellowing of the sclera caused by liver problems or high bilirubin levels.

Safety Action related to eye assessment

Report sudden vision changes immediately and maintain clear walking paths to prevent falls.

Purpose of Ear Assessment

To detect infection, hearing loss, and signs of skull fracture.

Key Tools for Ear Assessment

Gloves and penlight (optional).

Subjective Questions in Ear Assessment

Ask about hearing changes, tinnitus, ear pain, drainage, or dizziness.

Objective Measures in Ear Assessment

Inspect for symmetry, redness, swelling, and drainage; palpate tragus and mastoid process.

Expected Findings in Ear Assessment

Symmetrical ears with no redness or tenderness and a small amount of cerumen.

Red Flags in Ear Assessment

Bloody or clear drainage, severe pain with tragus movement, and sudden hearing loss with dizziness.

Definition of Otitis Externa

Infection of the outer ear canal causing pain, redness, and drainage.

Definition of Cerumen Impaction

Buildup of earwax that blocks the ear canal, reducing hearing.

Definition of Hearing Deficit

Partial or complete loss of hearing, often due to aging, noise exposure, or infection.

Safety Action related to ear assessment

Do not irrigate ears if perforation is suspected and report clear drainage immediately.

Purpose of Nose & Sinuses Assessment

To detect infection, allergies, obstruction, and skull fracture.

Key Tools for Nose Assessment

Penlight and gloves.

Subjective Questions in Nose Assessment

Ask about nasal congestion, pain, discharge, and history of allergies or sinus infections.

Objective Measures in Nose Assessment

Inspect mucosa color and moisture, check for drainage or swelling, palpate frontal and maxillary sinuses.

Expected Findings in Nose Assessment

Pink, moist mucosa; clear nasal passages; no sinus tenderness.

Red Flags in Nose Assessment

Thick green/yellow discharge, foul-smelling discharge from one nostril, and clear watery drainage post-head injury.

Definition of Sinusitis

Infection or inflammation of the sinuses causing facial pressure, congestion, and thick nasal discharge.

Definition of Allergic Rhinitis

Inflammation of the nose due to allergies, causing sneezing, itching, and clear drainage.

Definition of Foreign Body (Nose)

An object stuck in the nostril causing foul-smelling drainage from one side.

Definition of Basilar Skull Fracture

Serious fracture at the base of the skull causing clear fluid leakage from the nose or ears.

Safety Action related to nose assessment

Do not pack the nose if a skull fracture is suspected and report CSF-like drainage immediately.

Purpose of Mouth & Throat Assessment

To detect infection, airway risk, nutritional deficiencies, and cancer.

Key Tools for Mouth Assessment

Gloves and penlight.

Subjective Questions in Mouth Assessment

Ask about sore throat, mouth pain, difficulty swallowing or chewing, bleeding gums, and recent weight loss.

Objective Measures in Mouth Assessment

Inspect lips, teeth, gums, tongue, palate, and tonsils for lesions, swelling, or discoloration.

Expected Findings in Mouth Assessment

Pink, moist mucosa; firm gums; smooth tongue; no lesions or exudate.

Red Flags in Mouth Assessment

White patches that bleed when wiped, swollen red tonsils with exudate, non-healing mouth sores, and difficulty swallowing.

Definition of Thrush (Oral Candidiasis)

A fungal infection causing white patches in the mouth that leave red spots when wiped off.

Definition of Aphthous Ulcers (Canker Sores)

Small, painful sores inside the mouth with a white center and red border.

Definition of Gingivitis

Inflammation of the gums causing redness and bleeding.

Definition of Tonsillitis

Infection of the tonsils causing sore throat, swelling, and white patches.

Definition of Oral Cancer

Abnormal growth in the mouth appearing as a sore or lump that does not heal.

Safety Action related to mouth assessment

Keep patient NPO if swallowing is impaired and report signs of airway compromise.

Purpose of Neck Assessment

To detect airway obstruction, thyroid disease, infection, and cancer.

Key Tools for Neck Assessment

Gloves and stethoscope (if airway issues).

Subjective Questions in Neck Assessment

Ask about neck pain, stiffness, breathing difficulties, and lumps or swelling.

Objective Measures in Neck Assessment

Inspect trachea alignment, palpate lymph nodes and thyroid, assess range of motion.

Expected Findings in Neck Assessment

Midline trachea, full range of motion, no lumps or tenderness.

Red Flags in Neck Assessment

Shifted trachea, noisy breathing (stridor), fixed lymph nodes, and difficulty swallowing or breathing.

Definition of Thyroid Enlargement (Goiter)

Swelling of the thyroid gland in the neck due to hormone imbalance.

Definition of Lymphadenopathy

Enlarged lymph nodes due to infection, inflammation, or cancer.

Definition of Neck Mass

Any abnormal lump in the neck, such as cysts, swollen lymph nodes, or tumors.

Definition of Airway Obstruction

A blockage that makes breathing difficult, potentially causing noisy breathing.

Purpose of Clinical Mindset

To connect signs observed during assessment to their meanings and necessary actions.

Memory Hook for Stroke Recognition

FAST: Facial droop, Arm weakness, Speech difficulties, Time to call provider.

Universal Red Flags in Assessment

Facial droop, unequal pupils, sudden vision loss, clear or bloody ear/nose drainage, difficulty breathing or swallowing, new confusion or altered mental status.