Comprehensive Nursing Notes on Head, Neck, and Neurological Assessment

Clinical Assessment of the Head and Neck

• Essential Assessment Tools

  • A penlight is the primary tool necessary for assessing pupillary response and inspecting oral and nasal cavities during a head and neck examination.

• Skull and Scalp Inspection

  • The skull should generally be round and symmetrical.
  • Expected prominences are located in the frontal area anteriorly and the occipital area posteriorly.
  • Expected protrusions are found on the side of each parietal bone and on the mastoid process.
  • Normal findings include an absence of bumps, lesions, swelling, hair loss, or concavity.
  • Small, white, oval particles attached to hair strands during a hair assessment indicate the presence of lice.

• Trauma Indicators: Raccoon Eyes and Battle Sign

  • Internal hemorrhaging or head trauma may manifest as specific bruising patterns.
  • Raccoon Eyes: Dark circles or bruising around the eyes suggesting internal damage.
  • Battle Sign: Bruising over the mastoid process (behind the ear).
  • These signs can indicate a basilar bleed, which refers to bleeding in a specific area of the brain.
  • In pediatric cases, these signs may raise suspicion of violence against a child.

Migraine and Headache Assessment

• Identifying Migraine Characteristics

  • Nurses should ask specific questions to identify characteristics of migraine headaches, including:
    • The location of the headache (is it unilateral or bilateral?).
    • Frequency and duration of the pain.
    • Presence of an aura (sensory warnings before the headache starts).
    • Associated symptoms: Fatigue, dizziness, nausea, vomiting, and difficulty concentrating.
    • Pain scale rating (intensity of pain).
    • Medication history: What the patient takes for the pain.
    • Sensitivity: Sensitivity to light (photophobia) and sensitivity to sound (phonophobia).

• Visual Changes and Migraines

  • Visual changes such as blurring, halos, or spots can be associated with migraines.
  • However, these symptoms may also suggest increased intracranial pressure (ICP) or other serious neurological conditions.

• Tension-Type Headaches

  • Common triggers for tension headaches includes:
    • Stress.
    • Poor posture.
    • Eye strain.
    • Dehydrations.
    • Lack of sleep.
  • Physical symptoms often include tightness in the shoulders.

Increased Intracranial Pressure (ICP) and Herniation

• Physiological Mechanisms of ICP

  • The adult skull is a confined space and is considered "full"; there is no room for pressure to be released outward.
  • If there is a bleed, tumor, or inflammation taking up space, the pressure must go downward toward the spinal column.
  • Herniation: This occurs when high pressure forces brain tissue down into the spinal column, infringing on the spinal cord. This can lead to inflammation, damage, and the inability to breathe independently or regulate heart rate.

• The Brain Stem

  • The brain stem consists of areas like the pons and is part of the central nervous system (composed of the brain and spinal cord).
  • The brain stem controls vital functions including respiration and cardiac pumping (the heart's ability to pump).
  • Pressure on the brain stem during herniation is a lethal event that clinical assessments aim to mitigate.

• Cushing’s Triad

  • Cushing's Triad is a clinical sign of increased ICP and impending herniation. It consists of three primary findings:
    1. Irregular Respirations: This includes apnea (periods of not breathing) or abnormal breathing patterns. Respirations should be counted exactly, as they may be as high as $32$ or as low as $7$, rather than a standard estimated $18$ or $16$.
    2. Bradycardia: A low heart rate.
    3. Hypertension / Widening Pulse Pressure: The systolic blood pressure increases while the diastolic blood pressure decreases.

• Pulse Pressure Specifics

  • A widened pulse pressure occurs when the gap between systolic and diastolic pressure increases.
  • Example: A baseline blood pressure of $138/84\,mmHg$ with a heart rate of $80\,bpm$ might trend toward a systolic of $160\,mmHg$ or $180\,mmHg$ while the diastolic drops to $70\,mmHg$ or $60\,mmHg$.

Neck and Muscle Assessment

• Tracheal Assessment

  • A shifted or deviated trachea is a medical emergency.
  • It may indicate a hemothorax or a pneumothorax.
  • Treatment for these conditions involves the insertion of a needle to reinflate the lungs and restore negative pressure.

• Muscular Strength (Cranial Nerve XI)

  • Sternocleidomastoid Muscle: This muscle allows for head rotation.
  • Trapezius Muscle: A triangular muscle over the shoulders.
  • Testing Method: Assess strength by asking the individual to turn their head against resistance (pushing against the nurse's hand) and shrugging their shoulders against resistance (preventing the nurse from pushing them down).
  • Innervation: These muscles are controlled by the Spinal Accessory Nerve, which is Cranial Nerve $XI$. A mnemonic for this is to visualize the number "11" resting on the shoulders.

Ear, Nose, and Throat Assessment

• External Ear Assessment

  • The external ear should be healthy, clean, and intact.
  • Expected findings: No bumps, no leakage, no swelling, and no drainage.
  • Indications of infection include edema (swelling), warmth, tenderness, and pain upon palpation of the external ear or mastoid.

• Nasal Mucosa Assessment

  • Healthy nasal mucosa should be clear with no inflammation, swelling, discharge, or bleeding.
  • Foreign bodies (such as LEGOs, peas, or coins) are common in pediatric nasal assessments.
  • Anomalies: Pale nasal mucosa with clear drainage may indicate persistent allergies or sinusitis.

• Cerebrospinal Fluid (CSF) Test

  • Clear nasal drainage must be differentiated from CSF leakage.
  • The Halo/Napkin Test: Dab the drainage onto a napkin or paper towel and let it dry. While normal snot or mucus stays clear, CSF will dry with a yellow color or ring.

• Oral Assessment

  • Checking the floor of the mouth and bottom of the tongue requires the patient to open their mouth, move the tongue side-to-side, and lift the tongue.
  • A tongue depressor is often used for visibility.
  • Petechiae: The presence of petechiae (small purple/red spots) on the hard or soft palate suggests infection or hemorrhaging.
  • Dentures: Patients should remove dentures before an oral assessment, typically using a paper towel.

Neurological and Eye Exams

• Nystagmus

  • Nystagmus refers to involuntary "jumping" or twitching of the eyes during Extraocular Movement (EOM) testing.
  • This lack of control over the line of vision indicates potential issues with the vestibular system, brain stem, or cerebellum, requiring further neurological evaluation.

• Pupillary Light Reaction

  • Pupils should be tested for constriction and dilation.
  • The penlight should be shone from the side rather than directly in front of the patient to make the process more tolerable and prevent reflexive closing of the eyes.

• Facial Symmetry

  • To assess for cranial nerve damage, nurses check facial symmetry by asking the patient to:
    • Smile.
    • Puff out their cheeks.
    • Close their eyes tightly.
    • Raise their eyebrows.
  • Asymmetry may suggest nerve issues or slurring of function.

• Safety Precautions

  • Palpating the actual eye structure should be avoided during a routine head and neck assessment as the tissue is extremely sensitive and palpation could cause injury or affect vision.
  • Vision protection (safety glasses) is essential for athletes or workers in environments with airborne particles.

Questions & Discussion

• Question: What does nystagmus suggest if the person is not an albino?

• Response: It indicates involuntary movement which identifies issues with the vestibular brainstem or cerebellum and requires a full neurological evaluation.

• Question: Should we stop the assessment at the head for the virtual simulation?

• Response: Yes, for the virtual assessment, focus only on the head assessment; other assessments like arm movement, muscle grip, and the Romberg test are appropriate in person but may not be recognized by the software.

• Question: Can increased intracranial pressure cause a seizure?

• Response: Yes, it can cause seizures and coma secondary to herniation. It is not like shock (which involves low blood pressure and perfusion issues) but rather involves higher pressure pushing brain tissue into the spinal column.

• Discussion on Foreign Bodies: Participants mentioned instances of children inhaling LEGOs or peas. One student shared an anecdote about a child swallowing a quarter.

• Discussion on Albinism: It was noted that nystagmus is common in individuals with albinism due to a lack of melanin expression, noting that melanin affects various physiological systems beyond skin color.