NURS 2305 Health Assessment – Head, Neck & Eye Study Notes

Head, Face & Neck: Core Anatomy and Landmarks

• Bones & Sutures
  • Frontal, Parietal, Temporal, Occipital, Sphenoid, Ethmoid
  • Sutures: Coronal, Squamous, Lambdoid
  • Facial bones: Nasal, Lacrimal, Zygomatic, Maxilla, Mandible (ramus, body, mental foramen, alveolar margins)
  • Processes: Zygomatic, Mastoid, Styloid
  • External acoustic meatus—landmark for ear & cranial base exams
• Glands & Viscera
  • Parotid, Submandibular, Sublingual salivary glands
  • Thyroid (isthmus, lobes) & Parathyroids
  • Trachea midline—any shift ⇒ emergency differential (e.g., tension pneumothorax)
• Lymphatics (Regional)
  • Occipital, Posterior auricular, Pre‐auricular, Submental, Submandibular, Jugulodigastric, Superficial & Deep cervical, Posterior cervical, Supraclavicular
  • Drainage direction guides infection source tracing (e.g., tender occipital ⇒ inspect scalp)

Structure & Function Overview

• Head protects brain; face conveys emotion & houses sensory organs
• Neck supports head, houses major vessels/viscera, conduit for respiratory & digestive tracts
• Musculature innervated by CN V (Trigeminal) for mastication & CN VII (Facial) for expression
• Lymphatic system filters pathogens; nodes should be soft, movable, non-tender (<1 cm)

Headache Typology (Subjective ― PQRSTU)

• Tension (Musculoskeletal)
  • Location: bilateral “band-like”
  • Character: viselike; gradual (30 min–days)
  • Triggers: stress, poor posture
  • Relieved by rest
• Migraine (Vascular/Trigeminovascular)
  • Usually unilateral, throbbing \text{(Aura ±)}
  • Rapid onset; peaks 1–2 h; lasts 4–72 h
  • Triggers: hormones, certain foods (MSG, chocolate), sleep deficit, sensory stimuli, weather
  • Associated: N/V, photophobia, prodrome
  • Relief: dark room, sleep
• Cluster (Autonomic/CN V)
  • Strictly unilateral peri-orbital, “stabbing/burning”
  • Abrupt; peaks in minutes; lasts 45–90 min; may occur 1–2×/day for months
  • Triggers: alcohol, daytime napping, wind/heat
  • Associated: ipsilateral tearing, rhinorrhea, agitation
  • Relief: pacing, movement
• Clinical vignette: Severe throbbing h/a starting while studying, relieved by lying down ⇒ Migraine (exam Q)

Additional Subjective Data (Head/Neck)

• Head injury history (LOC? mechanism?)
• Dizziness types:
  • Presyncope (light-headed, cardiovascular)
  • Vertigo objective (room spins) vs subjective (person spins) ⇒ vestibular cause
  • Disequilibrium—musculoskeletal/neurologic gait imbalance
• Neck pain, limited ROM, lumps, swelling
• Past surgeries (thyroidectomy, carotid endarterectomy)

Objective Exam (Head/Neck)

• Skull: size, contour; palpate for lumps, tenderness, fontanels (infants)
• Face: symmetry (CN VII), involuntary movements, edema, pigmentation
• CN V (Motor & Sensory): clench teeth, resist opening; cotton wisp to forehead/cheeks/chin
• CN VII: smile, frown, puff cheeks, show teeth, close eyes tightly
• Neck: inspect, palpate trachea midline, thyroid (posterior or anterior approach; swallow water)
• ROM: flexion, extension, rotation, lateral bending; test strength (CN XI with shoulder shrug, head turn against resistance)
• Lymph nodes: systematic palpation using pattern; note size, mobility, tenderness, delimitation
• If node abnormal ⇒ explore area it drains (e.g., tender occipital ⇒ assess scalp)

Aging Adult – Head/Neck

• Prominent bones & orbits; skin sags from ↓ elasticity, subcutaneous fat, moisture
• Senile tremors (benign head nodding, tongue protrusion)
• ROM slow to avoid dizziness
• Drooping submandibular glands mimic tumor but are normal
• Subjective emphasis: dizziness & impact on ADLs (driving, housework, falls)

Common Abnormalities (Head/Neck)

• Parkinson disease: mask-like flat affect, staring, drooling (CN VII hypokinesia)
• Cushing syndrome: rounded “moon” face, red cheeks, hirsutism
• Acromegaly: enlarged skull & facial bones from GH hypersecretion
• Cachexia: sunken eyes, hollow cheeks—wasting illnesses
• Hyperthyroidism (Graves): exophthalmos, goiter, tachycardia
• Hypothyroidism (Myxedema): puffy, edematous face, periorbital edema, coarse hair
• Bell palsy: unilateral CN VII paralysis; inability to wrinkle forehead, close eye, whistle
• CVA (stroke): lower facial weakness sparing forehead; language deficits

Eye Anatomy – External

• Upper/lower lids, palpebral fissure, canthi, caruncle, limbus, sclera, iris, pupil
• Extra-ocular muscles (6):
  • Superior, Inferior, Medial, Lateral recti; Superior & Inferior obliques
  • Innervation: CN\;III (most), CN\;IV (Superior oblique), CN\;VI (Lateral rectus)

Eye Anatomy – Internal

• Three concentric layers:
  • Sclera (fibrous)
  • Choroid (vascular): ciliary body, iris, pupil control, lens accommodation
  • Retina (neural): optic disc, macula, retinal vessels
• Chambers: anterior & posterior (aqueous humor), posterior cavity (vitreous body)

Visual Reflexes & Physiology

• Pupillary light reflex (CN II afferent, CN III efferent):
  • Direct—constriction of illuminated pupil
  • Consensual—simultaneous constriction of opposite pupil
• Fixation: eye maintains object on fovea; smooth pursuit interrupted by nystagmus
• Accommodation: near focus ⇒ lens rounds, pupils constrict, convergence of eyes

Aging Adult – Eyes

• ↓ pupil size, tear production; lens stiffens causing Presbyopia (near vision loss from \text{lens elasticity}↓)
• Need more light; slow dark adaptation ⇒ fall risk
• Common diseases ↓ vision: cataracts (lens opacity), glaucoma (optic nerve neuropathy, ↑IOP), macular degeneration (central vision loss), diabetic retinopathy (leading cause <65 y)

Eye Subjective Data (PQRSTU)

• Vision difficulty (acuity, blurring, blind spots)
• Pain, photophobia
• Strabismus, diplopia
• Redness, swelling, watering, discharge (allergies, infection)
• Ocular surgery, trauma
• Corrective lenses, last Rx, hygiene
• Self-care: protective eyewear, screens, driving
• Older adult extras: stairs, night driving, last glaucoma test, cataract presence, dryness limiting activities

Eye Objective Data

1. CN II – Acuity
   • Snellen chart at 20 ft; record fraction \frac{test\,distance}{distance\;normal\;eye\;sees\;same\;line} (e.g., \frac{20}{30} ⇒ pt sees at 20 ft what normal sees at 30)
2. External inspection
   • Lids: ptosis, lesions; lashes outward, evenly distributed
   • Conjunctiva & sclera: clear, white; look for jaundice, injection
   • Lacrimal apparatus: palpate for tenderness, regurgitation of fluid
3. Anterior segment
   • Cornea/lens: clarity with oblique lighting; arcus senilis (lipid ring, benign aging)
   • Iris/pupil: size (3-5 mm adult), shape, equality
4. CN II – Peripheral Vision (Confrontation)
5. CN III, IV, VI – EOMs
   • Six cardinal fields (diagnostic positions test): note nystagmus, lid lag
   • Cover test for strabismus; Corneal light reflex (Hirschberg) for alignment
6. CN III – Pupillary reflex
   • Darken room; shine light from side across pupil, watch direct & consensual constriction
   • Record as PERRLA: Pupils Equal, Round, Reactive to Light & Accommodation
   • Accommodation: focus distant ⇒ near (≈7 cm); observe convergence & constriction

Eye – Aging Adult Expected Findings

• ↓ acuity (central & peripheral)
• Loss of outer brow hair; remaining coarse
• Sunken globes from atrophy; pseudo-enophthalmos
• Dry, lusterless eyes; delayed tear production
• Cloudy cornea possible; Arcus senilis gray ring; Xanthelasma yellow plaques on lids

Abnormal Eye Findings

• EOM (Strabismus): esotropia (in), exotropia (out); paralysis pattern matches affected CN
• Eyelids:
  • Periorbital edema (renal, allergy)
  • Ptosis (CN III palsy, Horner)
  • Exophthalmos (Graves) & Enophthalmos (dehydration, trauma)
  • Hordeolum (stye – infected follicle); Chalazion (meibomian cyst)
• Pupil size disorders:
  • Mydriasis >6 mm (SNS, glaucoma drugs, brain injury)
  • Miosis <2 mm (parasympathetic, opioids, iritis)
• Conjunctivitis: infection/allergy, preauricular node swollen
• Iritis (Circumcorneal redness): photophobia, vision blur—urgent

Clinical Q&A (Integrated)

• Severe throbbing h/a relieved lying ↓ while studying ⇒ Migraine
• Tender, firm occipital node ⇒ examine scalp for infection (drainage basin)
• Older pt asks about bony facial prominence ⇒ explain ↓ elasticity, subQ fat, moisture
• Staring, flat affect, drooling ⇒ Parkinson history
• Asymmetric smile/frown/forehead ⇒ CN VII damage
• Presbyopia cause ⇒ loss of lens elasticity
• Snellen 20/30 interpretation: patient reads at 20 ft what normal eye sees at 30 ft
• Testing pupillary light reflex: shine light from side and observe direct & consensual constriction
• Expected older-eye finding: arcus senilis, loss of brow hair (↑ tear production would be ABN)

Cranial Nerve Quick Reference

• CN II – Optic: acuity, fields, fundus
• CN III – Oculomotor: EOMs (except SO & LR), lid raise, pupil constrict
• CN IV – Trochlear: Superior oblique (down/in)
• CN V – Trigeminal: face sensation, mastication
• CN VI – Abducens: Lateral rectus (out)
• CN VII – Facial: expression, taste ant ⅔ tongue
• CN XI – Spinal Accessory: sternomastoid/trap strength

Practical & Ethical Implications

• Accurate documentation: only chart PERRLA if all elements assessed
• Safety: impaired vision & dizziness in elderly ⇒ fall prevention, home modifications
• Cultural competence: headache triggers (diet, stress) vary; tailor education
• Screening: include glaucoma checks ≥40 y, diabetic retinal exams annually
• Communication: clarify patient descriptors (“dizzy” vs “vertigo”) to target diagnostics