Head Neck and Neurological

Assessment ● Encompasses the skull, eyes, ears, nose, mouth, and throat ● Assess for alterations in sight, hearing, smell, and taste ● Have the client sit up with head at eye level ○ Remove glasses, hearing aids, and dentures Tools ● Penlight: Used to assess pupillary reaction, internal nares, and mouth ● Gloves: Used when assessing the eyes and mouth ○ Also for the nose and ears if there is drainage Anatomy and Physiology Head ● ● ● ● ● Frontal, parietal, occipital, and temporal bones Cranial bones connected by immovable suture joints 14 facial bones that make up the face contour The mandible has a hinge joint that allows for chewing and opening of the mouth The cranium is supported by the cervical vertebrae C1 through C7 Face ● Include the eyebrows, eyes, ears, nose, and mouth ● Facial structures should be symmetrical ● Skin should be the same color as the rest of the body and free from lesions Eyes ● ● ● ● ● Protected by the orbital cavity and surrounded by fat Eyelids: Protect from injury, strong light, and dust Eyelashes and eyebrows: Filter out dust and dirty Lacrimal gland: Secretes tears to keep the eyes moist Conjunctivae: Mucous membranes that line the bulbar conjunctiva and the palpebral conjunctiva ○ Bulbar conjunctiva: Eyeball ○ Palpebral conjunctiva: Inside surfaces of the eyelids ● The lacrimal apparatus keeps the conjunctiva and cornea moist and lubricated ○ Cornea: Transparent layer that covers the iris and pupil ● Sclera: Outer layer of the eyeball; tough, protective white covering over the majority of the eyeball’s surface ○ Merges with the cornea ● Iris: Colored portion of the eye with a center opening, the pupil ○ Round, muscular membrane that regulates the amount of light entering the lens of the eye by dilating or constricting the size of the pupil ○ Constrict in bright light and when accommodating for near vision ○ Dilate in dim light and when accommodating for far vision ● Pupillary light reflex: Expected constriction of the pupils when bright light shines onto the retina ● Lens: A transparent, round, convex-shaped structure that bends the light rays entering from the pupil to focus on the retina ● There are six muscles surrounding the eyeball, which allow coordinated movement ○ Innervated by three cranial nerves: ■ Permit light ■ Stimulate the reflex to blink ■ Allow closure of the eyelids ■ Stimulate the lacrimal glands to keep the eyes moist Cranial Nerves (Eyes) ● ● ● ● CN II (optic): Visual acuity, visual fields CN III (oculomotor), CN IV (trochlear), CN VI (abducens): Extraocular movements CN III (oculomotor): Pupillary reaction to light CN V: Corneal light reflex Visual Acuity: CN II (Optic) Sensory ● ● ● ● Measure the client’s ability to see small details If the client can read, use a Snellen and Rosenbaum chart, or newspaper to measure If the client has eyeglasses or contact lenses, have the client ue them during the test Ensure reading material is in the client’s language Snellen Chart ● ● ● ● ● ● ● ● Use to screen for myopia (impaired far vision); used for clients who cannot read Have the client stand 6.1 m or 20 feet from the chart Evaluate both eyes and then each eye separately with and without correction For each eye, cover the opposite one Ask the client to read the smallest line of print visible Note the smallest line the client can correctly read The first number is the distance (in feet) the client stands from the chart The second number is the distance at which a visually unimpaired eye can see the same line clearly Rosenbaum Eye Chart: ● Hold 35.5 cm (14 in) from the client’s face to screen for presbyopia (impaired near vision/farsightedness) ● Readings correlated with the Snellen chart Color Vision ● Assess using the Ishihara test ● The client should be able to identify the various shaded shapes Extraocular Movements: CN III, IV, VI ● Motor nerve ● Assess EOMs to determine coordination of the eye muscles using three different tests ● Assess for parallel eye movement, position of the upper eyelid, and abnormal movements as the client looks in each direction ● Test the corneal light reflex by directing a light onto the eyes and looking to see if the reflection is symmetric on the corneas ● Screen for strabismus with the cover/uncover test ○ While covering one eye, ask the client to look in another direction ○ Remove the cover and expect both eyes to be gazing in the same direction ● The six cardinal positions of gaze require the client to follow your finger with their eyes without moving their head ○ Move your finger in a wide “H” pattern about 20 to 25 cm (7.9 to 9.8 in) to from the client’s eyes ○ Expect smooth, symmetric eye movements with no jerky or tremor-like movements (nystagmus) Visual Fields: CN II Optic ● ● ● ● Sensory nerve Face the client at a distance of 60 cm (2 ft) The client covers one eye while you cover your direct opposite eye Ask to client to look at you and report when she can see the fingers on your outstretched arm coming in from four directions (up, down, temporally, nasally) ● The client should see your fingers at the same time you do Ears ● Tympanic Membrane: Eardrum; separates the external and middle ear ○ A transparent, thick piece of tissue; can be opaque or pearly gray in color ○ Vibrates when sound waves enter the external canal and are transmitted into the middle ear ● Sensory organ for hearing and maintaining equilibrium External Ear ● Auricle/Pinna: External ear; made of cartilage and skin ○ Serves to transfer sound waves into the external auditory canal ● The outer two-thirds of the external canal is lined with hair/glands that secrete cerumen ○ Cerumen: Prevents foreign matter from reaching the tympanic membrane ● The inner third of the canal is lined with thin, hairless skin Middle Ear ● The small, air-filled cavity inside the temporal bone ● Contains the auditory ossicles: the malleus, incus, and stapes ○ Move when the tympanic membrane vibrates ● Contains an opening to the Eustachian tube ○ Eustachian tube: A connection between the middle ear and nasopharynx ■ Allows equalization of pressure between the middle ear and environment ■ Typically closed, it opens when yawning or swallowing Inner Ear ● Contains structures that assist with balance and equilibrium, including the vestibule and semicircular canals; also includes the cochlea ○ Cochlea: A spiral-shaped organ that contains the organ of Corti ■ Organ of Corti: The receptor that transmits electrical impulses to the brain and allows hearing ● A disorder of the inner ear can disrupt balance and equilibrium ● Anything that obstructs the path of sound transmission can impair hearing Noses and Sinuses Nasal Cavity ● Extends back over the roof of the mouth and is highly vascular ● Septum: Medially divides the nasal cavity, creating the nares ○ Nares: Two oval openings; warm, moisten, and filter inhaled air ● Nasal hairs filter the coarsest material from inhaled air ● A mucous blanket filters out dust and bacteria ● The nose is the sensory organ of smell and provides an airway for gas exchange ● Made up of a bony upper section and a cartilaginous lower section ● Lined with a highly vascular mucous membrane ○ Mucous membrane: Warms and moistens inspired air; filters dust and bacteria ● Turbinates: Three bony prominences that protrude into the nasal cavity ○ Expands the available surface area of the mucous membrane Sinuses ● Air-filled cavities within the bones of the skull surrounding the nose and above the eyes ● Lined with ciliated mucous membrane ● Lighten the weight of the head, give resonance to the voice, and produce mucus that drains into the nasal cavity Mouth and Throat Oral Cavity ● Short passage boarded by the lips ○ Lips: Muscular tissue that surrounds the oral entrance ● Gingiva: Gums; snugly surround the teeth and encase the mandible ● Tongue: A mass of striated muscle that can change shape and position ○ The top of covered with papillae/taste buds, creating a rough appearance ○ The underside is smooth with visible blood vessels ● Hard palate: Bone that separates the mouth from the nasal cavity ● Soft palate: Muscular tissue behind the hard palate ○ Uvula: Hangs from the middle of the soft palate ○ The soft palate and uvula prevent food/liquid from entering the nose ● Buccal mucosa: Lines the inside of the cheeks Salivary Glands ● Moistens the mouth ● Includes the parotid, submandibular, and sublingual gland ● Saliva: The clear fluid excreted from these glands ○ Moistens/lubricates the food bolus ○ Starts digestion ○ Cleans and protects the mucosa ○ Then swallowed down the throat/pharynx Pharynx ● The area behind the mouth and nose ● Oropharynx: Separated from the mouth by the tonsils ○ Tonsils: Mass of lymphoid tissue; help protect against infection Neck ● The soft tissue of the neck is made up of arteries, lymph nodes, and the thyroid/parathyroid glands ○ Thyroid and parathyroid glands: Endocrine glands in front of the trachea ● The internal jugular veins run parallel to the anterior portion of the sternocleidomastoid muscle on both sides of the neck ○ Carotid arteries are buried deep alongside the veins Lymphatic System ● The vessels of here run through the body, carrying clear lymph fluid to fight infection ● Lymph nodes: Small groups of lymph tissue, which prevent foreign substances from entering the circulatory system ○ Works by detecting and destroying foreign substances ○ Numerous present in the head/neck area Cranial Nerves (Head & Neck) ● ● ● ● CN V (trigeminal): Assess the face for strength and sensation CN VII (facial): Assess the face for symmetrical movement CN XI (accessory) Assess the head and shoulders for strength CN V & VII are both motor and sensory nerves CN V (Trigeminal) ● Motor: Test the strength of the muscle contraction by asking the client to clench their teeth while you palpate the masseter and temporal muscles ○ Then, check the temporomandibular joint; movement should be smooth ● Sensory: Test light touch by having the client close their eyes while you touch the face gently with a wisp of cotton; ask the client to tell you when they feel the touch CN VII (Facial) ● Motor: Test facial movement and symmetry by having the client smile, frown, puff out the cheeks, raise the eyebrows, close their eyes tightly, and show their teeth ● Sensory: Ask the client to identify a salt or sweet taste on the front of the tongue CN XI (Spinal Accessory) ● Place your hands on the client’s shoulders and ask them to shrug them against resistance ● Then, have them turn their head against the resistance of your hand Lymph Nodes ● Extend from the lower half of the head down to the neck ● Palpate the skin over the tissue circularly to detect enlarged nodes ● Evaluate any for location, tenderness, size, shape, consistency, mobility, and warmth Sequence of Palpation ● ● ● ● ● ● ● ● ● Occipital nodes: Base of the skull Postauricular nodes: Over the mastoid Preauricular nodes: In front of the ear Tonsillar (retropharyngeal) nodes: Angle of the mandible Submandibular nodes: Along the base of the mandible Submental nodes: Midline under the shin Anterior cervical nodes: Along the sternocleidomastoid muscle Posterior cervical nodes: Posterior to the sternocleidomastoid muscle Supraclavicular nodes: Above the clavicles Health History Interview Head and Neck ● Do you have a history of headaches or a family history of migraines? ○ If so, how often do the headaches occur, how long do they last, and what medication relieves the headache? ● Have you ever had a head injury? ○ If so, what type of injury? Did you lose consciousness? ● Have you noticed any lumps or swelling in the neck area? ● Have you had any neck pain or problems with neck motion? Eyes ● Do you have any problems seeing close-up or at a distance? ● Have you ever had eye pain, blurred vision, blind spots, or seen halos/colors around objects or lights? ● Do you have excessive watering or discharge from the eyes? ● Do you wear glasses or contacts? ● Have you ever had any type of eye surgery? Ears ● Do you have any problems hearing? ○ If so, do you notice if you can hear low- or high-frequency sounds better? ● Do you ever experience ringing in either ear (tinnitus)? ○ If so, have you been exposed to loud environmental noises? ● Do common colds affect your hearing or cause ear pain? ● For ear pain: describe the onset, character, if the pain is constant or intermittent, how long it lasts, and what relieves the pain? ● Have you ever experienced ear drainage when having pain? ● Do you have excessive ear wax (cerumen)? ● Do you clean your ears? Describe how. ● Have you ever had a hearing exam? ○ Do you wear hearing aids? Nose and Sinuses ● Do you have frequent nasal congestion, nasal discharge, or runny nose? ○ For nasal discharge: Do you notice an odor? What color is the discharge, and is it chronic? ● How often do you have colds? Are they usually limited to the upper respiratory system? ● Do you have any notable sinus pain with or without having the common cold? ○ What medications do you take for this pain? ● Do you have any seasonal allergies that could contribute to nasal drainage and stuffiness? ● Have you had any type of nose trauma, surgery, unusual nose bleeds, or change in smell? Mouth and Throat ● Do you ever have a problem with sores/lesions in the mouth or on the tongue and gums? ○ If so, how often do the lesions occur, how long do they last, and do you take any medication to treat them? ○ Are the lesions or sores associated with stress, seasonal changes, or food? ● What are your dental hygiene habits? ○ Do you brush and floss? ○ How often do you have dental examinations? ○ Do you have any tooth pain? ● Do any teeth seem sensitive to heat or cold? ● Do you have any loose or lost teeth? Any bleeding of the gums? ● Do you wear dentures or have a dental bridge? ● Do you frequently have a sore throat? ○ How often? Is it related to postnasal drip or hoarseness? Do you still have your tonsils and adenoids? ● Do you smoke, vape, or chew tobacco? ○ If so, what type of tobacco? How long have you smoked, vaped, or chewed? ● Do you drink alcohol? ○ How frequently do you drink? How many drinks do you usually consume? ● Do you have any difficulty swallowing? ● Have you had any changes in your sense of taste? Intervention Needed: Orientation Deficity ● An orientation deficit is a gap in a client’s awareness of person, place, or time ○ Disorientation may be acute or chronic ● Infections, dehydration, low oxygen levels, medications, and other imbalances can cause acute disorientation ● Chronic disorientation can be present in some neurological disorders ● A change in orientation can also be a manifestation of a medical emergency, like a stroke Gather Subjective Data ● Determine orientation to self by asking: ○ What is your name? ○ When is your birthday? ● Determine orientation to time by asking: ○ What year is it? ○ Who is the president? ● Determine orientation to place by asking: ○ Where are you? ○ Why are you here? Assessment Inspect ● Inspect for signs of central nervous deficit ● Examine for symmetry of facial features ○ Take note of any drooping, decreased labial folds, or a mask-like appearance ● Watch for any signs that the client is having difficulty swallowing, such as coughing or excessive salivation ● Assess the client's eyes for signs of central nervous system alteration ● Ensure the pupils are the expected resting size (3-5 mm) and the same size bilaterally ● Use a penlight to assess pupillary response to light; ensure it is brisk and bilateral Palpate ● Assess for one-sided muscle weakness by asking the client to squeeze both of your hands simultaneously, also seeing their ability to follow instruction ● Unilateral weakness or inability to follow directions could indicate a stroke Measure Vital Signs ● Increased temperature or decreased oxygen saturation can change orientation ● Take note of any alterations in vital signs to determine the cause of orientation deficit Additional Nursing Actions ● Notify the provider immediately if orientation deficit is a finding ● Place the client on fall precautions and have them call for help before getting up ○ A stroke can cause weakness, paralysis, or gait alterations ● Check on the client frequently, completely lower the bed, provide floor mats, and ensure a clear environment for mobility ● If a stroke is suspected, ensure the client is NPO until a swallow assessment is done ● Calmly provide orientation to the client of time, date, and person with each interaction Head Assessment ● Inspect the position, size, shape, and contour of the skull ● Determine the distribution of hair ● Look at the shape and placement of facial features, including the eyebrows, palpebral fissures, nasolabial folds, and sides of the mouth ● Note unexpected findings, such as swelling or involuntary movements ● Palpate the skull for nodules or masses Expected Findings ● Expected protrusions are found in the frontal area anteriorly, occipital area posteriorly, side of each parietal bone, and mastoid process behind each ear ● The head should be proportional to the body and held upright/midline to the trunk ● Facial features should be symmetrical, and the face should seem relaxed ● The skin of the face and scalp should be uniform in color and smooth Expected Variations ● Slight asymmetry of facial features ● Dry, brittle hair and hair thinning due to aging Unexpected Findings ● ● ● ● ● ● ● ● ● Significantly asymmetrical features can indicate a stroke or paralysis of a cranial nerve Lumps, protrusions, or sunken areas in the skull can indicate head trauma Ecchymotic areas on the skull or face can indicate recent trauma Lesions or redness on the face or scalp can indicate a skin disorder or infection Hair loss can indicate an autoimmune inflammatory disorder ○ Alopecia, areata, Lupus, conditions of the thyroid, fungal infection, effects from medications, or stress Edema around the eyes (periorbital), cheeks, or overall facial edema can occur with trauma, infection, and heart issues A tense facial expression could indicate anxiety or pain Coarse facial hair on a female can indicate a hormonal/endocrine disorder (hirsutism) Small, ovular, white particles on the hair can indicate lice (Pediculus humanus capitis) Intervention Needed: Facial Drooping ● Asymmetry of facial features, unequal movement, or total lack of movement could indicate damage to a cranial nerve or the CNS Gather Subjective Data ● ● ● ● ● When did the facial drooping begin? Are you having any difficulty with vision, such as blurred/double vision or blind spots? Are you having any difficulty swallowing food or liquids? Did your symptoms occur suddenly or gradually? Have your symptoms gotten better or worse? Assessment ● Instruct the client to smile and show their teeth; assess for unequal movement of the lips and an absence of the nasolabial fold (smile line) ● Instruct the client to puff their cheeks out; press them in and observe for equal air escape ● Instruct them to open and close their eyes; observe for complete, equal opening/closure ● Instruct them to raise their eyebrows; assess for equal wrinkles on the forehead Orientation and Comprehension ● Is the client alert? ● Can they answer questions appropriately? ● Can they follow simple instructions? Speech ● Is their speech clear? ● Is the client using the correct words? Limb Paralysis and Awareness ● ● ● ● Can the client lift and hold each arm/leg above the bed for at least 10 seconds? Can they feel touching on their arms and legs? Can they touch their finger to their nose and their heel to their shin? Do they use limbs on both sides of their body? Eye Assessment ● ● ● ● Stand in front of the client at eye level and observe the outside eye structures Instruct the client to look at your eyes Observe the placement and appearance of the eyes, eyebrows, eyelashes, and eyelids Note the client’s ability to move their eyebrows and close their eyelids Conjunctiva and Scleral Assessment 1. 2. 3. 4. 5. Apply examination gloves Instruct the client to look upward Place your thumbs below each of the client’s lower eyelids Gently pull the skin down to the top edge of the bony orbital rim Inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, lesions, or drainage Pupillary Reaction 1. Darken the room 2. Instruct the client to look at a distant object and not directly at the light 3. Inspect the pupils for size and equality; both should dilate when the room is dark and when the client looks at a far object 4. Position your penlight on one side of the client’s head in line with their eyes 5. Turn your penlight to the on position 6. Advance the light in from the side of the eye until it shines directly on the pupil 7. Observe the response of both pupils to the light shined in one eye; both should quickly and equally constrict 8. Repeat the procedures with their client’s other eye 9. Instruct the client to shift their gaze to your finger, held 3 inches (7-8 cm) from the nose 10. Observe the response of both pupils and the shift in gaze; the pupils should constrict equally, and both eyes should turn inward Expected Findings ● The eyes should be parallel to one another and aligned in the socket ● Eyebrows should be symmetrical and extend over the width of the eye ○ They should move symmetrically with changes in expression ● The skin beneath the brows should be free of flakiness or lesions ● Eyelashes should have an even distribution and a curved outward shape ● Eyelids should be smooth and the same color as surrounding skin without edema ○ The margins should be pink and rest along the eyeball surface ○ When open, they should cover no more than the top portion of the iris ○ The upper eyelid should contact the lower one when the eyes are closed ● The sclera should be moist, glossy, and clear ○ With Sjogren syndrome, the eyes may be dry from impaired secretion ○ In clients with lighter skin tones, it is white ○ In clients with darker skin tones, it may appear slightly yellow ○ Slight vascularization is expected ● The conjunctiva should be pink and clear without lesions or edema ○ Numerous small blood vessels will be visible ● The client’s pupils should be black, round, regular, and equal in size with the iris visible ● Pupils should dilate and constrict equally/simultaneously Unexpected Findings ● Bulging eyes (exophthalmos) and crossed eyes (strabismus) ● Eyebrows not reaching past the eye (temporal canthus) can signal an endocrine disorder ● If the client is unable to move their brows, they may have facial nerve damage ● Scaling or flaking of the skin in the eyebrows can indicate a skin disorder ● Redness of the eyelids can indicate the presence of an infection or inflammation ● Edema of the eyelids can be associated with trauma, or kidney or cardiac disease ● A drooping of the eyelid can be caused by edema or damage to one of the cranial nerves ● An inability to completely close the eyelids is ● ● ● ● ● ● ● associated with lid edema, nerve paralysis, excessively protruding eyeballs, and unconsciousness ○ this condition can lead to drying and damage to the cornea An overall coloring of the sclera that is yellow or green can indicate liver disease A subconjunctival hemorrhage has clearly marked edges and is caused by activities that increase the pressure within the eye, like coughing and vomiting Conjunctivitis is an inflammation of the conjunctiva causing redness and drainage, usually the result of a bacterial or viral infection, allergy, or chemical injury to the eye Unequal-sized pupils, both at rest and in reaction to the light test, can be a sign of a central nervous system injury, as can pupils that are dilated and do not react to light Cloudy pupils indicate the presence of cataracts or a loss of transparency of the lens ○ Impairs the client’s vision Dilated pupils at rest (> 7 mm) can signify an eye disease or neurological disorder Pupils that are pinpointed at rest (< 3 mm) commonly indicate opioid intoxication Internal Structures Examination ● ● ● ● ● ● Darken the room Turn on the ophthalmoscope, and use the lens selector disc to find the large white disc The diopter is set at 0; You can change the setting to bring structures into focus Use your right eye to examine the client’s right eye and vice versa Instruct the client to stare at a point somewhere behind you Start slightly lateral and 25 to 30 cm from the client, finding and following the red reflex, to within a distance of 2 to 3 cm of the client’s eye Expected Findings ● The optic disc is light pink or more yellow than the surrounding retina ● The retina is without lesions ○ Dark pink in those with darker skin and light pink in those who have fair skin ● The arteries and veins have a 2:3 ratio with no nicking ● Without pupil dilation, you might only glimpse the macula briefly when the client looks directly at the light Intervention Needed: Vision Problems A sudden onset of vision difficulties in a single eye can signify a medical emergency. Gather Subjective Data ● Can you describe the vision difficulties you are experiencing? Is the vision blurred? Have you noticed blind spots? Do you experience double vision? Is it in one eye or both eyes? ● When did the symptoms begin? ● Did the vision change occur suddenly or come on slowly? ● Have you noticed the presence of a headache when the changes to your vision occur? ● Do you have any pain in your eyes? ● Have you had any recent injuries or trauma to your eyes? ● Do you have a history of having allergies? ● Do you wear corrective lenses? Assessment ● Redness, lesions, abrasions, edema, or the presence of a foreign body in the sclera and conjunctiva ○ Increased tearing with redness and lid edema typically indicates seasonal allergies ○ Redness of the sclera, throbbing pain, and unexpected pupil findings signify a serious eye condition; notify the provider immediately ○ Redness of the sclera, increased tearing, and pain are characteristic of an abrasion on the cornea ● The presence of drainage from the eye ○ Purulent drainage from the eye, along with redness and mild discomfort, typically indicates a bacterial or viral infection ● Any unexpected findings in the size and shape of the pupils ● The pupillary response to light Additional Nursing Actions ● Maintain adequate lighting, keep the call bell within reach, and ensure that the paths to a chair and bathroom are clear ● Ensure corrective lenses are clean and accessible ● Provide large print reading material ● If there is trauma to the eye, apply an eye patch until it is evaluated ○ This should not be done if there is a foreign body penetrating the eye Ear Assessment ● Position the client so their ears are at eye level ● Assess for size and shape, comparing each side for symmetry ● Note the color and condition of the skin; observe for lesions, lumps, or trauma ● Inspect the outer canal for alterations in color, edema, cerumen, or drainage ● Note the client’s ability to participate appropriately in a conversation Expected Findings ● The auricle should be symmetric in size and placement ● The color of the ear should be the same as the face; the skin should be intact ● Some cerumen is usually visible at the opening to the outer ear canal ○ Can be gray-yellow to tan to black ○ Can be moist and waxy to dry and flaky Expected Variations ● Unusually small, large, or atypically shaped ears are often a family trait Unexpected Findings ● ● ● ● ● Clients with skin conditions, such as eczema, can have crusts/scaling Redness of the ear is a sign of inflammation or fever Redness, edema, and purulent/crusty drainage can indicate infection Bright-red blood or watery drainage following trauma can indicate a fracture Clients who frequently ask you to repeat questions or provide an inappropriate response can have a diminished sense of hearing Intervention Needed: Ear Drainage or Pain Subjective Data Hearing Deficit ● ● ● ● Misunderstanding or asking you to repeat questions Lean or turn their head toward you so that their “good” ear is facing you Closely watching your lips instead of your eyes Speaking in an unexpectedly loud or flat, monotone voice Ear Drainage or Pain ● Have you noticed a ringing/buzzing sound? Is it constant, or does it come and go? ● Do you feel as if the room is feeling? Do you feel lightheaded or dizzy? ● Are you having pain in your ear? ○ Can you point to where? How would you rate it from 1-10? Is there anything that makes the pain better or worse? ● Have you noticed any changes in your ability to hear? ● Have you had any recent injuries to your head or ears? ● When did the symptoms begin? Assessment Inspection ● Inspect the outer ear for redness, edema, alterations in skin integrity, or trauma ● Inspect the outer ear canal for redness, edema, or drainage ○ Yellow, green, or crusted discharge can indicate an infection or foreign body ○ Watery clear or blood-tinged drainage can indicate an existing skull fracture Palpations ● Palpate the external ear and the mastoid area behind the ear for edema, warmth, and increased pain with palpation, which can indicate an infection ● Gently manipulate the pinna and push on the tragus to determine discomfort Nose and Sinus Assessment ● Assess the size, shape, and color of the external nose ● Assess the nasal mucosa for color and integrity at the opening of the nares Sinus Palpation 1. To assess the frontal sinus cavity, position your thumbs on the supraorbital ridge, just below the eyebrows; place your fingers on the side of the client’s head 2. Firmly press upward on the ridge, and make sure you don’t apply pressure on the eyes 3. Ask the client if that action causes pain or tenderness 4. To assess the maxillary sinus, position your thumbs just below the cheekbones, with your fingers along the side of the client’s head 5. Apply firm, upward pressure 6. Ask the client if that action causes pain or tenderness Expected Findings ● The client’s nose should be symmetrical and midline to other facial features ● The skin on the nose should match the color of their face ○ Should be free from lesions or lumps ● The nares mucosa should be a smooth, moist surface with a deeper color than the oral ○ Mucosa should be free from any swelling, discharge, bleeding, or foreign bodies Unexpected Findings ● Pale mucosa with a clear discharge is a manifestation of allergies ● Mucoid discharge with a bright red nasal mucosa may signify an upper respiratory infection ● Yellow/green discharge often indicates a sinus infection ○ If it is only from one naris, it may indicate the presence of a foreign body ● A unilateral water discharge following a recent head injury can indicate a skull fracture Cranial Nerves (Nose) ● Assess smell through the CN I by asking the client to close their eyes ● Occlude one naris at a time and have them identify a familiar smell Intervention Needed: Sinus Congestion or Pain The sinuses can become inflamed and swollen from both seasonal allergies and infection. Gather Subjective Data ● Do you have any nasal discharge or a runny nose? What color is the drainage? Does it have an odor? How long have you been experiencing the drainage? ● Do you have any sinus pain or feelings of pressure in your face? Can you point to where? ● Do you have problems breathing through your nose? Do you have allergies or hay fever? Assessment Inspection ● Inspect the color of the nasal mucosa with a penlight ● It will appear pale, swollen, and grayish-blue if the client has allergies ● It will appear reddened and swollen with the common cold Nasal Drainage ● ● ● ● Clear discharge is associated with allergies Mucoid discharge is present with the common cold Yellow/green purulent discharge usually results from a bacterial infection Foul-smelling discharge, usually on one side, is found with a foreign body or a chronic sinus infection Palpation ● Assess for an obstruction of the nares by pressing on each singularly and having the client inhale with their mouth closed ○ The inability to draw in air indicates an obstruction ○ May be due to the common cold or a physical obstruction ● If a client is experiencing allergies or a sinus infection, the interior of their sinuses will be inflamed and swollen ● Assess for pain and tenderness by externally palpating the frontal and maxillary areas Additional Nursing Actions ● Encourage sinus drainage by humidifying the air at home and applying warm compresses over the sinus area with the head of the bed elevated ● Have them avoid allergic sinusitis triggers, like animals, pollen, or second-hand smoke ● Instruct the client to wash their hands frequently ● Tell them to cough/sneeze into a tissue, their elbow, or their sleeve to prevent spreading ● Unless contraindicated, encourage the client to increase intake of fluids to 2L/day ○ Helps thin mucus secretions Mouth Assessment ● Inspect the lips for color, texture, and moisture ● Instruct the client to lightly clench their teeth and smile; inspect the teeth and gingiva ● Ask the client to open their mouth wide and inspect the color and condition of the oral mucosa, tongue, gums, palate, and uvula with a penlight ● Have them lift their tongue up and curl it back; assess the bottom surface of the tongue and the floor of the mouth ● Inspect the tonsils in the posterior pharynx for color, size, texture, and exudate ● Note broken, missing, or loose teeth and the presence of lesions or ulcers Expected Findings ● The lips should be moist, symmetrical, and smooth ● ● ● ● ● ● ● ● ○ Can range from pink to plum-colored; a deeper color than the surrounding skin Teeth should be smooth and shiny with varying whiteness Mucosa should seem glistening, smooth, and moist ○ Clients with darker skin tones can have more darkly pigmented mucosa with areas of hyperpigmentation; clients with lighter skin tones will have pink mucosa The gums should fit tightly around each tooth and appear smooth and moist ○ Clients with darker skin tones can have patchy pigmentation and dark pink to brown gums; clients with lighter skin tones will have pink gums The tongue should appear moist, slightly rough on top, medium-red, and smooth laterally ○ The ventral surface should be smooth and pink with veins between the frenulum The hard palate should be dome-shaped and whitish in color The soft palate should be smooth and light pink The tonsils should present as pink, smooth tissue Expect small blood vessels and small, irregular lymphatic tissue spots Unexpected Findings ● A smooth or dark red swollen tongue can indicate low vitamin B12 levels ● Swelling of the gums with redness and bleeding can indicate gingivitis ○ Can lead to tooth loss if not treated ● A yellow discoloration of the hard palate can indicate a liver disorder ● The presence of petechiae, lesions, edema, or drainage on the hard or soft palate can indicate infection ● A sore mouth with soft white plaques on the tongue/mucosa indicates thrush ○ Plaques leave a red open area when rubbed off; often found in immunocompromised clients ● A client who has a sore throat can have a red, edematous uvula, tonsillar pillars, and sometimes yellow exudate ● A painful round ulcer on the mucosa or lip with a white base surrounded by a red halo is known as a canker sore/aphthous ulcer Tongue ● ● ● ● Use a gauze pad to hold the tip of the gonue and move it from side to side Assess taste (CN VII, CN IX) by having the client close their eyes and identify foods Ask the client to move their tongue up, down, and side to side Test strength (CN XII) by applying resistance against each cheek while the client sticks their tongue into each cheek Tonsils ● The same color as surrounding mucosa and vary in size and visibility ● ● ● ● +1: Barely visible +2: Halfway to the uvula +3: Touching the uvula +4: Touching each either or midline Gag Reflex ● Elicit by using a tongue blade to stimulate the back of the throat (CN IX, CN X) ● Explain the procedure before performing the assessment Ears, Nose, Mouth, & Throat Nerves ● ● ● ● CN I (olfactory): Assess the nose for smell CN VII (facial) and CN IX (glossopharyngeal): Assess the mouth for taste CN VIII (auditory): Assess the ears for hearing CN IX (glossopharyngeal) and CN X (vagus): Assess the mouth for movement of the soft palate and the gag reflex; Assess swallowing and speech quality ● CN XII (hypoglossal): Assess the tongue for movement and strength Whisper Test (CN VIII) Technique ● Occlude one ear and test the other to see if the client can hear whispered sounds without seeing the mouth move; repeat with the other ear Expected Finding ● The client can hear you whisper softly from 30-60 cm (1-2 ft) away Rinne Test Technique ● Place a vibrating tuning fork against the mastoid bone ● Have the client state when they no longer hear the sound ● Note the length of time that they heard the sound (bone conduction) ● Then, move the tuning fork in front of the ear canal ● When the client can no longer hear it, note the length of time (air conduction) Expected Finding ● Air conduction sound is longer than bone conduction sound; a 2:1 ratio Weber Test Technique ● Place a vibrating tuning fork on top of the client’s head ● Ask whether they can hear the sound best in the right ear, left ear, or both equally Expected Finding ● The client hears equally in both (negative Weber test) Neck Assessment ● ● ● ● Inspect the position of the trachea Assess the smoothness and contour of the neck for unexpected nodules and swelling Inspect the overall color and condition of the skin Observe for stiffness with neck movement and ability to swallow Expected Findings ● ● ● ● ● The neck should be centered below the head The trapezius and sternocleidomastoid should be bilaterally symmetrical The trachea must be midline above the suprasternal notch There should be no visible/palpable lumps or swelling The neck should have the same pigmentation as other skin and be free of contusions/lesions ● The client should be able to move the neck in all directions without pain or difficulty ● The client should swallow without difficulty or choking Unexpected Findings ● Limited ability to move the neck or pain with movement can indicate a systemic infection in the spine or a musculoskeletal disorder ● A trachea away from the midline is associated with a mass in the neck or chest disorders ● Swelling on the anterior portion of the neck can indicate a thyroid disorder ● Visible lymph nodes can indicate an infection or malignancy ● Difficulty swallowing can indicate an inflammation or CNS disorder Intervention Needed: Lump on Anterior Neck Gather Subjective Data ● ● ● ● How long has the lump been present? Is it causing you any discomfort or pain? Have you noticed any difficulty swallowing or changes to your voice? Are you experiencing any difficulty breathing? Assessment Inspect ● Observe for signs of respiratory distress ● Inspect the position of the trachea Auscultate ● Auscultate over the trachea for sounds of stridor, indicating an airway obstruction Additional Nursing Actions ● Manifestations of respiratory, distress, stridor, or difficulty swallowing can indicate an emergency requiring immediate notification and NPO Health Promotion ● ● ● ● ● ● Encourage routine oral care and vision/hearing screenings Reinforce the importance of protecting vision, such as by wearing goggles Instruct the use of earplugs if the client is exposed to continuous/expected loud noises Remind the limiting of volume when using headphones Encourage the use of helmets when doing sports Remind the client to always wear a seatbelt Health Screenings Vision ● Adults under 40 without visual disorders should have a screening every 5-10 years ● For clients over 40, a baseline eye exam should be done to screen for diseases ● Clients with diabetes mellitus, hypertension, or a family history of eye disease should get one before 40 Hearing ● Changes are typically in adults above 50 ● Screenings are recommended for those with changes in hearing Dental ● Clients should be encouraged to drink fluoridated water, brush with fluoride toothpaste, brush their teeth twice a day, and floss their teeth daily ● All adults should have regular dental examinations at least annually for oral disorders ● Some chronic diseases could require more frequent visits Expected Changes With Aging Eyes ● ● ● ● ● ● ● ● ● ● ● ● Decreased visual acuity Decreased peripheral vision Diminishing ability to see close objects Diminishing ability to read small print (presbyopia) Decreased ability to accommodate extreme changes in light (glare, darkness) Difficulty distinguishing colors Intolerance to glare Delayed pupillary reaction to light Yellowing of the lens Thin gray-white ring surrounding the cornea (arcus senilis) Loss of the lateral third of eyebrows Decrease in lens opacity (cataracts) Ears ● Hearing loss ● Loss of acuity for high-frequency tones (presbycusis) ● Loss of acuity at all frequencies (strial) ● Loss acuity at all ○ Worse at high frequencies (cochlea conductive loss) ● Cerumen accumulation in the ear canal ● Thickening of the tympanic membrane Mouth ● ● ● ● ● ● Decreased sense of taste due to reduced number of taste buds Tooth loss Pale gums Gum disease due to inadequate oral hygiene Darkening of teeth Decreased salivation Voice ● Rise in pitch ● Loss of power and range Nose ● Decreased sense of smell