Head and Neck Assessment Nursing | Head to Toe Assessment of Head Neck ENT Lymphatic Cranial Nerves

Summary

In this instructional video, registered nurse Ari demonstrates how to perform a comprehensive head and neck assessment. She emphasizes the importance of patient privacy, proper hygiene, and thorough preparation with necessary tools like an otoscope, tongue blade, and pin light. The assessment includes inspecting the head for symmetry, testing cranial nerves, palpating the skull and lymph nodes, and examining the eyes, ears, nose, and mouth for abnormalities. Ari also highlights specific checks for signs of conditions such as Bell's palsy and sinus issues, ensuring a detailed understanding of each step in the assessment process.

Takeaways

• 😀 Always provide privacy, wash hands, and explain the procedure to the patient before starting a head and neck assessment.
• 🩺 Gather necessary supplies including an otoscope, tongue blade, penlight, and gloves for the assessment.
• 👁️ Inspect the head for skin color, size, involuntary movements, and symmetry of the face to identify any abnormalities.
• ✋ Palpate the head for any masses, indentations, or skin breakdown, especially in patients who are immobile.
• 🔍 Test cranial nerves 5 and 7 by checking facial muscle movement and clenching of the teeth.
• 👂 Examine the eyes for proper alignment, pupil size (normal 3-5 mm), and perform tests for cranial nerves 2, 3, 4, and 6.
• 🔦 Assess ear health by inspecting for abnormalities and testing cranial nerve 8 with a whispered voice test.
• 👃 Inspect the nose for midline alignment, septum deviations, and patency, while testing the olfactory nerve (cranial nerve 1) for smell.
• 🗣️ Examine the mouth for color, lesions, and any signs of oral health issues, testing cranial nerves 9 and 10 during the process.
• 💉 Assess the neck for alignment, inspect lymph nodes, palpate the carotid artery, and auscultate for bruits to ensure cardiovascular health.

Q & A

What is the primary purpose of the head and neck assessment demonstrated in the video?

The primary purpose of the head and neck assessment is to evaluate the overall health and functionality of the cranial structures, ensuring that there are no abnormalities or issues that need to be addressed.

What initial steps does the nurse take before beginning the assessment?

Before beginning the assessment, the nurse ensures patient privacy, performs hand hygiene, and establishes a comfortable environment for effective communication.

How does the nurse assess symmetry in the head?

The nurse inspects the head for symmetry by observing the alignment of facial features and looking for any signs of involuntary movements or abnormalities.

What specific cranial nerves are tested during the assessment?

The assessment includes testing cranial nerves 5 (trigeminal), 7 (facial), 1 (olfactory), 8 (vestibulocochlear), and 12 (hypoglossal).

What techniques are used to assess the eyes during the examination?

The nurse assesses the eyes by checking pupil size and reaction to light, as well as observing for any abnormalities in eye movement or alignment.

What does the nurse look for during the ear examination?

During the ear examination, the nurse looks for the condition of the tympanic membrane and assesses hearing capabilities, checking for any signs of infection or blockage.

How is nasal patency assessed?

Nasal patency is assessed by asking the patient to close one nostril and breathe through the other, ensuring that airflow is unobstructed.

What are the signs of oral health the nurse evaluates?

The nurse evaluates oral health by checking the condition of the gums, teeth, and mucous membranes, looking for signs of decay, inflammation, or other issues.

Why is the assessment of cranial nerve functionality important?

Assessing cranial nerve functionality is important because it helps identify potential neurological issues that could affect motor and sensory functions related to the head and neck.

What overall health aspects are covered in the head and neck assessment?

The assessment covers aspects such as symmetry, skin condition, cranial nerve functionality, and the health of the eyes, ears, nose, and mouth, providing a comprehensive overview of head and neck health.