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

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  • เผยแพร่เมื่อ 2 มิ.ย. 2024
  • Head and neck assessment (nursing) that includes the hair, head, cranial nerves, eyes, ears, nose, throat/mouth, lymph nodes, carotid artery etc. This exam assessment is part of the nursing head to toe assessment completed by the nurse.
    During the head and neck assessment the nurse is assessing for any abnormal findings. This assessment will start out with inspection and progress to palpation and auscultation.
    First, the nurse will inspect the head, which includes the face and hair. Then will palpate the cranium and inspect the hair for infestation, loss of hair, and skin breakdown etc.
    Next, the nurse will palpate the temporal artery and test cranial nerve V (trigeminal) along with palpating the temporomandibular joint and frontal/maxillary sinuses.
    Second, the nurse will inspect the eyes, which includes the sclera, conjunctiva, pupils, and eye lids. After assessing these structures, the nurse will want to check for anisocoria, strabismus, and nystagmus. Then the nurse will assess cranial nerves III (oculomotor), IV (trochlear), VI (abducens) and this will confirm if the pupils are PERRLA (pupils equals round reactive to light accommodate).
    Thirdly, the nurse will inspect the ears and assess the tympanic membrane with an otoscope along with testing cranial nerve VIII (vestibulocochlear).
    After this the nurse will progress to the nose and inspect for abnormalities along with testing cranial nerve I (olfactory). Next, the nurse will assess the mouth, which will include looking inside the mouth for abnormalities and testing cranial nerve XII (hypoglossal), IX (glossopharyngeal), and X (vagus).
    Lastly, the nurse will assess the neck. This will include inspecting/palpating the trachea and thyroid gland, palpating the lymph nodes of the neck, palpating/auscultating the carotid, artery, and testing cranial nerve XI (accessory).
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