Neurological and HEENT Health Assessment

• Neurological and HEENT (Head, Eyes, Ears, Nose, and Throat) health assessment involves physical examination and the use of specific tools.

Head Assessment

• Involves inspection and palpation to assess position, size, shape, and contour.
• Examine the size, shape, and contour of the skull.
• Palpate the temporomandibular joint (TMJ) bilaterally.
• Normal documentation includes: Head round, size appropriate for body, eyes symmetrical, nose and mouth midline and symmetrical, no lip drooping.

Eye Assessment

• Inspect appearance and placement of eyes, lashes, brows, and lids.
• Assess pupils for size, shape, and symmetry - PERRLA (pupils equal, round, reactive to light, and accommodation).
• Assess convergence by removing glasses.
• Use an ophthalmoscope to check for red-light reflex internally.

Ear Assessment

• Inspection of ear canals and ear drums.
• Check canal color, discharge (color, odor, amount), scaling, lesions, foreign bodies, and cerumen presence.
• Assess hearing acuity using whisper tests and tuning forks.

Neck Assessment

• Inspect for symmetry, masses, and swallowing difficulties.
• Palpate for swollen and tender areas.
• Lymph nodes, which are usually non-palpable, collect lymph from the head, ears, nose, cheeks, and lips.

Nervous System Assessment

• Includes assessment of mental status, cranial nerves, motor system, sensory system, and reflexes (DTR’s).

Mental Status: Levels of Consciousness

• Alert: Responds appropriately verbally with spontaneous eye-opening.
• Lethargic: Able to open eyes and respond but is drowsy and falls asleep easily.
• Obtunded: Responds to light shaking but can be confused and slow to respond.
• Stuporous: Responds to painful stimuli, may not respond verbally.
• Comatose: No response to repeated painful stimuli with abnormal posturing - Decorticate and decerebrate.

Mental Status: Appearance/Mood

• Also assess cognitive/intellectual functions: memory, knowledge, abstract thinking, insight, and judgment.
• Thought process - note rapid change in topic; use of nonsense words.
• Thought content - note presence of delusions, hallucinations.

Assessment of Speech and Language

• Evaluate quality, quantity, and volume.
• Screening tools include the Mini-Mental State Exam (MMSE) and Glasgow Coma Scale (highest value - 15).
• Includes level of consciousness, verbal and motor responses.

Motor Function Assessment

• Assess coordination – finger to nose (eyes open or closed) or heel down opposite shin.
• Assess gait by observing without the client knowing.
• Balance: Romberg test (feet together, arms at sides, eyes closed) – minimum swaying for at least 5 seconds; heel-toe walk.
• Muscle strength (push/pull).

Sensory System Assessment

• Sensory function – sharp/dull, light touch with cotton ball, pain, temperature, and vibration (tuning fork).
• Position sense (is arm raised or lowered).
• Discrimination: Stereognosis (identifies object in hand, eyes closed); graphesthesia (identifies a number drawn in hand, eyes closed).

Head: Expected Findings

• Includes symmetry/slight asymmetry
• Aging: Thinning, dry hair

Head: Unexpected Findings

• Significant asymmetry
• Paralysis of cranial nerve
• Stroke (FAST)
• Lumps, protrusions, sunken areas
• Ecchymosis
• Hair loss or excessive growth (hirsutism)
• Edema
• Infestation

Eyes: Expected Findings

• External structure position
• Eyebrows symmetrical
• Lashes symmetrical, full
• Sclera white
• Conjunctiva pink
• Pupils equal and round
• Equal pupil accommodation
• Changes in vision need to be investigated, expected with aging

Eyes: Unexpected Findings

• Protrusions, sunken appearance
• Exophthalmos
• Strabismus
• Inability to move brows (CN pathology)
• Lid redness, edema, and/or drooping (CN pathology)
• Yellowing of sclera
• Conjunctival redness, drainage
• Hemorrhage (bleeding)

Pupils: Abnormalities

• Cloudy (cataracts)
• Unequal (CNS pathology)
• Dilated (CNS pathology)
• Constricted (opioid toxicity)
• Sudden onset of alterations in vision

Eye Documentation: Expected Findings

• PERRLA/PERRL (if accommodation was not assessed)
• Sclera white
• Conjunctiva clear

Eye Documentation: Unexpected Findings

• Exophthalmos (bulging of the eyes)
• Strabismus (improperly aligned eyes)
• Eyelid drooping
• Sclera yellow
• Conjunctival redness, drainage, or discharge
• Pupils - cloudy, unequal, dilated, constricted
• Recent or sudden ear changes

Ears: Expected Findings

• External ear: Includes position/symmetrical in size, shape, and color
• Integrity?
• Variations in overall size and shape is genetic.

Ears: Unexpected Findings

• Warmth, redness, scaling, masses, edema
• External canal drainage, bleeding
• Signs of hearing loss

Ear Documentation: Expected Findings

• External ear: Symmetrical.
• Internal ear: Pink, expected amount of cerumen, no bleeding or draining, intact tympanic membrane, pearl gray color, no lesions or masses.
• Answers questions appropriately, no complaints of hearing loss, no assistive devices needed.

Ear Documentation: Unexpected Findings

• External ear: Asymmetrical or notable trauma or deformity.
• Internal ear: Canal red, excessive cerumen, bleeding or drainage (serous/purulent?), any foreign objects, tympanic membrane missing, torn.
• Hearing aids, hard of hearing, complete or partial hearing loss, lip reading.

Nose and Sinuses: Expected Findings

• Inspection: Midline Position, patency, color, no drainage or foreign bodies.
• Palpation: No tenderness, masses.

Nose and Sinuses: Unexpected Findings

• Inspection: Deviation from symmetry, large amounts of drainage (note color, consistency, blood), internal inflammation, lesions, mass, foreign bodies.
• Palpation: Tenderness, palpated masses.

Mouth/Pharynx: Expected Findings

• Lips, teeth, mucosa, gums, tongue, hard/soft palate, tonsils normal.

Mouth/Pharynx: Unexpected Findings

• Color changes, tongue texture changes, thrush, swelling, missing teeth, exudate, lesions (look under tongue).

Documentation – Nose, Sinuses, Neck, Pharynx/Mouth: Expected Findings

• Nose: Midline, no drainage, mucosa pink, nares patent, no foreign bodies present, no tenderness or masses.
• Neck: Trachea midline, no swelling or tenderness on palpation, lymph nodes non-palpable.
• Mouth/pharynx: Lips/mucosa appear hydrated and color consistent with ethnicity, teeth are present and well cared for, no dental caries or abnormalities noted, gums are pink and healthy, tongue pink, tonsils present - no swelling redness, or exudate noted; hard/soft palate unremarkable.
• Unexpected findings: Nose deviation (external), septal deviation (internal), excessive mucus (color/consistency), nares not patent, mucosa red/friable, turbinates swollen, foreign body present; sinuses sore on palpation, masses palpated.
• Neck: Tracheal deviation, swelling, masses, pain on palpation, lymph node swelling (document location).
• Mouth/pharynx: Excessive dryness or secretions, tongue texture changes, lesions, thrush, tonsil swelling or exudate/redness, missing teeth or obvious dental caries (cavities); hard or soft palate malformations (cleft lip or palate).

Age-Related Considerations

• Eyes: Decreased visual acuity, peripheral vision, intolerance glare, yellowing/cloudy lens.
• Ears: Hearing loss, cerumen accumulation, thickening of tympanic membrane.
• Mouth: Decrease in taste and saliva production, tooth loss, pale gums.
• Nose: Decrease in smell.
• Voice: Loss of power and range.
• Neurologic: Short term memory loss; slowed reflexes; reaction time; slower fine finger movement; difficulty with complex learning; smaller brain volume; decrease neurotransmitters; impaired balance; decrease touch sensation.

Health Promotion Strategies

• Prevention involves educating clients about unhealthy behaviors that contribute to head and neck injuries and diseases.
• Routine oral care, and vision and hearing screenings are important for all clients.
• Reinforce the importance of protecting their vision.
• Instruct clients to wear ear plugs if they are exposed to continuous or expected intermittent loud noises.

Health Screenings

• Encourage clients to have regular screenings for early detection of alterations in their visual, auditory, and oral health.
• Vision: Under the age of 40 and no visual disturbances: vision screening every 5 to 10 years to detect for deficits in near or far vision
• Over the age of 40: a baseline eye exam should be completed by an ophthalmologist to screen for diseases of the eye, even if the client is not experiencing any vision disturbances
• Diabetes mellitus, hypertension, or a family history of eye disease: should get a baseline eye exam prior to age 40
• Hearing: The United States Preventative Services Task Force (USPSTF) recommends screenings for individuals who report changes in hearing
• Routine screening of adults who are asymptomatic is not currently recommended due to insufficient evidence of benefit versus harm
• Dental: Clients should be encouraged to drink fluoridated water and brush with fluoride toothpaste, brush teeth twice a day, and floss teeth daily
• CDC recommends that all adults have regular dental examinations at least once per year to screen for oral disorders, including oral cancer

Cranial Nerve Assessment

• Olfactory: Smell, sensory.
• Optic: See, sensory.
• Oculomotor: Adjust pupils, motor.
• Trochlear: Move eyeballs, motor.
• Trigeminal: Chewing, both.
• Abducens: Move eyeballs, motor.
• Facial: Form facial expressions/produce tears/sensory of the tongue, both.
• Vestibulocochlear: Hear/maintain balance, sensory.
• Glossopharyngeal: Produce saliva/swallow/taste, both.
• Vagus: Control the peripheral nervous system (PNS), both.
• Accessory: Move neck and shoulder, motor.
• Hypoglossal: Formulate speech/move tongue movement/swallow, motor.

Assessment areas for Reflexes

• Biceps, triceps, brachioradialis, patellar, Achilles, plantar-Babinski.
• Normal plantar response is toes down (flexion).
• Babinski sign is fanning of toes.

Reflex Response Scale

• 0 = Absent reflex.
• 1+ = Diminished, low normal.
• 2+ = Normal response.
• 3+ = Brisker than average, may indicate disease but can be normal.
• 4+ = Very brisk, hyperactive with clonus, indicative of disease.