NURS 3308: WEEK 5 OUTLINE ATI HEALTH ASSESSMENT 2.0: HEAD, NECK, AND NEUROLOGICAL Study Guide (2025/2026) University of Texas, Tyler*

NURS 3308: WEEK 5 OUTLINE ATI HEALTH ASSESSMENT 2.0: HEAD, NECK, AND NEUROLOGICAL Study Guide (2025/2026) University of Texas, Tyler* Overview: Assessment details: The head, neck, and neurological assessment encompasses the skull, eyes, ears, nose, mouth, and throat, and assesses the senses of sight, hearing, smell, and taste. Begin with a health history interview to collect subjective data, then use inspection and palpation for objective data. Ensure the client is comfortable, preferably sitting with their head at your eye level, and use adequate lighting. Follow standard precautions by handwashing and wearing gloves (assessing eyes and mouth and nose and ears if there is any type of drainage present) when required. Have the client remove glasses, hearing aids, and dentures before assessing those areas. Complete an overall survey of the head, face, and neck, then perform a focused assessment from the skull downward. When identifying unexpected findings, complete a detailed inspection of that area for additional information. A&P Review (Should just be a brief review): Head: composed of skull (made up of the frontal, parietal, occipital & temporal). Face: include eyebrows, eyes, ears, nose & mouth should be symmetrical. Eyes: sensory organs of vision. Ears: composed of tympanic membrane & middle ear. Nose & sinuses: nose is the sensory organ for smell. Mouth and throat: mouth is moistened by three pairs of salivary glands: the parotid, submandibular, and sublingual gland. Saliva is the clear fluid excreted from these glands that moistens and lubricates the food bolus, starts digestion, and cleans and protects the mucosa. Saliva is then swallowed down the throat, or pharynx—the area behind the mouth and nose. The oropharynx is separated from the mouth by a mass of lymphoid tissue called the tonsils. These masses of lymph tissue in the posterior pharynx help protect against infection. Neck: arteries, lymph nodes (located in head and neck and they detect/destroy foreign substances), thyroid, parathyroid glands form neck’s soft tissue. Internal jugular veins️sternocleidomastoid muscle (carotid arteries in sternocleido…). Health History Interview • System-specific questions: Head and neck 1.: Do you have a history of headaches or a family history of migraine headaches? 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 associated with neck motion? Eyes: 2. Do you have any problems seeing close up or at a distance? Eye pain, blurred vision, or seen halos or colors around objects/lights? Do you have excessive watering or discharge from eyes? Wear glasses/contacts? Had any type of surgery? Ears 3.: do you have any problems hearing, if so, do you notice if you can hear low or high frequency sounds better? Have 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 (describe onset, character, if pain is consistent or intermittent, how long pain lasts, what relieves pain)? Do you have excess ear wax (cerumen)? Do you clean your ears (how)? Ever had a hearing exam (wear hearing aids)? Nose and sinuses 4.: have frequent nasal congestion/discharge️ (odor, color, is it chronic), or runny nose? Frequency of colds and are they usually limited to the upper respiratory system? Any notable sinus pain w/ or w/o having common cold (meds you take for this pain)? Have any seasonal allergies that could contribute to nasal drainage and stuffiness? Had any type of nose trauma, surgery, unusual nose bleeds, or change in the ability to smell? Mouth and throat 5.: Do you ever have problems w/ mouth, tongue, or gum sores or lesions? If so, how often, how long do they last, and do you take medication? Are the lesions/sores associated with stress, seasonal changes, or food? What are your dental hygiene habits? Do you brush, floss, and have dental exams? Any tooth pain, sensitivity to heat/cold, loose or lost teeth, gum bleeding, dentures, or bridge? Do you frequently have a sore throat? How often, and is it related to postnasal drip or hoarseness? Do you still have your tonsils and adenoids? Do you smoke, vape, or chew tobacco? What type and for how long? Do you drink alcohol? How often and how many drinks? Do you have difficulty swallowing or changes in taste? • Case study: Middle adult who has headaches • Intervention needed: Orientation deficit Gather subjective data 1. (what questions would we ask?) - orientation (person, place time), disorientation (chronic- neurological disorders or acute- infections, dehydration, low O2 levels, meds, other imbalances). Change in orientation (manifestation of a medical emergency- ex. Stroke) - orientation questions (subjective): self: what is your name/when is ur birthday? Time: year it is or who’s the president? Place: where are u or why are u here? 2. Assessment  Inspect: Observe the client’s face for signs of a central nervous deficit.  Face symmetry: Check for symmetry of facial features, noting any drooping, decreased labial folds, or a mask-like appearance. Watch for difficulty swallowing, such as coughing or excessive salivation.  Pupillary reaction: assess of possible signs of CNS alteration. Ensure they’re of normal resting size (3-5mm) & that they’re the same size bilaterally. Use penlight to assess pupillary response to light. Ensure that the response is both brisk & bilateral.  Palpate/Assess Strength: Check for one-sided muscle weakness by asking the client to squeeze both of your hands simultaneously. This also evaluates the client’s ability to follow simple instructions. Unilateral weakness or difficulty following instructions may indicate a stroke.  Measure Vital Signs: alterations in vital signs such as ⬆️ temp or ⬇️ O2 saturation can lead to changes in client’s orientation. Additional nursing actions • 1. Documentation and notification: Document and notify the provider of your findings immediately if the orientation deficit is a new finding. A suspected stroke is a medical emergency that requires intervention in a timely fashion to minimize long-lasting effects. Fall precautions 2.: client with an orientation deficit is at increased risk of injury and