Nursing Health Assessment of The Neck and Head by NgoRN

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									Head & Neck Assessment
     Health Assessment
        NURS 304
         Structure & Function
• Head
  – Cranial bones
  – Sutures
  – Facial bones
  – Salivary gland
    • Parotid
    • Submandibular
    • Sublingual
  – Temporal artery
 Assessment of the Head & Face
• Examination of the Head
  – Inspect and palpate the cranium
    • hair, size, shape and symmetry, tenderness, scalp
  – Palpate and auscultate temporal arteries
    • thickening, tenderness, bruit
  – Inspect and palpate the face
    • symmetry, movements, tenderness, nodules,
         The Jaw & Oral Cavity
•   Oral mucosa
•   Salivary glands
•   Tongue and taste buds
•   Gingiva and teeth
•   Palate
•   Oropharynx
The Jaw & Oral Cavity
        Physical Examination of the
            Jaw & Oral Cavity
• General Approach:
  – Technique: Inspection and Palpation
  – Use gloves when palpating oral cavity
  – Interview the client to elicit further information
• Equipment:
  – tongue blades, gauze pads (4”x 4”), gloves, penlight
    or flashlight
• Examination and documentation focus:
  – Mucous membranes
  – Structural integrity
  – Functional ability
        Physical Examination of the
       Jaw & Oral Cavity: Procedure
• Inspect and palpate the       • Normal findings
  outer structure s of the         – Upper and lower teeth
  oral cavity                        should align when jaw is
   – Assess for malocclussion        clenched
   – Palpate                       – Full-range of voluntary
     temporomandibular joint         motion
   – inspect and palpate skin      – Parotid gland enlargement,
     over the parotid gland          unilateral or bilateral
   – Inspect and palpate lips      – Lips are symmetric
                                • Deviations
                                   – Missing teeth, deviate from
       Physical Examination of the
      Jaw & Oral Cavity: Procedure
• Examine the dorsal
  surface of the tongue
  – Ask the client to extend
    tongue and say “ah”
  – Note symmetry of the
    tongue and uvula when
    the tongue is protruded
  – Observe the motion of the
    soft palate when the client
    says “ah”

                                  Normal tongue
       Physical Examination of the
      Jaw & Oral Cavity: Procedure
• Deviations from normal (dorsal surface of the
  – Appearance of tongue mucosa is altered with
    malnutrition, inflammation, and inflammatory states
     • whitish cast is a form of protective mechanism
  – Loss of symmetry may indicate pathologic processes
    involving the nervous system
     • CN XII; CN X – innervates soft palate
         Physical Examination of the
        Jaw & Oral Cavity: Procedure
• Inspect the hard and soft
   – Ask the person to tilt the head
     back with mouth open, and
     examine the palate with a light
     or dental mirror
• Normal findings
   – Anterior surface of hard palate
     is corrugated
   – Palate symmetric
   – Structural abnormalities often
       Physical Examination of the
      Jaw & Oral Cavity: Procedure
• Examine the oropharynx,
  posterior tongue, and
  – Gently press tongue with
    tongue blade (if required)
  – Inspect the uvula
  – Elicit a gag reflex by
    touching he posterior wall
    of the pharynx with the
    tongue blade
        Physical Examination of the
       Jaw & Oral Cavity: Procedure
• Examine the lip and cheek (buccal) oral mucosa
   – Examine the underside of the lips and anterior
     surface of the gums
   – Examine the inner cheek by using a tongue blade or
     gloved finger

• Deviations from normal
   – Abnormal color changes
      • erythema, cyanosis
   – Stomatitis
   – Xerostomia
      • excessive dryness of oral mucosa
         Physical Examination of the
        Jaw & Oral Cavity: Procedure
• Examine the lateral and
  ventral tongue surfaces
   – Inspect the mucosa by
     displacing the tongue
   – Ask the person to touch the
     hard palate with tongue tip,
     and examine the ventral
   – Palpate oral mucosa of the
     mouth floor with glove
          Oral lesions and Conditions

•   Lip vesicle (Herpes simplex)
•   Lip ulcers
•   Squamous cell carcinoma
•   Mucocele
•   Cheilitis
•   Leukoplakia
•   Glossitis
•   Pseudomonas infection
•   Stomatitis
•   Candida albicans
•   Pharyngitis (strep and viral)
Glossitis   Pharyngitis

Thrush      Oral herpes

                       Oral Cancer

  Nursing Diagnoses Related to Oral
         Cavity Assessment
• Impaired oral mucous membrane
  – Poor hygiene
  – Nutritional impairment
  – Fluid imbalance
  – Mechanical trauma
  – Chemotherapeutic agents
• Impaired swallowing
The Trachea
                  The Trachea
• Normally it is midline

• Palpate for tracheal shift
   – Place your index finger in the sternal notch and slip it
     off to each side
      • The space should be symmetrical on each side
                 The Thyroid Gland

• Primary function:
   – Control the metabolic rate with T3 and T4
  Physical Examination: Thyroid Gland

• General approach/Technique:
   – Inspection, palpation, and auscultation
   – Ask client to swallow from a glass of water during
     exam, and use adequate lighting to enhance
• Examination and documentation focus
   – Size
   – Shape
   – Consistency
   – Tenderness
   – occurrence of vascular sounds (bruit)
         PE of the Thyroid Gland (TG)
• Inspect the area of         • Normal finding:
  the anterior neck             – TG usually too small to
  containing the TG               be observed
  – Ask client to tilt head   • Deviations from
    back slightly and           normal
    swallow, note the
                                – Goiter
    movement of the
    trachea and other
    Palpation of TG (Anterior Approach)

• Stand facing the client: neck should be relaxed
  but held in slight extension
• Use pads of your first and second fingers and
  locate thyroid isthmus below cricoid cartilage
• Ask person to swallow (note rubbery texture on
• Palpate thyroid lobes
• Notes for any bulging or masses
• Palpate left and right thyroid lobes
     Palpation of TG (Posterior Approach)
• Stand behind the client (seated with neck slightly flexed)
• Rest your thumbs the back of the client’s neck and lightly
  place your fingers below the cricoid cartilage
• Palpate the middle isthmus as the client swallows
• Ask client to turn the head slightly to the side and
  palpate lobes. Use your fingers on the opposite site to
  displace the gland in a lateral direction
• Ask the client to swallow as you examine the lobe,
  repeat the same procedure with the other lobe
   Palpation of TG (Posterior Approach)

                        Easier Steps

• TG consists of two lateral lobes.
• Left lobe is frequently larger than the right.
• Place fingers on one lobe and push thyroid cartilage
  to the opposite side.
• Have patient swallow.
Palpation of TG (Anterior and Posterior Approach)

• Normal findings:
  – Size and shape
  – Rubbery texture
• Deviations from normal
  – Goiter
  – Firm nodule: usually painless (malignant)
  – Pain on palpation may be associated with
    inflammation, which often radiates to ears
        Auscultation of TG (optional)

• Sites for auscultation:
  – Both lobes of TG
  – Use bell of the stethoscope

• Deviations from normal
  – Bruit, which occasionally accompanied by a
                Thyroid Assessment

• Nursing Diagnoses
  –   Decreased cardiac output
  –   Activity intolerance
  –   Altered nutrition: less than body requirements
  –   Altered thought processes
  –   Anxiety
• Clinical Problems
  – Hypothyroidism
  – Hyperthyroidism
          Physical Examination of
         The Lymphatic System (LS)
• General approach/Technique:
  – Should be incorporated into head-to-toe assessment
  – Superficial lymphatic system is examined by
    inspection and palpation
  – Location of lymph nodes varies among individual
  – Encourage client to report tenderness when palpating
    lymph nodes
  – Palpable lymph nodes should be distinguished from
    underlying tissue
  – Lymph nodes could be rolled up and down, side to
    side between examiner’s fingers
          Physical Examination of
         The Lymphatic System (LS)
• General approach/Technique:
  – Small palpable lymph nodes are common
  – Malignancies may result in palpable lymph nodes:
    non-tender, non-mobile, irregularly shaped, firm,
    rubbery or nodular – these require further evaluation
• Examination and documentation focus:
  – Inspection: location of any visible nodes, presence of
    swelling or red streaks
  – Palpation: nodes are described in terms of location,
    size (mm or cm), consistency, mobility and
    tenderness. Determine if it was noticed first by the
Physical Examination of the LS: Procedure

• Inspect and palpate
  the lymphatics of the
  head and neck
Physical Examination of the LS: Procedure

• Palpate the lymphatics of the head and neck
  (note deep cervical chain)
     Head and Neck Lymphatic System
          Assessment Findings
• Normal findings:
   – Superficial nodes not palpable, and not tender on

• Deviations from normal:
   – Greater 1 cm in adults
   – Presence of infection (nodes are enlarged, warm and
   – Sore throat infections
   – Otitis media
Physical Examination of the Lymphatic System

• Other areas/sites (LS assessment):
  – Breast, axillae, supraclavicular area, epitrochlear
    area, inguinal region, popliteal fossa

• Nursing Diagnoses
   – Pain related to swelling and inflammation

• Clinical problems
   – Lymphadenopathy (local or systemic)
Nose & Sinuses
Focus of Assessment & Documentation

• Nose:
  –   Shape and configuration of external structures
  –   Position and integrity of nasal septum
  –   Color of mucous membranes
  –   Color and swelling of the turbinates
  –   Discharge, lesions, masses, and foreign particles
  –   Patency of the nares
  –   Displacement and tenderness along ridge and soft tissues

• Sinuses
  – Quality of transillumination
  – Tenderness
 General Principles of Physical Examination
          of the Nose & Sinuses
• PE technique
   – Inspection and palpation, and elicit subjective data
• Equipment
   – Nasal speculum (optional)
   – Penlight
• Clients requiring thorough physical exam of the nose and
   – Clients with symptoms:
       • upper respiratory infections
       • headaches
       • breathing obstruction
        Physical Examination of the Nose &
               Sinuses: Procedure
1. Inspect the external nose
    –    Note shape and configuration
    –    Observe nares during ventilation
    –    If nasal discharge is present, note character (watery, purulent,
         mucoid), color, amount, and whether it is unilateral or bilateral
    Normal Finding:
    –    Shape of the nose varies among people
    Deviations from normal:
    –    Deviations in the shape or configuration of the external nose
    –    Significant if (+) tenderness and/or secondary to trauma
    –    Flaring of the nares
    –    Nasal discharges (rhinitis) secondary to: common cold, allergy, CSF,
         rhinnorrhea, sinusitis, foreign body
       Physical Examination of the Nose &
              Sinuses: Procedure
2. Evaluate nasal patency
   •   Occlude one naris, ask the person to breathe in and out with
       the mouth close
   •   Repeat with other naris
   Normal finding:
   •   Quiet nasal breathing indicated patency
   Deviations from normal:
   •   Masses or foreign particles may interfere with airway patency
3. Inspect the internal nose
   –   Tip the person’s head back and look through the nares to view
       vestibule, septum, and turbinates. Use a penlight to enhance
   –   Note the color and condition of the nasal mucosa, appearance
       of turbinates and nasal septum
       Physical Examination of the Nose &
              Sinuses: Procedure
3. Normal findings and deviations from normal (Inspection):
  Nasal septum: deviated septum is common, and may interfere
    patency, septum should not be perforated

  Nares: masses or foreign particles may interfere patency

  Mucous membranes: color (pink or dull red), small amount of clear
    watery discharge is considered normal

  Turbinates: normal (nonedematous, no masses, pink or dull red)
       • Nasal polyps
       • Epistaxis
       Physical Examination of the Nose &
              Sinuses: Procedure
4. Palpate the sinuses
    –     Frontal sinuses: press
          upwards from the eyebrows
          with your thumbs. Pay
          attention with the eye orbits
    –     Maxillary sinuses: press
          upward under zygomatic
          process (cheekbones) with
          your finger or thumbs
    Deviations from normal:
    (+) tenderness on palpation
       Physical Examination of the Nose &
              Sinuses: Procedure
5. Transilluminate the sinuses       Normal findings:
      (done if (+) tenderness on     Frontal sinuses:
      palpation)                     • A glow above the eye
•     Darken the room                Maxillary sinus:
•     Frontal sinuses: Press a       • A glow should be noted in the
      bright light source firmly        area of the hard palate
      against the medial
      supraorbital rim               Deviations from normal:
•     Maxillary sinus: Ask the       • Absence of glow (may indicate
      person to tilt head back and      fluid in the sinuses)
      open mouth
•     Press light source against
      the skin just below the
      medial aspect of the eye

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