chapter 15 (health assessment)

Have you ever undergone radiation therapy for a problem in your neck region?

Radiation therapy has been linked to the development of thyroid cancer. Radiation to the neck area may also cause esophageal strictures, leading to difficulty with swallowing. The risk of hypothyroidism increases with head and neck irradiation (Skugor, 2014).

Do you find that you have headaches when you take any of the following medications?

Some prescription and nonprescription medicines may cause headaches as follows: Oral contraceptives and hormone therapy for menopause Blood-thinning medicines, such as warfarin, heparin, aspirin, and novel oral anticoagulants (NOAC) such as enoxaparin. Caffeine (or caffeine withdrawal) Heart and blood pressure medicines, such as nitroglycerin and antihypertensives Medications for erectile dysfunction Antihistamines and decongestants Corticosteroids, such as prednisone Ergotamine (Cafergot) therapy Medicines to prevent organ transplant rejection Immunosuppressants Certain types of chemotherapy Overuse of fat-soluble vitamins, such as vitamin A and vitamin D Radiation therapy Nonprescription medicines, such as acetaminophen, aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs) (especially medication overuse headache) (Auriel, Regev, & Korczyn, 2014). Prescription pain medicines and opioids such as codeine (Kristoffersen & Lundqvist, 2014).

Do you experience headaches? Use COLDSPA to further explore the symptoms of any headache. Be sure to include assessment of severity, location, and aggravating factors.

A precise description of the symptoms can help to determine possible causes of the discomfort. Abnormal Findings 15-1 summarizes typical findings for different headaches. The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes

Have you noticed a change in the texture of your skin, hair, or nails? Have you noticed changes in your energy level, sleep habits, or emotional stability? Have you experienced any palpitations?

Alterations in thyroid function are manifested in many ways. Box 15-1 discusses signs and symptoms of hypo- and hyperthyroidism.

Have the client complete the Headache Impact Character: Describe how the headache feels (sharp, throbbing, dull)? Onset: When did it first begin? Does it tend to occur with other factors (e.g., menstrual cycle, emotional or physical stress, ingestion of alcohol or certain other foods like cheese or chocolate)? Locations: Where does your headache begin? (Ask client to point to area in head if possible.) Does it radiate or spread to other areas? Duration: How long does it last? How often does it recur? Has there been any change in the duration of your headaches? Explain. Severity: How severe is the headache? Rate it on a scale of 1-10 (10 being most severe). Does the headache keep you from doing your usual activities of daily living? Explain. Pattern: What aggravates it? What makes the pain go away? What pain relievers work best for you? Associated Factors: Do you have other symptoms with the headache such as nausea, visual changes, dizziness, or sensitivity to noise or light?

Between 10% and 20% of women have migraine headaches provoked by hormone fluctuations and have a lifetime incidence twice as high as men (43% vs. 17%) (Sacco et al., 2012). Other vascular headaches may be caused by fever or high blood pressure ("cluster headaches"). Muscle contraction headaches may be caused by tightening of facial and neck muscles. Traction and inflammatory headaches may be warning signs of other illnesses such as stroke, sinus or gum infections, and meningitis (NINDS, 2015b). A sudden, severe headache with no known cause may be a sign of impending stroke.

In what kinds of recreational activity do you participate? Describe the activity.

Contact or aggressive sports may increase the risk for a head or neck injury.

Do you wear a helmet when riding a horse, bicycle, motorcycle, or other open sports vehicle (e.g., four-wheeler, go-cart)? Do you wear a hard hat for hazardous occupations?

Failure to use safety precautions increases the risk for head and neck injury (see Evidence-Based Practice 15-1).

The cranium houses and protects the brain and major sensory organs. It consists of eight bones:

Frontal (1) Parietal (2) Temporal (2) Occipital (1) Ethmoid (1) Sphenoid (1) In the adult client, the cranial bones are joined together by immovable sutures: the sagittal, coronal, squamosal, and lambdoid sutures.

Is there a history of head or neck cancer in your family?

Genetic predisposition is a risk factor for head and neck cancers.

Have any problems with your head or neck interfered with your relationships with others or the role you occupy at home or at work?

Head and neck pain may interfere with relationships or prevent clients from completing their usual activities of daily living.

Have you noticed any lumps or lesions on your head or neck that do not heal or disappear? Describe their appearance. Do you have a cough or any difficulty swallowing?

Lumps and lesions that do not heal or disappear may indicate cancer. A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck that the client may notice when shaving or putting on cosmetics. The client with a goiter may also have a tight feeling in the throat, a hoarse voice, cough, hoarseness, difficulty swallowing, difficulty breathing (Mayo Clinic,

Facial bones give shape to the face. The face consists of 14 bones (see Fig. 15-1):

Maxilla (2) Zygomatic (cheek) (2) Inferior conchae (2) Nasal (2) Lacrimal (2) Palatine (2) Vomer (1) Mandible (jaw) (1)

ASSESSMENT PROCEDURE Inspect the head. Inspect for size, shape, and configuration (Fig. 15-6).

NORMAL FINDINGS Head size and shape vary, especially in accord with ethnicity. Usually the head is symmetric, round, erect, and in midline and appropriately related to body size (normocephalic). No lesions are visible. ABNORMAL FINDINGS An abnormally small head is called microcephaly. The skull and facial bones are larger and thicker in acromegaly (see Abnormal Findings 15-2). Acorn-shaped, enlarged skull bones are seen in Paget disease of the bone.

Inspect the cervical vertebrae. Ask the client to flex the neck (chin to chest).

NORMAL FINDINGS: C7 (vertebrae prominens) is usually visible and palpable. ABNORMAL FINDINGS: Prominence or swellings other than the C7 vertebrae may be abnormal.

Ask the client to swallow as you palpate the right side of the gland. Reverse the technique to palpate the left lobe of the thyroid.

NORMAL FINDINGS: Glandular thyroid tissue may be felt rising underneath your fingers. Lobes should feel smooth, rubbery, and free of nodules. ABNORMAL FINDINGS: Coarse tissue or irregular consistency may indicate an inflammatory process. Nodules should be described in terms of location, size, and consistency.

Inspect for involuntary movement.

NORMAL FINDINGS: Head should be held still and upright. ABNORMAL FINDINGS: Neurologic disorders may cause a horizontal jerking movement. An involuntary nodding movement may be seen in patients with aortic insufficiency. Head tilted to one side may indicate unilateral vision or hearing deficiency or shortening of the sternomastoid muscle.

Neck: INSPECTION Inspect the neck. Observe the client's slightly extended neck for position, symmetry, and lumps or masses. Shine a light from the side of the neck across to highlight any swelling.

NORMAL FINDINGS: Neck is symmetric, with head centered and without bulging masses. ABNORMAL FINDINGS: Swelling, enlarged masses—or nodules—may indicate an enlarged thyroid gland (Fig. 15-9), inflammation of lymph nodes, or a tumor.

Auscultate the thyroid only if you find an enlarged thyroid gland during inspection or palpation. Place the bell of the stethoscope over the lateral lobes of the thyroid gland (Fig. 15-13). Ask the client to hold his or her breath (to obscure any tracheal breath sounds while you auscultate).

NORMAL FINDINGS: No bruits are auscultated. ABNORMAL FINDINGS: A soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries.

Palpate the superficial cervical nodes in the area superficial to the sternomastoid muscle. No enlargement or tenderness is present. Enlargement and tenderness are abnormal. Palpate the posterior cervical nodes in the area posterior to the sternomastoid and anterior to the trapezius in the posterior triangle. No enlargement or tenderness is present. Enlargement and tenderness are abnormal. Palpate the deep cervical chain nodes deeply within and around the sternomastoid muscle.

NORMAL FINDINGS: No enlargement or tenderness is present ABNORMAL FINDINGS: Enlargement and tenderness are abnormal. An enlarged, hard, nontender node, particularly on the left side, may indicate a metastasis from a malignancy in the abdomen or thorax.

Palpate the submental nodes, which are a few centimeters behind the tip of the mandible.

NORMAL FINDINGS: No enlargement or tenderness is present. ABNORMAL FINDINGS: Enlargement and tenderness are abnormal.

Inspect range of motion. Ask the client to turn the head to the right and to the left (chin to shoulder), touch each ear to the shoulder, touch chin to chest, and lift the chin to the ceiling.

NORMAL FINDINGS: Normally neck movement should be smooth and controlled with 45-degree flexion, 55-degree extension, 40-degree lateral abduction, and 70-degree rotation. ABNORMAL FINDINGS: Muscle spasms, inflammation, or cervical arthritis may cause stiffness, rigidity, and limited mobility of the neck, which may affect daily functioning. A stiff neck is often a late symptom seen in meningitis (Knight & Glennie, 2010).

Palpate the temporomandibular joint (TMJ). To assess the TMJ, place your index finger over the front of each ear as you ask the client to open the mouth (Fig. 15-8).

NORMAL FINDINGS: Normally there is no swelling, tenderness, or crepitation with movement. Mouth opens and closes fully (3-6 cm between upper and lower teeth). Lower jaw moves laterally 1-2 cm in each direction. ABNORMAL FINDINGS: Limited range of motion, swelling, tenderness, or crepitation may indicate TMJ syndrome.

Inspect the face. Inspect for symmetry, features, movement, expression, and skin condition.

NORMAL FINDINGS: The face is symmetric with a round, oval, elongated, or square appearance. No abnormal movements noted. Asymmetry anterior to the earlobes occurs with parotid gland enlargement from an abscess or tumor. Unusual or asymmetric orofacial movements may be from an organic disease or neurologic problem, which should be referred for medical follow-up. Drooping, weakness, or paralysis on one side of the face may result from a stroke (cerebrovascular accident, CVA) and usually is seen with paralysis or weakness of other parts on that side of the body. Drooping, weakness, or paralysis on one side of the face may also result from a neurologic condition known as Bell palsy. A "mask-like" face marks Parkinson disease; a "sunken" face with depressed eyes and hollow cheeks is typical of cachexia (emaciation or wasting); and a pale, swollen face may result from nephrotic syndrome. See Abnormal Findings 15-2 for Bell palsy and other abnormalities of the face.

Palpate the temporal artery, which is located between the top of the ear and the eye

NORMAL FINDINGS: The temporal artery is elastic and not tender. ABNORMAL FINDINGS: An acute urgent condition is seen when the temporal artery is hard, thick, and tender with inflammation, as seen with temporal arteritis (inflammation of the temporal arteries that may lead to blindness).

Inspect movement of the neck structures. Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage, thyroid gland (Fig. 15-10).

NORMAL FINDINGS: The thyroid cartilage and cricoid cartilage move upward symmetrically as the client swallows. ABNORMAL FINDINGS: Asymmetric movement or generalized enlargement of the thyroid gland is considered abnormal.

Palpate the lymph nodes. Assessment Guide 15-1 describes general technique for palpating the lymph nodes. Palpate the preauricular nodes (in front of the ear), postauricular nodes (behind the ears), occipital nodes (at the posterior base of the skull). Palpate the tonsillar nodes at the angle of the mandible on the anterior edge of the sternomastoid muscle (Fig. 15-14) Palpate the submandibular nodes located on the medial border of the mandible (Fig. 15-15).

NORMAL FINDINGS: There is no swelling or enlargement and no tenderness. No swelling, no tenderness, no hardness is present. No enlargement or tenderness is present ABNORMAL FINDINGS: Head and neck cancer includes cancers of the mouth, nose, sinuses, salivary glands, throat, and lymph nodes in the neck. Enlarged nodes are abnormal. Swelling, tenderness, hardness, immobility are abnormal. Enlargement and tenderness are abnormal.

Palpate the trachea. Place your finger in the sternal notch. Feel each side of the notch and palpate the tracheal rings (Fig. 15-11). The first upper ring above the smooth tracheal rings is the cricoid cartilage.

NORMAL FINDINGS: Trachea is midline. ABNORMAL FINDINGS: The trachea may be pulled to the affected side in cases of large atelectasis, fibrosis or pleural adhesions. The trachea is pushed to the unaffected side in cases of a tumor, enlarged thyroid lobe, pneumothorax, or with an aortic aneurysm.

Palpate the thyroid gland. Locate key landmarks with your index finger and thumb: Hyoid bone (arch-shaped bone that does not articulate directly with any other bone; located high in anterior neck). Thyroid cartilage (under the hyoid bone; the area that widens at the top of the trachea), also known as the "Adam's apple." Cricoid cartilage (smaller upper tracheal ring under the thyroid cartilage). Landmarks are positioned midline.Landmarks deviate from midline or are obscured because of masses or abnormal growths.To palpate the thyroid, use a posterior approach. Stand behind the client and ask the client to lower the chin to the chest and turn the neck slightly to the right. This will relax the client's neck muscles. Then place your thumbs on the nape of the client's neck with your other fingers on either side of the trachea below the cricoid cartilage. Use your left fingers to push the trachea to the right. Then use your right fingers to feel deeply in front of the sternomastoid muscle (Fig. 15-12).

NORMAL FINDINGS: Unless the client is extremely thin with a long neck, the thyroid gland is usually not palpable. However, the isthmus may be palpated in midline. If the thyroid can be palpated, the lobes are smooth, firm, and nontender. The right lobe is often 25% larger than the left lobe. ABNORMAL FINDINGS: In cases of diffuse enlargement, such as hyperthyroidism (see Fig. 15-9), Graves' disease, or an endemic goiter, the thyroid gland may be palpated. An enlarged, tender gland may result from thyroiditis. Multiple nodules of the thyroid may be seen in metabolic processes. However, rapid enlargement of a single nodule suggests a malignancy and must be evaluated further.

Palpate the head. Note consistency.

NORMAL FINDINGS: head is normally hard and smooth, without lesions. ABNORMAL FINDINGS: Lesions or lumps on the head may indicate recent trauma or a sign of cancer.

Pain: Do you experience neck pain? Use COLDSPA to further explore any neck pain. Be sure to ask about precipitating events (illness or injury), severity, and associated symptoms. Character: Describe how it feels. Onset: Did it begin after some strenuous activity, exercise, accident, or a direct injury? Locations: Does it radiate to the back, arms, or shoulders? Duration: How long does it last? Does it come and go? Severity: Are you able to continue your daily schedule and sleep at night? Pattern: Does it tend to occur more with exercise or stress? Are there any activities that relieve it or make it worse? Associated Factors: Do you have any limitation of movement of your head or neck or arms with this pain? Do you have any numbness or tingling with it?

Neck pain may accompany muscular problems or cervical spinal cord problems. Stress and tension may increase neck pain. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation.

What is your typical posture when relaxing, during sleep, and when working?

Poor posture or body alignment can lead to or exacerbate head and neck discomfort.

Normally lymph nodes are either not palpable or they may feel like very small beads. If the nodes become overwhelmed by microorganisms, as happens with an infection such as mononucleosis, they swell and become painful. If cancer metastasizes to the lymph nodes, they may enlarge but not be painful. Sources vary in their reference to the names of lymph nodes. The most common head and neck lymph nodes are referred to as follows:

Preauricular Postauricular Tonsillar Occipital Submandibular Submental Superficial cervical Posterior cervical Deep cervical Supraclavicular

Describe any previous head or neck problems (trauma, injury, falls) you have had. How were they treated (surgery, medication, physical therapy)? What were the results?

Previous head and neck trauma may cause chronic pain and limitation of movement. This may affect functioning.

Have you experienced any dizziness, lightheadedness, spinning sensation, blurred vision, or loss of consciousness? Describe.

Sudden trouble seeing or visual disturbances in one or both eyes or sudden trouble walking, dizziness, or loss of balance or coordination may be a sign of an impending stroke (National Stroke Association, 2015).

Have you had any weakness or numbness in your face, arms, or legs or on either side of your body?

Sudden weakness or numbness in the face, arms, or legs—especially on one side of the body—may indicate an impending stroke

Do you have any difficulty moving your head or neck?

Tension in muscles, vertebral joint dysfunction, and other disorders of the head and neck may limit mobility and affect activities of daily functioning.

Do you smoke or chew tobacco? If yes, how much? Do you use alcohol or recreational drugs? Describe the type used and how much.

Tobacco use increases the risk of head and neck cancer. Eighty-five percent of head and neck cancers are linked to tobacco use (smoking and smokeless tobacco). Symptoms of head and neck cancer include: a lump or sore that does not heal, a sore throat that does not go away, and trouble swallowing (National Cancer Institute [NCI] at the National Institutes of Health [NIH], 2012). Alcohol use is also a risk factor for head and neck cancers (NCI, 2012). Headaches can be precipitated by the use of alcohol.

Do you have any facial pain? Describe.

Trigeminal neuralgia (tic douloureux) is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Pain occurs over the divisions of the fifth trigeminal cranial nerve (the ophthalmic, maxillary, and mandibular areas).

The Neck: The structure of the neck is composed of muscles, ligaments, and the cervical vertebrae. Contained within the neck are the hyoid bone, several major blood vessels, the larynx, trachea, and the thyroid gland, which is in the anterior triangle of the neck (Fig. 15-2).

see (Fig. 15-2).

Blood Vessels: The internal jugular veins and carotid arteries are located bilaterally, parallel and anterior to the sternomastoid muscles. The external jugular vein lies diagonally over the surface of these muscles. The purpose and assessment of these major blood vessels are discussed in Chapter 21. It is important to avoid bilaterally compressing the carotid arteries when assessing the neck, as bilateral compression can reduce the blood supply to the brain.

see figure 15-5

Muscles and Cervical Vertebrae: The sternomastoid (sternocleidomastoid) and trapezius muscles are two of the paired muscles that allow movement and provide support to the head and neck (Fig. 15-3). The sternomastoid muscle rotates and flexes the head, whereas the trapezius muscle extends the head and moves the shoulders. The eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezius muscles and turning the head against resistance by the sternomastoid muscles. These two major muscles also form two triangles that provide important landmarks for assessment. The anterior triangle is located under the mandible, anterior to the sternomastoid muscle. The posterior triangle is located between the trapezius and sternomastoid muscles (Fig. 15-3). The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium (Fig. 15-4). The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.

see figures 15-2, 15-3, 15-4