Health Assessment Ch 15 Head and Neck
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
in what kinds of recreational activity do you participate?
contact or aggressive sports may increase the risk for a head or neck injury
cranial sutures
coronal, sagittal, lambdoid, squamous
temporary artery
located between the eye and the top of the ear
Posterior triangle of the neck
located between the trapezius and sternomastoid muscles
Internal jugular veins and carotid arteries
located bilaterally, parallel and anterior to sternomastoid muscles
submandibular glands
located inferior to the mandible, underneath the base of the tongue
parotid glands
located on each side of face, anterior and inferior to ears and behind mandible
Anterior triangle of the neck
located under the mandible, anterior to the sternomastoid muscle
scleroderma
a tightened hard face with thinning facial skin
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.
Palpate the thyroid gland
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
cluster headache
Stabbing pain; may be accompanied by tearing, eyelid drooping, reddened eye, or runny nose
do you have any difficulty moving your head or neck?
tension in muscles, vertebral joint dysfunction and other disorders of the head may limit mobility
cricoid cartilage
the ring-shaped structure that forms the lower portion of the larynx
Tension headache
Dull, tight, diffuse
Trachea
- Allows air to pass to and from lungs - made of C- shaped hyaline
bruit
- abnormal blowing or swishing sound heard during auscultation of an artery or organ - are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis.
Meningitis
- inflammation of the meninges - neck pain with fever
Preparing the client
- instruct client to remove any wigs, hats, hair pins, etc. - ask client to sit in upright position with the back and shoulders held back and straight - some clients may be nervous so always tell the client what you are doing and share your assessment findings
Thyroid gland
- largest endocrine gland - produces thyroid hormones that increase metabolic rate
Hyperthyroidism
- overactive thyroid condition - detected by exophthalmos
bell palsy
- usually begins suddenly and reaches a peak within 48 hrs - symptoms: twitching, weakness, paralysis, drooping eyelid, etc.
Bones of the cranium include: (8)
-Frontal -Parietal (2) -Occipital -Temporal (2) -Sphenoid -Ethmoid
collecting data about head and neck
-abnormalities cannot be directly observed in physical appearance -nurse must ask for detailed description of the type of pain, location and duration to assess problem - due to the overlapping of body systems, nursing history is needed to identify any systemic issues
Neck
-composed of muscles, ligaments and cervical vertebrae
lymph nodes function
-filter lymph - produce lymphocytes and antibodies as defense
Cranium
-houses and protects the brain and major sensory organs - consists of 8 bones
Cervical Vertebrae (C1-C7)
-located in posterior neck -support cranium -flex head and palpate C7
Parkinson's disease
-mask like facial appearance along with a shuffling gait, rigid muscles and diminished reflexes
cushing syndrome
-present with a moon shaped face with reddened cheeks and increased facial hair
cerebrovascular accident (CVA)
-results in neurologic damage
Equipment for health assessment
-small cup of water -stethoscope
hyoid bone
a U-shaped bone in the neck that supports the tongue.
Blood vessels caution
AVOID bilaterally compressing carotid arteries when assessing neck because it can reduce blood supply to brain
Migrain headache
Accompanied by nausea, vomiting, sensitivity to noise or light
Tumor related headache
Aching, steady, neurologic & mental symptoms as well as nausea & vomiting may develop
thyroid cartilage
Adam's apple
Palpate the temporal artery, which is located between the top of the ear and the eye
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
Lymph nodes
Bean-shaped filters that cluster along the lymphatic vessels of the body. They function as a cleanser of lymph as wells as a site of T and B cell activation
COLDSPA
C-character O- onset L- location D-duration S- severity P- Pattern A- Associated factors
lymph
clear substance made mostly of excess tissue fluid
sinus headache
Deep constant throbbing pain; pressure like pain in one specific area of face or head; tender to touch
Acromelagy
Enlargement of facial features (nose, ears), hands & feet
Inspect the head. Inspect for size, shape, and configuration
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.
temporal arteritis
Inflammation of temporal arteries that may lead to blindness
Palpate the head. Note consistency
Lesions or lumps on the head may indicate recent trauma or a sign of cancer.
TMJ syndrome
Limited range of motion, swelling, tenderness or crepitation (crackling sound)
Cushing Syndrome
Moon face shape, reddened cheeks, increased facial hair
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.
Acorn-shaped, enlarged skull bones are seen in
Paget disease of the bone.
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. Ask the client to hold his or her breath (to obscure any tracheal breath sounds while you auscultate).
Palpate the trachea.
Place your finger in the sternal notch. Feel each side of the notch and palpate the tracheal rings. The first upper ring above the smooth tracheal rings is the cricoid cartilage.
traumatic brain injury
Presence of transportation accidents, violence, falling, excessive alcohol digestion
Inspect the face. Inspect for symmetry, features, movement, expression, and skin condition.
The nasolabial folds and palpebral fissures are ideal places to check facial features for symmetry.
Movement of neck structures normal findings
The thyroid cartilage and cricoid cartilage move upward symmetrically as the client swallows.
Have you noticed a change in the texture of skin, hair or nails? have you noticed changes in your energy levels, sleep habits or emotional stability?
alterations in thyroid function are manifested in many ways
prodome
an early symptom indicating the onset of a disease or illness
exophthalmos
bulging eyes
Head
can be divided into two subsections: cranium and face
vertebra prominens (C7)
can easily be palpated when neck is flexed, using this will help locate other vertebrae
Hypothyroidism/myxedema
characterized by a dull, puffy face; edema around the eyes; and dry, course, and sparse hair.
acromeglay
disease characterized by enlarged features, especially the face and hands, caused by hypersecretion of the pituitary hormone after puberty, when normal bone growth has stopped; most often caused by a pituitary tumor
trapezius muscle
extends the head and moves the shoulders
do you wear a helmet when riding a horse, bicycle, motorcycle? Do you wear a heard hat for hazardous occupations?
failure to use safety precautions increases the risk for head and neck injury
Head and Neck Assessment
focuses on the cranium, face, thyroid gland, and lymph nodes contained with the head and neck
is there a history of head or neck cancer in the 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.
What structures are contained within the neck?
hyoid bone, several major blood vessels, larynx, trachea and the thyroid gland
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.
have you noted any lumps or lesions on your head or neck that do not heal or disappear?
lumps and lesions that do not heal or disappear may indicate cancer. A goiter(enlarged thyroid gland) may appear as a large swelling at base of neck. The client may have a tight feeling in throat, a hoarse voice, cough and difficulty swallowing.
thyroid gland lobes
made up of two lobes, right and left, which are connected by a midline bridge of tissue known as the isthmus.
Facial bones
maxillae(2) palatine (2) zygomatic (2) lacrimal (2) nasal (2) vomer (1) inferior nasal conchae (2) mandible (1)
is there a history of migraine headaches in your family?
migraine headaches commonly have a familial association
do you experience headaches?
most common types of headaches are related to vascular, muscle contraction, traction or inflammatory causes
Do you experience any pain?
neck pain may accompany muscular problems or cervical spinal 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.
hyperthyroidism/ grave's disease
o (overproduction of thyroid hormone) Weight loss, increased appetite, rapid heartbeat (tachycardia; more than 100 beats per min), irregular heartbeat (arrhythmia) or palpitations, nervousness, anxiety, irritability, tremors in hands & fingers, sweating, changes in menstrual pattern, incr. sensitivity to heat, changes in bowel movements, enlarged thyroid gland (goiter), fatigue, insomnia, muscle weakness
Altered thyroid function
o Increased sensitivity to cold o Constipation o Depression o Fatigue o Heavier menstrual periods o Pale, dry skin o Thin brittle hair or nails o Weakness o Unintentional weight gain
Older adult consideration in neck pain
older people who have arthritis or osteoporosis may experience neck pain and a decreased range of motion
Asymmetry anterior to the earlobes occurs with
parotid gland enlargement from an abscess or tumor.
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
describe any previous head or neck problems. How were they treated?
previous head and neck trauma may cause chronic pain and limitation of movement. This may affect functioning.
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 swallowing.
Eleventh cranial nerve
responsible for muscle movement that permits shrugging of shoulders by trapezius muscles and turning head against resistance by sternomastoid muscle
sternomastoid muscle
rotates and flexes head
do you find that you have headaches when you take any medication?
some prescriptions and nonprescription medicines may cause headaches
what are the muscle s that allow movement and provide support to the head and neck?
sternomastoid and trapezium muscle
have you experienced any dizziness, lightheadedness, spinning sensation, blurred vision or loss of consciousness?
sudden trouble seeing or visual disturbances on one or both eyes or sudden trouble walking, dizziness or loss of balance or coordination may be a sign of an impending stroke
have you had any weakness or numbness in your face, arms, legs or on either side of your body?
sudden weakness or numbness in the face, arms or legs especially on one side of body may indicate impending stroke
do you smoke or chew tobacco?
tobacco use increases the risk of head and neck cancer. 85% of head and neck cancers are linked to tobacco use.
do you feel any facial pain?
trigerminal neuralgia 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.