Health Assessment chapter 15 (head and neck)

Hyperthyroidism

(Fast like a cheetah) -Nervousness -Weight loss despite increased appetite -Excessive sweating and heat intolerance -Palpitations -Frequent bowel movements -Muscular weakness of the proximal type and tremor -Tachycardia -Increased systole and Decreased diastole

hypothyroidism

(Slow like a Hippo ) Fatigue, lethargy -Modest weight gain with anorexia -Dry, coarse skin and cold intolerance -Swelling of face, hands and legs -Constipation -Weakness, muscle cramps, arthralgias, impaired memory and hearing -Bradycardia -Decreased systole and Increased diastole - Myxedema

how to palpate the thyroid

-The patient is examined in the seated or standing position. -Attempt to locate the thyroid isthmus by palpating between the cricoid cartilage and the suprasternal notch. -Use one hand to slightly retract the sternocleidomastoid muscle while using the other to palpate the thyroid. -Have the patient swallow a sip of water as you palpate, feeling for the upward movement of the thyroid gland.

The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse do first?

Ask the patient to sip and swallow water.

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?

Assess the woman for hypothyroidism.

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position the head in order to best facilitate this exam?

Flex the head toward the side being examined

questionnaire for headaches

HIT-6

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open the mouth

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?

Sternocleidomastoid

if you find thyroid is enlarged what should you do

auscultate the thyroid. use bell. ask them to hold their breath to see if you hear soft blowing sounds (this is bad)

intense stabbing pain, may be accompanied by tearing, eyelid dropping, reddened eye or runny nose. has sudden onset, may be due to alcohol, usually in eye or around facial and temporal regions

cluster headache

what do you listen to when doing a physical exam on the neck

enlarged thyroid gland

which hyroidism is fast

hyperthyroidism

which thyroidism is slow

hypothyroidism

during a health assessment of the head what are you looking for

inspection of head: size, shape, configuration, involuntary movement palpate the head

where should the trachea be

midline in neck

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

migraine headache

normal characteristics of the thyroid

mobile, soft, nontender

how to test for TMJ

place your index finger over the front of the ear and ask your client to open their month should be no swelling, tenderness

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

range of motion of neck

deep, constant throbbing pain, pressure like pain in one specific area of the face or head

sinus headache

how to assess the thyroid

stand behind client ask them to lower the chin to the chest and turn the neck slightly to right. place thumbs on the nape of the clients neck with your other fingers on either side of the trachea and below the cricoid cartilage. should move up as they swallow. use left fingers to push the trachea to the right and right fingers to feel deep into the steroid mastoid muscle. repeat on other side.

to facilitate palpation of the thyroid gland, you instruct the patient to what

swallow

what are you looking for when inspecting the face?

symmetry features movement expression skin condition

what do you palpate when doing a physical exam on the head

temporal artery and temporomandibular joint (TMJ)

dull, tight headache may occur with stress, anxiety or depression. usually lasts for days or months and is aching.

tension headache

headache that is aching, steady, and mental and neurologic symptoms may occur. may be aggravated by coughing, sneezing, or movements of head.

tumor headache