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.