Ch. 10 The Head and Neck

Sequence of Palpating Lymph Nodes

1. preauricular 2. posterior auricular 3. occipital 4. tonsillar 5. submandibular 6. submental 7. superficial cervical 8. posterior cervical 9. deep cervical chain 10. supraclavicular

Inspect the Head

-check the size, shape, and symmetry -note the quantity of the hair, distribution, texture, and pattern of loss -part the hair in several places to inspect the scalp and assess for scaliness, lumps, nevi, and other lesions

Tension Headaches

-due to possibly heightened CNS pain sensitivity -usually bilateral -severity is steady; pressing or tightening; non-throbbing pain -onset is gradual -usually is 30 minutes per day -can have photophobia, phonophobia, scalp tenderness -triggered factors include sustained muscle tension; stress; sleep disturbances

Abnormal Facial Findings

-facial appearance is inconsistent with persons ethnicity, age, sex, or race group -movements and features are asymmetric -uneven movements of the jaw, pain or popping with movement

Expected Facial Findings

-facial expressions are appropriate for the situation -no visible lesions -movements and features are symmetric -no crepitus or clicking of the jaw and smooth movement

Some Focused History Questions

-have you ever had any recent headaches? -have you ever had a head injury or loss of consciousness? -have you ever had a seizure? -do you ever have jaw or facial pain? -do you have difficulty swallowing? -do you have any neck pain or stiffness? -do you have any neck masses or lumps? -do you have a history of thyroid disease?

Common or Concerning Symptoms of the Head

-headache -head injury -head or neck surgery -traumatic brain injury

Inspect Trachea

-inspect for any deviation from its usual midline position -then feel for any deviation (does it feel straight? or there any raises or bumps?)

Migraine Headaches

-involve low serotonin level and is a neuronal dysfunction -10% of headaches -unilateral (70%) but can be bifrontal or global (30%) -severity is throbbing or aching, pain, moderate to severe in intensity -can be fairly rapid -causes nausea, vomiting, photophobia, aura in 30% (either visual or motor) -triggered factors may include alcohol, stress, certain foods, aggravated by noise and bright light

Abnormal Findings of the Head

-larger or smaller than expected size for age -asymmetry of the skull -contour abnormalities (indentations/bumps)

Inspect the Trachea

-look for any deviation from its usual midline position -feel for any deviation by placing your finger along one side of the trachea and note the space between it and the sternocleidomastoid and compare it with the other side (the spaces should be symmetric)

Posterior Approach of the Palpating Thyroid

-move behind the person -person sit's straight and bends head slightly forward and to the right -use fingers of left hand to push trachea slightly to the right -curve fingers between trachea and sternomastoid muscle, retract it slightly and ask patient to swallow -thyroid should move up under examiner's fingers

Inspect the Face

-note the patient's facial expression -are the features symmetrical? -are there any abnormal movements? -assess the skin, noting color, pigmentation, texture, thickness, hair distribution, and any lesions -look for symmetry in the palpebral fissures and nasolabial folds

Inspect the Neck

-note the skin, color, pigmentation, texture, thickness, hair distribution, and any lesions -note ROM -inspect for its symmetry and any masses or scars -look for any visible lymph nodes

Headache

-one of the most common complaints in clinical practice -important to elicit a full description of the it and all seven attributes of the patient's pain

Cluster Headache

-process unclear -<1%; more common in men -unilateral, usually behind or around the eye -severity is sharp, continuous, intense -onset is abrupt -causes lacrimation, rhinorrhea, miosis, ptosis, eyelid edema, conjunctival infection -may be triggered during attack, sensitivity to alcohol

Common or Concerning Symptoms of the Neck

-swollen lymph nodes or neck lumps -enlarged thyroid gland -hoarseness

Inspect the Thyroid

-tip the patient's head back a bit -use tangenital lighting directed downward from the tip of the patient's chin, inspect the region below the cricoid cartilage for the gland

Palpate Lymph Nodes

-use your finger pads of the index finger and middle finger -move the skin over the underlying tissue in each area in a circular motion -patient should be relaxed with the neck slightly flexed forward and to the side being examined -examine both sides at once

Expected Findings of the Head

-wide variation in head size and shape -shape is symmetrical and rounded -the head should be erect, midline and proportional to the body size based on age -head is smooth with no tenderness or lesions

What can soft consistency of the thyroid suggest?

Grave's disease

What can firm consistency of the thyroid suggest?

Hashimoto thyroiditis

OLDCART and TBI

O: when did this occur? can you describe what happened? L: can you show me where you hurt your head? D: did you lose consciousness? if yes, for how long? did you fall first or lose consciousness first? C: did you experience any symptoms prior to the head injury (headache, shortness of breath, chest pain, numbness, or tingling)? A: do you experience vision changes; nausea pr vomiting; attention span deficits; dizziness, confusion, drainage from the ears, eyes, nose, or mouth; tremors; seizures; or gait changes? R/T: prevention of further injury

OLDCART and Headache

O: when did you first notice the headache? L: where do you feel the headache? can you point the area (s)? D: how long has this been going on? did it begin suddenly (in a few min)? or gradually (over a few hours or days)? is it temporary or constant? how long do they last? C: describe what it feels like (throbbing, hammering, or squeezing); describe it on a scale of 1-10 A: do you notice any other symptoms when this occurs? blurred vision? nausea? vomiting? dizziness? R: what have you tried to make the headache go away? (sleep? cool compressions? dark room? or relaxation techniques?) T: has anyone treated you for your headaches in the past? if yes, what type of headache were you diagnosed? have you used any meds?

A client arrives in the emergency department by ambulance after falling down his front steps. The nurse notes two soft lumps, approximately 3 cm in diameter, on the side of his head. What would the nurse identify these as? a) pilar cysts b) pigmented nevi c) signs of abuse d) edema from fall

a

The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristics would the instructor use for the thyroid cartilage? a) the notch on its superior edge b) its position just below the mandible c) its relation to the cricoid cartilage d) the curve on its inferior edge

a

What does a scar of past thyroid surgery suggest?

a clue to under-reported thyroid disease

A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? select all that apply a) constipation b) lower systolic bp c) cool skin d) lethargy e) weight loss

a, b, c, d

What are associated manifestations of a headache caused by a traumatic head injury? (mark all that apply) a) gait changes b) apthy c) changes in appetite d) seziures e) attention span deficit

a, d, e

Who is more likely to sustain a TBI from a fall, blunt trauma, or a motor vehicle accident?

adolescents

Macrocephaly

an anomaly characterized by a large head in proportion to the body and an underdeveloped brain; the circumference of the head is more than two standard deviations above average for the person's age and sex

Microcephaly

an anomaly characterized by a small head in proportion to the body and an underdeveloped brain; the circumference of the head is more than two standard deviation below average for the person's age and sex

Secondary Headaches

arise from a serious underlying cause often warranting urgent attention (may endanger the patient's life)

What to do if the the patient has a shorter neck and you are assessing their thyroid gland?

ask them to extend their neck more

What activity is known to aggravate a tension headache? a) exercise b) driving c) prolonged sleep d) listening to music

b

What does the nurse assess the face for? (select all that apply) a) affect b) asymmetry c) edema d) involuntary movements e) hair color

b, c ,d

The nurse should ask about or assess which associated factors when a patient complains of cluster headaches? Select all that apply a) photophobia b) lacrimation c) miosis d) rhinorrhea e) ptosis

b, c, d, e

The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? select all that apply a) muscle tension b) recurrent c) continuous d) throbbing e) photophobia

b, d, e

Where do you inspect the thyroid region?

below the cricoid cartilage

A 16 year old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting more than 24 hours. The mother states, "just before the headache started my daughter was craving food. I couldn't feed her enough". What is this called? a) aura b) neurologic onset c) prodrome d) aberrant sign

c

The nurse does a health history. The patient states he has lost 30 pounds in the last couple of months without really trying. The patient also states he feels warm all the time and sometimes feels he has heart palpitations. The nurse would anticipate orders to evaluate the patient for: a) hypernatremia b) hyperbilirubinemia c) hyperthyroidism d) hyperproteinemia

c

What are the bordering landmarks of the anterior triangle of the neck (mark all that apply) a) the clavicle b) the omohyoid muscle c) the midline of the neck d) the mandible e) the sternomastoid

c, d, e

Psoriasis

chronic skin condition producing red lesions covered with silvery scales

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73 degrees F. The nurse also notes that the patient has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect? a) hyperthyroidism b) hypothyroidism c) brain tumor d) effects of age-related changes

d

During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do? a) look for involvement of other regions of the body b) assess for dietary changes c) assess for meningitis d) look for a source such as infection in the area that it drains

d

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of: a) a goiter b) nasopharyngitis c) tonsillitis d) a metastasis

d

When assessing a patient with Graves disease, how would you expect the thyroid gland to be? a) tender b) firm c) nodular d) soft

d

When doing an examination of the thyroid gland, the suggested sequence of examination for a posterior approach is : a) flex the neck forward b) place the fingers of both hands on either side of the thyroid c) displace the trachea right then left, evaluating the margins of the lobes d) have the patient sip and swallow

d, b, a, c

Parkinson Disease

decreased facial mobility blunts expression; a mask-like face may result with decreased blinking and a characteristic stare; the neck and upper trunk tend to flex forward resulting in the patient to seem like they are peering upward toward the observer; facial skin becomes oily, and drooling may occur (shuffling gait)

Goiter

enlarged thyroid gland

Hirsutism

excessive facial hair

T or F: primary headaches are more worrisome than secondary headaches

false

What does fine hair accompany with?

hyperthyroidism

What does coarser hair accompany with?

hypothyroidism

What does a tender thyroid indicate?

inflammation

What does tender lymph nodes suggest?

inflammation

A "Tonsillar Node" that Pulsates...

is really the carotid artery

What do you do if the thyroid gland feels enlarged?

listen over the lateral lobes with a stethoscope to detect a bruit, which is a sign similar to a cardiac murmur but of non-cardiac origin

Who is the thyroid gland usually easier to feel in?

long slender neck patients

What does enlarged lymph nodes suggest?

malignancy

Primary Headaches

no identifiable underlying cause

What do you do if lymph nodes are palpated?

note its size, shape, delimitation (discrete or mattered together), mobility, consistency, and any tenderness

Palpate the Face

palpate for symmetry, tenderness, muscle tone, and temporomandibular joint function

Factors that May Relieve Tension Headaches

possibly massage or relaxation

What factors relieve migraine headaches?

quiet, dark room; sleep; sometimes transient relief from pressure on the involved artery

"Shotty" Lymph Nodes

refers to small, mobile, discrete, nontender nodes found in children frequently

What does redness in the scalp indicate?

seborrheic dermatitis, psoriasis, pilar cysts, or pigmented nevi

What is the most common type of headache?

tension

Nephrotic Syndrome

the face is edematous and often pale; swelling usually appears first around the eyes and in the morning; eyes become slitlike when edema is severe

Acromegaly

the increase growth hormone produces enlargement of both bone and soft tissue; the head is elongated, with bony prominence of the forehead, nose, and lower jaw; soft tissues of the nose, lips, and ears also enlarge; the facial features appear generally coarsened

Cushing Syndrome

the increased adrenal cortisol production which produces a round or "moon" face with red cheeks; excessive hair growth may be present in the mustache and sideburn areas and on the chin

Myxedema

the patient with severe hypothyroidism has a dull, puffy facies; the edema, often pronounced around the eyes, does not pit with pressure; the hair and eyebrows are dry, coarse, and thinned and the skin is dry

What are the most important characteristics of a headache?

the severity and chronological patterns

Purpose of Palpating the Head

to check for masses, tenderness, and scalp mobility

What is the leading cause of death and disability in infants and children?

traumatic brain injury (TBJ)

T or F: the thyroid gland is usually larger in women than in men

true

Expected Findings of the Thyroid

usually not palpable; if some tissue is, the consistency is firm and smooth; there is no nodularity, enlargement, or tenderness