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HEALTH ASSESSTMENT > Head and Neck > Flashcards

Head and Neck Flashcards

1
Q

Framework of the head is the skull; divided into 2 subsections:

A

the cranium and the face.

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2
Q

Facial bones give shape to the face: consists of __ bones

A

14

➢Maxilla (2)
➢Zygomative (cheek) (2)
➢Inferior conchae (2)
➢Nasal (2)
➢Palatine
➢Vomer (1)
➢Mandible (jaw) (1)

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3
Q

Structure located in the facial region:

A

➢Parotid gland
➢Mandibular salivary gland

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4
Q

Composed of muscles, ligament and the cervical vertebrae

A

The Neck

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5
Q

______________________ and
_________ muscles allow movement and provide
support to the head and neck.

A

STERNOMASTOID and Trapezius

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6
Q

muscles rotates and flexes the
head,

A

Sternocleidomastoid

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7
Q

muscle extends the
head and moves the shoulders.

A

Trapezius

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8
Q

The eleventh cranial nerve is responsible for muscle
movement that permits shrugging of the shoulders
by the

A

tapezius muscles

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9
Q

turning the head
against resistance by the

A

stemomastoid muscles.

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10
Q

located under the mandible, anterior to
the stenomastoid muscle.

A

Anterior triangle

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11
Q

locate between trapezius and
sternomastoid muscles.

A

Posterior triangle

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12
Q

located in the
posterior neck and support the cranium.

A

Cervical Vertebrae

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13
Q

Internal jugular veins and carotid arteries – located bilaterally, parallel
and anterior to the sternomastoid muscles.
➢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.

A

BLOOD VESSELS

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14
Q

argest endocrine gland
produces thyroid hormones that increase metabolic rate

A

THYROID GLAND

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15
Q

through which air enters the lungs is composed of: C
shaped hyaline cartilage rings

A

TRACHEA

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16
Q

first upper tracheal ring, has small notch in it.

A

Cricoid cartilage

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17
Q

larger and located just above the
cricoid cartilage

A

Thyroid cartilage (“Adam’s apple”)

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18
Q

is attached to the tongue, lies above the thyroid
cartilage and under the mandible.

A

➢ Hyoid bone

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19
Q

filter lymph, a clear substance composed mostly of
excess fluids, filtering removes bacteria and tumor cells from lymph.
➢Produce lymphocytes and antibodies as a defense against invasion by
foreign substances.
➢Not palpable or they may feel like very small beads.
➢If the nodes become overwhelmed by microorganisms, as happens with
an infection they swell and become painful
➢If cancer metastasizes to the lymph nodes, they may enlarge but not
painful.

A
  • Lymph nodes
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20
Q

Post auricular
Tonsillar
Occipital
Submandibular

A

Pre-auricular

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21
Q

Superficial cervical
Posterior cervical
Deep cervical
Supraclavicular

A

Submental

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22
Q

Describe how it feels

A

Character:

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23
Q

Did it begin after some sternous activity, exercise,

accident or a direct injury?

A

Onset:

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24
Q

Does it radiate to the back, arms or shoulders?

A

Location:

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25
Q

How long does it last? Does it come and go?

A

Duration:

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26
Q

Are you able to continue your daily schedule and sleep

at night?

A

Severity:

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27
Q

Does it tend to occur more with exercise or stress?

Are there any activities that relieve it or make it worse?

A

Pattern:

28
Q

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?
Do you experience headaches?

A

Associated factors:

29
Q

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

A

Past Health History

30
Q

Do you find that you have headaches when you
take any of the following medications?
* Is there a history of head or neck cancer in your
family?
* Is there a history of migraine headaches in your
family?

A

Family History

31
Q
  • Do you smoke or chew tobacco? If yes, how much?
  • Do you use alcohol or recreational drugs? Describe
    the type used and how much?
A

Lifestyle and Health Practices

32
Q

Examining the head allows the nurse to evaluate the overlying protective
structures (cranium and facial bones)
* This examination can detect head and facial shape abnormalities, asymmetry,
structural changes or tenderness.
* Assists the nurse to detect enlarged or tender lymph nodes
* Thyroid enlargement, nodules masses or tenderness may be detected by
palpating the thyroid gland.

A

Physical Examination

33
Q

Instruct the client to remove any wig, hat, hair ornaments, pins, rubber
bands, jewelry, and head or neck scarves.

A

Preparing the client

34
Q

➢Take care to consider cultural norms for touch assessing the
head. Some cultures, prohibit touching the head or touching
the feet before touching the head.

A

Cultural Considerations

35
Q

Ask the client to sit in an upright position with the back
and shoulders held back and straight
* Explain the importance of remaining still during most of
the inspection and palpation of the head and neck.
* Explain the need for the client to move and bend the neck
for examination of muscles and for palpation of the
thyroid gland.

A

Preparing the Client

36
Q

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.
* Neck is symmetric, with head centered and without bulging
masses.
* Swelling, enlarged masses – or nodules – may indicate an
enlarged thyroid gland, inflammation of lymph nodes, or a
tumor.

A

The Neck

37
Q

The thyroid cartilage
and cricoid cartilage
move upward
symmetrically as the
client swallows.

A

Normal Findings THE NECK

38
Q

Asymmetric
movement
generalized
enlargement of the
thyroid gland is
considered abnormal. -

A

Abnormal Findings - THE NECK

39
Q

C7 (vertebrae prominens)
usually visible and palpable.
OLDER ADULT
CONSIDERATIONS
In older clients, cervical
curvature may increase
because of kyphosis of the
spine. Moreover, fat may
accumulate around the
cervical vertebrae
(especially in women). This
is sometimes called a
“dowager’s hump.”

A

Normal Findings The Neck

40
Q

Prominence or swelling
other vertebrae may be
abnormal.

A

Abnormal Findings the neck

41
Q

Palpate the trachea. Place you
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.

A

PALPATION

42
Q

Trachea is midline

Landmark are positioned
midline.
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.
OLDER ADULT CONSIDERATIONS
If palpable, the older client’s
thyroid may feel more nodular
or irregular because of fibrotic
changes that occur with aging;
the thyroid may also be felt
lower in the neck because of
age-related structural changes.

A

Normal Findings Palpation

43
Q

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.

Landmark are positioned
midline.

In cases of diffuse
enlargement, such a
hyperthyroidism, graves’
disease, or an endemic
goiter, the thyroid gland
may be palpated. An
enlarged, ender 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.

A

Abnormal Findings Palpation

44
Q

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

A

Neck Assessment Procedure

45
Q

Glandular thyroid may be
felt rising underneath your
fingers. Lobes should feel
smooth, rubbery and free
of nodules. - Neck Normal Findings

A

Coarse tissue or irregular
consistency may indicate an
inflammatory process.
Nodules should be
described in terms of
location, size and
consistency. - Neck Abnormal Findings

46
Q

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).

A

AUSCULTATION

47
Q

No bruits are auscultated.

A

Normal Findings - Auscultation

48
Q

A soft, blowing, swishing
sound auscultated over the
thyroid lobes is often head
in hyperthyroidism because
of an increase in blood flow
through the thyroid arteries.

A

Abnormal Findings

49
Q

▪ Normally lymph nodes (LN) \, round and smaller than 1 cm
are not palpable.
▪ In older clients, the LN become fibrotic fatty and smaller
because of loss f lymphoid elements related to aging

A

Clinical tip
* When palpating the LN note the following:
➢Size and shape

50
Q

Lymphadenopathy-lymph node enlargement (exceeds 1
cm), may be cause by infection an autoimmune disorder, or
metastatic disease.

A

Lymphadenopathy

51
Q

normally lymph node delimitation (the LN’s
position or boundary) is discrete.

▪ In chronic infection, LN’s become confluent
▪ In acute infection, they remain discrete.

A

➢Delimitation

52
Q

normal LN is soft, abnormal LN is hard and firm,
unilateral node are seen with metastic cancers

A

➢Consistency

53
Q

not sore or tender

A

Normal LNs

54
Q

LNs are tender and enlarged

A

▪ Acute infection

55
Q

After collecting the assessment data, identify abnormal
findings and client strengths using diagnostic reasoning.

A

Analysis of Data

56
Q

Readiness for Enhanced
health management: Requests assistance and information
on how to quit smoking.

A

Health promotional diagnosis:

57
Q

risk for Injury to head and neck related to
poor posture.

A

Risk Diagnosis:

58
Q

Ineffective gear during contact sports or
slat belt while driving or riding as a passenger.

A

Actual Diagnosis:

59
Q

TENSION HEADACHE
Dull, tight, diffuse

MIGRAINE HEADACHE
Accompanied by nausea,
vomiting and sensitivity, to noise
or light.

A

CHARACTER

60
Q

No problem stage: may
occur with stress, anxiety
or depression

May have prodromal stage
(visual, disturbances, vertigo,
tinnitus, numbness or tingling of
fingers or toes), maybe
precipitated by emotional
disturbances; anxiety, or ingestion
of alcohol, cheese, chocolate, or
other foods & substances to
which client is sensitive.

A

ONSET

61
Q

Usually located in frontal,
temporal or occipital region

Located around eyes,
temples, cheeks or
forehead; may affect
only one side of the
face.

A

LOCATION

62
Q

Lasts days, months or years Lasts up to 3 days

A

DURATION

63
Q

Aching Throbbing, severe

A

SEVERITY

64
Q

Symptomatic relief may be
obtained by located heat,
massage, analgesics,
antidepressant and muscle
relaxants.

REST may bring relief

A

PATTERN

65
Q

Affect women more often

than men

Occur more often in
women

A

ASSOCIATED FACTORS

HEALTH ASSESSTMENT (31 decks)

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