Head and Neck Flashcards
Framework of the head is the skull; divided into 2 subsections:
the cranium and the face.
Facial bones give shape to the face: consists of __ bones
14
➢Maxilla (2)
➢Zygomative (cheek) (2)
➢Inferior conchae (2)
➢Nasal (2)
➢Palatine
➢Vomer (1)
➢Mandible (jaw) (1)
Structure located in the facial region:
➢Parotid gland
➢Mandibular salivary gland
Composed of muscles, ligament and the cervical vertebrae
The Neck
______________________ and
_________ muscles allow movement and provide
support to the head and neck.
STERNOMASTOID and Trapezius
muscles rotates and flexes the
head,
Sternocleidomastoid
muscle extends the
head and moves the shoulders.
Trapezius
The eleventh cranial nerve is responsible for muscle
movement that permits shrugging of the shoulders
by the
tapezius muscles
turning the head
against resistance by the
stemomastoid muscles.
located under the mandible, anterior to
the stenomastoid muscle.
Anterior triangle
locate between trapezius and
sternomastoid muscles.
Posterior triangle
located in the
posterior neck and support the cranium.
Cervical Vertebrae
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.
BLOOD VESSELS
argest endocrine gland
produces thyroid hormones that increase metabolic rate
THYROID GLAND
through which air enters the lungs is composed of: C
shaped hyaline cartilage rings
TRACHEA
first upper tracheal ring, has small notch in it.
Cricoid cartilage
larger and located just above the
cricoid cartilage
Thyroid cartilage (“Adam’s apple”)
is attached to the tongue, lies above the thyroid
cartilage and under the mandible.
➢ Hyoid bone
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.
- Lymph nodes
Post auricular
Tonsillar
Occipital
Submandibular
Pre-auricular
Superficial cervical
Posterior cervical
Deep cervical
Supraclavicular
Submental
Describe how it feels
Character:
Did it begin after some sternous activity, exercise,
accident or a direct injury?
Onset:
Does it radiate to the back, arms or shoulders?
Location:
How long does it last? Does it come and go?
Duration:
Are you able to continue your daily schedule and sleep
at night?
Severity:
Does it tend to occur more with exercise or stress?
Are there any activities that relieve it or make it worse?
Pattern:
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?
Associated factors:
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?
Past Health History
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?
Family History
- Do you smoke or chew tobacco? If yes, how much?
- Do you use alcohol or recreational drugs? Describe
the type used and how much?
Lifestyle and Health Practices
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.
Physical Examination
Instruct the client to remove any wig, hat, hair ornaments, pins, rubber
bands, jewelry, and head or neck scarves.
Preparing the client
➢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.
Cultural Considerations
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.
Preparing the Client
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.
The Neck
The thyroid cartilage
and cricoid cartilage
move upward
symmetrically as the
client swallows.
Normal Findings THE NECK
Asymmetric
movement
generalized
enlargement of the
thyroid gland is
considered abnormal. -
Abnormal Findings - THE NECK
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.”
Normal Findings The Neck
Prominence or swelling
other vertebrae may be
abnormal.
Abnormal Findings the neck
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.
PALPATION
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.
Normal Findings Palpation
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.
Abnormal Findings Palpation
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.
Neck Assessment Procedure
Glandular thyroid may be
felt rising underneath your
fingers. Lobes should feel
smooth, rubbery and free
of nodules. - Neck Normal Findings
Coarse tissue or irregular
consistency may indicate an
inflammatory process.
Nodules should be
described in terms of
location, size and
consistency. - Neck Abnormal Findings
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).
AUSCULTATION
No bruits are auscultated.
Normal Findings - Auscultation
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.
Abnormal Findings
▪ 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
Clinical tip
* When palpating the LN note the following:
➢Size and shape
Lymphadenopathy-lymph node enlargement (exceeds 1
cm), may be cause by infection an autoimmune disorder, or
metastatic disease.
Lymphadenopathy
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.
➢Delimitation
normal LN is soft, abnormal LN is hard and firm,
unilateral node are seen with metastic cancers
➢Consistency
not sore or tender
Normal LNs
LNs are tender and enlarged
▪ Acute infection
After collecting the assessment data, identify abnormal
findings and client strengths using diagnostic reasoning.
Analysis of Data
Readiness for Enhanced
health management: Requests assistance and information
on how to quit smoking.
Health promotional diagnosis:
risk for Injury to head and neck related to
poor posture.
Risk Diagnosis:
Ineffective gear during contact sports or
slat belt while driving or riding as a passenger.
Actual Diagnosis:
TENSION HEADACHE
Dull, tight, diffuse
MIGRAINE HEADACHE
Accompanied by nausea,
vomiting and sensitivity, to noise
or light.
CHARACTER
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.
ONSET
Usually located in frontal,
temporal or occipital region
Located around eyes,
temples, cheeks or
forehead; may affect
only one side of the
face.
LOCATION
Lasts days, months or years Lasts up to 3 days
DURATION
Aching Throbbing, severe
SEVERITY
Symptomatic relief may be
obtained by located heat,
massage, analgesics,
antidepressant and muscle
relaxants.
REST may bring relief
PATTERN
Affect women more often
than men
Occur more often in
women
ASSOCIATED FACTORS
