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Nursing Fundamentals/Assessment > Head and Neck > Flashcards

Head and Neck Flashcards

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1
Q

Inspect head and scalp for

A

tilt, tremor

size, shape (molding), symmetry, lesions, trauma

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2
Q

Inspect facial features for

A 
symmetry
shape 
unusual features 
tics
characteristic faceis
pallor/pigmentation
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3
Q

Palpate head and scalp for

A

symmetry, tenderness (sinuses)
scalp movement
sutures, fontanels
hair texture, color distribution

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4
Q

Auscultate the temporal arteries for

A

thickening, hardness and tenderness

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5
Q

Inspect and palpate the…

A

salivary glands

and check for infant head cricumference

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6
Q

Inspect neck for the following

A

tracheal position
tracheal tug
movement of hyoid bone and cartilage
lymph nodes

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7
Q

Palpate thyroid gland for

A 
consistency 
size 
shape 
configuration 
tenderness 
nodules 
auscultate for bruits if gland is enlarged 
ROM of neck
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8
Q

Skulls is composed of seven fused bones

A

Frontal: 2 bones
Parietal: 2 bones
Temporal: 2 bones
Occipital: 1 bone

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9
Q

What are the three facial cavities

A

eyes, nose and mouth

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10
Q

Face bones

A 
frontal 
nasal 
zygomatic 
ethmoid
lacrimal 
sphenoid 
maxillary 
madible (movable)
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11
Q

What cranial nerves innervate the muscles of the fave

A

CN V and VII

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12
Q

Salivary Glands

A

Produce saliva - moisten, prevent caries and intiate digestion of carbs

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13
Q

Three paired glands

A

Parotid
Submandibular
Sublingual

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14
Q

Structure of the neck formed by

A

cervical vertebrae
ligaments
SCM muscles
trapezium muscle

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15
Q

Posterior triangle consists of

A

trapezius
SCM
clavice

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16
Q

Anterior triangle consists of

A

medial border of SCM

madible

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17
Q

Neck contains

A 
trachea 
esophagus 
internal and external jugular veins 
common carotid 
internal and external carotid arteries 
thyroid
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18
Q

Thyroid

A

largest endocrine gland
T3 - thyroxine
T4 - triiodothyronine

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19
Q

Infants

A

Bones are soft and separated by sutures
sutures ossify (6-18 years)
Fontanels close (2 months - 2 years)
Skull is molded when infant is exiting the birth canal
resumes normal shape and size within first few days
Ossification of sutures begins after brain growth at about 6y/o

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20
Q

Male Adolescent Changes during Childhood

A

Nose and thyroid cartilage enlarge

Facial hair appears on upper lip

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21
Q

Pregnant women

A

Euthyroid state
Increase in renal clearance of iodine
thyroid enlarges to produce sufficient hormones
Adequate iodine intake (200mcg/day) will not cause thyroid to change in size

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22
Q

Older Adults

A

T4 production and degradation decreases

Thyroid gland becomes fibrotic

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23
Q

HPI: Head injury

A

independent observer description
state of conciousness after injury - immediately, 5 minutes after, combative, alert or dazed
predisposing factors-epilepsy, hypoglycemia, syncope
associated symptoms - head or neck pain, laceration, local tenderness, change in breathing pattern, diplopia, discharge, n/v, incontinence, ability to move extremeties
medications

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24
Q

HPI: Headache

A

onset - time of day?
duration - relieved by medication or sleep, clusters
location - entire head, neck, sinus, behind eyes,
character
severity
visual prodone - scotoma, hemianopia, decreased vision or blindess
pattern - awakens patient, worse in evenings?
change in LOC
associated symptoms
precipitating factors - alcohol, fever, fatigue, food, stress, allergies, menstrual cycle, sexual, oral contraceptives, caffeine
treatment efforts medications

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25
Q

HPI: Stiff neck

A

neck injury or stain, head injury, swelling
fever, bacterial or viral
character - limited ROM, pain with movement, pain relieved by movement, radiating
predisposing factors - unilateral vision, hearing loss, work position
efforts to treat - heat or PT

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26
Q

HPI: thyroid problems

A

Change in temperature preference
swelling of neck - dysphagia, redness, pain with touch,
change in texture of hair, skin and nails
change in emotional stability - mood or energy
increased prominence of eyes (exopthalmus)
tachycardia, palpitations
change in menstrual flow
change in bowel habits
medications: thyroid preparations

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27
Q

PMHx

A

head trauma, subdural hematoma, recent lumbar puncture
radiation treatment around head and neck
Headaches: migraines, vascular
surgery for tumor, goiter
seizure disorder
thyroid dysfunction

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28
Q

FH

A

headaches: type, character

thyroid dysfunction

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29
Q

Personal and Social

A

Employment risks
stress
injury risks
nutrition - intolerances, skipping meakls
use of alcohol, street, recreational drugs
sports played, weight training, new activities, use of productive padding and helmet if necessary

30
Q

Hx for infants

A

prenatal hx - maternal use of drugs, uterine abnormalities, treatment of hyperthyroidism
birth hx - firstborn usually torticollis, c-section, difficult delivery,
unsual head shape - bulging or flattening
head control
acute illness - diarrhea, vom, fever, limited head movement, irritability (meningitis)
congenital abnormalities - craniofacial, microcephaly
neonatal screening for hypothyroidism -

31
Q

Hx for pregnant women

A

Gestation or postpartum duration
presence of preexisting conditions
hx of pregnancy -induced HTN
use of alcohol or recreational drugs

32
Q

Hx for older adults

A

Dizziness with head or neck movement

weakness or impaired balance

33
Q

Inspection of head and face

A 
facial features
facial asymmetry 
tics
spasms, tremor? - horizontal jerking or bobbing 
head position and shape - upright and still
skull size and shape 
scalp 
hair pattern
34
Q

Palpation of head and face

A 
skull symmetric and smooth
scalp movement
hair texture
temporal arteries 
temporomandibular (TMJ) joint
salivary glands
35
Q

Percussion and Auscultation

A

Percussion is not routinely performed

Auscultation is only used for bruits in cerebral aneurysm or temporal arteritis

36
Q

Neck

A 
muscle symmetry
alignment of trachea 
landmarks of triangles
fullness at base of neck 
masses
webbing
unusual shortness
asymmetry
carotid artery prominence
JVD
ROM
37
Q

Palpation of Neck

A

tracheal alignment
smoothness and tenderness of hyoid bone, thyroid cartilage, cricoid cartilage
tracheal tugging (possible aortic aneurysm) Cardarelli sign
Lymph nodes

38
Q

Inspection of thyroid gland

A

symmetry and swallowing symmetry

39
Q

palpation of thyroid gland

A

size and shape
configuration and consistency
tenderness
nodules

40
Q

Auscultation of thyroid gland

A

If enlarged, auscultate for vascular sounds

A hypermetabolic state increases blood supply and soft rushing sound (vascular bruit) may be heard

41
Q

Examination in infants

A 
head circumference
head symmetry and shape 
fontanels
scalp scaling or crusting, dilated scalp veins
hair and hairline
cephalhematoma
head control, position and movement
42
Q

Inspection of infants

A

facial features, symmetry

neck symmetry, size and shape

43
Q

Palpation of infants

A

suture lines and fontanels - sites of fusion should not be palpable after 6 months, sagittal suture may be felt
craniotabes: softening of the outer table of the skull
neck muscle tone and masses
trachea
thyroid goiter
Scalp should move freely over skull c no tender, swelling or depression

44
Q

Transillumination

A

Inspect skull of infants for possible lesions or rapidly increasing head circumference
A ring of 2cm or less (or 1cm at occiput)
Any larger will indicate excess fluid or decreased brain tissue in the skull

45
Q

Palpation in children

A

Can be performed with one finger
Bruits common up to age 5
Thyroid may or may not be palpable

46
Q

Examination of pregnant women

A

inspect for chloasma - dark brown “confetti” blotches on face
Palpate for hypertrophy of thyroid
Auscultate for thyroid bruit

47
Q

Examination in older adults

A

facies - facial distortions
sunken eyelids, loose and wrinkled
evaluate ROM for pain or crepitus or jerkiness
Palpate thyroid for nodules or abnormalities
Thyroid will be more fibrotic
Feels nodular an irreguar

48
Q

Abnormalities of the head

A 
Classic migraine
Common migraine
cluster
hypertensive
muscular tension
temporal arteritis
49
Q

Abnormalities of thyroid

A

Hypo-, hyperthyroidism

Myxedema - skin disorder

50
Q

Graves disease

A

Autoimmune, antibodies go to TSH, leading to overactive thyroid

51
Q

Hashimoto disease

A

Autoimmune antibodies AGAINST thyroid causing hypothyroidism

52
Q

Thyroid isthmus

A

lies across the trachea below the cricoid cartilage
A pyramidal lobe extends upward from isthmus and slightly to the left of midline
present in about 1/3 of population

53
Q

Head bobbing may indicate?

A

aortic insufficiency if nodding is synchronized c a pulse

54
Q

Unilateral hearing loss indicator

A 
holding the head tilted to one side to favor good eye or ear
or torticollis (excessive contraction of SCM)
55
Q

Facies

A

edema, bruising, coarsened features, exophthalmos (eye-bulging), hirsutism, lack of expression, excessive perspiration, pallor or pigmentation

56
Q

When facial asymmetry is present….

A

Note whether features on one side of the face are affected or one portion such as forehead, lower face or mouth.
Facial nerve paralysis when entire side of the face is affected and suspect facial nerve weakness when lower face is affected
Mouth problem? peripheral trigeminal nerve

57
Q

Tics

A

spasmodic muscular contractions of the face, head or neck

Possibly psychogenic or Tourette’s

58
Q

Alopecia

A

hair loss
Bitemporal recession of hair or balding at the crown is common in men
Hair loss in younger girls may be d/t tight braiding
Fungal infection of scalp may be tinea capitis

59
Q

Palpation of salivary glands

A

check for asymmetry or enlargement
fixed, movable, soft, hard, tender or nontender
Have pt open mouth to express material through ducts

60
Q

Stenson duct

A

is the parotid duct that opens into the mouth next to the maxillary second molar tooth

61
Q

Submandibular duct (Wharton duct)

A

opens in a small papilla at the sides of the frenulum
Enlarged, tender gland may indicate either viral or bacterial infection, or a ductal stone preventing saliva from exiting gland.
Discrete nodule may be cyst or tumor (benign or malignant)

62
Q

Chvostek sign

A

Percussion of masseter muscle may produce a hyperactive masseteric reflex in those c hypocalcemia

63
Q

Webbing, excessive cervical skin or an unusually short neck may be…

A

Chromosomal abnormality

Turner syndrome

64
Q

Cervical lymphadenitis

A

Edema of the neck may be a local infection
Mass filling the base of the neck or visible thyroid tissue that glides upward when the patient swallows may be enlarged thyroid

65
Q

ROM of neck

A

flex, extend, rotate, and laterally turn head and neck
Movement should be smooth and painless and not cause dizziness
Nuchal ridgidity, resistance to flexion, may be meningeal irritation (CN XI)

66
Q

Compare space between the trachea and SCM on each side

A

Unequal space may indicate displacement of the trachea from midline and may be associated with a mass or pathologic condition in chest

67
Q

Thyroid cartilage

A

Hyoid, thyroid and cricoid should be smooth and nontender and should move under finger when patient swallows

68
Q

Thyroid Gland - Swallowing

A

Inspect for size, symmetry and contour

Inspect lateral side for enlargement

69
Q

Inspection for goiter

A

no visible thyroid on lateral inspection

70
Q

Cardarelli sign

A

pressing and displacing thyroid to pt’s left
increase contact between left bronchus and aorta
Systolic pulsations form aorta can be felt at the surface is aneurysm is present

71
Q

Oliver sign

A

grasp cricoid cartilage and applying upward pressure whle the patient stands with his or her chin extended up
Downward tug may be felt if aneurysm is present

72
Q

Abnormalities in thyroid during swallow eval

A

Right lobe 25% larger then left
consistency should be firm yet pliable
coarse tissue or gritty sensation may be inflammation
enlarged, tender thyroid is thyroidits

Nursing Fundamentals/Assessment (24 decks)

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