head and neck assessment Flashcards
Anatomy of the head
cranial bones are joined by immovable sutures in adults. only mandible is movable
Cranial bones
frontal, parietal, temporal, occipital, ethmoid, sphenoid
sutures
sagittal, coronal, lambdoid, squamosal
Facial bones
maxilla, zygomatic, lacrimal, palatine, vomer, mandible, nasal, inferior conchae
Anterior triangle of the neck
hyoid bone, trachea, larynx, major blood vessels, thyroid gland
Muscles and landmarks in the neck
sternocleidomastoid rotates and flexes head. trapezius extends head, moves shoulders, 11th cranial nerve.
Lymph nodes of the neck
preauricular, posterior auricular, occipital, superficial cervical, deep cervical chain, posterior cervical, tonsillar, submental, submandibular, supraclavicular
What happens when a nurse notices an enlarged lymph node?
need to know where receives drainage from
Preauricular nodes
in front of ear
Posterior auricular nodes
lie superficial to the mastoid process
Occipital nodes
at the base of the skull
Superficial cervical nodes
overlay the sternocleidomastoid muscle
Deep cervical chain nodes
deep to the sternocleidomastoid
Posterior cervical nodes
appear in the posterior triangle along the edge of the trapezius muscle.
Tonsillar nodes
angle of mandible
Submandibular nodes
found halfway between the angle of the mandible and its tip
Submental nodes
midline under the chin
Supraclavicular nodes
located just above and behind the clavicle, at the sternocleidomastoid muscle
Inspect the head
size - microcephaly, acromegaly. shape, configuration
Inspect the face
symmetry, features, movement, expression, skin condition
Palpate the head
note consistency, temporal artery, TMJ - swelling, tenderness, crepitation (crackling sound)
Inspect neck (slightly extended)
position, symmetry, lumps, masses, movements - swallowing water observe thyroid, normal rom. cervical vertebrae (look down), see c7
Palpate neck
trachea - midline, thyroid gland - midline (from the back), swallowing right/left separate
Auscultate neck
if enlarged thyroid, use bell, hold breath
When palpating lymph nodes what are you looking for?
swelling, enlargement, tenderness
Headaches
sinus, cluster, tension, migraine, tumor related
Sinus headaches
deep constant throbbing (front of face)
Cluster headaches
stabbing pain (ex: behind eye)
Tension headaches
dull, tight, diffuse (forehead)
Migraine
nausea, vomiting, light/sound sensitivity
COLDSPA
character, onset, locations, duration, severity, pattern, associated factors (other symptoms)
Using Coldspa, Which question would be next after asking the patient how long the headaches lasts?
a. “Rate your pain on a scale of 1-10”
b. “Where does it hurt now?”
c. “When did it start?”
d. “Describe the pain, is it dull, tight, or sharp?”
a
Which data below, collected by the nurse during a head and neck assessment would be considered abnormal (select all that apply)?
a. Trachea midline
b. Palpable Submandibular lymph node
c. Tender Tonsillar lymph node
d. Thyroid is midline
e. TMJ crepitus with movement
f. C7 visible when patient flexes neck
g. Auscultating the Thyroid and notes bruits
b, c, e, g
OLDCARTS
Onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity
What is the order of assessing the neck?
Inspection, palpation, and auscultation.
What is the order of assessing the head and face?
Inspection of head and face, palpatation
