Head/Face/Neck Assessment Flashcards
normal findings for SUTURES
should be NONPALPABLE and NON-MOBILE by adulthood
hyoid bone
the ONLY BONE that is not connected to the other bones
- supports the TONGUE
- provides ATTACHMENT for MUSCLES for NECK MOVEMENT & SWALLOWING
name the LYMPH NODES that we find in the HEAD & NECK
- PREAURICULAR
- POSTERIOR AURICULAR
- OCCIPITAL
- SUPERFICIAL CERVICAL
- POSTERIOR CERVICAL
- SUPRACLAVICULAR
- TONSILLAR
- SUBMANDIBULAR
- SUBMENTAL
name all CRANIAL NERVES in order
CN I - olfactory
CN II - optic
CN III - oculomotor
CN IV - trochlear
CN V - trigeminal
CN VI - abducens
CN VII - facial
CN VIII - acoustic/vesticochlear
CN IX - glossopharngeal
CN X - vagus
CN XI - spinal accessory
CN XII - shoulder shrug
name all TESTS for Cranial nerves
CN I - smelling test
CN II - looking at vision/snellen chart/near vision
CN III - looking up, medial, downward
CN IV - looking down and in
CN V - soft/dull test /clenching teeth
CN VI - looking side to side/tracking pen
CN VII - facial expressions
CN VIII - WEBER/RINNE test + hearing
CN IX - speaking/swallowing/gag reflex
CN X - gag reflex/looking at vital signs
CN XI - shrugging the shoulders
CN XII - sticking out the tongue/movements
what occurs as we get OLDER - developmental differences?
- loss of ELASTICITY in the SKIN
- more PROMINENT bone structures
- more difficulty PALPATING LYMPH NODES & THYROID GLAND
- ATROPHY
vertigo
spinning sensation within the inner ear
syncope
fainting sensation - could be a cardiovascular issue
disequilibrium
feeling off balance; issue with CNS
important to assess with HEAD INJURY
- is there LOC? did they faint?
- signs of associated symptoms; vomiting, headaches, or amnesia
- any predisposing factors?
assessment of a STIFF NECK
- asking about past neck injuries or strains
- any fevers, headaches, or signs of meningitis?
- medications?
assessment of they THYROID GLAND
- want to assess for any indication of HYPERTHYROIDISM or HYPOTHYROIDISM
- changes in temp
- swelling?
- change in texture in hair, skin, or nails?
- EXOPHTHALMOS/SWELLING/DOUBLE VISION
- menses changes
past personal or family history
- job?
- activities or hobbies?
- sports?
- stressors?
- family history of headaches or thyroid issues?
what can a TRACHEAL DEVIATION be a sign of?
can be a sign of a collapsed lung or trauma
what is the LYMPHATIC SYSTEM consist of?
- LYMPH FLUID
- COLLECTING DUCTS
- SPLEEN
- THYMUS
- TONSILS + ADENOIDS
where is LYMPH TISSUE LOCATED?
seen in MULTIPLE BODY SYSTEMS
ex. stomach mucosa, appendix, bone marrow or the lungs
function of the LYMPHATIC SYSTEM
retrieves EXCESS FLUID from TISSUE SPACES and returns it to the BLOODSTREAM
definition of LYMPH
a FLUID that begins to OOZE out of the body’s TINIEST BLOOD VESSELS
- helps to carry away damaged cells, cancer cells or any pathogens
function of LYMPH NODES
helps to FILTER out any DAMAGED CELLS, CANCER CELLS ,or FOREIGN PARTICLES
- has WBC to help destroy those damaged cells etc..
assessment of LYMPH NODES
if ENLARGED;
- can be FIRM and MOBLE
- any local/systemic symptoms?
- medications?
if SWELLING;
- is it UNILATERAL or BILATERAL?
- is it INTERMITTENT or CONSTANT?
**unilateral - emphysema
**could be swollen due to BUILD UP of lymphatic fluid
what to INSPECT for in LYMPH NODES
- EDEMA
- ERYTHEMA
-RED STREAKS **can be LYMPHANGITIS - sign of strep or staph infection
enlarged lymph nodes
LYMPHADENOPATHY
lymphangitis
red streaks on the overlying skin
lymphedema
build-up of fluid
what do we look/feel for while PALPATING the LYMPH NODES?
- SIZE
- CONSISTENCY
- MOBILITY
- TENDERNESS
- WARMTH
what are the NODE CHARACTERISTICS?
**specific signs of malignancy, tenderness?
HARD - sign of MALIGNANCY
TENDER - sign of INFLAMMATORY PROCESS
RAPID ENLARGEMENT - sign of MALIGNANCY
SLOW ENLARGEMENT - sign of BENIGN PROCESS
**use CIRCULAR MOTIONS
**should NOT PULSATE – ARTERIES PULSATE
how do NORMAL NODES feel like?
- often 1 CM or LESS
- can feel MOVABLE + DISCRETE + SOFT + NON-TENDER
how do ABNORMAL LYMPH NODES feel like?
if ACUTE;
- can be UNILATERAL or BILATERAL
- often ENLARGED
- WARM & TENDER
- FIRM but MOVABLE
if CANCEROUS;
- can be HARD
- UNILATERAL
- NON-TENDER
- FIXED
describe HYPOTHYROIDISM
where the patient does not produce ENOUGH T4/THYROID HORMONE
symptoms;
- COLD INTOLERANCE
- INCREASED FATIGUE
- infertility
- weight gain/coarse voice
- thinner/brittle hair and nails
- heavier menses
assessment;
- thyroid tenderness/inflammation
- enlargement/goiter
- low T4 lab levels
describe HYPERTHYROIDISM
where the patient has INCREASED PRODUCTION of T4/TH
symptoms;
- rapid HR, irregular HR
- increased appetite
- weight loss
- goiter
- increased HEAT SENSITIVITY
- more BM
- BULGING EYES
assessment;
- goiter
- ECG
- swelling/enlarged neck
- tender to touch/warmer skin
- movement of gland swallowing
traumatic brain injury
often resulting from;
- transportation accidents
- violent events
- falling
- excessive alcohol ingestion
- caregiver incidents–infants or elderly
things to consider in OLDER ADULTS
- can have arthritis or osteoporosis - NECK PAIN/decreased ROM
- SPINE - KYPHOSIS
- decreased movements of the neck
- more of a NODULAR THYROID
fxn of thyroid gland
- produces T4 and T3
- hormones influence the rate at which the body uses energy, affecting processes like calorie burning, cell growth, and development
- impacts HR, digestion etc…
