Head, Neck, Mouth, Nose, Throat and Sinus Flashcards
Glands to know
Parotid and the Sublingual and Submandibular
Developmental Considerations
In infants, cranial bones are soft and separated by a membraneous space, which allows brain to expand
Closed by 9-24 months of age
Head size is greater than chest circumference
Subjective data collection
Headache Head injury Dizziness Neck Pain Past medical history Family history Past surgeries
Objective Data Inspection
General size - Normocephalic
Facial Expressions- appropriateness, look for ptosis of the eyelids
Check for facial symmetry (features and movement)
Position of head (midline, erect and still)
Inspect hair for lesions, scabs, parasites, nits or scaliness)
Range of motion
Objective Data: Palpation
Head/skull: palpate for shape
Objective data for lymph nodes
Normal nodes feel movable and soft
If the nodes are enlarged, check the area they drain for the source of the problem
Lymph nodes: Palpation
Use gentle circular notion with pads of fingers
Easily palpable nodes are not found in adults
Nodes are normally small, movable, less than a centimeter in diameter
Note: location, size, consistency, shape, tenderness, movability, or fixation
Best way to palpate the thyroid
Posterior approach is easiest
Move behind pt
Bend head slightly forward and to right
Use fingers of your left hand to push trachea to right
You should not be able to palpate the normal adult thyroid!
Ask client to swallow and note movement of thyroid
Note enlargement or nodules
Note size, shape, consistency, and presence of nodules
If thyroid is enlarged, auscultate for bruit. (normally absent)
Pregnant females may have slightly enlarged thyroid glands.
If thyroid gland is enlarged, what do you do next?
Auscultate for a bruit: soft, whooshing, blowing sound
If there is no bruit sound, does that mean your thyroid gland is fine and okay?
No, not neccessarily. The presence of a bruit is abnormal, but its absence does not mean thyroid gland is totally fine
Talk about the nose …
Nares widen into vestibules, nose has rich blood supply, contains cilia that traps dust and debris, numerous nasal hairs to filter air
Describe sinuses
Air filled extensions of the nasal cavity within the bones of the skull. Lined by ciliated mucous membranes
Developmental Considerations
Salivation begins at 3 months of age and infant drools until swallowing is learned
Teeth begin to erupt in children by 6-24 months. Twenty deciduous teeth (temporary) and begin to loose by age 6 through age 12
Pregnant women- increase estrogen levels cause increase vascularity in nasal area
Subjective data for nose
Nasal discharge Frequent Colds Sinus Pain Trauma Snoring Allergies Stuffiness Altered smell Epistaxis
Subjective for Mouth and Throat
Sore or lesions Self Care Practices SOre Throat Altered Taste Bleeding Gums Smoking and Alcohol use Toothache Hoarseness Dysphagia Dysphasia
Objective Data Inspection for Mouth and Throat
Soft palate should be continuous with hard palate note lesions, ulcerations, pain, or discharge
Uvula should be midline and soft palate rise with saying ”ah”- CN IX and X
Depress tongue with a tongue blade scan the posterior wall for color, exudate, or lesions including tonsils
Inspecting the Tonsils
1+ Visible 2+ Half between tonsillar pillars and uvula 3+ Touching the uvula 4+ Touching each other Normal is +1 to +2
Nose Inspection
Midline, inspect for deformities, assymmetry
The C1 vertebrae that helps support the cranium is known as the _____________ while the C2 vertebrae is known as the ________________.
atlas ; axis
Coronal, Sagittal and Lamboid sutures are each unions of which bones?
Coronal is the union between the frontal and parietal bones
Sagittal is union between two parietal bones
Lamboid is union between parietal bones and occipital bone.
What are palpebral fissues ?
These are the openings between the eyelids. They should be equal bilaterally.
What are the nasolabial folds ?
These are the creases which extend from the nose to the corner of the mouth should be symmetric.
Parotid glands are what ?
The largest of the salivary glands- they are in the cheek over the mandible and are not normally palpable.
Where can you palpate the temporal artery?
Anterior to the ear. The temporal artery lies superior to the temporalis muscle.
The major neck muscles are …………
they are innervated by what cranial nerve?
the trapezius and sternomastoid muscles
Innervated by the spinal accessory cranial nerve (XI)
The greatest supply of lymph nodes are in the ____________
head and the neck
such as the preauricular (in front of the ears)
the submandibular (below the mandible)
the supraclavicular (above the clavicle)
and more
What to ask about headaches ?
any unusually frequent or unusually severe headaches ?
Subjective data collection for head, face and neck
- Headache
- Head injury
- Dizziness
- neck pain
- lumps or swelling
- head or neck surgeries
family history of head/neck cancers/thyroid problems
the thyroid cartilage is called the ____________ in males.
Adam’s apple
What is the TMJ?
The temporomandibular joint - it should be palpated as client opens mouth
Tracheal deviation - when is the trachea pulled toward the affected (diseased side)?
WIth large atelectasis, pleural adhesions or fibrosis
When is the trachea pulled toward the unaffected (or healthy side)
with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement and pneumothorax
What do normal lymph nodes feel like?
movable, discrete, soft and non tender.
if nodes are enlarged, what should I do?
Check the area they drain for the source of the problem
What is lymphadenopathy?
Enlargement of lymph node greater than 1 cm that can be caused by infection , allergy or neoplasm
There are how many groups of lymph nodes in the face and neck?
10 groups of lymph nodes
- Preauricular
- Posterior Auricular
- Occipital
- Submental
- Submandibular
- Jugulodigastric
- Superficial cervical
- Deep cervical chain
- Posterior cervical
- Supraclavicular
Are lymph nodes easily palpable in adults ?
the answer is no,
If the thyroid gland is enlarged, what should one do?
Auscultate it with the bell of stethoscope for the presence of a bruit indicating hyperplasia of the thyroid.
The bruit is not present normally
Pregnant women may have slightly enlarged thyroid glands. True or False?
True
The newborn infants head size should be 2 cm larger than chest circumference. True or false?
At what age are both measurements the same
True
By age 2 both measurements, head size and chest circumference are the same.
During childhood, chest circumference grows to exceed head circumference by 5-7 meters
Caput Succedaneum is what ?
This is a edematous swelling and ecchymosis (discoloration of the skin) of the presenting part of the head caused by birth trauma , which gradually resolves during the first few days of life and needs no treatment
What are some nursing diagnoses related to the head and neck?
Self-care deficit
Body image disturbance R/T scalp dryness
Risk for impaired skin integrity R/T pruritus (severe itching of the skin)
What are sinuses ?
These are air filled extensions of the nasal cavity within the bones of the skull. They are lined by ciliated mucous membranes.
frontal, ethmoid and maxillary sinuses
The uvula is an extension of the _________
soft palate
When does salivation begin ?
At 3 months of age and infant drools until swallowing is learned
When do teeth begin to erupt in children?
By 6-24 months. 20 teeth are normally in place by 2 1/2 years of age. Teeth begin to be lost at age 6 until 12 years of age
Pregnant women have increased what in the nasal area because of high estrogen levels?
Increased vascularity
Newborns are ____________ breathers so it is important to determine the patency of their nares.
nose
The soft palate should be _____________ with the hard palate .
continuous
What is the inspection grading for tonsils ?
1+ Visible 2+ Half between tonsillar pillars and uvula 3+ Touching the uvula 4+ Touching each other Normal is +1 to +2
Nursing diagnoses for mouth, nose and throat
Altered oral mucous membrane
Impaired swallowing
Pain
Sensory/perceptual alterations: olfactory
Sensory/perceptual alterations: gustatory
What is nystagmus ?
Involuntary movement of the eyes. .. known as dancing eyes
What is pneumothorax?
A collapsed lung
What is hyperplasia ?
the enlargement of an organ or tissue caused by an increase in the reproduction rate of its cells
What is neoplasm ?
new and abnormal growth of new tissue
