week 8: head, neck, eyes, ears, nose, mouth Flashcards
what is the skull
Protects brain/sensory organs
Includes bones of the cranium, face
Bones, sutures, orbit, upper/lower jaw
parts of the face
Facial expression, expresses mood
Facial muscles (CNV Trigeminal; mastication)
Salivary Glands (Parotid, Submandibular, Sublingual)
Temporal Artery (anterior to the ear)
parts of the neck
Sternocleidomastoid Muscle (Rotates head) and Trapezius (Shoulder Elevation)
Controlled by CN XI - Spinal Accessory
Thyroid Gland
Highly vascular endocrine gland
Synthesizes/Secretes Thyroxine (T40) and Triiodothyronine (T3)
Butterfly; has 2 lobes between tracheal/sternomastoid muscles
Hyoid Bone: Floating bone, top of the neck
Thyroid Cartilage (above thyroid, cricoid, has Adam’s apple)
Cricoid Cartilage (between thyroid and thyroid cartilage)
parts of the lymphatic system
Extensive throughout head/neck, major part of the immune system
Detects and eliminates foreign substances
Lymph nodes: Small oval clusters of lymphatic tissue
Engulfs pathogens, prevents harmful substances from entering circulation
You have to palpate all of them:
3 Around the Ear (Preauricular -> Posterior Auricular -> Occipital) -> 4 around the Jaw (Submental, Submandibular, Jugulodigastric/Tonsillar, Parotid), 4 around the Neck (Superficial Cervical, Deep Cervical Chain, Posterior Cervical, Supraclavicular,)
Use two fingers, light-to-medium touch
sinuses
Hollow areas in bones that help with voice resonance, lightens skull weight
Present at birth; in Frontal, Maxillary, Ethmoid, and Sphenoid bones
carotid artery
Common Carotid; branches into internal/external carotids up head, palpate one at a time
pediatric fontanelles
In children, the sutures are not fully formed yet.
Anterior, Posterior, Sphenoid, Mastoid Fontanelles
Skull is not yet fused when born; allows for birth, growth of the brain
Posterior closes by 1-2 months, Anterior closes by 9 months - 2 years
Normally film, slightly concave
Shrunken = Dehydration
Bulging = Increased ICP (edema, bleed, not good)
They also look like they have no neck; it’s shorter, no control of neck muscles yet
nose
First segment of respiratory system; warms, moistens, filters air in nasal cavity
Has the sinuses inside
Shaped like a triangle with 2 oval openings at the base; divided in half by the septum
mouth
First segment of the digestive system; also an airway for respiratory system
Bordered by the lips, palate, cheek, tongue
Contains teeth, gums, tongue, salivary glands (parotid, submandibular, sublingual)
Adults have 32 permanent teeth; children have up to 20 deciduous (baby) teeth
Age in months - 6 = number of teeth
Don’t give bottle while lying down = pools in mouth, tooth decay
Xerostomia: Decreased saliva production
throat
(Pharynx)
Area behind the mouth and nose
Separated from the mouth by the tonsils (check for these), uvula
eyelids
Palpebra; protects the eye from foreign substances with eyelashes
Canthus; Where they meet (medial/lateral), Caruncle (has sebaceous glands)
conjunctiva
Transparent protective mucous membrane, between eyelids, eyeball
Bulbar (on eyeball) and Palpebral (on the eyelid)
extraocular muscles
There are 6. Controlled by CN’s III, IV, VI (Most are 3, other than LR6, SO4)
sclera
the white
cornea
outer covering the helps bend light into pupil
pupil
dark, round hole - lets light in
lens
focuses light
retina
actually receives light, has photoreceptors
optic disc
where the optic nerve is
macula/fovea centralis
super high visual acuity point
ear
sensory organ for hearing and balance; conducts sounds waves
external ear
Auricle/Pinna: The swirly ear part of your ear.
External Auditory Meatus: The ear hole
External Auditory Canal: The tube that conducts sound into your ears.
Lined with glands that secrete cerumen (earwax)
Lymph fluid from external ear drains into parotid, mastoid, superficial cervical lymph nodes
tympanic membrane
Eardrum; separates the external and middle ear
Is oval, concave, pulled in by the malleus (hammer)
Normally pearly grey***, translucent, malleus is visible, “annulus” is the ring around it
middle ear
Air filled area inside temporal bone; has the ossicles
Malleus, Incus, Stapes which conduct sound from the tympanic membrane
Eustachian Tube: Connects to middle ear; allows for passage of air, equilibrates pressure when swallowing yawning
Functions: Hearing, Protects inner ear by dampening loud sounds, air pressure equalizing
Infection Drainage (via Eustachian tube) (?)
inner er
Contains the bony labyrinth; made of several parts
Vestibular Apparatus: The vestibule, semicircular canals = balance
Hearing Apparatus: The cochlea = use it for hearing
Pathways are either air conduction (using ears) or bone conduction (vibrations, our own voices)
pediatrics ears
Children have shorter, horizontal eustachian tubes; prone to infection when they move from nasopharynx to the middle ear
older adults ears
Stiff, coarse cilia and impact on cerumen:
Presbycusis: Gradual hearing loss; nerve degeneration
subjective assessment: nose
Any nasal discharge/runny nose? (rhinorrhea) Is it watery, bloody, like pus, mucus?
Any unusually frequent or severe colds? (upper respiratory infections)
Any sinus pain or sinusitis? Treatment?
Any trauma or broken your nose? When?
Any nosebleeds (epistaxis)? How often? Colour? Nostrils? Causes? Treatment?
Any allergies? What are you allergic to? Symptoms?
Any altered smell? Change/decrease? (CN I - Olfactory)
subjective data: mouth and throat
Any sores or lesions in your mouth/on the tongue/gums?
How long? Had it before? SIngle/multiple? How’d you get it? Treatment?
Any sore throat? How frequently do you get it? Have it now? When did it start? Causes?
Any bleeding gums? How long have you had it?
Any toothaches? Sensitivity to hot/cold? Lost teeth?
Sugar, Bruxism (grinding teeth)
Any hoarseness or voice change? Lump in your throat? For how long?
Any dysphagia (difficulty swallowing)?
Any altered sense of taste?
Do you smoke or consume alcohol? How many per day? Trying to quit?
Self Care; Tell me about your dental care: dentist frequency, brush/floss, dentures/appliances
subjective assessment: neck and thyroid
Do you have any thyroid problems?
Do you have any hormonal problems?
subjective assessment: head
Any unusually frequent/severe headaches? How often, what kind of pain, how long, Tx?
Any history of head injuries? When? Knocked out? How? Where? Symptoms after? Tx?
Experienced any Dizziness? Faint? Confused? Lightheadedness/Falling vs. Spinning (vertigo)
Any head or neck pain? Limitations to your range of motion?
Noticed any lumps or swelling? Recent infection/tenderness? When/Duration/Change in size?
History of head/neck surgery? What condition, when, aftermath?
Health Teaching: Sunscreen, Helmets (bikes/vehicles, sports), Seatbelts
inspection and palpation of skull
Size and Shape (Normocephalic: Round, symmetrical, proportioned to body, vs. Micro/Macrocephalic), feel scalp, hair
Palpate the temporal artery (temple; between eye and ear)
Examine Facial Symmetry, Expression, Presence of structures, abnormalities (tics)
CN VII - Raise eyebrows, frown, close eyes tightly, show upper/lower teeth, smile, puff out both cheeks - Do this if you suspect stroke
Mastoid (TMJ, CN V Trigeminal)
inspection and palpation of nose
Any symmetry, deformity of the nose
Any lesions, inflammation
Pain or break in contour while palpating
Test patency of nostrils: hold one shut, get them to breathe in with other nostril, do both
Palpate sinus areas: Below eyebrows (Frontal) and Below cheekbones (maxillary)
Pressure with no pain if normal; Pain if infected, allergies
inspection and palpation of the lips
Colour, moisture (cyanosis/pallor, cherry red w/ CO)
Cracking and lesions (Cheilitis)
inspection and palpation of the teeth and gums
Any diseased, absent, loose, misplaced teeth
Upper/lower Jaw alignment
Colour, Bleeding, Swelling of gums (Normally pink)
inspection and palpation of the tongue
Colour, surface characteristics, moisture (pinkish with thin white coating, moist)
Palpate any white patches, lesions
Ask patient to touch tongue to roof of mouth; examine underside - glistens, moist, veins, “U-shape”, palpate under as well for any problems
inspection and palpation of the buccal mucosa/palate
Inspect (inside cheeks) for colour, nodules, lesions
Inspect bony ridged palate
Look for tonsils and uvula (stick out tongue, depress it, “say ahh”); CN X - Vagus
inspection of tongue
Throat: Use a depressor, slightly off centre, halfway back
INSPECTION:
Note colour, any exudate, lesions
Observe tonsils; graded in size from 1+ - 4+ (visible to touching)
Don’t test the gag reflex
Note any halitosis (breath odour)
inspection and palpation of the neck
Symmetry of the neck: Head is central
Tracheal Symmetry; run finger down midline - tracheal shifts are bad
Palpate the thyroid gland (uncomfortable, requires shifting the trachea with one hand; palpating with the other. Landmark by going below the thyroid cartilage (adam’s apple))
Auscultate as well with bell if enlarged, listen for bruit
Palpate the Lymph Nodes (there are 11 groups), order doesn’t really matter, circular motion and touch by pressing light-medium (pushing too hard can push them in)
3 Around the Ear (Preauricular -> Posterior Auricular -> Occipital) -> 4 around the Jaw (Submental, Submandibular, Jugulodigastric/Tonsillar, Parotid), 4 around the Neck (Superficial Cervical, Deep Cervical Chain, Posterior Cervical, Supraclavicular,)
Neck Muscle Range of Motion (CN XI; Accessory) - Head rotation and Shoulder shrug + resist
subjective for eyes
Any vision difficulties? Decreased acuity, blurring, blind spots
Any eye pain? Please describe it (photophobia: sensitivity to light)
Any history of crossed eyes or double vision? (strabismus, diplopia)
Any redness or swelling in the eyes?
Any watering or discharge (excessive tearing?)
Do you use corrective lenses/contacts?
Self-care/Last eye exam?
History of ocular problems/glaucoma/conditions?
subjective for ears
Any earaches or other pains in the ears? Shallow, deep in head, hurt? Dull? Trauma?
Any ear infections? When?
Any discharge from your ears? Bloody? Pus? Odour? Ear pain?
Any trouble hearing or hearing loss? When?
Exposure to any loud environmental noise? At home or on the job?
Any ringing in the ears (tinnitus)?
Ever felt vertigo or the room or yourself spinning? Or Dizzy/lightheaded?
How do you take care of your ears? How do you clean them?
Don’t use Q-tips; use warm water + cloth
Last hearing test if you have hearing loss? Hearing aids?
Do you protect your ears if you’re around loud things?
objective for eyes inspection
General function to move around room
Observe presence of eyebrows, their movement
Eyelids and Eyelashes - Presence; note any ptosis (drooping), xanthelasma (plaque buildup on inside orbit - they’re cholesterol deposits)
Eyeballs themselves; colour of sclera, iris, pupil shape, cornea/lens
Any exophthalmos (bulging) or enophthalmos (very sunken in)
Conjunctiva/Sclera: Patient looks up, pull down lower eyelids
Should be pink lids, few blood vessels, moist/white sclera
Note any moisture
Any abnormal swelling/lesions
snellen eye chart
from 20 feet away; Normal = 20/20 vision
Numerator = Distance from chart
Denominator = Distance from which a normal eye can read; bigger = worse
Children may use Allen test or E chart
xtraocular muscles/cardinal gazes
CN III, IV, VI; 6 Directions
visual reflex test/accommodation
Finger close = Pupils constrict; Finger far = Dilate
pupillary light reflex/constriction
CN II; Dark room, shine light from side
Can measure pupil size in mm; resting size = 3-5mm
Constriction speed = brisk/sluggish/fixed (none)
Consensual Light Reflex (both pupils constrict when light is in one eye)
PEERLA
Pupils Equal, Round, Reactive to Light and Accommodation
inspecting the ocular fundus
Uses an opthalmoscope
Look through the pupil in a dark room; person looks at a distance object
Match sides; For their right eye, use your right eye, rest free hand on shoulder/head to orient
Observe the red reflex to make sure you’re centre, look at the optic disc, macula, etc.
objective ear inspection and palpation
Size (4-10cm) and shape of the auricle/pinna, symmetrical, no swelling
Skin condition, colour, lumps, lesions
Move the pinna, push on tragus, mastoid for tenderness - it should not hurt
Inspect the external auditory meatus for size, swelling, redness
Note any discharge, cerumen (some is normal)/colour, lesions, foreign bodies
otoscopy
Choose the largest speculum that will fit the canal
Pull the ear up and back for adults, straight down for children
Insert otoscope into ear upside down, brace hand along cheek for balance, insert slowly
Inspect the tympanic membrane for colour, translucency, malleus, note any Otitis media, should be flat and slightly concave at the centre, intact
hearing acuity
Whispered voice test: Test one ear while covering the other, cover mouth slightly
Whisper two syllable words and get them to repeat it
Ex., Tuesday, Armchair, Baseball, Fourteen
vestibular test
Romberg Test for balance: Hands at sides, feet together, eyes closed - Positive if they fall
DARP Documentation
D: Data
Subjective + Objective
What you (the nurse) can see, hear, touch, smell
Findings that indicate that an action needs to be taken
A: Analysis and Action
Your interpretation of the patient’s issue/concern/need
Summarize the data that informs your action
Make some sort of conclusion; things that need to be done immediately or in the future
R: Response
How the patient/client responds to the care (action/intervention)
What happened to the patient as a result of the action
Outcomes
P: Plan
Plan for care, based on observation of patient’s response
What else could be done in a given span of time
Planned interventions, further assessments, therapeutic interventions, teaching strategies
SMART goals: (Specific, Measurable, Attainable, Realistic, Timed - Also specify frequency)
