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nursing 301

head and neck assessment

QuestionAnswer
why do an assessment of the head and neck? congenital anomalies like hydrocephalus, lymphadenopathy second to infx, allergies, neoplasms, trauma to cervical spine/nerve damage, enlarged thyroid from thyroid hormonal probs and cancer probs, elderly changes
elderly changes less subq tissue make for skinny necks, rom limitations - neck will hunch over. diziness with movement
types of diziness disequilibrium, vertigo, near-syncope
disequilibrium unsteady, worse in dark, need cane or railing
vertigo spinning sensation
near-syncope feeling faint
what questions should you ask during interview? chief complaints, past history, social history, health maintenance activities
cheif complaints pain, swelling, lesions
past history trauma, thyroid swelling, infx, headaches with pain.
social hx substance use, risk activities, abuse risk
health maintenance activities safety devices
type of headaches muscle contraction, vascular, systemic, intracranial, facial/cervical
muscle contraction ha aka tension ha. vise-like. like something squeezing your head
vascular ha vessels in brain are dilated. migraines and cluster has
systemic ha fever
intracranial ha meningitis, anyeurisms
facial/cervical ha sinuses, oral/dental problems
migraine ha s/s 1-2 times a month, last about 1-3 days long. aura, n/v, throbbing sensation, one-sided, photophobia, severely limiting.
cluster ha s/s affects men more than women. occurs in heavy smokers and drinkers, emotions and stress can trigger too. clusters last weeks or months. absent for a period of time. severe but short. centered around one eye (can get teary). may occur at same time of day
nursing interventions for has acknowledge the pain, decrease light and noise, use nonpharmacologic and pharmacologic remidies
nonpharmacologic nursing interventions muscle stretching in face, massage, soothing music, herbals, warm or cool compress
pharmacologic nursing interventions seven types of triptans. cause vasoconstriction. caffiene works too.
head and neck cancer warning signs dysphagia, chronic ulcer, chronic lump in neck.
physical exam of head and scalp: inspection size, shape, symmetry, lesions
physical exam of head and scalp: palpation head for tenderness, symmetry, scalp movement, temporal arteries for hardness, thickening, and tenderness
physical exam of head and scalp: ascultation temporal arteries for bruits
abnormal findings of physical exam of head and scalp craniosynostosis, hydrocephalus, craniotabes, tenderness, lesions
hydrocephalus water on the brain
craniosynostosis early closure of sutures can lead to eye and brain damage
craniotabes second to hydrocephalus. demineralization of cranium. soft or snappy sensation like a ping pong ball
lesions cysts, lacerations from injury, hematomas or blood blisters, lipomas or fatty tumor
physical exam of face: inspection symmetry, shape, facial expressions, facial features, tics
tic muscle contraction that is regular and uncontrolled
physical exam of face: palpation tmj
tmj temporal mandibular joint. clicking, crepitus, pain. is abnormal. jaw stretching exercises encouraged.
trigeminal nerve motor and sensory
trigeminal nerve motor test for masseter and temporalis muscles. clench muscles, chew or bite on tongue blade
trigeminal nerve sensory test test forehead, cheeks, anc chin with cottonball wisps. corneal reflex if pt is onconsciuous
corneal reflex take cottonball wisp along cornea, if pt blinks, trigeminal nerve is intact
facial nerve motor and sensory
facial nerve motor test facial expressions. have pt smile, frown, close eyes, lift brows, puff cheeks. check for symmetry
facial nerve sensory test anterior taste. we don't do in hopspital. put little bit of sugar or salt into pt's hand and have them put it onto the tip of their tongue and tell you what it is.
abnormal findings for physical exam of the face. down syndrome, trigeminal neuralgia, bell's palsy, lesions
down syndrome low-set ears, flattened bridge of nose, mouth small, large tongue, slitted eyes
trigeminal neuralgia aka tic doloreaux. disorder of trigeminal nerve. pressure on nerve root. rxed with carbamazepeine, a nerve block, sometimes use surgery to rx.
bell's palsy disorder of facial nerve. infxs can cause. paralysis, tearing, salivating on one side of face.
lesions hemangioma
hemangiomas on face or tongue. benign tumor of dilated blood vessels
physical assessment of neck: inspection position, posture
physical assessment of neck: palpation ROM, strength, pain.
spinal accessory nerve motor
spinal accessory nerve motor test trapezius and sternocleidomastoid muscle. test trap by putting hands on pt's shoulder and have them shrug. should have symmetry. test sternocleido by putting hands on cheeks and having pt turn to the sides
abnormal findings for physical assessment of neck torticollis, webbing.
torticollis aka wryneck. birth trauma, if untreated it will become fibrotic and will permanently shorten muscle.
webbing excessive posterior cervical skin
physical exam of the thyroid gland: palpation posterior approach. client flexes neck down and to the side. place thumbs on back of neck. displace cartilage on one side with fingers. palpate opposite side while client swallows
physical exam of the thyroid gland: ascultation check enlarged thyroid for bruits
physical exam of lymph nodes: inspection assess for swelling
physical exam of lymph nodes: palpation size, shape, delimitation (does it feel like one or many), mobility, consistency, tenderness
lymph nodes in order of palpation preauricular, postauricular, occipital, submandibular, retropharyngeal, submental, superficial cervical, posterior cervical, deep cervical, subclavicular
lymph nodes concerns nontender, hard, matted, fixed
lymph nodes in TB cold, soft, matted, nontender
conjunctivitis will swell what node preauricular
ear infection will swell what node auriculars and cervicals
mono will swell what node anterior and posterior cervical
strep will cause swelling to what node anterior cervical
malignancies in thorax/abd will cause swelling in what node left supraclavicular aka virchow's
hodkin's lymphoma will cause swelling in what node cervicals
Created by: leaman.15 on 2008-05-05



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