ASSESSING THE HEAD, NECK AND RELATED LYMPHATICS

ASSESSING THE HEAD, NECK AND RELATED LYMPHATICSEDWIN DR. ABU RN,MNFACULTY, COLLEGE OF NURSINGAteneo de Zamboanga UniversityTERMINOLOGIESACROMEGALY An enlargement of the skull and cranial bones due to increased growth hormone.ANTERIOR TRIANGLE One of the trapezius muscles, also innervated by cranial nerve XI, originates on the occipital bone of the skull and spine of several vertebrae and the insertion of these muscles is on the scapulae and lateral third of the clavicles. The mandible, the midline of the neck, and the anterior aspect of the sternocleidomastoid muscles border this triangle.ATLAS The first cervical vertebra (which carries the skull).

AXIS The second cervical vertebra (C2), allows for movement of the head.BELL'S PALSY A temporary disorder affecting cranial nerve VII and producing a unilateral facial paralysis.GOITER Enlarged thyroid caused by an iodine deficiency.HYDROCEPHALUS The enlargement of the head caused by inadequate drainage of cerebrospinal fluid, resulting in abnormal growth of the skull.

HYPERTHYROIDISM The excessive production of thyroid hormones, resulting in enlargement of the gland, exophthalmos (bulging eyes), fine hair, weight loss, diarrhea, and other alterations.HYPOTHYROIDISM Metabolic disorder causing enlarged thyroid due to iodine deficiency.HYOID A bone that is suspended in the neck approximately 2 cm (1 in.) above the larynx.LYMPHADENOPATHY The enlargement of lymph nodes due to infection, allergies, or a tumor.

POSTERIOR TRIANGLE One of the trapezius muscles, also innervated by cranial nerve XI, originates on the occipital bone of the skull and spine of several vertebrae and the insertion of these muscles is on the scapulae and lateral third of the clavicles. The trapezius muscle, the sternocleidomastoid muscle, and the clavicle form the posterior triangle.SUTURES Nonmovable joints.THYROID GLAND The largest gland of the endocrine system.It is butterfly shaped, and is located in the anterior portion of the neck.TORTICOLLIS A spasm of the sternocleidomastoid muscle on one side of the body, which often results from birth trauma.

PURPOSESAssess condition of clients head, neck, thyroid gland and lymph nodes by gathering subjective and objective data.Use data to assess clients general health condition.Differentiate expected from unexpected findings in physical assessment.EQUIPMENTSPrepare a warm, comfortable and private assessment environment.Prepare the following equipments: examination gloves, glass of water, stethoscopeINTERVIEW ASSESSMENTDo you have any problems that affect your scalp?Describe the condition of your scalp today. Is it different from two months ago, two years ago?Have you experienced hair loss (gradual, sudden, symmetrical). Have you experienced recent change in texture, appearance?INTERVIEW ASSESSMENTIs there anyone in your family who has had a problem with their scalp or a problem that affected their scalp?Do you have any problems that affect your neck or thyroid (or trachea)Neck pain, limitation of motionLumps or swellingHistory of head or neck injuryIs there anyone in your family who has had a problem with their thyroid (or trachea)?

PREPARATIONKnow the norms or expected findings to determine the meaning of the data as one proceeds in the examination.Identify client and introduce self.Explain each step of the procedure, including specific instructions about what is expected of the client such as removal of hats and jewelry may be required for thorough assessment.PREPARATIONExplain the purpose of each procedure and if and when discomfort will accompany any procedure. Tell the client to inform you of any discomfort or difficulty during the assessment.Provide for client privacy.Perform hand hygiene and adhere to standard precautions.TECHNIQUE (HEAD EXAMINATION)Practice proper hand hygiene before seeing a client.Ensure all equipments are properly cleaned.After an assessment interview, instruct the client by telling him/her that you will be examining his/her head, neck and thyroid gland.It is best to have client sit comfortably. Start by inspecting the face and hair.Ask client to remove items that would interfere with the assessment including jewelry, hairpieces or wigs.Note facial expression, symmetry of structure.Note the size, shape, symmetry and integrity of head and scalp. Identify prominences or irregularities of the head. Note any unexpected findings.Put on gloves.Part the hair & systematically evaluate the characteristics of the hair and scalp. Evaluate hair distribution, quality, quantity and hygiene.Inspect scalp for scaliness, lesions or foreign bodiesThoroughly palpate scalp, noting contour, size texture and areas of tenderness.Palpate the temporal artery. Palpate between eye and top of ear. The artery between eye and top of artery should feel smooth.Auscultate the temporal artery. Use the bell of stethoscope to auscultate for a bruit or a soft blowing sound.Remove gloves and dispose properly.THYROID & LYMPH EXAMINATIONInspect neck for skin color, integrity, shape and symmetry.Observe the carotid arteries and jugular veins for distention or pulsations.Palpate the external notch. Lightly palpate the area and feel the C-rings of the trachea. Identify the lateral borders of the trachea. As the trachea begins to widen, you have identified the thyroid cartilage. Continue to slide your thumb and index finger high into the neck.Inspect the thyroid gland. Distinguish the thyroid from other structures in the neck by asking the client to drink a sip of water.Palpate thyroid gland from behind the client. As client swallows, it moves superiorly.With the fingers of your left hand, push the trachea to the right. With your right hand fingers, gently palpate the thyroid gland as it moves up during swallowing.Reverse the procedure for the left side.Palpate the hyoid bone. Confirm that the hyoid bone and tracheal cartilages move when the client swallows.To evaluate the thyroid from the front, gently displace the sternocleidomastoid muscle with the left hand. Feel for any thyroid enlargement of the right lobe as the client swallows.Reverse the procedure for the left side.If the thyroid is enlarged, auscultate the gland with the bell of the stethoscope. Note any bruit or vascular sounds.Palpate the lymph nodes by applying gentle circular pressure with the finger pads of both hands. Begin with the pre-auricular. Move next to the post-auricular and occipital nodes. Ask the client to bend head to relax the muscles and make the nodes easier to palpate.Next, move more anteriorly to evaluate the retro-pharyngeal and sub-maxillary nodes. The submental nodes are located directly under the chin.There are additional lymph node chains that should be evaluated. These include the superficial cervical chain and the deep cervical chain.Finish the lymph node examination by evaluating the supraclavicular lymph nodes located superior to the clavicles.SAMPLE DOCUMENTATIONSNurses NotesSubjective DataDenies problems with the head and neck, reports no current headache, no lesions, and no changes in skin or hair. Recalls no problem with swollen glands or breathing. No personal or family history of headache, allergy, or thyroid disease. Takes 2 Tylenol for occasional headache, that is once a week during busy season at work (1 month) and maybe one a month. Headache is associated with lack of sleep or stress and relieved with single dose (2 tablets) of Tylenol. Weight has been constant for several years.Objective DataSkull round with symmetrical protuberances. Skull nontender to palpation. Hair even distribution, scalp free of lesions, clean. Eyebrows symmetrical, equal distances of brow to pupil and outer canthus to pinna. Nose is midline with equal nasolabial folds. Lips symmetrical. Facial movement and expression symmetrical. Trachea mobile, midline with palpable C rings. TMJ movement smooth and symmetrical. Thyroid nonpalpable, rises with swallow. Lymph nodes of neck nonpalpable.ASSESSMENT FORMGeneral Overview NeckSkull: round, symmetrical Trachea: midline, mobile, C rings palpable Protuberances: symmetrical Thyroid: nonpalpable, rises with swallow Hair: even distribution Lymph NodesScalp: clean, no lesions PALPABLE NO YES Eyes Preauricular: x Brows: symmetrical Postauricular: x Distance Brow to Pupil: equal Occipital: x Distance Outer Canthus to Pinna: equal Retropharyngeal: x NoseSubmaxillary: x Position: midline Submental: x Deviation: none, straight Superficial cervical: x Nasolabial Folds: equal Deep cervical: x Supraclavicular: x MouthLips: symmetrical