Nursing Assessment of Head and Neck

 

The Head and Neck

Head and neck assessment focuses on cranium , face ,thyroid gland , lymph node structure.

1. Cranium : ( frontal , parietal, temporal , occiptial , ethmiod , spheniod)

2. Face : ( maxilla, zygomatic, lacrimal , mandible , nasal )

3. Neck

4. Muscles and cervical vertebrae

5. Blood vessels : ( jugular, carotid)

6. Thyroid gland

7. Lymph node of the head and neck

 

Head  anatomy

 

Subjective Data

  • Have you noticed any lesion or lumps on your head or neck that not heal or disappear ?
  • Do you have any difficult moving your head or neck ?
  • Do you have experience neck pain ? Describe
  • Do you have any facial pain? Describe .
  • Describe any pervious head or neck problems ? ( past history)
  • Have you ever undergone radiation therapy for problem in your neck region? (past history)
  • Is there history of head neck cancer in your family ? ( family history )
  • PQRST
  • Headaches
  • Jaw tightness/pain
  • Neck pain
  • Nasal congestion/nose bleeds
  • Mouth lesions
  • Sore throat/hoarseness

 

Nursing Assessment of Head, Neck

  • Position: Sitting
  • Approach : anterior – posterior
  • Equipment
  • 1. Penlight, Transilluminator of light
  • 2.Stethoscope
  • 3.Glass of water
  • 4.Tongue depressor
  • 5.Tape measure
  • 6.Gloves
  • 7.Gauze 4×4
  • 8.Nasal speculum or ophthalmoscope
  • Technique :
  • Inspection , Palpation , Percussion , Auscultation

 

Nursing Assessment of the Head

The skull is generally round , support and protect the brain sensory organs and other structure .

  • Contour
  • Shape
  • Hair
  • Scalp
  • History of trauma

 

Inspection

  • Head size , shape and configuration
  • Inspect head involuntary movement
  • Face : facial expression and movement , color , or any abnormalities in shape , contour or symmetry
  • Inspect skin face lesion , rash, swelling, redness
  • Eye are equidistant both midline and laterally and that the align horizontally with helix, the prominent outer rim of ear

Palpation

  • Palpate the head for symmetry and contour ; then palpate the scalp, using a gentle rotary movement of fingertips.
  • Gently palpate bilateral the face to assess skin tone and facial contour
  • Facial muscle by palpate the skin of cheeks for recoil.
  • Evaluated Temporomandibular joint by palpated place the middle three finger of each hand bilaterally over each joint then gently press on the joint , as the client to open and close the mouth
  • Palpate the muscle on both sides of the face while the client smiles, frown , grits the teeth and puffs out of the cheek.
  • Check temporal artery pulse the should equal and strength and rhythm.

 

Auscultation

Auscultate over major vessels of the head ( temporal , occipital arteries) by using bell of the stethoscope

 

Assessment of the Neck

  • Rang of motion (ROM)
  • Muscle strength
  • Lymph nodes
  • Cervical vertebrae
  • Trachea
  • Thyroid Gland
  • Assessment done by inspection and palpation.
  • Full range of motion is assessed by asking the client to tilt the head backward and side to side.
  • Inspect neck should be symmetrical. No neck vein distention should be visible.
  • Trachea should be centered , move easily. place your fingers in the sternal notch feel each side of the notch and palpate the tracheal rings when the clients swallow.
  • On the posterior aspects of the neck the cervical vertebrae are inspected and palpated for symmetry, tenderness, masses or swelling.

 

Assessment of the Thyroid Gland

Thyroid Gland

 

assessment of Thyroid Gland

 

 

Palpation of the Thyroid Gland

  • Normal thyroid gland not palpable.
  • Stand behind the client . Ask to lower chin to the chest and turned neck slightly to right to relax the client’s neck .
  • Place your thumb on the nap of client’s neck and other finger on either side of trachea below the cricoid cartilage
  • Use your left finger to push the trachea to the right .
  • Then use your right fingers to feel deeply in front of the steromastoid muscle
  • Ask the client to swallow as you palate the right side of the gland.
  • Reverse the technique to palpate the left lobe of the thyroid

 

Auscultation an enlargement thyroid gland

  • If enlargement of thyroid gland is detected, the area over the gland is auscultated for a bruit.
  • N.B: In enlargement of gland, blood flow through arteries is increased and produces vibrations that heard with the bell of stethoscope as a soft, rushing sound or bruit.

 

Location of Lymph Nodes

Lymph Nodes

 

Assessment of lymph nodes in head and neck areas:

1. Preauricular: in front of the ear.

2. Mastoid or posterior auricular : behind the ear. Above the mastoid process.

3. Occipital : at the base of skull posterior.

4. Parotid : near the angle of the jaw.

5. Submandibular : midway between angle of jaw and the tip of the mandible.

6. Submental : in the midline posterior to the tip of the mandible.

 

Nursing Assessment of the lymphatic system

  • Lymphatic System consists of a network of collecting ducts, lymph fluids
  • Examination of lymphatic system for enlargement indication of infection or malignancy.
  • Examination of lymphatic System done firstly by inspection for enlarged lymph nodes, skin lesions, edema, erythematic
  • Second step is palpating gently the lymph nodes areas using pads of “2, 3, 4″ fingers in gentle circular motion.
  • When detecting Lymph node you must describe according to location, size, regularity, and consistency.
  • N.B enlarged nodes due to malignancy are generally not tender vary in size, hard, asymmetrical.

 

Nursing Assessment of the neck muscle

neck muscle

Sternocleidomastoid muscle divides the neck into anterior and posterior triangles – so you can assess:

  • Anterior superficial nodes – in the anterior triangle of the neck.
  • Posterior cervical nodes – in the posterior triangle of the neck.
  • Deep cervical nodes – very deep and difficult to be examine.
  • Supra clavicular nodes – In the angle formed by clavicle and Sternocleidomastoid muscle.
  • N.B To enhance accurate palpation has client bend head forward or toward the side of neck to be examined

 

Assessment of the Nose

Assessment of the Nose

 

 

  • Nose
  • Color
  • Position
  • Septal deviation
  • Color
  • Cranial Nerve I (Olfactory)
  • When inspecting the nose, nurse observes for asymmetry, inflammation, and deformity.
  • Normally the external nose is symmetrical, strait, non tender, and without discharge.
  • Assess mucosa which is normally pink in color.
  • Yellowish or greenish discharge – means sinus infection.
  • Pale mucosa with clear discharge – means allergy.
  • N.B: For client with NGT nurse routinely checks for local breakdown of skin “Excoriation” of the nostrils characterized by redness and sloughing of the skin.

 

Assessing the Sinuses

Assessing the Sinuses

 

Frontal and maxillary sinuses are examined for pain and edema.

palpate sinuses both frontal and maxillary for tenderness, which verbalized by client during exam.

Percuss sinuses for resonance which is normally hollow tone, and noting abnormality e.g. flat, dull tone elicited or expresses pain on percussion.

Assessing the Sinuses

 

Sinus Transillumination

Sinus Transillumination

 

Sinus Transillumination

Absence of light indicates mucosal thickening or full sinuses

 

Structure of the Mouth

Structure of the Mouth

 

Assessment of Mouth & Tongue

  • Assess lips and oral mucosa
  • Color
  • Texture
  • Moisture
  • Odor
  • Symmetry with movement (Cranial Nerve VII & XII)
  • Taste (Cranial Nerve VII and IX)

Assessment of Mouth and pharynx

  • Assessment of oral cavity can be made during administration of oral hygiene.
  • Lips – inspected for color, texture, hydration, contour, and lesions.
  • Inner and buccal mucosa for ulcers, abrasions
  • Assessment of palate “soft and hard” by extending client’s backward, assessment for color, shape, texture, and extra bony prominences or defects.
  • Assessment for pharynx done: by using tongue depressors.
  • Pharyngeal tissues are normally pink and smooth.
  • Edema, ulceration, or inflammation indicates infections or abnormal lesions.

 

Assessment of the Throat

Assessment of the Throat

  • Hard & soft palate
  • Uvula movement Cranial nerve IX
  • Gag reflex
  • Cranial nerve X

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