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Assessment of Head, Neck, Nose, Throat. NUR123 Spring 2009 K. Burger, MSEd, MSN, RN, CNE PPP by: Victoria Siegel RN, CNS, MSN Sharon Niggemeier RN, MSN Revised by: Kathleen Burger. Subjective Data-Head. Headache (HA) Injury Dizziness/Syncope/Vertigo Neck Pain

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assessment of head neck nose throat

Assessment of Head, Neck, Nose, Throat

NUR123 Spring 2009

K. Burger, MSEd, MSN, RN, CNE

PPP by: Victoria Siegel RN, CNS, MSN

Sharon Niggemeier RN, MSN

Revised by: Kathleen Burger

subjective data head
Subjective Data-Head
  • Headache (HA)
  • Injury
  • Dizziness/Syncope/Vertigo
  • Neck Pain
  • Limited ROM
  • Lumps or Swelling
  • Hx. Head or Neck Surgery
objective data head skull and face
Objective Data-HeadSKULL and FACE
  • Normocephalic
  • Cranium (Skull): Inspect and palpate
  • Temporal area:Inspect & palpate temporal arteries temporomandibular joint
  • Face: Inspect and palpate, note symmetry, involuntary movement, color, texture, masses, lesions
subjective data neck
Subjective Data-Neck
  • History of problems
  • Neck pain
  • Lumps
  • Swelling
  • Surgery
objective data lymph nodes
Objective Data – Lymph Nodes
  • Palpate all 10 nodal areas beginning with the: Preauricular nodes and ending with the Supraclavicular nodes.
  • Use gentle pressure and slight circular motion. Palpate both sides simultaneously
  • Note enlargements ( bi or unilateral ) by location, size, mobility, tenderness
  • If nodal enlargement – check the area they drain for S/S of inflammation, neoplasm
objective data neck
Objective Data-Neck
  • Inspect- symmetry, midline, erect
  • Palpate- carotid pulse Any abnormal pulsations?
  • Note enlargement of lymph nodes
  • Test for ROM, naturally decreases with age.
  • Auscultate carotid arteries.
objective data neck1
Objective Data-Neck
  • Inspect & palpate
  • Masses
  • Swelling
  • Bruises
  • Use of accessory muscles.
  • Alignment
  • Symmetry
subjective data trachea
Subjective Data- Trachea
  • History trachea problems?
  • Tracheotomy
  • Tracheostomy
objective data trachea
Objective Data-Trachea
  • Palpate trachea for:
  • Deviations
  • Tenderness
  • Masses
  • Masses push trachea away from affected area, whereas atelectasis causes pull toward affected area.
subjective data thyroid
Subjective Data- Thyroid
  • History thyroid problems
  • Thyroid levels
  • Thyroid medication
objective data thyroid
Objective Data-Thyroid
  • Inspect: note deviations or bulges
  • As person extends neck slightly and swallows water, note upward, symmetrical movement of trachea and other cartilage
palpating thyroid
Palpating Thyroid
  • Ask person to tilt head slightly to side and palpate lobes.
  • Use fingers on opposite side to displace gland in lateral direction, ask person to swallow: isthmus rises
palpating thyroid1
Palpating Thyroid
  • Anterior approach
  • Rest fingers around sternomastoid muscle place thumbs on side of trachea. Displace gland & palpate isthmus as person swallows, thyroid rises
palpating thyroid2
Palpating Thyroid
  • Posterior approach
  • Rest thumbs on back of person’s neck, place fingers on cricoid cartilage. Displace gland & palpate isthmus as person swallows, thyroid rises
thyroid
Thyroid
  • Auscultate thyroid if enlarged
  • Normal thyroid documented as:
  • Thyroid palpated as symmetric, without enlargement. Texture consistent, with no masses, nodules or tenderness.
subjective data nose
Subjective Data- Nose
  • Discharge
  • Frequent upper respiratory infections
  • Sinus pain
  • Trauma
  • Epistaxis
  • Allergies
  • Sense of smell
objective data nose
Objective Data- Nose
  • Inspect external nose:

symmetry, deformity, lesions

  • Palpate sinuses, note tenderness
  • Test patency of each nostril
  • Inspect using nasal speculum:
    • Color and integrity of nasal mucosa
    • Septum- note any deviation,perforation, bleeding
    • Turbinates- Note color, exudate, swelling
subjective data oral cavity
Subjective Data- Oral cavity
  • Sores/lesions
  • Sore throat
  • Bleeding gums
  • Toothache
  • Dysphagia
  • Altered taste
  • Tobacco
  • Self-care behaviors
objective data oral cavity exam
Objective Data- Oral Cavity Exam
  • Inspect and palpate:
  • Note condition gums, mucosa, teeth (caries? # of teeth malocclusion)
  • Lips: (lumps, lesion, cracking,color)
  • Tongue: color, moisture, surface characteristics. Check for white patchesWharton’s Duct: opening of submandibular glands
  • Stensen’s Duct: opening of parotid salivary glands
  • Remember proper PPE
objective data oral cavity exam1
Objective Data- Oral Cavity Exam
  • With tongue blade inspect cheeks and underside lips
  • With gloves and gauze- pull tongue L and R
objective data throat
Objective Data- Throat
  • Inspect uvula, palate, tonsils
  • Uvula looks like hanging pendant (if split in two= bifid)
  • Palate:anterior hard palate=whitish
  • posterior soft palate = pinkish
  • Tonsils- graded by enlargement:
  • 1+ visible 2+ near uvula
  • 3+ touching uvula 4+ touching together
summary assessment of head neck
Summary: Assessmentof Head & Neck
  • Includes:
  • Head
  • Neck & Lymph nodes
  • Trachea
  • Thyroid
  • Nose
  • Oral cavity
  • Throat
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