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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. Headache (HA) Injury Dizziness/Syncope/Vertigo Neck Pain

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Assessment of Head, Neck, Nose, Throat

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  1. 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

  2. Subjective Data-Head • Headache (HA) • Injury • Dizziness/Syncope/Vertigo • Neck Pain • Limited ROM • Lumps or Swelling • Hx. Head or Neck Surgery

  3. 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

  4. Subjective Data-Neck • History of problems • Neck pain • Lumps • Swelling • Surgery

  5. 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

  6. 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.

  7. Objective Data-Neck • Inspect & palpate • Masses • Swelling • Bruises • Use of accessory muscles. • Alignment • Symmetry

  8. Subjective Data- Trachea • History trachea problems? • Tracheotomy • Tracheostomy

  9. Objective Data-Trachea • Palpate trachea for: • Deviations • Tenderness • Masses • Masses push trachea away from affected area, whereas atelectasis causes pull toward affected area.

  10. Subjective Data- Thyroid • History thyroid problems • Thyroid levels • Thyroid medication

  11. 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

  12. 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

  13. Palpating Thyroid • Anterior approach • Rest fingers around sternomastoid muscle place thumbs on side of trachea. Displace gland & palpate isthmus as person swallows, thyroid rises

  14. 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

  15. Thyroid • Auscultate thyroid if enlarged • Normal thyroid documented as: • Thyroid palpated as symmetric, without enlargement. Texture consistent, with no masses, nodules or tenderness.

  16. Subjective Data- Nose • Discharge • Frequent upper respiratory infections • Sinus pain • Trauma • Epistaxis • Allergies • Sense of smell

  17. 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

  18. Subjective Data- Oral cavity • Sores/lesions • Sore throat • Bleeding gums • Toothache • Dysphagia • Altered taste • Tobacco • Self-care behaviors

  19. 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

  20. Objective Data- Oral Cavity Exam • With tongue blade inspect cheeks and underside lips • With gloves and gauze- pull tongue L and R

  21. 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

  22. Summary: Assessmentof Head & Neck • Includes: • Head • Neck & Lymph nodes • Trachea • Thyroid • Nose • Oral cavity • Throat

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