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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