Head and Neck Assessment PDF

ADL113 Assessment of Head, eye, and Neck Prepared by: Dr. Shereen Abd Elmoniem professor of Medical-Surgical Nursing Faculty of Nursing/ SCU  HEAD Parts Techniques Skull &Face Inspection Eyes &Vision Palpation Ears and Hearing...

ADL113 Assessment of Head, eye, and Neck Prepared by: Dr. Shereen Abd Elmoniem professor of Medical-Surgical Nursing Faculty of Nursing/ SCU  HEAD Parts Techniques Skull &Face Inspection Eyes &Vision Palpation Ears and Hearing Percussion Nose and Sinuses Auscultation MouthandOropharynx  SKULLANDFACE Deviation from Characteristics Normal normal Rounded (normocephalic) Lack of symmetry Size, shape and Increased skull size Symmetrical symmetry Smooth skull contour. Smooth uniform Sebaceous cysts Nodules ,masses consistency Local deformities Absence of nodules or from trauma and depressions masses Masses and nodules  SKULLANDFACE Deviation from Characteristics Normal normal Increased facial hair Symmetric or slightly Thinning of eyebrows asymmetric facial features Asymmetric features; Facial features symmetric nasolabial folds. Exophthalmos myxedema facies moon face Eyes for edema Periorbital edema No edema Sunken eyes  SKULL AND FACE Deviation from Characteristics Normal normal Asymmetric facial movements Drooping Symmetry of of eyelid Symmetric Involuntary facial facial movements movements facial movements  EYES AND VISION Assessment of eye includes: External eye structures Visual fields Extra ocular muscle tests Visual acuity Eye brows Hair distribution and alignment Symmetry Skin quality Movement Eye lashes Evenness ofdistribution Direction of curl Eye lids Position in relation to the cornea Ability to blink and frequency o f blinking Lesions/edema/stye/signs of infection xanthelasma: white/yellow deposit puffy eyelids: general edema, e.g. nephrotic syndrome conjunctiva Color Texture Presence of lesions Lacrimal gland , lacrimal sac and nasolacrimal duct Edema Tenderness and Evidence of tearing Cornea Clarity and texture Perform corneal sensitivity test Anterior chamber Transparency Depth sclera, icterus: jaundice Pupils Color/shape/symmetry of size PERRLA(pupils are round and react to light and accommodation)  Visual fields Normal Deviation from normal Whenlooking straight ahead ,client Visual field smaller than can see objects in the periphery the normal (possible glaucoma) One half vision in one or both e y e s ( p o s s i b l e nerve damage) Extra ocular muscle tests  Extra ocular muscle tests Normal Deviation from normal Both eyes Eye movements not coordinated coordinated or parellel. Strabismus (cross eye): ,move in abnormal alignment of the unison ,with eyes; the condition of having parallel alignment a squint. Nystagmus : rapid involuntary movements of the eyes. Visual acuity Snellen’s chart  Refractive errors Myopia Nearsightedness Hyperopia Farsightedness Presbyopia Loss of elasticity of the lens and thus loss of ability to see close objects Astigmatism An uneven curvature of the cornea that prevents horizontal and vertical rays from focusing on the retina  Inflammation Conjunctivitis Inflammation of the bulbar and palpebral conjunctiva Dacryocystitis Inflammation of the Lacrimal sac Hordeolum (sty) Redness swelling and tenderness of the hair follicle and gland that empty at the edge of the eye lids Iritis Iflammation of the iris Contusions or hematomas “Black eyes” resulting from injury Cataracts Opacity of lens and its capsule Glaucoma Adisturbance in the circulation of aqueous fluid which causes an increase in intra ocular pressure.  Mouth Look at the tongue: cyanosed, moist or dry Cyanosis is a reduction in the oxygenation of the blood, with more than 5 g/dl deoxygenated hemoglobin. Central cyanosis (blue tongue) denotes a right-to-left shunt (unsaturated blood appearing in systemic circulation): – congenital heart disease, e.g. Fallot’s tetralogy – lung disease, e.g. obstructive airways disease. Peripheral cyanosis (blue fingers, pink tongue) denotes inadequate peripheral circulation. A dry tongue: – salt and water deficiency (often called ‘dehydration’) – also occurs with mouth-breathing.  Mouth Look at the teeth: caries, and poor dental hygiene Look at the gums: bleeding, swollen Look at the throat: swelling, redness, ulceration of tonsils or pharynx Smell patient’s breath: – Ketosis is a sweet-smelling breath occurring with starvation or severe diabetes. – Hepatic fetor : is a musty smell in liver failure.  Nose Assessment Observe external structure for symmetry Check air movement through nostril separately. Smell (CN 1 – Olfactory) not usually assessed use coffee grounds or other distinctive odor - detect odor when presented @ 10cm. Look into each nostril using otoscope /speculum – note color, septum (medial), turbinates (lateral)  NECK Assessment includes: Techniques Neck muscles Inspection Lymph nodes Palpation Trachea Auscultation Thyroid gland Carotid arteries and jugular veins Neck muscles Sternocleidomastoid muscle Trapezius muscle  Neck muscles Inspect the neck muscles Observe head movements – Move chin to the chest (sternocleidomastoid) – Move the head so that the ear is moved toward the shoulder on each side (sternocleidomastoid) – Turn the head to the right and to the left (sternocleidomastoid) – Move head back so that the chin points upward (Trapezius) Assess the muscle strength  Thyroid Inspect: then ask the patient to swallow, having given him a glass of water. Is there a lump? Does it move upwards on swallowing? Palpate bimanually: Is the thyroid of normal size, shape and texture? –The thyroid is normally soft. If there is a goiter (swelling of thyroid), assess if the swelling is: – localized, e.g. thyroid cyst, adenoma or carcinoma – generalized, e.g. autoimmune thyroiditis, thyrotoxicosis – multi-nodular. A swelling does not mean the gland is under- or overactive. In many cases the patient may be euthyroid. The thyroid becomes slightly enlarged in pregnancy. If possibility of patient being thyrotoxic, look for: – warm hands – perspiration - tremor  Examine for palpable lymph nodes In the neck: – above clavicle (posterior triangle) – medial to sternomastoid area (anterior triangle) – submandibular (can palpate submandibular gland) – occipital: best felt by sitting the patient up and examining from behind. - A left supraclavicular node can occur from the spread of a gastrointestinal malignancy (Virchow’s node). In the axilla: – abduct arm, insert your hand along lateral side of axilla, and adduct arm, thus placing your fingertips in the apex of the axilla. Palpate gently In the epitrochler region: medial to and above elbow In the groins: over inguinal ligament  Lymph nodes Palpate the entire lymph node for enlargement  Lymph nodes Generalized large, rubbery nodes suggest. Localized hard nodes suggest. Tender nodes suggest  “Lets have a brake” THANK YOU