Health Evaluation in Nursing - Assessment of Head and Neck PDF 2021-2022

## Health Evaluation in Nursing - Assessment of Head and Neck ### 2nd Year 2021-2022 **Introduction:** Assessment of Head and neck focuses on: - Cranium - Face - Neck - Thyroid gland - Lymph node structure - Eye - Ear **Subjective Data Collection:** - Lumps presence (onset, location, size, t...

## Health Evaluation in Nursing - Assessment of Head and Neck ### 2nd Year 2021-2022 **Introduction:** Assessment of Head and neck focuses on: - Cranium - Face - Neck - Thyroid gland - Lymph node structure - Eye - Ear **Subjective Data Collection:** - Lumps presence (onset, location, size, texture) - Limited ROM of neck - Facial/neck pain - Family history of migraines, headache or head/neck cancer. - Pervious injuries to head or neck - Pain radiation to head or neck - Prior thyroid surgery - Head and neck self-care **Risk factors for head or neck injury:** 1. High-risk sports or lack of protective devices 2. Thyroid disease 3. Lymphatic enlargement 4. Immunosuppression, chronic disease and malnutrition. **Headache: ** Assess for: 1. Location 2. Onset 3. Duration 4. Precipitating factors 5. Relief factors **Assessment of Cranium** It consists of eight bones: - Frontal - Parietal - Temporal - Occipital - Ethmoid - Sphenoid **Head Abnormalities:** - **Congenital Abnormalities:** - Head shape: - Asymmetrical - Head size: - Resistance to movement - **Scalp Abnormalities:** - Extremely large or small (growth hormone) - Large, acorn shape e.g. (Paget disease of bone) **Assessment of Face:** The face consists of 14 bones: - Maxilla - Zygomatic "cheek" - Inferior conchae - Nasal - Lacrimal - Palatine - Vomer (1) - Mandible "jaw" (1) **Face Abnormalities:** - **Asymmetrical face** may be due to: - Parotid gland enlargement - Bell's palsy - Moon shaped (Cushing's syndrome) - **Facial features (Abnormalities):** - Tightened, hard face - Scleroderma - Sunken, hollow face (Cachexia) - Swollen face (nephrotic syndrome) **Assessment of the Ear:** **Subjective Data:** - Recent changes in hearing, drainage, pain, occurrence, relief - Associated factors such as sore throat, sinus infection - Dizziness, unbalanced spinning (vertigo) - Ringing or crackling in ears (Tinnitus) - Use of oto toxic medications - Last hearing check-up, history of prior surgery **Risk factors:** - **Risk for hearing loss related to:** - Genetic predisposition - Congenital anomalies, loud noise, medication, - Aging changes **Ear Abnormalities:** - **External ear:** - **Size & Shape** - Unequal size - **Position** - Pinna positioned below line from corner o eye, or unequal alignment - Malaligned or low-set ears: seen in chromosomal defects - **Lesion & Discolorations:** - Erythema, edema, nodules, areas of discoloration - Post auricular cysts seen in sebaceous glands - Ulcerated crusted nodules - Pale blue color seen in frostbite - **Tenderness:** - Pain on palpation of mastoid process with mastoiditis. - **Tympanic membrane (inspect by otoscope):** - Normally: gray in color - Red, bulging TM in-acute otitis media - Yellow bulging TM in-otitis media - Blue or dark in -Trauma where there is blood behind **Assessment of the Eye:** **Subjective Data:** - Recent change in vision, use of corrective glasses, lenses - Difficulty in night vision, double and or blurred vision - Eye infection (pain, redness, swelling, discharge, tearing) - History of prior eye surgery or trauma - Eye care habits (use of sunglasses) - Exposure to chemical (Sparks, smoke, fumes, dust) **Risk factors:** - **Risk for vision loss related to:** - Glaucoma related to DM & Family H &elderly - Age related change in vision such as cataract & myopia **Eye Abnormalities:** - **Iris & Pupil:** - Abnormalities in shape - Miosis (constricted fixed pupils) - Mydriasis (dilated fixed pupils) - Pupils are large (>5mm) - **Sclera assessment:** - Sclera with petechiae - Marked jaundice **Assessment of the Thyroid Gland:** - **Normal thyroid gland:** - Not palpable and tenderness **Subjective Data - Thyroid:** - History thyroid problems - Thyroid levels - Thyroid medication **Thyroid Gland Abnormalities:** - **Position:** - Deviates from midline - **Size:** - Enlarged lobes - Diffuse enlargement (hyperthyroidism, endemic goiter) - Graves's disease -nodule malignancy **Assessment of Cervical Lymph Nodes:** **Location:** 1. Pre-auricular: 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. Sub-mandibular: midway between angle of jaw and the tip of the mandible. 6. Submental: in the midline posterior to the tip of the mandible. 7. Superficial cervical 8. Deep cervical 9. Posterior cervical 10- Supraclavicular **Cervical Lymph Nodes Normally:** - Not palpable (size less than 1cm.) - No tenderness **Cervical Lymph Nodes Abnormalities:** - Enlarged nodes with irregular borders greater than 1 cm - Acute & chronic infection **Diagnostic Studies for Head & Neck Abnormalities:** - **X-Ray** - **Biopsy** - A biopsy is the removal of a small amount of tissue for examination under a microscope. - **Computed Tomography (CT or CAT) scan:** - A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. - **Magnetic Resonance Imaging (MRI):** - An MRI uses magnetic fields, not x-rays, to produce detailed images of the body, especially images of soft tissue, such as the tonsils and base of the tongue. **Nursing Intervention** (for MRI) - Carefully screen patients for contraindications: determine whether the patient has a pacemaker, metal plates, prosthetic joints, or other metallic implants that can become dislodged if exposed to MRI. - During an MRI, the patient is positioned supine on a table that is placed into an enclosed imager or tube that contains the magnetic field. - People who are claustrophobic may need to receive a mild sedative before undergoing an MRI. **Laboratory Investigation:** - Examine thyroid hormone test (T3-T4)