nursing exam 2 head/neck assessment – Flashcards

1. Skull 2. Face 3. Neck 4. Health teaching

Ask questions and investigate - headaches - head injury - dizziness - neck pain or limited range of motion (ROM) - lumps or swelling - history of head or neck surgery

Inspect - general size and contour - lumps, deformities, tenderness Palpate - temporal artery and temporomandibular joint - maxillary sinus, frontal sinus

Inspect facial structures - facial expression - symmetry of movement (cranial nerve VII) - any involuntary movements, edema, lesions Abnormal findings - expressions of hostility - periorbital edema - asymmetry -- bell's palsy (cranial nerve VII paralysis); stroke - grinding of jaw, tics, fasciculations, excessive blinking

Inspect - symmetry - range of motion - enlargement of salivary gland, thyroid gland, and lymph nodes Palpate - trachea - thyroid gland

normal: head position midline, erect and still, accessory muscles symmetric

- chin to chest - ear to shoulder - extend neck backward - resist movement with hand (cranial nerve XI)

non-palpable: parotid glands accessible: submandibular and sublingual glands

have client take sip of water -- thyroid moves up under fingers if enlarged auscultate for bruit (turbulent blood flow = hyperthyroidism)

if palpable, note: size, shape, delimitation (clumped, matted), mobility, consistency, tenderness normal: pea size, movable, discrete, soft, and non-tender lymphadenopathy: enlargement of nodes ;1cm explore area *proximal to the affected node*

normal: midline palpate both sides of trachea to determine shift

Sternomastoid and trapezius - innervated by cranial nerve XI

Contusions, lacerations, abrasions, punctures, swelling, deformity

Tenderness, instability, crepitus, subcutaneous emphysema, distention

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