nursing exam 2 head/neck assessment – Flashcards
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Assessment checklist
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1. Skull 2. Face 3. Neck 4. Health teaching
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Subjective Assessment
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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
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1. Skull Assessment (Objective)
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Inspect - general size and contour - lumps, deformities, tenderness Palpate - temporal artery and temporomandibular joint - maxillary sinus, frontal sinus
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2. Face Assessment (Objective)
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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
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3. Neck assessment
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Inspect - symmetry - range of motion - enlargement of salivary gland, thyroid gland, and lymph nodes Palpate - trachea - thyroid gland
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Symmetry
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normal: head position midline, erect and still, accessory muscles symmetric
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Range of motion
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- chin to chest - ear to shoulder - extend neck backward - resist movement with hand (cranial nerve XI)
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Salivatory glands
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non-palpable: parotid glands accessible: submandibular and sublingual glands
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Thyroid gland
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have client take sip of water -- thyroid moves up under fingers if enlarged auscultate for bruit (turbulent blood flow = hyperthyroidism)
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Lymph nodes
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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*
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Trachea
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normal: midline palpate both sides of trachea to determine shift
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Major neck muscles
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Sternomastoid and trapezius - innervated by cranial nerve XI
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Inspect for CLAPS-D
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Contusions, lacerations, abrasions, punctures, swelling, deformity
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Feel for TICS-D
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Tenderness, instability, crepitus, subcutaneous emphysema, distention
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4. Health promotion
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Prevent brain injury by wearing a helmet when bicycling How to recognize postconcussion syndrome