nursing exam 2 head/neck assessment

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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)
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)
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
Salivatory glands
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non-palpable: parotid glands accessible: submandibular and sublingual glands
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Thyroid gland
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
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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Drainage patterns of lymph nodes
Drainage patterns of lymph nodes
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Trachea
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

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