Assessment of Head, Neck and Related Lymphatics
Objectives
1. Identify the anatomy and physiology of the structures of the head and neck.
2. Develop questions to be used when completing the focused interview.
3. Describe the techniques required for assessment of the head and neck.
4. Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.
5. Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.
6. Discuss the focus areas related to the overall health of the head, neck, and related lymphatics as presented in Healthy People 2010.
7. Apply critical thinking in selected simulations related to physical assessment of the head, neck, and related structures.
Overview
- The integration of body systems and regions begins with the head and neck.
- The head provides a means of identifying individuals through the uniqueness of hair, eyes, and facial characteristics.
- With assessment of the head and neck, clues to the client’s nutritional status, airway clearance, tissue perfusion, metabolism, level of activity, sleep, rest, stress, and self-care abilities will be identified.
Anatomy and physiology review
- The skull is made up of the bones of the cranium and the face.
- The cranium includes frontal, parietal, temporal, and occipital bones.
- The muscles of the face play a role in expression of emotions and assist in neck movement.
- Movement of the facial muscles is controlled by cranial nerves V and VII.
- The carotid arteries provide the blood supply to the head; the temporal artery supplies blood to much of the face.
- The neck is supported and made mobile by vertebral processes and the sternocleidomastoid and trapezius muscles.
- The neck muscles divide the neck into the anterior and posterior triangles.
- The hyoid bone, superior to the larynx, is the only bone in the body that does not directly articulate with another bone. It serves as a movable base for the tongue, and an attachment for muscles of the neck.
- The thyroid gland is in the middle of the neck anterior to the trachea. The isthmus is the center, and the two lobes lie on either side of the trachea.
- The nine sets of lymph nodes drain the head and neck.
Gathering the data
- Comprehensive assessment of the head and neck includes gathering subjective and objective data about the head, the face, and structures of the neck including the trachea, thyroid, and lymph nodes.
- The focused interview includes general and specific questions to elicit subjective data about the head and neck.
- Physical assessment of the head and neck proceeds in an organized fashion and includes inspection and palpation of the skull, inspection and auscultation of the temporal artery, inspection of the face, and palpation of the trachea, thyroid gland, and lymph nodes.
- The structures of the head and face should be symmetrical, and facial movements should be smooth.
- The neck should have full range of motion and appear without swelling or discoloration.
- The trachea is midline and mobile.
- The thyroid is visible upon swallowing and should not be palpable.
- The lymph nodes of the head and neck are the pre- and postauricular, occipital, tonsillar, submandibular, submental, superficial and deep cervical, and supraclavicular. All nodes should be nonpalpable.
Abnormal findings
- Abnormal findings in the head and neck include headaches, abnormalities in the size and shape of the skull, malformations or abnormalities of the face and neck, and thyroid disorders.
- Headaches include migraine, cluster, and tension headaches.
- Hydrocephalus, craniosynostosis, and acromegaly are some abnormalities of the skull.
- Abnormalities of the face and neck include Bell’s palsy, Cushing’s syndrome, Down syndrome, Parkinson’s disease, paralysis following brain attack, fetal alcohol syndrome, and torticollis.
- Thyroid disorders include hypothyroidism and hyperthyroidism.
- Hypothyroidism occurs congenitally, postpartally, as an autoimmune disease, and with aging.
- Hyperthyroidism occurs in Grave’s disease, with thyroiditis, and as a result of excessive iodine in some medications.
- Females with a family history of thyroid dysfunction should have regular thyroid testing.
- Thyroid dysfunction typically occurs in males and females after the age of 60.
- Medications with excessive iodine may cause thyroid dysfunction. The nurse should provide information about medications and side effects to all clients.
- Depression in old age may be associated with hypothyroidism. Clients should be advised to seek healthcare if the symptom occurs.
Glossary
acromegaly An enlargement of the skull and cranial bones due to increased growth hormone.
anterior triangle One of the trapezius muscles, also innervated by cranial nerve XI, originates on the occipital bone of the skull and spine of several vertebrae and the insertion of these muscles is on the scapulae and lateral third of the clavicles. The mandible, the midline of the neck, and the anterior aspect of the sternocleidomastoid muscles border this triangle.
atlas The first cervical vertebra (which carries the skull).
axis The second cervical vertebra (C2), allows for movement of the head.
Bell's palsy A temporary disorder affecting cranial nerve VII and producing a unilateral facial paralysis.
goiter Enlarged thyroid caused by an iodine deficiency.
hydrocephalus The enlargement of the head caused by inadequate drainage of cerebrospinal fluid, resulting in abnormal growth of the skull.
hyperthyroidism The excessive production of thyroid hormones, resulting in enlargement of the gland, exophthalmos (bulging eyes), fine hair, weight loss, diarrhea, and other alterations.
hypothyroidism Metabolic disorder causing enlarged thyroid due to iodine deficiency.
hyoid A bone that is suspended in the neck approximately 2 cm (1 in.) above the larynx.
lymphadenopathy The enlargement of lymph nodes due to infection, allergies, or a tumor.
posterior triangle One of the trapezius muscles, also innervated by cranial nerve XI, originates on the occipital bone of the skull and spine of several vertebrae and the insertion of these muscles is on the scapulae and lateral third of the clavicles. The trapezius muscle, the sternocleidomastoid muscle, and the clavicle form the posterior triangle.
sutures Nonmovable joints.
thyroid gland The largest gland of the endocrine system.It is butterfly shaped, and is located in the anterior portion of the neck.
torticollis A spasm of the sternocleidomastoid muscle on one side of the body, which often results from birth trauma.
The head, face, and neck form a large portion of what is often referred to as the head, eyes, ears, nose, and throat (HEENT) system. This is actually a complex set of varied organs, combined during assessment because of their proximity to one another and the integration among the components of the system. The HEENT encompasses almost all of the systems: integumentary, respiratory, cardiovascular, gastrointestinal, musculoskeletal, neurological, endocrine, and lymphatic. The vascular, neurological, and musculoskeletal components of the HEENT, as well as the eyes and ears are covered in separate chapters. The components addressed in this chapter include the head, face, nose sinuses, neck , mouth ,and pharynx. These components are complex in their actions and are involved in expression, communication, nourishment, respiration, and sensation, among other functions. Furthermore, disorders involving the head and face can be devastating to patients because they can greatly affect appearance. Even minor disorders involving the head, face, or neck can be perceived as disfiguring by patients.
Anatomy and Physiology Review
Before you begin your assessment, you need an understanding of these complex structures, their basic anatomy (Figs. 11.1 through 11.10) and function, the ways in which they relate to other systems, and expected normal findings.
Interaction with Other Body Systems
The head, face, and neck include many structures with highly varied functions. Disruption or disease of several other systems can affect the organs of the head, face, and neck. These other systems include those described in the following paragraphs.
The Respiratory System
The nasal and oral cavities are entry points to the respiratory system. Injuries or diseases of these two structures can result in impaired ability to breathe. The ears, nose, and pharynx form the upper respiratory system. These structures communicate with the lower respiratory system through the trachea, so that infections in one area can be transmitted to the other.
SYSTEMS PHYSICAL ASSESSMENT
The Cardiovascular System
Many structures of the head, face, and neck system receive rich vascular supply. The mucosa of the nasal cavity includes a plexus of vessels that bleed easily. The temporal arteries are assessed during the examination of the face, as are the carotids during the examination of the neck. Disorders of the cardiovascular system may be reflected in the structures of the head, face, and neck. Infarct or ischemic pain may radiate to the jaw or throat Facial edema can reflect fluid retention
The Musculoskeletal System
Common complaints include headaches, jaw pain, neck pain or stiffness, masses, nasal congestion, epistaxis, mouth or dental pain, mouth lesions, sore throat, and hoarseness. Any such complaints, as well as others that you might identify later, should be explored and developed using an organized system of symptom analysis, such as the PQRST format. Because disorders of several systems can influence the head, face,and neck, it is important to determine the patient’s overall health status. There will be times, however, when the patient’s presenting problems are particularly acute or distressful, and the initial history and physical will have to be very focused.
Symptom Analysis
Symptom analysis tables for the symptoms described in the following paragraphs are available for viewing and printing on the compact disc that came with the book
Head Pain
Head pain can be associated with a variety of problems including migraines, tension, systemic infections, and trauma.
Jaw Tightness and Pain
When a patient presents with jaw tightness and/or pain, the cause may be TMJ syndrome, but it could also be trauma or infection/inflammation in the structures near the jaw. An important consideration for jaw discomfort is whether it might be caused by cardiovascular disease. Always ask patients if they have a personal or family history of heart disease.
Neck Pain and Stiffness
Neck pain and stiffness can stem from musculoskeletal problems as well as from infections. Symptom analysis can help identify any forgotten trauma or physical exertion that might explain the complaint.
Neck Mass
When a patient complains of a neck mass, it might be a goiter of the thyroid gland or enlarged lymph nodes. Enlarged nodes may signal either an infectious or a malignant disorder.
Nasal Congestion
Nasal congestion is usually caused by an upper respiratory infection or allergy.
Nosebleed
Epistaxis, or nosebleed, is usually self-limited and has relatively benign causes. However, it can be caused by coagulopathies or other hematologic disturbances, malignancies, hypertension, or trauma.
Mouth Lesions
A mouth lesion can be caused by a malignancy, trauma, nutritional deficit, or poorly fitted dentures or orthodontic appliances.
Mouth and Dental Pain
Mouth pain can be caused by ischemic heart disease, musculoskeletal disorders, or dental problems.
Sore Throat
When a patient complains of a sore throat, the most common cause is a bacterial or viral illness. However, throat discomfort can be associated with throat masses, including thyroid hypertrophy or malignancies, foreign objects in the throat, and other causes.
Hoarseness
Another common complaint is hoarseness. Hoarseness may be caused by overuse of the voice, for example, prolonged periods of shouting or loud speech. It can also be an indication of gastroesophageal reflux, malignancies, neuromuscular disorders, or other health problems.
Past Health History
Once you have investigated the patient’s chief complaint, explore the past health history. This portion of the history includes childhood and adulthood illnesses, surgeries, or major injuries; hospitalizations; major diagnostic procedures; exposures to infectious diseases; and allergies; as well as an immunization and medication history. The muscles of the face (Fig.11.11) are highly involved in expression, communication, and nourishment. Diseases of the musculoskeletal system can have profound effects on these actions. Inflammatory changes of the temporomandibular joint (TMJ) can cause limited jaw motion and jaw pain and can be unilateral or bilateral. Disorders of the cervical vertebrae or strain or inflammation of supporting structures can have profound effects on neck comfort and motion.
The Neurological System
The head, face,and neck are highly involved in many sensory processes. The neurological system includes the structures responsible for olfaction and taste as well as for sensation in the face and related structures. Dysfunction of the neurological system can have intense effects on these senses. Furthermore, the neurological system is involved in the complex movements necessary for speech, feeding, and expression.Altered neurological function is often evident in these actions. For example, Bell’s palsy, an inflammatory paralysis of the trigeminal nerve, has a profound effect on the function of the motor components on the affected side.
The Endocrine System
The neck houses the thyroid gland, a major endocrine organ. Dysfunction of the thyroid is often accompanied by organ hypertrophy, or enlargement, regardless of whether the dysfunction results in hyperactivity or hypoactivity of the thyroid gland. Enlargements, called goiters, are evident during the examination of the neck. Many endocrine disorders have typical facies. For example, when hypocalcemia develops from parathyroid disease, Chvostek’s sign, a facial spasm, may be an early symptom.
The Lymphatic/ Hematologic System
The nasopharynx and oropharynx are rich with mast cells, responsible for allergic control symptoms. After exposure to allergens, the mast cell and basophil mediators are triggered, with resulting inflammatory responses responsible for the typical sneezing, itching, and secretions of the nasal, nasopharyngeal, or pharyngeal, and other linings. The ultimate result can include congestion, drainage, and secondary infections involving additional structures including the sinuses.The cervical nodes are sensitive to infection or inflammatory changes in the regions they drain, with resulting enlargement of nodes often signalling a disorder. Because of the rich vascular supply of the nasal and oral mucosa, hematologic changes may first be reflected here. For instance, thrombocytopenia may first cause petechiae of the mucous membranes or bleeding of the gums or nose.Anemia may be accompanied by pallor of the mucosa or glossitis.
Performing the Head, Face, and Neck Assessment
Assessment of the head,face,and neck involves obtaining a complete health history and performing a physical examination. As you perform the assessment, be alert for signs and symptoms of actual and potential problems of the various components of the head, face, and neck.
Health History
The health history identifies any related symptoms or risk factors and the presence of diseases involving the head, face, and neck. It must also detect any other disorders that may affect these structures. Your history will include obtaining biographical data and asking questions about the patient’s current health,past health, and family and psychosocial history. It also includes a review of systems (ROS). If you don’t have the time to perform a complete health history, make sure to at least perform a focused health history of the head, face, and neck.
Biographical Data
Review the patient’s biographical information. Note your patient’s age—certain diseases are more prevalent in specific age groups.For example,children tend to have more upper respiratory problems and pharyngitis than older adults. Also ask about your patient’s occupation. Does he or she have a job that puts him or her at risk for head injury? Does he or she spend long hours at a computer terminal (may result in tension headaches)? Questions like these will help to identify the potential for exposures to physical and environmental situations that could harm the head, face, and neck structures.
Current Health Status
Determine whether the patient has any specific presenting complaints related to the head, face, or neck. Some common complaints include headaches, jaw pain, neck pain or stiffness, masses, nasal congestion, epistaxis, mouth or dental pain, mouth lesions, sore throat, and hoarseness. Any such complaints, as well as others that you might identify later, should be explored and developed using an organized system of symptom analysis, such as the PQRST format. Because disorders of several systems can influence the head,face,and neck, it is important to determine the patient’s overall health status.There will be times, however, when the patient’s presenting problems are particularly acute or distressful, and the initial history and physical will have to be very focused.
Symptom Analysis
Symptom analysis tables for the symptoms described in the following paragraphs are available for viewing and printing on the compact disc that came with the book.
Head Pain
Head pain can be associated with a variety of problems, including migraines, tension, systemic infections, and trauma.
Jaw Tightness and Pain
When a patient presents with jaw tightness and/or pain, the cause may be TMJ syndrome, but it could also be trauma or infection/inflammation in the structures near the jaw.An important consideration for jaw discomfort is whether it might be caused by cardiovascular disease. Always ask patients if they have a personal or family history of heart disease.
Neck Pain and Stiffness
Neck pain and stiffness can stem from musculoskeletal problems as well as from infections. Symptom analysis can help identify any forgotten trauma or physical exertion that might explain the complaint.
Neck Mass
When a patient complains of a neck mass, it might be a goiter of the thyroid gland or enlarged lymph nodes. Enlarged nodes may signal either an infectious or a malignant disorder.
Nasal Congestion
Nasal congestion is usually caused by an upper respiratory infection or allergy.
Nosebleed
Epistaxis, or nosebleed, is usually self-limited and has relatively benign causes.However, it can be caused by coagulopathies or other hematologic disturbances, malignancies, hypertension, or trauma.
Mouth Lesions
A mouth lesion can be caused by a malignancy, trauma, nutritional deficit, or poorly fitted dentures or orthodontic appliances.
Mouth and Dental Pain
Mouth pain can be caused by ischemic heart disease, musculoskeletal disorders, or dental problems.
Sore Throat
When a patient complains of a sore throat, the most common cause is a bacterial or viral illness. However, throat discomfort can be associated with throat masses, including thyroid hypertrophy or malignancies, foreign objects in the throat, and other causes.
Hoarseness
Another common complaint is hoarseness. Hoarseness may be caused by overuse of the voice, for example, prolonged periods of shouting or loud speech. It can also be an indication of gastroesophageal reflux, malignancies, neuromuscular disorders, or other health problems.
Past Health History
Once you have investigated the patient’s chief complaint, explore the past health history. This portion of the history includes childhood and adulthood illnesses, surgeries, or major injuries; hospitalizations; major diagnostic procedures; exposures to infectious diseases; and allergies; as well as an immunization and medication
Family History
The purpose of the family history is to identify health problems that are familial or genetic.The history should include information on close relatives, both living and dead. The focus should be on problems that either have a genetic component or are attributed to environmental/ living situations shared with the patient. The genogram described in earlier chapters is a helpful way to organize the information obtained through the family history.
Psychosocial Profile
The psychosocial profile provides information about the patient’s occupation, social involvement, recreational interests, and daily activities and habits in order to identify factors that can influence the health of the head, face, and neck. It determines risks associated with exposure to hazards, provides information about the patient’s support system, and helps identify the patient’s ability to perform self-care activities and obtain and carry out recommended treatments.
Drugs That Adversely Affect the Head, Face, and Neck
When obtaining a health history to assess a patient’s head and neck, the nurse must ask about current drug
Psychosocial Profile
The psychosocial profile provides information about the patient’s occupation, social involvement, recreational interests, and daily activities and habits in order to identify factors that can influence the health of the head, face, and neck. It determines risks associated with exposure to hazards, provides information about the patient’s support system, and helps identify the patient’s ability to perform self-care activities and obtain and carry out recommended treatments.
Anatomical Landmarks
Before you begin your physical assessment of the head, face, and neck,
you need to visualize the underlying structures and identify landmarks. Two
landmarks on the face that are useful in determining symmetry of facial
features are the palpebral fissures and the nasolabial folds (Fig.11.12).The
palpebral fissure is the distance between the upper and the lower eyelid .The
nasolabial fold is the distance from the corner of the nose to the edge of the
lip. This is the facial crease that is often seen when someone smiles. The
anterior and posterior triangles (Fig. 11.13) are important landmarks of
the neck. The sternocleidomastoid and trapezius
muscles form the triangles. Both triangles are helpful in locating the
underlying structures of the neck.
Physical Assessment
During the history, you probably developed a sense of the patient’s concerns and may have begun to cluster the data obtained to help guide your physical examination. You should have an awareness of any physical limitations or discomfort that will influence the physical examination. Throughout the history, you observed the patient’s body posture, fluidity of movements, facial expressions, and speech—all of which are important observations for the head, face, and neck. Now, as you approach the physical examination, you must be very objective in your observations as you inspect the internal structures of the nose, mouth, and throat.
Approach
All four techniques of physical assessment—inspection, palpation, percussion, and auscultation—are used in the examination of the head, face, and neck. Some structures, like the throat and internal nose, can only be inspected; generally only the sinuses are percussed, and only the vessels of the neck and thyroid are auscultated. The cranial nerve (CN) assessment is generally incorporated in the examination of the face, mouth, nose, throat, and neck. The assessment of the arteries and veins is also incorporated into the examination of the neck and face. Although there is no “right” sequence to follow for the examination of these structures and organs, you should develop, practice, and adhere to a set routine in order to avoid omitting a test. One common sequence is the head-to-toe approach that begins with inspection of the shape and general placement of the head and facial structures, followed by a thorough inspection of the facial muscles and then the neck. Some examiners prefer to examine the nose, mouth, and throat along with the face, whereas others do this only after they have completed the examination of the neck. No matter what sequence you use, always take into consideration the structures’ symmetry during your examination.
Performing a General Survey
The first step of the physical examination is a general survey, although in many cases this is accomplished during history taking. Besides providing early information regarding speech and movements, the general survey allows you to detect clues about the patient’s emotional status,nutritional status,and overall posture.During the general survey,obtain vital signs.Altered pulse can be associated with thyroid disease. Respiratory rate changes can be related to an altered airway,including the nose,mouth,or pharynx.The temperature is an important consideration for infection.Blood pressure elevations may explain epistaxis.Aside from the vital signs, be alert for other signs that may indicate underlying problems with the head,face,and neck.
For example:
■ Note facial expression.Is it appropriate? Nervousness or a flat expression may be associated with thyroid disease. A masklike expression is seen with Parkinson’s disease.
■ Note any gross abnormalities, such as exophthalmus, which is seen with thyroid disease.
■ Consider dress and grooming. Are they appropriate? Temperature intolerance associated with thyroid disease may cause people to overdress or underdress.
■ Note speech and thought processes. Are responses appropriate? Are thought processes intact? Problems with focusing may be related to thyroid disorders.
■ Look for changes in weight or weight distribution. A buffalo hump (fat pads on the lower midcervical and upper thoracic areas) is associated with Cushing’s disease or steroid use.
Performing a Head-to-Toe Physical Assessment
The head, face, and neck reflect many different systems, so look for changes
that may indicate underlying pathology. Next, perform a head-to-toe physical
assessment, checking for specific signs of disease in other organ systems that
might be reflected in the head, face, and neck.
Performing the Physical Assessment for the Head, Face, and Neck
After the general survey and head-to-toe assessment, perform a physical examination that focuses on the head, face, and neck. Although inspection and palpation are discussed separately below, they are not distinct, sequential activities. They are actually performed almost in concert. Although you inspect an area or structure before touching or moving it, this takes only a moment and is usually followed immediately by touching or palpating the area. The only area of the head, face, and neck to be percussed is the sinus area,and this generally occurs after you have applied pressure over the sites during palpation. The only areas to be auscultated are the carotids and jugulars and, if it is enlarged, the thyroid.
Assessing the Head and Face
Examination of the head and face involves inspection and palpation.
Inspection
Have patients remove hats,wigs, or hair ornaments if present. Put on gloves in case there are open lesions under the hair. Begin with inspection. Identify the prominences of the brows, cheeks, mastoids, and occiput.
Palpation
Next, palpate the head and face. There should be no tenderness and, except in infants, no soft areas in the head. As you palpate the TMJ, ask the patient to open and close his or her mouth and deviate his or her jaw from side to side. Determine sensation, motion, and strength of the face, as described in Chapter 20, assessing the Motor- Musculoskeletal System, and assess the temporal artery/Assessing the Peripheral Vascular and Lymphatic Systems.
Assessing the Sinuses
Assessment of the sinuses includes inspection (with transillumination), palpation,and percussion.Only the frontal and maxillary sinuses are readily accessible for assessment. Envision the areas of the face that overlay the sinuses. Remember, the frontal sinuses are located above the eye brow sand the maxillary sinuses are located below the eyes.
Inspection
The sinus areas are inspected for edema and discoloration. If you suspect a sinus problem after regular inspection, palpation, and percussion, you can also transilluminatethe sinuses. A transilluminator should be used; however, either a penlight or an otoscope with a speculumattached are good alternatives. Transilluminationrequires a darkened room. To transilluminate the frontal sinuses, hold the light source so that the light is directed upward from just below the brows. A glow of light may be detected over the brow. To transilluminate the maxillary sinuses, have the patient open her or his mouth and position her or his head so that you can observe the roof of the mouth. Place the light source below the eyes and above the cheek, with the patient’s mouth opened, and look for a glow on the roof of the mouth. Absence of transilluminationsuggests sinus fullness or thickening. Any glow noted with transillumination of either the frontal orthe maxillary sinus should be symmetrical. However, absence of transillumination may not always indicate pathology. It may simply be a normal variant caused byte thickness of the bones overlying the sinuses or underdevelopment of the sinuses.
Palpation
Palpate the sinuses for tenderness. To palpate the frontal sinuses, press upward just below the medial third of each eyebrow. To palpate the maxillary sinuses, apply pressure to the lower portion of the cheeks, below the eyes.
Percussion
Percussion is performed to further assess for sinus discomfort. If tenderness is elicited with palpation, omit percussion over that area. Otherwise, you should percuss the sinuses by tapping over these same areas. Direct percussion, using the tapping finger to strike directly over the bony prominence, is most frequently used. Because the sinuses are normally filled with air, percussion should elicit somewhat of a resonant tone.
Assessing the Nose
To examine the nose, inspect the external structures, palpate the external structures, and then inspect the internal structures (nasal cavity).
Inspection
Inspection of the internal structures includes the septum, nasal mucosa, and medial and inferior turbinates. If you are using an otoscope with a wide-tipped speculum, stabilize the patient’s head with one hand and then slowly and gently insert the speculum into the nares. If you are using a penlight and nasal speculum, insert the closed speculum and then gently open it once it is in the nose,being careful not to open it too much.Take care not to scrape or press on the central septum because this area is sensitive.During your assessment,take note of any sounds the patient is making with his or her nose,such as sniffing or snorting
Palpation
Palpate the bony ridge and soft tissues of the external nose. The cartilaginous, distal two-thirds of the nose should be mobile, without pain. Gently occlude one nostril at a time and have the patient inhale through the nose to determine patency.
Assessing the Mouth and Throat
The mouth and throat are components of both the respiratory and the digestive tracts. Assessment involves inspection and palpation. The assessment begins with examination of the lips, then the structures of the mouth and throat. Remember to wear gloves when examining the internal structures of the mouth. You will also need a penlight and tongue depressor to perform the examination.
Inspection
Inspect the lips, gingiva, buccal mucosa, tongue, and pharynx for colour, lesions, and exudates. Note the colour, number, condition, and occlusion of the teeth. The upper and lower molars should approximate with the jaw closed. The front teeth should slightly override the lower ones. Observation of the teeth with a physical assessment does not replace a dental examination, so remind the patient of the importance of maintaining routine dental care. Using the tongue blade to displace the cheeks and lips, first inspect the buccal mucosa. The Stensen’s ducts, openings for the parotid glands,are located on the buccal mucosa at the point of the second upper molars.
The Wharton’s ducts, openings for the submandibular glands, are located on either side of the frenulum under the tongue. Inspect all aspects of the tongue: dorsal, ventral, and lateral edges. Note the color, moisture, and surface texture and observe for any swelling. Observe the frenulum and the mobility of the tongue.
Palpation
Palpate the tongue for nodules or areas of thickening. Palpate the floor of the mouth for nodules or masses.To palpate the floor of the mouth, use your nondominant hand to press upward beneath the patient’s chin to provide support while palpating downward with a gloved hand inside the mouth. The support provided externally helps ensure that the examining hand actually palpates a mass and does not merely push it away. The use of two hands will help to assess any mass, examining the dimensions, consistency, tenderness, and texture.
The parotid, submandibular, and sublingual glands should also be palpated for enlargement and tenderness. The parotid glands are located anterior to the ear, and the submandibular and sublingual glands are located under the mandible.
Assessing the Neck
Examination of the neck integrates components of the vascular, respiratory, musculoskeletal, neurological, lymphatic, and endocrine systems. This chapter focuses on the lymphatic and endocrine systems, primarily on assessment of the cervical lymph nodes and the thyroid through inspection, palpation, and auscultation.
Inspection
You will be inspecting the cervical lymph nodes and thyroid gland. Remember, lymph nodes drain toward the center of the body. When examining the thyroid gland, focus your attention on the middle to lower third of the anterior neck, checking for enlargements.
Palpation
The order in
which you palpate the cervical lymph nodes is not important, although it is
best to develop a sequence and be consistent to ensure that you do not omit a
group.One common sequence is to start with the preauricular nodes, followed by
the postauricular nodes, then move to the tonsillar,submandibular,
and submental nodes along the
mandible. Next, palpate the occipital area, followed by the superficial and
deep cervical, posterior cervical, and supraclavicular nodes. Palpate node
groups gently with one or two fingers, applying alternate pressure. Palpate any
identified nodes between two fingers to establish their dimensions, texture,
consistency, and shape. Although the lymph nodes are generally not palpable, it
is not unusual to identify them at
The term used to describe enlarged nodes (_1 cm in diameter) is lymphadenopathy. Lymphadenopathy can be regional (involving one or two groups) or more generalized (involving three or more groups). To palpate the thyroid, use an anterior or posterior approach. Some examiners combine both approaches when assessing a thyroid nodule or enlargement. Both approaches are depicted here, so that you can determine which works best for you. Begin by locating the thyroid gland. Although the thyroid is usually nonpalpable, you may be able to feel the isthmus, which connects the two lobes and lies below the cricoid cartilage. The lobes are located behind the sternocleidomastoid muscle.The likelihood of palpating the isthmus increases with very thin or pregnantpatients.You may be able to feel the edge of the gland,especially in women,who have larger thyroid glands than men. The thyroid gland moves as the individual swallows. Therefore, have the patient drink water while you palpate the gland, to facilitate detection. Instruct her or him to take a sip from the cup and hold it in the mouth until you ask her or him to swallow. Do this at least twice, as you examine both the left and the right thyroid lobes. To use the posterior approach, stand behind the patient and ask him or her to flex his or her neck slightly forward and to the left.This relaxes the muscles and the skin overlying the left side of the neck, making it easier to detect the tissue of the left thyroid lobe.Using the fingers of your left hand, locate the cricoid process. Push the trachea slightly to the left with your right hand as you palpate just below the cricoid process and between the trachea and the sternocleidomastoid muscle with your left hand. As you palpate, ask the patient to swallow the water he or she is holding in the mouth. Now, repeat the steps with the patient’s head flexed slightly forward and to the right. This time, displace the trachea slightly to the right with your left hand and palpate the right lobe of the thyroid with your right hand. To use the anterior approach, stand in front of the patient and ask her or him to flex the neck slightly forward and in the direction you intend to palpate. Place your hands on the neck and apply gentle pressure to one side of the trachea while palpating the opposite side of the neck for the thyroid. The patient should take a sip of water during this approach as well thyroid. The patient should take a sip of water during this approach as well.
Auscultation
The final portion of the neck examination, auscultation of the thyroid gland, is generally reserved for situations in which the thyroid is enlarged or a mass is palpated. To auscultate the gland, place the bell of your stethoscope over one lobe, then the other. Ask the patient to briefly stop breathing as you auscultate, to optimize your ability to hear without the distraction of the tracheal breath sounds. There should be no thyroid sounds. Because the thyroid is a very vascular organ, vascular sounds are sometimes present in hyperthyroidism.
.
S U M M A R Y
■ Disorders of the head, face, and neck have the potential to exert profound influence over the morbidity and mortality of patients.
■ The physical changes associated with these disorders can have devastating effects. ■ The structures and function of the head, face,and neck are greatly influenced by changes in other systems.
■ It is essential that nurses be skilled in performing examinations of this system and differentiating between normal and abnormal findings.