Docsity
Log inSign up
Docsity
Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity

Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan

Guidelines and tips
Guidelines and tips
Sell on Docsity
Sell on Docsity
Log inSign up

Prepare for your exams

Study with the several resources on Docsity

Find documents

Prepare for your exams with the study notes shared by other students like you on Docsity

Search Store documents

The best documents sold by students who completed their studies

Search through all study resources
Docsity AINEW

Summarize your documents, ask them questions, convert them into quizzes and concept maps

Explore questions

Clear up your doubts by reading the answers to questions asked by your fellow students

Earn points to download

Earn points by helping other students or get them with a premium plan

Share documents
download point icon20 Points

For each uploaded document

Answer questions
download point icon5 Points

For each given answer (max 1 per day)

All the ways to get free points
Get points immediately

Choose a premium plan with all the points you need

Study Opportunities

Choose your next study program

Get in touch with the best universities in the world. Search through thousands of universities and official partners

Community

Ask the community

Ask the community for help and clear up your study doubts

University Rankings

Discover the best universities in your country according to Docsity users

Free resources

Our save-the-student-ebooks!

Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors

From our blog

Exams and Study
Go to the blog

Head and Neck Assessment: Preparing the Client for Examination, Lecture notes of Health sciences

De La Salle University (DLSU)Health sciences

Detailed instructions and considerations for preparing a client for a comprehensive head and neck assessment. It covers key steps such as instructing the client to remove any items that could interfere with the examination, assessing cultural norms for touch, ensuring the client is in an upright position, and explaining the examination process. The document also outlines the equipment needed and the specific areas to inspect, including the shape and symmetry of the head, the features and condition of the face, the movement and palpation of the neck structures, and the palpation of lymph nodes in the head and neck region. Additionally, it includes sample objective data and appropriate nursing diagnoses related to head and neck health. This comprehensive guide aims to ensure a thorough and effective head and neck assessment, enabling healthcare professionals to identify any potential issues or abnormalities and provide appropriate care.

Typology: Lecture notes

2022/2023

Available from 10/27/2024

Oishiiii
Oishiiii 🇵🇭

22 documents

1 / 2

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
PREPARING THE CLIENT
Instruct
Instruct the client to remove any wig, hat, hair
ornaments, pins, rubber bands, jewelry and
head or neck scarves
Consider
Consider cultural norms for touch when
assessing the head
Ask
Ask the client to sit in an upright position with
the back and shoulders held back and straight
Explain
Explain that the client may be requested to
move and bend the neck
Be
Be aware that some clients may be anxious as
the lymph nodes in the neck are palpated
Tell
Tell the client what you are doing and share
your assessment findings
EQUIPMENT NEEDED
Gloves
Small cup of water
Stethoscope
INSPECTION OF THE SHAPE OF THE HEAD
Inspect the head for:
Shape and symmetry
Size, shape, and configuration
Involuntary movement
HEAD AND FACE
Head size and shape may vary, especially in
accord with ethnicity
Head is symmetric, round, erect, and in
midline
No lesions are visible
Still and upright
Palpate the head for consistency
Head is normally hard ans smooth without
lesions
Inspect the face for symmetry, features,
movement, expression, and kin condition
Face is symmetric with a round oval,
elongated or square appearance
Olde clients - facial wrinkles are normal
Palpate the temporal artery
The temporal artery is elastic and not
tender
Abn. - temporal arteritis
Palpate the temporomandibular joint (TMP)
No swelling, tenderness or crepitation
with movement
Mouth opens and closes fully (3-6cm
between upper and lower teeth)
Lower jaw moves laterally 1-2cm in each
direction
Abn. - limited ROM, swelling, tenderness,
crepitation
THE NECK
Inspect the neck
Is symmetric with head centered and
without bulging masses
Inspect movement of neck structures
Thyroid and cricoid cartilages, thyroid
gland move upward as patient swallows
Inspect the cervical vertebrae
C7 is usually visible and palpable
Inspect ROM
Neck movement should be smooth and
controlled with 45oflexion, 55oextension,
40olateral abduction and 70orotation
Palpate the trachea
Trachea is midline
Palpate the thyroid gland
Landmarks are positioned midline
The isthmus may be palpated at the
midline
If the thyroid can be palpated, the lobes
are smooth, firm and non-tender
The right lobe is often 25% larger than the
left lobe
Glandular thyroid tissue may be felt rising
underneath your fingers
Lobes should feel smooth, rubbery and
free of nodules
Auscultate the thyroid gland
Done only if there is thyroid enlargement
pf2

Partial preview of the text

Download Head and Neck Assessment: Preparing the Client for Examination and more Lecture notes Health sciences in PDF only on Docsity!

PREPARING THE CLIENT

Instruct  Instruct the client to remove any wig, hat, hair ornaments, pins, rubber bands, jewelry and head or neck scarves Consider  (^) Consider cultural norms for touch when assessing the head Ask  (^) Ask the client to sit in an upright position with the back and shoulders held back and straight Explain  Explain that the client may be requested to move and bend the neck Be  Be aware that some clients may be anxious as the lymph nodes in the neck are palpated Tell  Tell the client what you are doing and share your assessment findings EQUIPMENT NEEDED  Gloves  Small cup of water  Stethoscope INSPECTION OF THE SHAPE OF THE HEAD Inspect the head for:  Shape and symmetry  (^) Size, shape, and configuration  Involuntary movement HEAD AND FACE  Head size and shape may vary, especially in accord with ethnicity  Head is symmetric, round, erect, and in midline  No lesions are visible  Still and upright  Palpate the head for consistency  Head is normally hard ans smooth without lesions  Inspect the face for symmetry, features, movement, expression, and kin condition  Face is symmetric with a round oval, elongated or square appearance  Olde clients - facial wrinkles are normal  Palpate the temporal artery  The temporal artery is elastic and not tender  Abn. - temporal arteritis  (^) Palpate the temporomandibular joint (TMP)  No swelling, tenderness or crepitation with movement  (^) Mouth opens and closes fully (3-6cm between upper and lower teeth)  Lower jaw moves laterally 1-2cm in each direction  Abn. - limited ROM, swelling, tenderness, crepitation THE NECKInspect the neck  Is symmetric with head centered and without bulging masses  Inspect movement of neck structures  Thyroid and cricoid cartilages, thyroid gland move upward as patient swallows  Inspect the cervical vertebrae  C7 is usually visible and palpable  Inspect ROM  Neck movement should be smooth and controlled with 45 o^ flexion, 55 o^ extension, 40 o^ lateral abduction and 70 o^ rotation  (^) Palpate the trachea  Trachea is midline  Palpate the thyroid gland  Landmarks are positioned midline  The isthmus may be palpated at the midline  If the thyroid can be palpated, the lobes are smooth, firm and non-tender  The right lobe is often 25% larger than the left lobe  Glandular thyroid tissue may be felt rising underneath your fingers  Lobes should feel smooth, rubbery and free of nodules  Auscultate the thyroid gland  Done only if there is thyroid enlargement

 (^) No bruits are auscultated LYMPH NODES OF THE HEAD AND NECK Palpation of the Lymph Nodes  Preauricular nodes  Postauricular nodes  Occipital nodes  Tonsillar nodes  Submandibular nodes  Submental nodes  Superficial cervical nodes  Posterior cervical nodes  Deep cervical chain nodes  Supraclavicular nodes SAMPLE OBJECTIVE DATA  Head symmetrically round, hard, and smooth without lesions or lumps.  Face oval, smooth, and symmetric.  Temporal artery elastic and non tender.  (^) TMJ palpated with full range of motion without tenderness  Neck symmetric with centered head position and no bulging masses.  C7 is visible and palpable with neck flexed.  Has smooth, controlled full ROM neck.  Thyroid gland not visible but palpable upon swallowing.  Trachea in midline.  Lymph nodes non palpable except for a few deep cervical less than 1cm bilaterally. APPROPRIATE NURSING DIAGNOSES Wellness Diagnoses  (^) Health-seeking Behavior: requests assistance information on how to quit smoking Risk Diagnoses  Risk for injury to head and neck related to poor posture Actual Diagnoses  Impaired swallowing related mechanical obstruction of the head and neck secondary to tissue swelling, tracheostomy, or abnormal growth  Impaired physical mobility of head and neck secondary related to cervical injury