Head, Neck and Regional Lymph Nodes

Nursing 330

Governors State University

Shirley Comer

Inspection

Inspect head for skull size and symmetry– Normocephalic- normal round, symmetrical skull– Microcephalic- abnormally small– Macrocephalic- abnormally large (Ex. hydrocephalic)

Inspect facial expression and appropriateness– Symmetrical expressions v. drooping, injury, tics, or

malformations– Flat affect=unmoving expression (depression, anger, neuro)

Macro/microcephalic and flat affect

Palpation

Palpate head/scalp Palpate temporal artery Palpate tempro-mandibular joint

– Crepitus-popping or crackling /c movement

Sinus pix

Inspect Sinuses

Frontal and Maxillary Sinuses– Assess for edema, swelling or redness

Trans-illuminate the sinuses– Frontal – shine light under eyebrow: see

above brow– Maxillary – shine light below eye: see on

hard palate

Palpate/Percuss Sinuses

Palpate Sinuses – Tenderness = sinusitis

Percuss– Frontal- above the eyebrows– Maxillary – below eyes

Resonant tone expected Dull = thickening or fullness of sinus

Inspect Nose

– External noseSize, shape, symmetryNote drainageNasal flaringPatency – occlude each side

– Internal nasal mucosa – use penlightNote color, moisture, lesions, septum midlineInspect Turbinates (concha)

– Inferior, medial and superior

Mouth pix

Lips/mouth

Lips– Inspect for Color, condition, lesions, odor– Palpate for consistency and tenderness

Teeth and bite– Ask to smile and open and close mouth– Note number, color and condition of teeth

Oral Mucosa and Gums– Inspect color, condition, bleeding retraction or

hypertrophy

Mouth (Cont)

Inspect hard and soft palate– use penlight – Color and condition

Salivary Glands – Use tongue blade– Inspect

Stensen’s Duct – inner cheek Wharton’s Duct – under tongue

– Palpate Parotid – in front of ears Submandibular and sublingual – under mandible

Mouth (cont)

Tongue – both top and bottom– Inspect color, texture, moisture and mobility– Palpate for consistency and tenderness

Inspect Oropharynx – use tongue blade– Lesions, color, drainage

Inspect Tonsils – (if present)– Note color, size and exudate

Mouth (cont)

Inspect Uvula – Note color, moisture, lesions, midline position– Note movement by having pt say “AH”

Tonsils

Neck

Inspect– in neutral and hyperextended positions– Note lesions, color, trachea position, resp

movement, pulsations, asymmetries

Palpate– Use light palpation to check for masses or

tenderness– Note range of motion

Lymph Nodes

Palpate using a gentle circular motion Palpate all positions

– Pre and post auricular-in front and behind ear– Occipital Juguldigastric-below ear lobe– Superficial cervical-Along upper SCM muscle– Posterior Cervical-base of lateral neck– Supraclavicular-above clavicle– Submandibular-under jaw– Submental-under chin– Deep cervical-jaw line along SCM to clavicle

Cervical Lymph node pix

Lymph nodes cont

Lymphadenopathy– Enlarged lymph glands (cervical nodes often normally felt)– Assess area drained for:

Acute infection– nodes are bilateral, enlarged, warm, tender and firm but moveable

Chronic inflammation– nodes clumped. May be asymmetrical

Cancerous– nodes are hard, unilateral, non-tender and fixed

Thyroid Gland

Inspect – position light across neck – have pt swallow and note thyroid movement

Palpate– Observe from the front – locate isthmus of thyroid– move behind person – pt head sl forward and to right to relax neck– curve fingers on either side of gland and displace sl right – ask pt to swallow – usually not palpable

Auscultate using bell for bruit

Thyroid Pix

Age Specific Considerations- Infant

measure head with tape until age 2 – Sunken fontanels /c dehydration or malnutrition

bulging /c increased ICP anterior

– 2.5 to 5 cm – may see/feel pulse – may bulge if infant crying – closes 9 to 24 months

Posterior– may not be present at birth 1 cm

Infants and children- Head

Adult Age Specific considerations

Pregnant– May normally feel thyroid gland

Older adult– Senile tremors of head are benign– If wears dentures face will appear distorted when

not in mouth– Increased cervical concave curvature of neck

Cranial Nerves

1. Olfactory- smell 2. Optic – vision 3. Oculomotor – sight 4. Trochlear – vision 5. Trigeminal – mouth and jaw 6. Abducens - Vision 7. Facial – facial muscles 8. Acoustic – hearing 9. Glossopharyngeal- speech and soft palate 10. Vagus – palate 11. Spinal – shoulders 12. Hypoglossal - tongue

Testing Cranial Nerves

I - Olfactory- test when pt reports decreased sense of smell– Place aromatic substance under each nostril – Should be able to identify bilaterally

II – Optic – Test visual fields– Use ophthalmoscope to examine retina and observe

optic disk

Testing Cont

III, IV, and VI – Oculomotor, Trochlear and Abducens– Observe pupil size and reactivity (PERRLA)– Assess extraocular movements and cardinal

positions of gaze Nystagmus oscillation of eye abnormal Ptosis – drooping eye lids

Testing Cont

V – Trigeminal– Palpate muscles as pt clenches teeth– Test sensory function by touching cotton wisp to face /c

eyes closed. Pt says “now” when felt– Corneal Reflex for those /c abnormal facial movements

Touch cotton to cornea – should blink bilaterally

VII – Facial – Observe for facial symmetry

Smile, frown Close eyes Lift eyebrows Puff cheeks

Testing Cont

VIII – Acoustic – test hearing acuity with whispered voice, Rinne and Weber tests

IX and X – Glossopharyngeal and Vagus– Watch uvula as pt says “Ahhh”- use tongue blade– Test gag reflex when appropriate – use blade

XI – Spinal Accessory – Shrug shoulders and turn head against your resistance

XII – Hypoglossal – stick out tongue– No tremors or deviations from midline

Practice Exam Question

Your Mother has a sinus infection. Which changes would you expect to find on your head and neck exam?

A. Tender earlobes with enlarged lymph nodes B. Tender maxillary area with enlarged lymph nodes C. Tender neck muscles with enlarged lymph nodes D. Enlarged thyroid gland with enlarged lymph nodes.

Rationale

The correct answer is b. The maxillary sinuses are located here and the lymph nodes would be enlarged r/t increased immune system activity r/t sinus infection