Open Resources for Nursing (Open RN) Show
Subjective AssessmentBegin the head and neck assessment by asking focused interview questions to determine if the patient is currently experiencing any symptoms or has a previous medical history related to head and neck issues. Table 7.4a Interview Questions for Subjective Assessment of the Head and Neck
Life Span ConsiderationsInfants and ChildrenFor infants, observe head control and muscle strength. Palpate the skull and fontanelles for smoothness. Ask the parents or guardians if the child has had frequent throat infections or a history of cleft lip or cleft palate. Observe head shape, size, and symmetry. Older AdultsAsk older adults if they have experienced any difficulties swallowing or chewing. Document if dentures are present. Muscle atrophy and loss of fat often cause neck shortening. Fat accumulation in the back of the neck causes a condition referred to as “Dowager’s hump.” Objective AssessmentUse any information obtained during the subjective interview to guide your physical assessment. Inspection
If any neurological concerns are present, a cranial nerve assessment may be performed. Read more about a cranial nerve assessment in the “Neurological Assessment” chapter. AuscultationAuscultation is not typically performed by registered nurses during a routine neck assessment. However, advanced practice nurses and other health care providers may auscultate the carotid arteries for the presence of a swishing sound called a bruit. PalpationPalpate the neck for masses and tenderness. Lymph nodes, if palpable, should be round and movable and should not be enlarged or tender. See the figure illustrating the location of lymph nodes in the head and neck in the “Head and Neck Basic Concepts” section earlier in this chapter. Advanced practice nurses and other health care providers palpate the thyroid for enlargement, further evaluate lymph nodes, and assess the presence of any masses. See Table 7.4b for a comparison of expected versus unexpected findings when assessing the head and neck. Table 7.4b Expected Versus Unexpected Findings on Adult Assessment of the Head and Neck
What technique should the nurse use to assess for a bruit?Bruits are detected by auscultation over the large and medium-sized arteries (e.g., carotid, brachial, abdominal aorta, femoral) with the diaphragm of the stethoscope using light to moderate pressure.
Which technique would the nurse use to assess the patient's thyroid gland quizlet?To palpate the thyroid, use a posterior approach. Stand behind the client and ask the client to lower the chin to the chest and turn the neck slightly to the right. The nurse detects enlarged, tender, preauricular nodes in a client.
What can be heard upon auscultation over the thyroid lobes of a client with hyperthyroidism?You may hear a thyroid bruit. A thyroid bruit is described as a continuous sound that is heard over the thyroid mass. (If you only hear something during systolic, think about a carotid bruit or radiating cardiac murmur.)
What is the correct procedure for palpation of a client's thyroid gland?Place first two digits of both hands just below cricoid cartilage so that left and right fingers meet on the patient's midline. Place thumbs posterior to patient's neck and flatten all fingers against the neck. Use finger pads, not tips, to palpate.
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