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Course: Health Assessment�Unit Title: Assessment of the Head and Neck

By Lucy Vermeulen, RN

Developed: December, 2018 Copyright Nurses International 2018

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Module Goals

Learner Outcome:

At the completion of these modules the learner will demonstrate knowledge and skills to perform a complete health assessment of an individual.

Module Objectives

Explain the processes, procedures and techniques in the assessment of the head and neck.
Differentiate between normal and abnormal assessment findings of the head and neck, including lymph nodes of the neck
Outline the nurse’s actions in the assessment of the head and neck.

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Content Outline

Structure of the Head and neck
Size and shape of skull, Facial symmetry, hair distribution, moon face/edema
Temporal artery, Temporomandibular joint
Neck ROM, nuchal rigidity, torticollis
Position of trachea, cricoid cartilage, Thyroid gland
Carotid artery (assess for bruit and thrill), jugular vein (assess for JVD), Sternocleidomastoid muscle
Lymph nodes of the head and neck (location and area drained): Occipital, Postauricular, preauricular, submandibular, submental, superficial anterior cervical, posterior cervical, supraclavicular, inferior anterior cervical

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Anatomy

Head & Neck Assessment

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Structures of Head & Neck: Skull

Jarvis (2016), p. 344

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Mouth

Public domain, n.d.

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Muscles of Head & Neck

Jarvis (2016) p. 346

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Neck

Supple vs. Nuchal rigidity
Trachea midline, no deviation
Thyroid enlargement, goiter
Lymph nodes
Jugular venous distension
Neck circumference: enlarged neck circumference associated with HTN and sleep apnea

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Neck Muscles

https://www.youtube.com/watch?v=x5b7BUMy_8k

Jarvis, (2016) p. 348

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Neck Muscles

Jarvis (2016), p. 349

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Lymphatic System of Face & Neck

Jarvis (2016) p. 352

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Vasculature of Face & Neck

Jarvis, (2016), p. 347

The head and neck have a rich supply of 60 to 70 lymph nodes

Submental, midline, behind the tip of the mandible

• Submandibular, halfway between the angle and the tip of the mandible

• Jugulodigastric (tonsillar), under the angle of the mandible

• Superficial cervical, overlying the sternomastoid muscle

• Deep cervical, deep under the sternomastoid muscle

• Posterior cervical,in the posterior triangle along the edge of the trapezius muscle

• Supraclavicular, just above and behind the clavicle, at the sternomastoid muscle

When nodes are enlarged, check the area they drain for the source of the problem. Assess the area proximal (upstream) to the enlarged node. All head and neck structures eventually drain into

the deep cervical chain.

Remember: the External carotid supplies the face and salivary glands

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Thyroid Gland: Anatomy & Function

Encyclopaedia Britannica:Thyroid Gland Anatomy (2018)

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Developmental Considerations: Newborn

Jarvis (2016), p. 353

Fontanels

https://www.youtube.com/watch?v=QYK2I50pTdw

The bones of the neonatal skull are separated by sutures and fontanels, the spaces where the sutures intersect.

These membrane-covered “soft spots” allow for growth of the brain during the 1st year.

They are also important during delivery through the birth canal.

They gradually harden with the addition of minerals to the sutures; the triangle-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 yea�The fontanels should feel firm . A tense or bulging fontanel can occur when fluid builds up in the brain or when the brain swells, leading to increased intracranial pressure.

One may also see this when a baby is crying or vomiting - it should resolve when the baby settles.

A sunken fontanel (noticeably curving inward) can indicate dehydration, and other less common conditions: diabetes insipidus, toxic megacolon, failure to thrive, lack of protein with malnutrition.

At infancy, the head is disproportionately larger when compared to the adult; this has implications for balance.

Infants also lose a great deal of heat through their head

Necks - lengthen considerably during the first 3-4 years after birth.

newborns cannot hold their heads up; they must be supported.

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Additional Developmental Considerations

Neck: short, weak musculature at birth

Adolescent Boys: develop facial hair

Voice deepens

Thyroid cartilage enlarges

Pregnancy: Some enlargement of thyroid

Older adult: Decreased elasticity to facial skin

Decreased moisture to facial skin

Decreased subcutaneous fat to face

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Data Collection

Head & Neck Assessment

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Subjective Data: Patient Information

Headache

Onset, Provoking & Relieving factors, Quality

Radiation, Severity, Timing, Understanding

History of same?

Sudden vs gradual onset

Associated symptoms

Pattern?

Other illnesses?

Complete a full pain assessment

Onset, provoking and relieving factors, quality of pain, does it radiate anywhere, severity, timing - weather? menstrual

cycle? stress? during hypertensive state? Food related?

For patients with a history of headaches, they frequently know what type of headache they are experiencing

Inquire whether this headache developed gradually or suddenly. Sudden onset of worst headache ever is a red flag -

could suggest the presence of a cerebral bleed. (Particularly in the presence of a hypertensive state)

Associated symptoms: nausea and vomiting are not uncommon in patients with migraines, with severe pain, of in

patients having headaches due to increased intracranial pressure.

Migraine sufferers frequently suffer from photophobia (light sensitivity) and dislike noise.

Pattern: For patients with a history of headaches, it is useful to ask about patterns - this may assist in management

Other illnesses: Patients may have headaches with strokes, fever, dehydration, even illnesses like mononucleosis

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Headaches

Meningitis

Encephalitis

Temporal arteritis

Sinusitis

Temporomandibular joint (TMJ)

https://www.youtube.com/watch?v=rZTEzBBMdCE

Meningitis: usually viral or bacterial, bacterial can be deadly; infectious. Associated with fever, tachycardia,

can have torso rash, nausea, vomiting, altered level of consciousness. Antibiotics and fluids are prioritized along

with isolation. Confirmed by lumbar puncture.

Encephalitis: numerous causes, usually viral. Associated with fever, flu-like symptoms. More serious cases can

cause seizures, altered mental status, Babies can have bulging fontanels, and feed poorly.

Temporal arteritis: Other vessels can also be involved which could lead to serious health problems.

Can contribute to blindness, TIA. Symptoms can include fever, jaw pain, fatigue, visual changes, tenderness at the

temples. Cause is not known. Treatment includes steroids.

Sinusitis: inflammation of a sinus cavity (there are 4 paired cavities in the head connected by narrow tunnels They make mucus that drains through to the nose. This helps keep the nose clean. Normally the cavities are filled with air; however, they can get plugged and then filled with fluid; this can contribute to bacterial growth.

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What Should the Nurse Do?

A father brings his 15 yo son into your clinic: He has a 8/10 frontal headache, facial pain and pressure.

VS: BP=96/48 HR=112 RR=22 Temp= 37.9 Celsius

What type of assessment will be performed by the nurse?

What specific questions do you want to ask?

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Neck & Throat Pain

Nuchal Rigidity

Cervical spine tenderness

Peritonsillar abscess

Epiglottitis

Torticollis

https://www.dystonia.org.uk/neck-dystonia

Dysphagia

Nuchal rigidity: Associated with meningitis. Not all patients will have this neck stiffness

Cervical spine tenderness: with new onset of tenderness, spinal immobility is critical until imaging is completed

and a fracture has been ruled out. Always consider the possibility of C-spine injury with trauma.

Peritonsillar abscess/tonsillitis: associated with sore throat, swelling, lymph node enlargement, fever. Patency of airway is priority along with antibiotic therapy.

Epiglottitis: while not common, this bacterial infection can cause significant swelling and threaten airway. Associated with increased drooling, patient needs to sit up and requires very close monitoring. Treated with antibiotics.

Torticollis: See definition - can be gradual, or acute - from trauma or even as a side effect from medications. Also known as cervical dystonia.

See link

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Inspection & Palpation

Head & Neck Assessment

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Inspection & Palpation of Skull

Size and shape of skull
Hair distribution, texture

Lice: https://www.youtube.com/watch?v=9S1lrliT9w0

Symmetry
Palpate for abnormalities, tenderness

Temporal artery, Temporomandibular joint

Shape: should be fairly symmetrical on both sides.

Size: the adult skull is rigid - and there’s little room for expansion. If patient experiences swelling of the brain, or bleeding this increased need for space causes significant pressure on the brain, and damage.

Babies - have less rigid skulls; if they suffer from congenital hydrocephalus or brain trauma their skulls will actually increase in size.

Size of head should be proportionate to body - keep in mind that infants have a disproportionately larger head than adults, when compared to bodies.

Hair distribution - check for hair and scalp for lice, dryness, texture.

Need to separate the parts of the hair to assess for this.

Hair texture varies amongst races

In older adults, hair can thin. Both men may experience baldness. Older women may experience

hair growth on chin or upper lip.

Scaling or dandruff is usually caused by dryness or psoriasis.

Condition of one’s hair often can indicate patient’s state of health

Loss of hair is common with chemotherapy.

To assess shape, place your fingers in the person's hair and palpate the scalp on both sides. The skull

should feel symmetric and smooth and non-tender to the patient.

Cranial bones with normal protrusions include:

forehead, parietal bones, occipital bone, and each mastoid process (behind

each ear).

Palpate temporal artery above the cheekbone between the eye and top of the ear.

This will be tender with temporal arteritis.

The temporomandibular joint is just below the temporal artery and in front of the tragus of ear.

Palpate the joint as the person opens and closes the mouth. There should be no crepitus or tenderness. The patient should have full range of motion.

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Inspection & Palpation of Face

Facial symmetry
Colour
Moon face
Presence of unusual muscle movements

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Facial Assessment: Abnormal Findings

Trigeminal Neuralgia

2018 Mayo Foundation for Medical Education and Research (MFMER).

Bell’s Palsy

Trigeminal neuralgia - inflammation, pain affecting the 5th cranial nerve, which innervates the face as seen above

Typically only one side is affected.

Some people don’t require treatment, simply time. Others can be managed medically: anti-spasmodics, anti-convulsants, Still others may be treated with surgery, including microvascular decompression

Bell’s palsy - temporary weakness or paralysis of the facial muscles (usually one-sided). Can be mistaken for stroke.

Cause is unknown, can occur at any age. Symptoms caused by inflammation of the 7th cranial nerve.

Risk factors thought to be affecting one’s ability to suffer from bell’s palsy include: exposure to virus, pregnancy, diabetes. Treatment includes rest/time, steroids, protection of affected eye as it may not close or blink.

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Head & Facial Injuries

Consider loss of consciousness

Consider mechanism of injury

https://www.youtube.com/watch?v=qXi8EWkXoVI

Raccoon eyes/Battle’s sign

https://www.youtube.com/watch?v=yRg6IbwuytE

Facial Trauma

https://www.youtube.com/watch?v=G8IHcZQS68M

Always prioritize Airway, breathing, circulation

Consider whether patient lost consciousness - this speaks to reliability of injury (patient may have injuries he/she is unaware of).

Also important is the determination of whether injury was witnessed (ex. fall). This often helps determine how patient may have been injured. Also, look at the scene of injury site - does the injury make sense in light of the environment?

Consider whether patient is on blood thinners - if so, patient would likely need imaging of head to rule out bleed.

Will not discuss types of braininjuries as they should be included in neuro assessment. But assessment of face can help inform underlying concerns:

Raccoon eyes (periorbital eccyhmosis) can indicate a basilar skull fracture

Battle’s sign - bleeding behind the ears.

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What should the nurse do?

A patient is completing of itching to face and torso which began shortly after taking a new medication.

The nurse completes an inspection and notes facial flushing, and significant swelling of the lips and tongue. Also noted is the presence of welts on the patient’s torso.

What should the nurse do?

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Inspection of Neck

Symmetry

Trachea midline

Range of Motion (ROM)

Pulsation of carotid artery

Thyroid gland

Jugular venous distention

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Neck Assessment

Lump

Surgery

Therapies

Social habits

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Neck Assessment

Carotid Artery Assessment

https://www.youtube.com/watch?v=tz_UBbSgdKo

p

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Neck Assessment

Jugular Venous Distention

https://www.youtube.com/watch?v=baxNxWIWdK8

The Free Dictionary, 2018

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Palpation

Lymph Nodes:

https://www.youtube.com/watch?v=SZkIq6P-0UQ

Determine: tenderness, size, mobility, firmness

Lymphadenopathy: enlargement of lymph nodes

(> 1 cm)

Thyroid:

https://www.youtube.com/watch?v=Ed2WE7heOdU

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Thyroid Hormone Imbalances

https://www.youtube.com/watch?v=SVSBo065hmw

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Additional Learning Resources

Ashina, S., Bendtsen, L., Lyngberg, A., Lipton, R., Hajiyeva, N. and Jensen, R. (2015). Prevalence of neck pain in migraine and tension-type headache: A population study. Cephalagia 35(3), 211-219. https://www.researchgate.net/profile/Richard_Lipton/publication/295372179_Neck_Pain_Is_Highly_Prevalent_in_Migraine_and_Tension-Type_Headache_A_Cross-Sectional_Population_Study/links/5abbb6de45851584fa6d8f48/Neck-Pain-Is-Highly-Prevalent-in-Migraine-and-Tension-Type-Headache-A-Cross-Sectional-Population-Study.pdf

Centers for Disease Control and Prevention (2017). What is a Concussion? https://www.cdc.gov/headsup/basics/concussion_whatis.html

Moore, D. (2018). Hypothyroidism and nursing care. American Nurse Today, 13(2). https://www.americannursetoday.com/hypothyroidism-nursing-care/

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Glossary

Carotid Bruit: A murmur heard when auscultating the carotid artery in the neck; suggests narrowing of artery

Dysphagia: Difficulty swallowing or pain with swallowing

Encephalitis: inflammation of the brain

Fontanels: the membrane-covered ‘soft spot’ created by the space where 2 sutures join; present in newborns.

Foramen: hole or opening

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Glossary

Nuchal Rigidity: Inability to flex the neck forward due to stiffness of the neck.

Temporal Arteritis: inflammation and constriction of the temporal arteries.

Torticollis: The flexion, bending or twisting of neck muscles beyond their normal position; can be a gradual onset, or acute

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References

AMBOSS (2017). Examination of the jugular venous pressure - clinical examination

https://www.youtube.com/watch?v=baxNxWIWdK8

AMBOSS (2015). Thyroid examination - Clinical examination.

https://www.youtube.com/watch?v=Ed2WE7heOdU

Anatomy & Physiology of Skull Fractures. (2007). https://www.youtube.com/watch?v=qXi8EWkXoVI

Anatomy Zone (2016). Neck Muscles Anatomy Anterior Triangle Part 1 & 2. https://www.youtube.com/watch?v=x5b7BUMy_8k

Basilar Skull Fracture (2012). https://www.youtube.com/watch?v=yRg6IbwuytE

Encyclopaedia Britannica (2018). Thyroid Gland Anatomy. https://www.britannica.com/science/thyroid-gland

Coronary Artery Palpation and Auscultation (2013). https://www.youtube.com/watch?v=aTub9RP7Uuk

Examination of the jugular venous pressure - clinical examination

https://www.youtube.com/watch?v=baxNxWIWdK8

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References

Family Pediatrics (2015). What lice and their eggs look like.

https://www.youtube.com/watch?v=9S1lrliT9w0

Heart And Neck Vessels Assessment - Adult Health Assessment

https://www.youtube.com/watch?v=tz_UBbSgdKo

Health Channel TV (2013). https://www.youtube.com/watch?v=SVSBo065hmw

Jarvis, C. (2016). Physical Examination & Health Assessment (7th ed.). St. Louis, Missouri: Elsevier.

Mayo Foundation for Medical Education and Research(2018). Trigeminal Neuralgia.

https://www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/symptoms-causes/syc-20353344

Nishikawa, J. (2015). Lymph Node Examination- Head and Neck.

https://www.youtube.com/watch?v=SZkIq6P-0UQ

Swatski, R. (2015). Fontanels of the infant skull. https://www.youtube.com/watch?v=QYK2I50pTdw

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References

Teshima, T. (2016). Plastics: Facial Injuries

https://www.youtube.com/watch?v=G8IHcZQS68M

The Dystonia Society (n.d.) https://www.dystonia.org.uk/neck-dystonia

The Free Dictionary (2018). Jugular venous pressure definition. https://medical-dictionary.thefreedictionary.com/jugular+venous+pressure

thenaturalbodyworks. (2017). TMJ tricks tips and secrets. https://www.youtube.com/watch?v=rZTEzBBMdCE