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ASSESMENT OF HEAD AND NECK in nursing.pptx
- 1. ASSESMENT OF HEAD,NECK EYES AND EARS LECTURER : Mrs. CHRISTINE JOY PRESENTED BY; AARAKIT MARY MAGDALENE ALANYO FLORANCE.
- 2. Assessment of headand neck Cont’ • Begin by inspecting the head for skin colour and symmetry of facial movement .This refers how evenly and equally both sides of the face move during expressions or actions, noticing any dropping. If dropping is noted, ask the patient to smile, frown, and raise their eyebrows and observe for symmetrical movement. • Note the presence of any previous injury or deformation.
- 3. REQUIREMENTS: • Examination gloves •Light • Tongue depressor • Glass of clean water • Stethoscope .otoscope .
- 4. Examination of thehead and neck con......1 • Inspect the nose for patterns and noticing any nasal drainage. • Inspect the oral cavity and ask the patient to open the mouth and say Ah, inspect the patient’s mouth to using a good light and tongue Blade. • Inspect the ear for any drainage, symmetry and hearing ability.
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- 6. Examination of thehead • Introduce your self • Verify the patient. • Explain the procedure to the client. • Interview and collect the subjective date. • Perform hand hygiene. • Provide privacy. • Wear gloves.
- 7. Examination of thehead • Observe or inspect the head to check for anything of asymmetry or oedema. • Inquire about any pain or discomfort. • Palpate the head for consistency while wearing gloves for any tenderness or oedema. The head must be : • Symmetrical • Hard • Round • In the midline • Nomoceaphalic (appropriate to the body)
- 8. Normal Findings ofhead • Shape is oval or rounded • Face is symmetrical • No involuntary muscle movement • One can move facial muscles at will • Men measurements 56cm -58cm • Women 54-56cm • At birth 35cm • At one year 47cm.
- 9. Appearance of anormal head
- 10. Examination of thehead cont.......1 • There must be no presences of : • Lession • Scars • Infections • Masses • Hair loss.
- 11. Examination cont.....2 • Inspectface for symmetry features, movement expression, and skin condition. Note the following; • Involuntary movement of the Face when the patient is ask to perform some procedure to determine the presence of his/her facial nerves. (cranial nerve) by asking the patient to smile and raise the eyebrows. • No dropping of the Face on both sides indicates function of cranial nerve. • The head is still and upright
- 12. Examination of thehead cont......3 • The facial features are symmetrical • The eyebrow hair are equally distributed.
- 13. Palpate Temporal Artery •For tenderness and elasticity • Observe for elasticity • The client must not feel any tenderness or pain as you palpate the temporal artery • There must be no acute urgent condition which is seen when temporal Artery hard and thick • There must be no tenderness with inflammation that is commonly seen in temporal arteries which can cause blindness.
- 14. Palpate temporomanibular joint •By placing your index finger over the front of each and asking client to open the mouth. Note the following: • No swelling and tenderness • No crepitation of movement • Cracking as the patient opens her/his mouth for inspection • No eye sunkeness. • Ask if client has history of frequent headache.
- 15. The Neck • InspectNeck while it is slightly in extended position • The head of patient is symmetrical with head centred • No present lumps or bulging muscles. • Observe the patient’s thyroid and cricoid cartilage as they swallow the water. It must move symmetrically upwards. • Inspect movement of thyroid and cricoid cartilage and thyroid gland.
- 17. Examination of theneck cont......1 • Inspect cervical vertebrae : • As you let the patient flex their neck (chin to the chest) you must visibly see and palpate the vertebrae • Inspect Neck range of motion: • The neck movement of the patient must be normal, smooth and controlled. • No muscle spasms, inflammation or ( cervical arthritis that may cause stiff neck. • No webness.
- 18. Palpate Trachea by: •Placing your fingers in the sternal notch, feeling to each side and palpating the tracheal rings. • The trachea is in in the midline no present pulling of the trachea to the affected side. • Like in cases of fibrosis or pleural adhesion. • Palpate the thyroid gland • Auscultate thyroid gland for bruits which is caused turbulent blood flow usually due to narrowing of the an artery, if the gland is enlarged • Must not hear any sounds that may result in bruits • No soft, blowing, swishing
- 19. The Neck cont......3 •Sounds auscultated over the thyroid gland lobes. • Inspect cervical vertebrae: • As. You let the patient flex their neck (chin to chest) you must visibly see and palpate the vertebrae. • Palpate lymph nodes ,(preauricular nodes)) Infront of the ear • Palpalte (postauricular (behind the ear.
- 20. The Neck cont......4 •Palpate the occipital nodes • There must be no enlarged nodes that can be considered as an abnormal findings. • No tenderness • No hardness • No immobility. • Palpate the tonsillar nodes • There must be no enlarged nodes
- 21. The Neck cont......5 •Palpate submandibular nodes on both sides • There must be no tenderness • Palpate the segmental nodes • There must be no tenderness/pain. • Palpate the superficial cervical nodes • There must be no tenderness, pain
- 22. The neck cont......6 •Palpate the deep cervical chines nodes • There must be no tenderness / pain, enlargement • Palpate the posterior cervical nodes • There must be no tenderness/pain., Enlargement . • Palpate supraclavicular nodes also for enlargement, tenderness and pain.
- 23. Normal neck • Shouldlook along the line of the following: • Neck and back have no deformities, external skin changes, or sign of trauma, curvature of the cervical, throat and lumbar spine are within the normal limits • Make necessary referrals if not normal.
- 24. Eyes Exam: KeyPoints • Always check red reflex • Strabismus and Amblyopia (preschool child (cover/uncover test, corneal light) • Tumbling “E”, Allen, Snellen charts for older children (visual acuity) • PERRLA • EOMs: tracking 6 fields of vision • Fundoscopic exam of internal eye & retina
- 25. www.stjude.org/retinoblastoma For more information:http://s.stjude.org/multimedia/disease_summaries/retinoblastoma/spotli ght_retinoblastoma_0602.swf
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- 29. Ears Exam: KeyPoints • Examine last in younger children, hold young children in lap, head braced against parent’s chest • Hearing: language delay or frequent otitis media • Otoscope exam: • Pull auricle down & back for infants, toddlers, preschoolers • Pull auricle up & back for school aged & adolescents • Cerumen removal may be necessary • Use pneumatic otoscopy • Tuning fork: • Weber & Rinne tests to differentiate conductive vs sensorineural
- 30. Pregnancy--Eyes spindle-shaped, vertical depositof chocolate-brown coloured pigment in the cornea of the eye, created by flakes of pigment rubbed off the back of the iris.
- 31. Conductive vs. Sensorineural •Conductive hearing loss = external/middle ear dysfunction • (noisy environment helps) • Sensorineural hearing loss = inner ear • (sounds like people are mumbling, noisy environment worse)
- 32. Special Ear Tests Weberand Rinne are quick office screenings. If you or your patient has any concern with their hearing , you refer to audiologist for diagnostic testing. Pneumatic otoscopy is quite tricky Typanonometry- sensitive and specific for inner ear fluid, many office have these devices
- 33. Ears: Abnormal Tests •Weber: • Unilateral conductive hearing loss= sound heard in impaired ear • Unilateral sensorineural hearing loss=sound is heard in good ear • Rinne: • Conductive: heard through bone as long or longer than air • Sensorineural: sound is heard longer through air (normal pattern prevails)
- 36. REFERENCE Tomey, A.M.,(1994). NursingTheorists and their work. 3rd ed. Missouri: Mosby • Kozier and ERB’s Fundamentals of NURSING concepts, process and practice 9th edition. • https://brooksidepress.org/nursing_fundamentals
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Editor's Notes
- #25 Leukocoria means white pupil