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Chapter 13 Head, Face, and Neck, Including Regional
Nursing Assessment across the Life Span (Texas Woman's University)
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
The Head
★ Skull - rigid bony box that protects the brain and special sense organs
★ Cranial bones:
○ Frontal
○ Parietal
○ Occipital
○ Temporal
★ Cranial sutures
○ Coronal suture - crowns the head from ear to ear at the union of frontal and
parietal bones
○ Sagittal suture - separates the head lengthwise between parietal bones
○ Lambdoid suture - separates the parietal bones crosswise from the occipital bone
★ Facial bones
○ Nasal bone
○ Zygomatic bone
○ Maxilla
○ Mandible
★ Cranium is supported by the cervical vertebrae: C1 (axis), C2 (atlas) through C7
(vertebra prominens)
★ The face:
○ Facial muscles mediated by cranial nerve VII
○ Facial muscle function is symmetric bilaterally
○ Facial structures are symmetrical: eyebrows, eyes, ears, nose, mouth, palpebral
fissures, nasolabial folds
○ Facial sensations of touch are mediated by cranial nerve V (trigeminal nerve)
○ Salivary glands:
■ Parotid glands - in the cheeks over the mandible; largest salivary glands
but not normally palpable
■ Submandibular glands - beneath the mandible at the angle of the jaw
■ Sublingual glands - lie in the floor of the mouth
○ Temporal artery - superior to the temporalis muscle and its pulsation is palpable
anterior to the ear
★ The Aging Adult
○ Facial bones and orbits appear more prominent
○ Facial skin sags
The Neck
★ Major neck muscles
○ Sternomastoid - arises from the sternum and clavicle and extends diagonally to
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the mastoid process behind the ear; it accomplishes head rotation and flexion
○ Trapezius - arise from occipital bone and vertebrae, extend to the scapula and
clavicle; move the shoulders and extend and turn the head
○ Anterior triangle - lies in front between the sternomastoid and midline of the
body, with its base up along the lower border of the mandible and its apex at the
suprasternal notch
○ Posterior triangle - behind the sternomastoid muscle, with the trapezius muscle
on the other side and its base along the clavicle
Thyroid Gland
○ Straddles the trachea in the middle of the neck
○ Synthesizes and secretes thyroxine and triiodothyronine that stimulate rate of
cellular metabolism
○ Two lobes that curve posteriorly between trachea and sternomastoid muscle and
connect in the middle (isthmus).
Cricoid cartilage
○ Just above the thyroid isthmus - upper tracheal ring
Thyroid cartilage
○ Above the cricoid cartilage with a small palpable notch in its upper edge
○ “Adam’s apple” in males
Hyoid bone
○ Palpated high in the neck at the level of the floor of the mouth
★ Head and neck have 60 to 70 lymph nodes
○ Preauricular - in front of the ear
○ Posterior auricular - superficial to the mastoid process
○ Occipital - at the base of the skull
○ 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
○ Supraclavicular - just above and behind the clavicle at the sternomastoid muscle
★ Drainage patterns
○ When nodes are enlarged, check the area they drain.
○ All drain down expect for supraclavicular, which drains up
Subjective Data
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★ Headache
○ An unusually frequent or unusually severe headaches?
○ Ever had this kind of headache before?
○ Do you have any other illnesses?
○ Do you take any medications?
○ Any family history of headaches?
○ Tension headaches:
■ occipital or frontal with bandlike tightness
■ Viselike
■ Associated with anxiety and stress
○ Migraines:
■ Vascular
■ tend to be supraorbital, retroorbital, or frontotemporal
■ throbbing, severe pain
■ occur twice per month, each lasting 1 to 3 days
■ alcohol, stress, menstruation, chocolate, cheese precipitate
■ associated with N/V and visual disturbances
■ Family history
■ People lie down to feel better
○ Cluster headaches:
■ produce pain around the eye, temple, forehead, cheek
■ unilateral on same side of head
■ excruciating pain
■ occur once or twice per day, each lasting ½ to 2 hours
■ alcohol and daytime napping precipitate
■ Associated with eye reddening and tearing, eyelid drooping, rhinorrhea
and nasal congestion
■ People need to move to feel better
○ Hypertension, fever, hypothyroidism, vasculitis, oral contraceptives,
bronchodilators, alcohol, nitrates, and carbon monoxide inhalation can cause
○ How have these headaches affected your self-care or ability to function?
★ Head injury
○ Any head injury or blow to your head?
○ Are symptoms worse, better, or unchanged since injury?
○ Loss of consciousness before a fall may have a cardiac cause
○ A change in LOC is most important in evaluating a neurologic deficit
★ Dizziness
○ Experienced any dizziness?
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○ Describe it for me
○ Presyncope: a light-headed, swimming sensation or feeling of fainting or falling
caused by decreased blood flow to the brain or heart irregularity causing
decreased cardiac output.
○ Vertigo: true rotational spinning often from labyrinthine-vestibular disorder in
inner ear
■ Objective vertigo: the person feels like the room is spinning
■ Subjective vertigo: the person feels like he or she is spinning
○ Disequilibrium: a shakiness or instability when walking related to
musculoskeletal disorder or multi-sensory deficits
Neck Pain
○ Acute onset of neck stiffness with headache and fever occurs with meningeal
Lumps or Swelling
○ Any recent tenderness or infection?
■ Tenderness suggests acute infection
■ Persistent lump arouses suspicion of malignancy
○ Any history of irradiation of head, neck, upper chest?
■ Increased risk for salivary and thyroid tumors
○ Any difficult swallowing?
■ Dysphagia
○ Smoking history
■ Smoking and chewing tobacco increases risk for oral and respiratory
○ Alcohol history
■ Increases risk for cancer when combined with smoking
○ Thyroid problems?
History of head or neck surgery
○ Ever had surgery of the head or neck?
■ Can cause disfigurement and increases risk for body image disturbance
○ For what condition?
○ When was the surgery?
○ How do you feel about the results?
The Aging Adult
○ Patient-centered care: how does condition affect ADL’s and IADL’s?
■ Assess potential for injury
Objective Data
The Head
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★ Inspect and Palpate the Skull
○ Size and shape
■ Normocephalic - a round symmetric skull that is appropriately related to
body size
■ Microcephalic - abnormally small head
■ Hydrocephalic/Acromegaly - abnormally large head
■ Place fingers in person’s hair and palpate scalp. No tenderness to palpation
■ Note lumps, depressions, or abnormal protrusions
○ Temporal area
■ Palpate the temporal artery above the zygomatic bone between the eye and
the top of the ear
● Note if the artery looks tortuous, feels hardened, or is tender
■ The temporomandibular joint is just below the temporal artery
● Palpate as the person opens the mouth
● Observe smooth movement with no limitation or tenderness
● Abnormal: crepitation, limited ROM, tenderness
★ Inspect the Face
○ Facial structures
■ Note facial expression and appropriateness to behavior or reported mood
● Anxiety is common in hospitalized or ill person
○ Tense, rigid muscles
● Note hostility or aggression
● Flat affect may indicate depression
■ Features should always be symmetric - eyebrows, palpebral fissures,
nasolabial folds, sides of mouth
● Marked asymmetry with central brain lesion (stroke), cranial nerve
VII damage (Bell palsy)
■ Note any abnormal facial structures
● Coarse features, exophthalmos, changes in skin color/pigmentation
■ Note abnormal swelling
● Edema occurs first around the eyes and cheeks (where subQ tissue
is loose)
■ Note involuntary movements
● Tics, grinding of jaws, fasciculations, excessive blinking
The Neck
★ Inspect and Palpate the Neck
○ Symmetry
■ Head position is centered in midline
■ Accessory neck muscles should be symmetric
■ Head should be erect and still
■ Head tilt occurs with muscle spasm
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■ Rigid head and neck occur with arthritis
○ Range of Motion
■ Note any limitation or pain of movement
■ Ask person to perform ROM
● Motion should be smooth and controlled
● Ratchety or limited movement could be from cervical arthritis or
inflammation of neck muscles
■ Cranial nerve XI
● Try to resist person from shrugging shoulders and turning head
from side to side
■ Note enlargement of salivary or lymph glands
● Swollen parotid gland can be seen when head is extended swelling below angle of jaw
● Thyroid enlargement may be unilateral or diffuse
● Parotid can be swollen with mumps or AIDS
■ Note any obvious pulsations (carotid)
★ Lymph Nodes
○ Use gentle circular motion of finger pads
○ Begin with preauricular nodes and move in systematic order
○ Use gentle pressure
○ Compare bilaterally
○ Note location, size, shape, delimitation, mobility, consistency, and tenderness
○ Normal nodes feel movable, discrete, soft, and nontender
○ Lymphadenopathy: enlargement of lymph nodes (> 1 cm) from infection, allergy,
or neoplasm
○ If nodes are enlarged or tender, check the area they drain for the source of the
■ Acute infection: acute onset, < 14 days duration, nodes are bilateral,
enlarged, warm, tender, and firm, but freely movable
■ Chronic inflammation: in TB the nodes are clumped
■ Cancerous nodes: hard, > 3 cm, unilateral, nontender, matted, fixed
■ HIV infection: enlarged, firm, nontender, mobile (occipital node)
■ Neoplasm in thorax or abdomen: single, enlarged, nontender, hard, left
supraclavicular node
■ Hodgkin lymphoma: painless, rubbery, discrete, gradually appear,
commonly in cervical region
★ Trachea
○ Normally the trachea is midline
○ Trachea is pushed to unaffected (healthy) side with aortic aneurysm, tumor,
unilateral thyroid lobe enlargement, pneumothorax
○ Trachea is pulled toward affected (diseased) side with large atelectasis, pleural
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adhesions, or fibrosis
○ Tracheal tug - a rhythmic downward pull that is synchronous with systole and
occurs with aortic arch aneurysm
★ Thyroid Gland
○ Difficult to palpate
○ Look for diffuse enlargement or a nodular lump
○ Usually you cannot palpate the normal adult thyroid
○ Sometimes feel the isthmus over the tracheal rings
○ If the thyroid is enlarged, auscultate it for the presence of a bruit (a soft, pulsatile,
whooshing, blowing sound heard best with the bell)
The Aging Adult
★ Temporal arteries may look twisted and prominent
★ Senile tremors - mild rhythmic tremor of the head such as nodding and tongue protrusion
★ If teeth have been lost, lower face looks abnormally small with mouth sunken in
★ Kyphosis
★ Perform ROM slowly
★ Prolapse of submandibular glands
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