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Nursing Fundamentals/Assessment > Head, Neck and Lymph Assessment > Flashcards

Head, Neck and Lymph Assessment Flashcards

1
Q

Cranial Bones

A

frontal, parietal, occipital and temporal

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2
Q

Sutures

A

immovable joints that unite the cranial bones

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3
Q

Coronal Suture

A

crowns the head from ear to ear (frontal/parietal)

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4
Q

Sagittal Suture

A

separates the head lengthwise between 2 parietal bones

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5
Q

Lambdoid Suture

A

separates the parietal from the occipital bones

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6
Q

Salivary Glands include

A

parotid glands, submandibular gland and sublingual glands

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7
Q

parotid glands

A

cheeks over the mandible (non-palpable)

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8
Q

submandibular glands

A

below the mandible at the angle of the jaw

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9
Q

sublingual glands

A

floor of the mouth

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10
Q

Temporal Artery

A

pulsation is palpable in front or anterior to the ear

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11
Q

Neck

A

base of skull to the clavicle, 1st rib and 1st thoracic vertebra

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12
Q

Major Neck Muscles include

A

sternomastoid and trapezius

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13
Q

sternomastoid

A

sternum to mastoid process behind the ear (diagonally)

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14
Q

trapezius

A

occipital bone to scapula and clavicle (fans out)

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15
Q

thyroid gland

A

important endocrine gland with a rich blood supply

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16
Q

cricoid

A

just above the trachea (below the adam’s apple - thyroid cartilage)

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17
Q

lymphatics

A

major part of the immune system; detects and eliminates foreign substance from the body

18
Q

Preauricular lymph

A

in front of the ear

19
Q

Posterior auricular lymph

A

behind the ear (mastoid process)

20
Q

Occipital lymph

A

base of the skull (posterior)

21
Q

Submental lymph

A

under the chin (midline) behind the tip of the mandible

22
Q

Submandibular lymph

A

along the mandible (jaw)

23
Q

Tonsillar (Jugulodigastric) lymph

A

under the angle of the mandible

24
Q

Superficial Cervical lymph

A

overlying the sternomastoid muscle

25
Q

Deep Cervical lymph

A

deep under the sternocleidomastoid muscle

26
Q

Posterior Cervical lymph

A

along the trapezius muscle

27
Q

Supraclavicular lymph

A

above the clavicle

28
Q

Infraclavicular lymph

A

below the clavicle

29
Q

History (Subjective)

A

A. Headaches - unusually frequent, unusually severe
B. Head Injury
C. Dizziness - light headed
D. Neck Pain - limited ROM
E. Lumps or Swelling - in the head or neck
F. History of head or neck surgery
G. Medications

30
Q

Inspect and Palpate the Skull

A
  1. Note Size and Shape - normocephallic, symmetrical skull that is appropriate to body size
  2. Temporal Area - palpate temporal artery; palpate temporomandibular joint as the client opens mouth (movement should be smooth, nontender)
31
Q

normocephalic

A

term used to describe round

32
Q

Inspect facial structures

A

Note symmetry, emotion, abnormal swelling, involuntary movements

33
Q

Inspect and Palpate Neck

A

symmetry, ROM and swelling (parotid and thyroid gland)

34
Q

symmetry of the neck

A

neck muscles symmetrical, head midline, (head erect/upright)

35
Q

ROM of neck

A

a. Flexion, extension, side to side

b. Resistant ROM - shoulder shrug and side to side

36
Q

Inspect and Palpate Lymph Nodes

A

using gentle circular motion of your finger pads

37
Q

lymphadenopathy

A

enlargement of the lymph nodes (> 1 cm ) secondary to infection, allergy, neoplasm.

38
Q

When assessing for lymphadenopathy, check

A
  1. Location
  2. Size
  3. Shape
  4. Delimitation (discrete or matted together)
  5. Mobility
  6. Consistency
  7. Tenderness
39
Q

Normal Lymph Nodes

A

<1 cm, movable, soft, nontender, discrete

40
Q

Inspect and Palpate Trachea

A

midline

41
Q

Thyroid Gland Inspection and Palpation

A
  1. Inspection - observe swallowing with a sip of water
  2. Palpation - move behind patient, L hand/fingers sl push trachea to R, apply R fingers between the trachea and sternomastoid muscle, ask pt to swallow

Nursing Fundamentals/Assessment (24 decks)

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