Nursing Assessment
Series Number 126

The Head and Neck, Mouth and Throat (126.8)

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T he functions related to the head and neck are far-reaching and complex. Our eyes and ears are constantly gathering information from the world around us. Our mouth and throat provide speech for communicating with others, and also provide the pathway for intake food and drink. To better address the complexities, assessment has been broken down into smaller components. We begin with the assessment of the head and neck, and then proceed to the mouth and throat. Assessments of the eyes, ears and nose are covered in the next program. Because the head contains the brain, subjective data overlaps with the neurological exam. Headaches and dizziness, for example, are detailed in the program on the neurologic assessment. Head and Neck Subjective Data
Inquire about pain in the head and neck region and if present, do a pain assessment. Ask what medication or non-pharmacologic pain treatments have been used and how effective they are. Ask if there is any history of head or neck injury or surgery, including cosmetic procedures. Neck pain is a common complaint. It may be muscular in origin as the neck bears the full weight of the Poor posture, and sitting for long periods at the computer can put significant strain on the neck muscles, as In addition, emotional stress can cause tightening of the neck muscles, leading to pain and stiffness. The patient may report the presence of lumps or swelling, particularly in the neck region. Ask when these occurred and whether they were painful or restricted movement.  Educational Media Distributors 2013 Head and Neck Objective Data
Begin your physical assessment by observing the size and shape of the skull. The normal skull is a rounded, symmetrical, and somewhat oblong. Palpate the skull with your fingertips, noting any asymmetry or unexpected prominences. There are normal prominences at the forehead, the parietal region, the occipital region, and the mastoid processes. These should be palpable but not exaggerated in size. Overly large prominences should be Abnormalities which should be noted include microcephaly and macrocephaly, meaning an abnormally Microcephaly is usually congenital in origin, but may occur in the first few years of life if brain development is abnormal. It is unusual for it to go undiagnosed into adulthood. It is commonly associated with reduced mental capacity and a shortened lifespan. Macrocephaly may be related to a variety of pathologies, including Paget’s disease and acromegaly. However, it should be remembered that large skulls with no underlying pathology may also occur. Now assess the facial features. If the patient is wearing glasses, ask him to remove them so you can get an The features should be symmetrical. Note any abnormalities, including coarseness of the features, swelling, or unusual pigmentation. Palpate the frontal and maxillary sinuses for tenderness or pain. Also observe the facial expression. The face is capable of expressing many emotions and facial expression should be congruent with the current situation.  Educational Media Distributors 2013 Blunted facial expression can denote nerve problems, but may also be related to emotional and mental Stand behind your patient and gently palpate along the front central portion of the neck. Take care not to apply pressure to the carotid arteries. Note if the trachea is straight and midline. Swelling at the base of the throat just above the clavicle can indicate a thyroid mass and should be reported. An assessment of the head and neck also includes assessment of the lymph nodes and range of motion of the facial and jaw muscles. Lymph assessment is covered in the program on the cardiovascular and lymph systems, and assessment of facial and jaw movement is covered as part of the cranial nerve assessment. There are other findings related to the face and neck which may indicate an ongoing disease process. Hypothyroidism can produce myxedema, which includes puffy edema of the face, particularly around the eyes, dry skin, a course, dry feel to the hair and a coarsening of facial features. Exopthalmos, or bulging of the eyes, and goiter, a significant increase in the size of the thyroid gland, are Immobile facial features accompanied by a flat, mask-like facial expression called hypomimia, is seen in Mouth and Throat Subjective Data
Now we will look at the mouth and throat. Ask the patient if he has had any recent sores on his lips, If yes, ask him to describe them and tell you how often they occur, how long they last, and if any treatment was used and the degree of effectiveness. Is his throat sore, or does he have any history of sore throats, or problems with hoarseness?  Educational Media Distributors 2013 Ask about tooth ache and problems with bleeding gums. Ask when he last saw her dentist and what dental work he has had in the past year. Does he have a dental bridge or false teeth? Does he have any difficulty with chewing or swallowing, or any recent alteration in his sense of taste? Finally, ask about the use of chewing tobacco or snuff, both of which are implicated in oral cancer. Mouth and Throat Objective Data
Begin by visually assessing the mouth. The lips should be smooth, moist, and free of cracking, peeling, or Use a tongue blade to gently retract the lips so you can see the gums, which should be pink, moist, and lie It is normal for people of African heritage to have a dark line at the gingival margin. Inspect the teeth. Note any missing or broken teeth, abnormal spacing or position. Are any teeth loose? When the teeth are closed, do they line up appropriately, or is there an obvious underbite, overbite, or Are the chewing surfaces of the molars abnormally worn down? This can be caused by teeth grinding during sleep or times of stress, or may be related to poor enamel strength. The breath odor can provide significant clues to the overall health status. Is it clean or foul smelling? Patients with undiagnosed or poorly controlled diabetes may have a fruity breath odor, signifying the  Educational Media Distributors 2013 Poor oral hygiene commonly causes halitosis, or bad breath, due to the release of sulfurous compounds by a heavy growth of oral bacteria. It is also an indicator of the individual’s level of self-care. A fishy or ammonia-like odor may indicate chronic renal failure, and an odor of feces on the breath may be a sign of recent vomiting or bowel obstruction. Abscess, gum infection, and high intake of vitamin supplements are other common causes of breath odor. Ask the patient to open his mouth wide so you can view the tongue. It should be pink in color, moist, and Small surface bumps called papillae give the tongue surface a roughened appearance. Ask him to raise his tongue inside an open mouth so you can observe the underside. The undersurface is normally smooth and glistening, and the veins are clearly visible. Also observe for excessive swallowing and drooling, both of which can indicate oral infection or injury, or drainage from congested sinuses. Excessive drooling with or without cough is seen in patients with swallowing difficulties, called dysphagia. Inspect the inside of the mouth and the margins of the tongue for any signs of lesions. These can be related to a variety of causes, but the biggest concern is early detection of oral cancer. Using a tongue blade to gently lift the cheeks away from the teeth, inspect first one side of the buccal Cancer lesions are often seen as white patches. Any noted should be palpated to see if they are flat or indurated. Inspect the entire oral cavity, giving particular attention to the edges of the tongue and the entire floor of the mouth underneath the tongue.  Educational Media Distributors 2013 Examining the edge of the tongue is best done by grasping the tongue with a gauze square, pulling it gently Next, ask the patient to tip his head back so you can inspect the hard and soft palate. The hard palate is posterior and white with irregular ridges, while the soft palate is anterior and is pink and moist. Now, with the patient facing you and his mouth open, hold down the tongue and use the flashlight to The uvula should hang midline, and when the patient says “ah-h-h” the uvula and soft palate should rise Inspect the throat, again asking the patient to say “ah-h-h”. The throat should be pink and moist and free of patches or obvious areas of swelling. You may see the tonsils at either side of the throat behind the arch of the soft palate. If they protrude out into the opening or touch the uvula or each other, they are enlarged and should be reported. Also report if Other Abnormalities of the Mouth and Throat
Thrush is an accumulation of candida albicans on the tongue and inside the mouth, forming creamy white lesions that are often painful and may make eating difficult. It is most common in infants, but can be a problem for adults who are on antibiotics, have a compromised immune system, use oral corticosteroid inhalers, have been on oral steroids, or wear dentures. In some instances, it may move downward, coating the throat and making swallowing difficult. Herpes simplex lesions, often called cold sores or fever blisters, can occur on the lips or in the mouth. They are painful and contagious until healed. They frequently recur and affect as high as 50% of the adult population. Good hand-washing is necessary during outbreak as the virus can be transferred to other areas  Educational Media Distributors 2013 “Meth Mouth” is caused by the use of methamphetamines. The symptoms include gingivitis, extensive dental caries, cracked teeth, and eventual tooth loss. Gingival hyperplasia is the painless overgrowth of the gums, sometimes to the extent of over-reaching the teeth. It may occur with puberty, pregnancy, and for some patients with leukemia. But it is most commonly associated with the long-term use of the seizure medication phenytoin/Dilantin. Two bacterial infections that affect the throat are tonsillitis and epiglottitis. While commonly thought of as childhood diseases, they both occur in adults. Tonsillitis causes tonsils to swell, turn red and show white or yellow patches of exudate. It is very painful and may be accompanied by fever and difficulty swallowing. Epiglottitis presents very rapidly and is considered an emergency. Swelling here affects the epiglottis, which swells and turns bright red like a cherry. This can cause total airway obstruction. The hallmark signs that differentiate epiglottitis from tonsillitis are rapid onset of fever, malaise and sore throat, and a muffling of the voice referred to as “hot potato” voice because it sounds like someone is talking around a mouthful of hot food. Patients, particularly children, will sit up and prop themselves forward on their hands in a tripod position and breath through an open airway. They may drool rather than While epiglottitis is less likely to cause full airway obstruction in adults, it is still a significant possibility. If a patient presents with symptoms that suggest epiglottitis, immediate intervention by medical specialists skilled in airway management is needed. Do not attempt to visualize the airway. As we have seen, assessment of the head and neck encompasses many aspects of health. It is important to document any and all unusual findings as they can be clues to other health issues.  Educational Media Distributors 2013



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