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286 PHYSICAL EXAMINATION
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PHYSICAL EXAMINATION
EXAMINATION OF THE
SKIN
UNIT 2
EXAMINATION OF THE
HAIR
INSPECTION COLOUR Uniformly brown
BLEEDING,
ECCHYMOSIS AND
VASCULARITY
LESIONS 20–30 vesicles of varying sizes over lower
PALPATION MOISTURE Mild xerosis
TEMPERATURE Hands/feet/trunk all warm and equal
TENDERNESS Nontender except for hyperaesthesia in regions
TEXTURE Smooth
TURGOR Skin returns to original contour immediately
OEDEMA No oedema except as noted above
INSPECTION
PALPATION
COLOUR Black with grey roots, shiny
DISTRIBUTION No hirsutism or alopecia
LESIONS No infestations
TEXTURE Mildly coarse, brittle
No bleeding, ecchymosis or increased vascularity
abdomen, dermatomal level T 9–10 with extended
base of erythema; mild oedema of area, no
crusting of vesicles
inferior and superior to the lesions
EXAMINATION OF THE
NAILS
INSPECTION
PALPATION TEXTURE Firm
EVALUATION AND CLINICAL
REASONING FOR CASE STUDY
The assessment and clinical decisions you make should reect
your scope of practice. For example, advanced practice health
professionals, such as nurse practitioners and remote nurses
with endorsement, may be able to make diagnostic decisions and
prescribe medications without referring to a medical ofcer.
Fundamentally, all health professionals collect, evaluate and
act on person-focused health information, which will at times
include referral to, or collaboration with, other healthcare team
members. Nurses assess consumer responses to interventions
and determine when to escalate key changes in a consumer’s
condition. The clinical reasoning cycle provides health professionals with a framework to consider all this information in a
meaningful way for planning consumer care. These phases
are stepped out below, and draw on information presented and
collected during the health history and physical examination. We
then work through the cycle components that are relevant to this
case study (cycle components are bolded).
For Mrs Amrita Singh, the 62-year-old woman who presents
with a painful rash over her lower abdomen, the signicant data
that needs to be considered includes the following.
COLOUR Light brown with brisk cap rell
SHAPE AND
CONFIGURATION
Smooth and at; no splintering or brittle edges;
nail edge less than 160°
Collecting cues/information
Recall and Review: In the first instance you will need to reflect
on what you know about rashes and their connections to
disease processes, infection, allergies and lifestyle aspects
such as nutrition.
Chief complaint and history of present illness
> Painful rash on lower abdomen.
> Four days ago, consumer reported burning RLQ pain, malaise,
and a 37.5°C temperature.
> Pain started as a 1–2/10 and progressed over the next 24 hours
to 8/10. Consumer denied radiation of pain, or nausea, vomiting,
diarrhoea, constipation. Ibuprofen did not help the pain.
Nothing made the pain worse.
> Denies history of Crohn’s disease, ulcerative colitis and
diverticulitis; still has appendix.
> Consumer had blood work and an abdominal CT, which were
negative, and was sent home with instructions to follow up
with her GP.
> Last night, consumer noted a rash on her lower abdomen and
presents today for evaluation.
INTEGUMENTARY 287
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Processing information
Interpret, Discriminate and Infer: These symptoms and details
of history outline the scope of the issue for this consumer. The
absence of specic disease (Crohn’s disease, ulcerative colitis
etc.) is signicant, as it rules out other reasons for the symptoms
and narrows the eld of causes for the symptoms.
Match and Predict: Pain at this level that is not relieved by simple
analgesia will need to be managed in another way, as it is too
painful to remain untreated – otherwise consumers will continue
to re-present regardless of other management.
Medical history
> Not sure about childhood diseases; had some illnesses with
rashes and fever
> Had little medical attention as young person, no immunisation
until mid-20s
> History of malaria, eczema and hypothyroidism
Infer: Amrita’s medical history, while not pinpointing a specic
childhood illness, shows she has experienced rashes and fever as
a child, and little medical attention makes it likely she would have
received tribal/home remedies only.
Relate and Infer: Her medical history of malaria and
hypothyroidism puts her at risk of becoming run down and
immunologically compromised. Eczema is present and shows she
is likely to be affected by stress-related skin disorders as well.
Social history and health maintenance activities
> Work history and travel history to poor parts of India, living and
working in conditions that are likely to be dirty, and exposure to
many people in low socioeconomic conditions
> Stressed about possibility of family immigrating to Australia
and ability to support them here
> Has travelled often to India to assist in family business or care
for older relatives as is her ‘requirement to do so’
> Grown-up children, good relationships, still has one daughter
living at home, this daughter does not conform to family
expectations, but is supported living at home
> Has difculty falling asleep and staying asleep; never tried any
sleep aid
Relate, Infer and Predict: Amrita’s social information supports her
medical history of likely being exposed to many viruses in poor
conditions, with little access to medical assistance. There are also her
feelings of obligation to her family, the stress caused by the possibility
of their immigration and the extra work this will bring for her. Alongside
this, Amrita has been dealing with stress on a longer-term basis
around her daughter’s life choices and the conict this is causing
in her family. Amrita is not sleeping well, so this will be affecting her
ability to deal with stress and to allow her body to recuperate.
Physical assessment
> 20–30 vesicles of varying sizes over lower abdomen,
dermatomal level T 9–10 with extended base of erythema; mild
oedema of area, no crusting of vesicles, mild xerosis
> Nontender except for hyperaesthesia in regions inferior and
superior to the lesions
Interpret, Discriminate and Infer: This information shows the
extent of the vesicles’ area, the physical location and the patterns
that correspond to dermatomes or nerve tracts, all of which
are important cues to consider. The type of vesicle, extent of
erythema, oedema and pain and tenderness in surrounding
regions are also important in considering the cause of the
vesicles. Also important are whether they are infected, weeping
or may be infectious. This will affect how to contain the infectious
risk to others as well.
Putting it all together – synthesise information
Considering all the cues above, it is likely that the vesicles are
caused by the herpes zoster virus. As Amrita is unsure what
childhood illnesses she may have had, it is probable that she
has had chickenpox (varicella virus). Once a person has had
chickenpox there is a risk of experiencing an outbreak of herpes
zoster after the initial infection, perhaps many years later, and
usually it is triggered by stress and the body becoming run-down.
This condition is also known as shingles and ts with the other
symptoms of an initial localised pain without radiation, malaise,
low-grade fever then, within 48 hours, appearance of vesicles
(often uid-lled) and increasing pain not affected by other
variables.
The nurse in this case would document all these abnormalities,
and refer to the medical ofcer, as the consumer may have the
duration of the symptoms shortened with antiviral medications,
analgesia and anti-inammatories. As it is likely these medications
will be prescribed (non-steroidal anti-inammatory drugs such
as ibuprofen usually do not require prescription), the nurse will
need to check again that the consumer has no drug allergies and
that the medications prescribed will have no contraindications or
adverse interactions with Amrita’s current medications.
Actions based on assessment ndings
The nurse should also provide additional education for
interventions that do not require a doctor’s order, such as:
1 Apply cool cloths or cloth-wrapped ice packs over the lesions
or take a cool bath twice a day.
2 Avoid exposure to warm and hot water because this could lead
to further itching and irritation.
3 Cover lesions with a clean cloth or loose-tting gauze after
cleansing because they are contagious to people who have not
had chickenpox before.
4 Trim ngernails to reduce the chance of bacterial infection
from scratching.
5 Avoid wearing tight clothing over the rash because this could
irritate the rash further.
The nal step in the process is accurate documentation. The
nurse must document ndings, referrals, interventions, advice and
education given. The consumer would continue to have ongoing
long-term management and follow-up by specialist medical staff in
collaboration with general practitioner.
CHAPTER 8
288 PHYSICAL EXAMINATION
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CHAPTER RESOURCES
REVIEW QUESTIONS
UNIT 2
For answers to these questions, see Answer section at the end of
the book.
1. Which of the following are functions of the skin? Select all
that apply.
a. Serves as a protective barrier to pathogens
b. Filters dust and particulate matter
c. Excretes water, salts and nitrogenous wastes
d. Regulates temperature
e. Produces vitamin E
f. Permits sensory perception
2. The consumer mentions to the nurse that there are a lot of skin
problems in his family. Which of the following does the nurse
recognise as familial skin conditions? Select all that apply.
a. Squamous cell cancer
b. Melanoma
c. Eczema
d. Psoriasis
e. Shingles
f. Tinea pedis
3. While inspecting the skin of a consumer, you note circular
lesions that are pruritic, and have a silvery scale appearance
with clearly demarcated borders on the elbows and knees.
What medical condition might you suspect this consumer has?
a. Psoriasis
b. Second-degree burns
c. Ichthyosis vulgaris
d. Diabetes mellitus
4. A consumer complains of pruritus over the trunk and upper
limbs. You note a raised red, itchy rash. What is a possible
aetiology of this rash?
a. Ringworm
b. Herpes zoster
c. Drug reaction
d. Dermatitis
5. The nurse teaches her consumer about skin cancer
prevention measures. Which of the following should be
included in the discussion? Select all that apply.
a. Using sunscreen when the anticipated time of outdoor
activity is more than two hours
b. Using a tanning bed no more than once a month
c. Avoiding the sun between 10:00 a.m. and 4:00 p.m.
d. Reapplying sunscreen every four hours while swimming
e. Applying a lip balm with an SPF of 30 or higher
f. Using sunscreen even on cloudy days
6. Which of the following might the nurse expect to see in a
consumer who had an insect bite or a reaction to an allergy
shot?
a. A macule
b. A vesicle
c. A wheal
d. A cyst
7. A chronic supercial inammation of the face and extremities
that evolves into pruritic, red, weeping, crusted lesions is
usually associated with which of the following conditions?
a. Contaminated clothing and bedding
b. Contact with harsh detergent
c. Cold weather and trauma
d. Asthma and allergic rhinitis
8. The skin lesions that occur in impetigo are best described by
which of the following ndings?
a. A maculopapular rash with erythemic borders that
appears rst on the wrists
b. A blotchy maculopapular rash that appears rst on the
cheeks
c. Vesicles that measure 2cm, are pustular and rupture
easily, and have straw-coloured discharge
d. Flesh-coloured, hyperkeratotic papules that are slightly
umbilicated
9. A consumer shows you the area on her arm where she burned
herself with an iron. The skin is red and painful but has no
blistering. What type of burn do you suspect the consumer
incurred?
a. Epidermal
b. Partial thickness
c. Deep dermal partial thickness
d. Full thickness
10. The consumer tells you that when she was a child her nger
was caught in a piece of machinery that damaged her
ngernail. What type of nail condition might the consumer
have?
a. Onychorrhexis
b. Clubbing
c. Onychophagy
d. Eggshell nails
CLINICAL SKILLS
The following Clinical Skills are relevant to this chapter and
can be found in Tollefson & Hillman, Clinical Psychomotor
Skills, 8th edition:
> 5 Hand hygiene
> 6 Personal protective equipment
> 7 Aseptic non touch technique
> 27 Healthcare teaching
> 59 Pressure area care – preventing pressure injuries
> Part 13: Wound management
> 67 Dry dressing technique
> 68 Complex wounds – drain, suture or clip removal
> 69 Complex wounds – wound irrigation
> 70 Complex wounds – packing a wound.
INTEGUMENTARY 289
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FURTHER RESOURCES
> Australia and New Zealand Burn Association: http://www.
anzba.org.au/
> Australian Dermatology Nurses Association: http://www.adna.
org.au/
> Cancer Council Australia: http://www.cancer.org.au/home.htm
REFERENCES
Australian Government Department of Health. (2018). Communicable
diseases information. Retrieved 2 September 2018 from http://www.
health.gov.au/internet/main/publishing.nsf/content/ohp-communic-1
Australian Institute of Health and Welfare (AIHW). (2016). Skin cancer
in Australia. Cat. no. CAN 96. Canberra: AIHW. https://www.aihw.
gov.au/getmedia/0368fb8b-10ef-4631-aa14-cb6d55043e4b/18197.pdf.
aspx?inline=true
Australian Institute of Health and Welfare (AIHW). (2022). Rural and remote
health. Retrieved 5 December 2022 from https://www.aihw.gov.au/
reports/rural-remote-australians/rural-and-remote-health
Baranoski, S., Ayello, E. A., & Langemo, D. K. (2008). Wound assessment. In
S. Baranoski and E. A. Ayello (Eds.), Wound care essentials: practice
principles (2nd ed.). Ambler PA: Lippincott, Williams and Wilkins.
Benbow, M. (2016). Best practice in wound assessment. Nursing Standard,
30(27), 40–7. Retrieved 2 September 2018 from https://rcni.com/sites/
rcn_nspace/les/ns.30.27.40.s45.pdf
Cancer Australia. (2022). Melanoma of the skin. Retrieved 5 December 2022
from https://www.canceraustralia.gov.au/cancer-types/melanoma/
statistics
Davidson, L., Knight, J., & Bowen, A. (2020). Skin infections in Australian
Aboriginal children: a narrative review. Medical Journal of Australia,
212(5): 231−7. doi:10.5694/mja2.50361
Health Promotion Agency, New Zealand, Nov 2018, SS102, Skin Cancer in
New Zealand. Retrieved 5 December 2022, from: https://www.hpa.org.
nz/sites/default/les/4.3%20SS102%20Skin%20Cancer%20Facts%20
Infographic.pdf
Mayo Clinic. (2021a). Basal cell carcinoma. Mayo Clinic website. https://
www.mayoclinic.org/diseases-conditions/basal-cell-carcinoma/
symptoms-causes/syc-20354187. Updated 1 October 2021. Accessed
18 July 2022.
Mayo Clinic. (2021b). Squamous Cell Carcinoma. Mayo Clinic website.
https://www.mayoclinic.org/diseases-conditions/squamous-cellcarcinoma/symptoms-causes/syc-20352480. Updated 13 May 2021.
Accessed 18 July 2022.
> Cancer Society of New Zealand: http://www.cancernz.org.nz/
> International Society for Burn Injuries:
http://www.worldburn.org
> New Zealand Dermatology Nurses Society Incorporated
(NZDNS): https://www.nzdermatologynurses.nz/
Melanoma Institute Australia. (2022). A report into melanoma − a national
health priority. Retrieved 5 December 2022 from: https://melanoma.org.
au/wp-content/uploads/2022/03/MIA-and-MPA_SoN-Report_FinalReport_28-March-2022.pdf
Melanoma New Zealand. (2022). Melanoma facts and risk factors.
Retrieved 5 December 2022, from: https://www.melanoma.org.nz/factsrisk-factors
Mullane, M., Barnett, T., Cannon, J., Carapetis, J. R., Christophers,R.,
Cofn,J., … Bowen, A. C. (2019). SToP (See, Treat, Prevent) skin
sores and scabies trial: study protocol for a cluster randomised,
stepped-wedge trial for skin disease control in remote Western
Australia. British Medical Journal 9: e030635. doi:10.1136/bmjopen2019-030635
Pham, C. H., Collier, Z. J., & Gillenwater, J. (2018). Changing the way
we think about burn size estimation.Journal of Burn Care &
Research,39(suppl_1), S39–S40. https://doi.org/10.1093/jbcr/iry006.073
Skin Health Institute. (2022). Occupational Contact Dermatitis. https://www.
skinhealthinstitute.org.au/page/96/occupational-dermatitis . Accessed
18 July 2022.
Turnidge, J., Coombs, G., Daley, D., Nimmo, G., & Australian Group on
Antimicrobial Resistance (AGAR) participants 2000–14. (2016). MRSA:
A tale of three types: 15 years of survey data from AGAR. Sydney,
Australia: Australian Commission of Safety and Quality in Health Care.
Retrieved 2 September 2018 from https://www.safetyandquality.gov.
au/wp-content/uploads/2016/11/MRSA-A-Tale-of-Three-Types.pdf
Verma, C., Lehane, J., Neale, R., & Janda, M. (2022). Review of sun
exposure guidance documents in Australia and New Zealand. Public
Health Research and Practice 32(1):e3212202.
Victorian Adult Burns Service. (2022). Burn % TBSA. Burns Management
Guidelines. https://www.vicburns.org.au/burn-assessment-overview/
burn-tbsa/. Accessed 18 July 2022.
CHAPTER 8
290
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CHAPTER
9
HEAD, NECK AND REGIONAL LYMPH NODES
LEARNING OUTCOMES
By the end of this chapter you should be able to:
1 identify the anatomic structures of the head and neck
2 identify the lymph nodes of the head and neck
3 describe the health history for the head, neck and regional lymph nodes
4 demonstrate the physical examination of the head, neck and regional lymph nodes
5 explain normal ndings, common abnormalities and pathophysiology of these abnormalities in the
physical examination of the head, neck and regional lymph nodes
6 discuss the clinical reasoning in evaluating outcomes of health assessment and physical examination,
including documentation, health education provision and relevant health referral.
BACKGROUND
The most common head, neck and regional lymph node disorders are head and
neck cancers (of which there is a higher incidence in males) (Cancer Australia,
2022a), malignant neoplasms of lymphoid and other tissue, headache and thyroid
cancer (AIHW, 2022a).
Headache is one of the most common health problems experienced by Australians
and New Zealanders. As no major studies have been undertaken in either country,
statistics related to prevalence and cost are based on overseas research findings
(Headache Australia, 2023). Individuals aged between 20 and 50 years are more likely
than others to encounter headaches (Headache Australia, 2023). Cancer of the thyroid
gland is a significant health problem, with a marked increase in annual incidence in
Australia from 2.7 to 14 cases per 100000 people between 1982 and 2022 (Cancer
Australia, 2022b). There is no single explanation for this increase, which is evident
between obesity and thyroid cancer (Laaksonen et al., 2021). In New Zealand, thyroid
cancer disproportionately affects women and prevalence is higher among Pasifika
people (Health Navigator New Zealand, 2021). Also of note is the low mortality rate for
thyroid cancer: 0.4 deaths per 100000 people (Cancer Australia, 2022b).
The most common oral health problems are tooth decay and gum disease
(AIHW, 2020). Oral health is a significant issue for Aboriginal and Torres Strait
Islander peoples, with hospitalisation rates for dental conditions in 2019–20
reported to be 1.8 times higher than for non-First Nations people (AIHW, 2022b).
Gingivitis, the most common type of periodontal disease, is seen more commonly
in First Nations children, especially those living in remote areas, and is almost twice
as prevalent as the rate in the broader community (AIHW, 2022c) . Thirty-four per
cent of First Nations Australian children aged between 4 and 14 years (in 2014–15)
self-reported a tooth or gum problem (Australian Indigenous HealthInfoNet, 2017).
HEAD, NECK AND REGIONAL LYMPH NODES 291
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Major causes of periodontal disease among First Nations people in Australia
include poor oral hygiene and lack of access to appropriate diet and dental services
(AIHW, 2022c) as well as the high prevalence of smoking (37% in 2018–19 of those
aged 15 years and over; almost three times the rate of the general population)
(Australian Government Department of Health and Aged Care, 2020). Systemic
disadvantage and intergenerational trauma in Aboriginal and Torres Strait Islander
communities, in addition to inaccessibility of appropriate services, contribute to a
range of health issues, including oral health.
Māori and Pasifika people also experience poorer oral health and attend the
dentist less frequently than the broader population of New Zealand. Children
are 1.5 times more likely to have had a tooth extracted due to decay (Ministry of
Health, 2018). Lack of access to services is a significant risk factor for periodontal
disease; it is important that you are aware of the services available for consumers
close to where they live.
Assessment of the head and neck provides a wide range of critical clues about
the functions of various body systems. As you assess the head and neck, you will
learn about the skin, endocrine function, musculoskeletal integrity and neurological
function. You should refer to the relevant chapters in this textbook to assist in your
understanding of these health assessment areas.
CHAPTER 9
ANATOMY AND PHYSIOLOGY
The skull, face, neck, thyroid, lymph nodes and blood supply are discussed in the
following sections.
Skull
The skull is a complex bony structure that rests on the superior end of the vertebral
column (
a surface for the attachment of the muscles that assist with mastication and the
production of facial expressions.
The most prominent sutures are the coronal suture, the sagittal suture and the
lambdoidal suture. The junction of the coronal and sagittal sutures is called
the
Figure 9.1). The skull protects the brain from direct injury, and provides
The cranial bones of the skull are connected by immovable joints called sutures.
bregma.
Face
The face of every individual has its own unique characteristics, which are influenced
by factors such as ethnicity, state of health, emotions and environment. Facial
structures are symmetrical, so that the eyes, eyebrows, nose, mouth, nasolabial folds
and palpebral fissures look the same on both sides.
Neck
The neck is made up of seven flexible cervical vertebrae that support the head while
allowing it maximum mobility. The first cervical vertebra, the atlas, articulates
with the occipital condyles to support and balance the head. The second vertebra,
the axis, has an odontoid process that extends into the ring of the atlas, allowing
it to pivot as the head is turned from side to side. The seventh cervical vertebra has
a long spinous process called the vertebra prominens, which serves as a useful
landmark during physical assessment of the neck, back and thorax.
The major muscles of the neck are the sternocleidomastoids and the trapezii
(Figure 9.2). The sternocleidomastoid muscles extend from the upper portion of
the sternum and the clavicle to the mastoid process and allow the head to bend
laterally, rotate, flex and extend. They also divide each side of the neck into two
triangles: the anterior cervical and the posterior cervical, which serve as assessment
landmarks. The anterior triangle is formed by the mandible, the trachea and
the sternocleidomastoid muscle, and contains the anterior cervical lymph nodes,
the trachea and the thyroid gland. The posterior triangle, the area between
292 PHYSICAL EXAMINATION
Vertebra
prominens (C7)
Coronal suture
Zygomatic bone
Mandible
Clavicle
T
muscle
Right
anterior
fossa
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Sagittal suture
UNIT 2
Lambdoidal
suture
External
occipital
protuberance
Occipital bone
External
auditory
meatus
Mastoid process
Atlas (C1)
Axis (C2)
T1
Parietal bone
Frontal bone
Temporal
bone
Temporomandibular
joint
Superior rim
of orbit
Orbit
Sphenoid bone
Maxilla
Mandible
FIGURE 9.1 Bones of the face and skull (lateral view)
the sternocleidomastoid and the trapezius muscles with the clavicle at the base,
contains the posterior cervical lymph nodes (
Figure 9.3).
The trapezii extend from the occipital bone down the neck to insert at the outer
third of the clavicles, at the acromion process of the scapula, and along the spinal
column to the level of T12. They allow the shoulders and scapula to move up and
down, and rotate the scapula medially.
Thyroid
The thyroid gland, the largest endocrine gland in the body, secretes thyroxine (T4)
and triiodothyronine (T
CN XI
(Spinal
accessory
nerve)
rapezius
Sternocleidomastoid
muscle
FIGURE 9.2 Major cervical muscles
), which regulate the rate of cellular metabolism.
3
sternocleidomastoid
muscle
Right trapezius
Sternal head
Right
posterior
triangle
Omohyoid
muscle
FIGURE 9.3 Anterior and posterior cervical triangles
Mandible
Left
supraclavicular
Right
triangle
Left
clavicle
HEAD, NECK AND REGIONAL LYMPH NODES 293
Isthmus of thyroid
Sternocleidomastoid
muscle
Trachea
Posterior cervical
(from posterior
scalp, ear, and skin
of posterior neck)
(from scalp, throat and face)
tonsils and pharynx)
Sternocleidomastoid
External
jugular
vein
vein
Sublingual
Temporal
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The gland, a flattened, butterfly-shaped structure with two lateral lobes connected
by the
isthmus, weighs about 25 to 30g and is slightly larger in females (Figure 9.4).
The isthmus rests on top of the trachea, inferior to the cricoid cartilage.
Lymph nodes
An extensive system of lymphatic vessels drains the head and neck and is an
important part of the immune system (
Figure 9.5). Lymphatic tissue in the nodes
is responsible for the filtering and sequestration of pathogens and other harmful
substances. Lymph nodes are usually less than 1cm, round or ovoid in shape, and
smooth in consistency. When nodes are enlarged or tender, it is important to assess
for infection or malignancy. Note the direction in which each node drains (
Figure 9.5).
If a tender or enlarged lymph node is found on clinical examination, assess the entire
lymph node area, as well as the area that the involved node drains. For example, if a
consumer’s posterior cervical node is enlarged, examine the posterior scalp, the ear
(both externally and internally) and the skin of the posterior neck for pathology.
Blood supply
The blood supply to the head and neck is quite extensive, with arterial and venous
patterns. Major arteries that carry blood to the head and neck include the common
carotids (which bifurcate into the internal and external carotid arteries), the
brachiocephalic artery (the right common carotid artery branches from this), the
subclavian arteries, and the temporal arteries. Deoxygenated blood from the head
and neck is returned to the heart via the internal and external jugular veins, the
brachiocephalic vein, and the subclavian veins (Figure 9.6).
Hyoid bone
Thyroid
cartilage
Right lobe of
thyroid
Cricoid cartilage
CHAPTER 9
Clavicle
FIGURE 9.4 Structures of the thyroid gland
Posterior auricular
(from scalp and
auditory canal)
Occipital (from
posterior scalp)
Supraclavicular (from
abdomen, thorax, arm
and breast)
FIGURE 9.5 Lymph nodes of the head and neck and drainage patterns
Superficial and deep cervical
Sternum
Left lobe
of thyroid
Preauricular
(from face and
auditory canal)
Submental
(from lower face
and front of mouth)
Submandibular
(from face and
oral cavity)
Tonsillar (from
muscle
Internal
jugular
FIGURE 9.6 Major veins and arteries of the neck
Common
carotid
artery
artery
Parotid
gland
gland
Submandibular
gland
294 PHYSICAL EXAMINATION
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UNIT 2
ASSESSMENT: TAKING THE CONSUMER’S HEALTH HISTORY
Assessment is the first phase of the nursing process, and involves collecting
subjective information about the consumer’s health status in order to identify
consumer problem areas to focus on.
Subjective data is most frequently collected during a health history, and serves as the
starting point for the health professional to base the depth of their assessment on.
The sections for the health history include:
> Consumer prole
> Chief complaint (explained systematically using variations of location, quality,
quantity, associated manifestations, aggravating factors, alleviating factors,
setting and timing. This is a variation on the OPQRST assessment mnemonic you
may use for other conditions such as pain assessment)
> Past health history (including medical history, surgical history, allergies,
medications, injuries and accidents, special needs and childhood illnesses)
> Family health history
>
Social history (including alcohol, tobacco and drug use, sexual practice, work
and home environment, hobbies and leisure activities, stress and culture).
HEALTH HISTORY
CONSUMER
PROFILE
CHIEF COMPLAINT Common chief complaints for the head, neck and regional lymph nodes are dened, and information on the
The head and neck and regional lymph nodes health history provides insight into the link between a consumer’s life/
lifestyle and head, neck and regional lymph nodes information and pathology.
Diseases that are age- and sex-specic for the head, neck and regional lymph nodes are listed.
AGE
SEX FEMALE > Hypothyroidism or hyperthyroidism, thyroid cancer, migraines
characteristics of each sign or symptom is provided.
1. STIFF NECK Painful movement of the neck that restricts range of motion
> Lymphadenopathies related to Hodgkin’s disease (11–29 years)
> Cervical spine trauma (young adults)
> Hyperthyroidism (reproductive years in young women)
> Temporal arteritis (older adults)
> Decreased mobility of the cervical spine related to an inammatory or degenerative process
(older adults)
> Degenerative cervical bone disease
MALE > Lymphadenopathy related to Hodgkin’s disease
> Trauma-related cervical spine injury
QUALITY Limited range of motion, either passive or active
ASSOCIATED
MANIFESTATIONS
AGGRAVATING
FACTORS
Headache, neck tenderness, swelling, fever, numbness and tingling in
arms or hands
Position (sitting, standing, lying down), immobilisation of position for a
prolonged period, mobility, stress, weather
ALLEVIATING
FACTORS
SETTING Work, driving, stress
TIMING With all movements, with rotating movements only, with exion and
Immobility or rest, certain positions, analgesics, muscle relaxants, heat
extension only, with weather changes, after falls, motor vehicle or
other accidents
>>
HEAD, NECK AND REGIONAL LYMPH NODES 295
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>>
2. NECK MASS Discrete area of swelling found in the neck
QUALITY Mobile, nonmobile, smooth, irregular, tender, nontender
ASSOCIATED
MANIFESTATIONS
AGGRAVATING
FACTORS
ALLEVIATING
FACTORS
TIMING Longstanding, recent
3. HEADACHE Pain felt within the head, behind the eyes, or at the nape of the neck (
LOCATION Temporal, frontal, occipital, orbital, hemicranial/bilateral, neck, facial pain,
QUALITY Neck pain: aching, sore, dull, sharp
ASSOCIATED
MANIFESTATIONS
AGGRAVATING
FACTORS
ALLEVIATING
FACTORS
Shortness of breath, hoarseness, weight loss, fever and chills, dysphagia,
ear pain, prior radiation therapy to head/neck
Eating, talking, movement, tight clothing around the neck, swallowing
Avoidance of tight clothing, analgesic medications, decreased
dietary intake
behind the eyes, and upper shoulders
Head pain: throbbing, sharp, dull, aching
Neck pain: fever, headache, swelling, tenderness
Head pain: nausea and vomiting, aura (visual, olfactory, auditory, tactile),
diplopia, blurred vision, irritability, sneezing, rhinorrhoea, weakness,
dizziness, photophobia, phonophobia, hypertension, nosebleed, cough
Neck pain: stress, trauma, ageing, position, mobility, weather changes
Head pain: stress, fatigue, foods, noxious odours, caffeine intake,
coughing, alcohol intake, smoke, hunger, season, menstruation,
chemicals, toxins
Medications such as analgesics, anti-inammatory agents, ergotamine,
caffeine or caffeinated medications, antidepressants, triptan medications;
position change; rest; sleep; shaking head; food intake
CHAPTER 9
Table 9.1)
4. HEAD INJURY
SETTING Work, outdoors, relationship to biologic events, stressful environment,
change in weather, head trauma
TIMING Acute and sudden onset, at rest with weather changes
Head pain: constant intermittent, in the morning, at the end of the day,
premenstrual, seasonal
Neck pain: with movement
QUALITY Open, closed
ASSOCIATED
MANIFESTATIONS
ALLEVIATING
FACTORS
SETTING Mechanism of injury, use of helmet or protective headgear, use of seat
Light-headedness, photophobia, phonophobia, poor attention and
concentration, sleep disturbances, depression, neck pain, nausea,
vomiting, projectile vomiting, dizziness or vertigo, headache, seizure
activity, loss of consciousness, amnesia, visual disturbances, gait
disturbances, speech disturbances, confusion, drowsiness, abnormal
behaviour, abnormal movement of extremities, change in respiratory
pattern, discharge from nose or ear, head or neck lacerations/
abrasions/ecchymoses
Ice, analgesics, rest, surgical intervention
belt, violent activity, fall, sports injury, motor vehicle collision, alcohol or
drug use, concurrent history of seizure disorder, heart disease or
diabetes mellitus
>>
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