Weber HEENT

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cswett
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Weber HEENT
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2011-11-26 17:56:08
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Weber HEENT
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  1. Head and Neck Anatomy:
    Skull – 6 bones; protects brain & sensory organs; immobile/fixed

    Face –14 bones give shape; immobile except mandible; CN’s V(trigeminal - both) ; VII - (Facial - both) temporal artery behind eyes and ears

    • Neck – C1-7 with C7 most prominent; sternocleidomastoid & trapezius muscles; blood vessels
    • (jugular veins & carotid arteries)

    Larynx – voice box above trachea; thyroid cartilage or “Adam’s apple” protects larynx Hyoid bone = U-shaped bone at base of mandible that anchors tongue & only bone doesn’t articulate with another in body

    • Thyroid Gland – largest endocrine
    • gland in front of trachea; regulates cell metabolism

    Cardiovascular/Lymphatic Structures – supraclavicular drains abd. & thoracic areas
  2. Head & Neck Chief Complaints
    Headaches (migraine, tension, luster, tumors)

    Dizziness/Syncope (loss of contiousness) - cardiac, neuro, or inner ear problem

    Neck Pain or Stiffness (esp. suddenly with temp & HA = meningitis)

    Hoarseness/voice change

    Neck Mass (lump or lesion) with decreased range of motion

    • Thyroid Disorders (change in skin or hair): Hypo or
    • Hyperthyroid

    “OLDCARTS” mnemonic - onset, location, duration, characteristics, aggravating/alleviating factors, related s/s, tried treatments & severity 0 to 10 scale
  3. Head & Neck: Health History
    • Past Medical History:
    • Surgeries to head, neck, or thyroid
    • History of chronic headaches, falls
    • Chronic diseases (HT, DM, hypothyroid)
    • Radiation to neck
    • Medications

    • Family History
    • Autoimmune disorders (thyroid disease, type I diabetes, rheumatoid arthritis, myasthenia gravis)
    • Family member with hypertension or migraine headaches?
    • Family history of head or neck cancer
  4. Head & Neck: Lifestyle and Health Practices
    • Use of tobacco & alcohol
    • Preventative practices (helmets & seatbelts)
    • Recreational activities/contact sports
    • Interference with ADL’s
    • Risk factors for traumatic brain injury
  5. Head & Neck Physical Exam
    • Inspect, palpate skull (firm & nontender) -
    • Normocephalic
    • - appropriately proportioned
    • Microcephalic
    • - small head
    • Macrocephalic - large head

    • Inspect facial features, symmetry, & appropriateness of facial expression - Facial features calm plus alert & oriented
    • Cranial nerve VII (facial - both) -tongue (salt, sugar, lemon) raise eyebrows, purse lips, stick out tongue, close eyes tightly, show teeth, puff cheeks
    • Facial drooping - CVA or Bell’s palsy

    Inspect, palpate, & auscultate temporal arteries - temporal artery is elastic and not tender

    • Inspect, palpate bony structures of face
    • Tenderness = Sinus infection
    • Acromegaly -enlarged bony structure due to increased growth hormones

    Palpate temporomandibular joint for movement or tenderness/pain - no swelling, tenderness, or crepitation with movement - mouth opens fully (3 to 6 cm) & moves laterally 1-2 cm each direction

    • Inspect neck for positioning and range of motion (midline trachea, sternocleidomastoid & trapezius)
    • Torticollis = “wry” neck due to muscle spasm/ contraction
    • ROM: flex, extend, lateral & rotate

    Palpate neck/trachea: midline position not deviated; check neck against resistance - Neck resistance 0-5+ (musculoskeletal) & shrug shoulders against resistance (CN XI, spinal accessory- motor)
  6. Physical Examination :Thyroid Gland
    Inspect anterior neck for thyroid enlargement below cricoid cartilage

    • Palpate thyroid gland (swallow) -
    • Posterior approach
    • Anterior approach
    • Flex neck slightly forward and to the side you are examining
    • Push the trachea over to one side then the other

    • Thyroid = size of thumb pad, right lobe larger than left; May not be felt
    • Ausculate thyroid only if enlarged (bruit/bell)
  7. Physical Examination: Lymph Nodes
    • Inspect/palpate regional lymph nodes
    • Enlarged, tender, and firm but movable suggests infection
    • Unilateral, hard, asymmetric, fixed, nontender suggests malignancy
    • Lymphadenopathy > 1 cm
    • Regional lymphadenopathy

    Generalized lymphadenopathy (AIDS)
  8. Head & Neck Lymph Nodes
    • Preauricular = in front ear high
    • Postauricular = behind ear high
    • Occipital = base skull / back neck
    • Parotid = anterior ear lobe
    • Tonsillar = below ear/jaw level behind
    • Submandibular = under jaw
    • Sublingual=between jaw & chin
    • Submental = under chin
    • Cervical = along sternocleidomastoid (anterior & posterior cervical chains in neck)
    • Supraclavicular = below clavicle (bad if enlarged as drains from abd. & thorax, esp. left side)

    • Check on lymph nodes:
    • Size & shape (< 1 cm & pea shaped)
    • Delimitation (discrete boundaries v. confluent/merge)
    • Mobility (mobile in infection v. fixed in CA)
    • Consistency (soft v. CA is hard & firm esp. unilateral)
    • Tenderness (tender with infection v. nontender/painless with CA)
  9. Elderly Variations: Head/Neck
    • Neck pain with decreased ROM due to arthritis
    • Facial wrinkles from less SQ fat with prominent nose
    • Mouth drawn inward from mandibular reabsorption
    • Head position more forward & downward
    • Cervical curvature with kyphosis

    • Women with “dowager hump” from vertebrae degeneration
    • Extrapyramidal invol. head movements
    • Thyroid nodular with fibrosis from aging
    • Lymph nodes more fibrotic & fatty
  10. Classification of Headaches:
    Migraine-throbbing unilat., pain begins with aura (smells); photophobia & nausea due to vasospasm; esp. women

    • Cluster-unilat. intense pain in eye (burning, stabbing) lasts daily for weeks then remission for months; esp. young
    • men & ETOH

    Tension-bilat. front or back of head due to stress; viselike tight band around head (dull, aching); esp. women; relief analgesics - aggrivated by activity

    Tumor-related-morning HA subsiding in day; N&V; location varies; aggravated by moving
  11. Risk Factors: Headaches
    • Risk Factors for Headaches:
    • Stress/anxiety
    • Visual disturbances
    • Medication side effects
    • Alcohol (sulfites in wine)
    • Smoking
    • Lights
    • Family history of migraines or headaches
    • Trigger foods: chocolate, dairy products, fruits, coffee, nitrates (bacon), Chinese (monosodium glutamate), caffeinated beverages
  12. Risk Factors: Thyroid Disease
    • Thyroid Disease Risk Factors:
    • Autoimmune disease family history
    • Family history thyroid cancer
    • Gender-females with more nodules (hyper), yet males with more thyroid cancer
    • Radiation exposure to head or neck
  13. Hyperthyroidism =
    Increased thyroid hormone due to autoimmune disorder (Graves’ disease)

    • SIGNS & SYMPTOMS:
    • Enlarged thyroid
    • + Bruit from goiter
    • Tachycardia
    • Weight loss yet increased appetite
    • Muscle tremor
    • Fine hair & hair loss
    • Warm skin with increased perspiration
    • Exophthalmos = bulging eyes
  14. Hypothyroidism
    Decreased production of hormone due to autoimmune or iodine deficiency

    • SIGNS & SYMPTOMS:
    • Goiter as compensatory response
    • Fatigue/lethargy
    • Bradycardia
    • Weight gain with decreased appetite
    • Slow movements/muscle aches
    • Dry, brittle hair with flaky skin
    • Cold intolerance

    TSH - thyroid stimulating hormore - will be up because the body is trying to compensate

    Synthroid early in the morning - normal circadian rhythem - body distributes hormones early morning (6am)
  15. Thyroid Nodules Compared
    • Benign:
    • Adult, More prevalent in females
    • Slow growth
    • + Family history
    • No change in voice
    • More than one
    • No lymphatic involvement

    • Malignant:
    • Adult, More prevalent in males
    • Rapid growth
    • No family history,
    • Hoarseness, dysphagia
    • One Nodule, may have + lymph node involvement
    • Repeated x-ray exams
  16. Head & Neck Nursing Diagnoses:
    • Risk for head trauma RT lack of protective gear (helmets & seatbelts)
    • Ineffective tissue perfusion to brain
    • Impaired swallowing RT decreased gag reflex
    • Activity intolerance RT hypothyroidism
    • Imbalanced nutrition, less than required RT hyperthyroidism/hypermetabolism

    • Imbalanced nutrition, more than required RT hypothyroidism
    • Risk for infection RT lymphadenopathy
  17. Anatomy & Physiology: Nose Functions -
    • Humidifies, filters & warms air
    • 3 turbinates provide heat & water exchange
    • Lined with cilia (nasal hairs) that trap particles from getting into lungs
    • Identifies odors (CN I – Olfactory)
    • Gives resonance to voice
    • Kiesselbach’s area – nasal septum with blood supply
    • Kiesselbach’s area for most nose
    • bleeds (front/anterior nasal septum with rich blood supply esp. veins)
    • However, posterior bleeds (epistaxis) more
    • severe as difficult to pack
  18. Anatomy & Physiology: Mouth & Throat
    • Tongue – dorsal surface with taste buds (sweet, sour, bitter, salty); ventral surface vascular
    • Teeth: 20 deciduous (baby teeth)
    • 32 permanent teeth
    • Salivary glands – 3 pairs:

    • Parotid – in front ears above mandible
    • Submandibular – under mandible
    • Sublingual – floor of mouth
    • Oropharynx – structures in back mouth
    • Uvula – suspended midline
    • Tonsils – lymphoid tissue
  19. A&P: Pharynx/Throat
    • Throat (Pharynx) structures
    • Hard anterior palate (roof)
    • Soft posterior palate
    • Uvula
    • Tonsils (protect against infection) – palatine, lingual, pharyngeal (adenoids)
  20. Anatomy & Physiology: Paranasal Sinuses
    • Bilateral air-filled cavities that make skull lighter
    • 4 sets:
    • Frontal – above eyebrows
    • Maxillary – either side of nose by cheekbones (drain supine—not upright)
    • Ethmoid – bridge of nose
    • Sphenoid – behind ethmoid to ear
  21. Present History/Chief Complaint (“OLDCARTS”)
    • Nasal Discharge
    • Yellow-green = bacterial infection
    • Bloody = neoplasm or trauma
    • Clear, watery = allergies or CSF
    • Foul smelling & unilateral discharge = foreign body
    • Sinus congestion – pain in eyes & front teeth
    • Epistaxis (bloody nose)
    • Mouth pain/lesions – TMJ, gingival disease, herpes, dental problems
    • Throat problems -
    • Dysphagia (difficulty swallowing)
    • Sore throat – nasal congestion, dust & pollen
    • Hoarseness
  22. Health History :Past History & Family Hx.
    • Past Medical History – oral or nasal surgeries for tonsils, polyps, teeth extractions, broken nose, etc.; history of
    • sinus infections; Chronic illnesses (nasal polyps with C.F., mouth lesions with herpes simplex, & dysphagia with CVA)

    Family History – allergies or allergic rhinitis; any mouth, throat, nose or sinus cancer
  23. Health History of Nose, Mouth, Sinuses & Throat
    • Life Style & Health Practices:
    • Tobacco (smoking & smokeless)
    • Alcohol use
    • Bruxism/teeth grinding
    • Mouthcare – last dental visit; halitosis; brush, floss, brush tongue; lip screen; dentures fit
  24. Physical Exam Areas:
    • Nose (external & internal)
    • Lips
    • Teeth
    • Sinuses
    • Mouth & Tongue
    • Tonsils & Uvula
  25. Examine Nose, Sinuses, Mouth & Throat:
    Inspect & palpate nose for general appearance, symmetry, tenderness, discharge; rhinophyma

    Assess nose for patency & evaluate olfactory nerve (CN I – smells, anosmia (can't small very well)

    Inspect internal nasal cavity (mucosa, turbinates & septum) with light source
  26. Examine Nose, Sinuses, Mouth & Throat:
    Inspect & palpate nose for general appearance, symmetry, tenderness, discharge; rhinophyma

    Assess nose for patency & evaluate olfactory nerve (CN I – smells, anosmia)

    Inspect internal nasal cavity (mucosa, turbinates & septum) with light source
  27. Exam: Sinuses, Lips & Mouth
    • Palpate frontal & maxillary sinus areas for tenderness
    • Transilluminate the sinus areas
    • (no illumination = congested or not developed)
    • Inspect lips for color, symmetry, moisture & texture
    • Inspect & palpate teeth for condition, color, stability & alignment (CN VII, facial for clench teeth & smile)
    • Inspect & palpate inner lips & gingiva (gums) for tenderness, color & moisture
  28. Examination of Mouth & Tongue
    • Inspect buccal (cheek) mucosa for color & characteristics (coral to pink color)
    • Leukoplakia – white patches due to Candida
    • Erythroplakia – red patches on oral mucosa

    • Inspect tongue for movement, color & texture (stick out tongue; dorsal rough, ventral smooth)
    • Beefy- red = vit. B deficiency
    • Yel.-brown hairy = antibiotics, pipe, steroids, excess mouthwash
    • Enlarged = mental retardation/Down’s Syndrome or
    • hypothyroidism
    • Longitudinal fissures = dehydration
  29. Examine Uvula, Soft Palate, & Tonsils
    Inspect & palpate uvula for texture, color, & surface characteristics (Asians & Amer. Ind.split)

    Inspect movement of soft palate “ah” with tongue blade (CN IX glossopharyngeal & CN X vagus)

    Inspect posterior wall of pharynx & tonsils for color & surface characteristics (pink, irreg.)

    • 0 = no tonsils
    • 1+ = visibly swollen
    • 2+ = halfway between pillars & uvula
    • 3+ = tonsils nearly touch uvula
    • 4+ = “kissing” tonsils (touch one another)
  30. Age Variations: Elderly
    • Larger nose due to unabated cartilage formation
    • Coarser nasal hair with less filtering more colds
    • Decrease smell due to less sensory cells in nose
    • Decrease taste buds/perception
    • Problems swallowing/dysphagia

    • Teeth darken/stain with enamel
    • Decrease gingival tissue as less elastic so more bleeding gums
    • Xerostomia (dry mouth)
    • Varicose veins on ventral surface of tongue
  31. Oropharyngeal Cancer=
    • Slow growing squamous cell cancer
    • Signs & Symptoms –
    • Nonhealing ulcerated sore on lower lip
    • Leukoplakia (white) or erythroplakia (red) patches
    • Painless, nonhealing ulcer
    • Later a mass, bleeding, loose teeth & dysphagia (difficulty swallowing)
  32. Oropharyngeal Cancer: Risk Factors -
    • Tobacco (90% smokers)
    • Excess alcohol (75 – 80%)
    • Excess sun exposure (lip CA)
    • Diet low in vitamins A, C & E
    • Poorly fitting dentures
    • Gender: males 2X > females
    • Race esp. African Americans
    • Age > 40 yrs. (peaks ages 64-74 yrs.)
    • Previous history of cancer, or immuno-suppression
    • Ethnicity
  33. Gingivitis =
    Inflammation of gums usually due to poor dental hygiene

    • SIGNS/SYMPTOMS -
    • Hyperplasia of gums
    • Erythema & bleeding (painless)
    • Progresses to Pyorrhea (periodontitis) with loss of supporting bone, inflammation & erosion of gum tissue & loose teeth
  34. Tonsillitis=
    Infection of tonsils usually due to beta-hemolytic streptococci

    • SIGNS/SYMPTOMS -
    • Sore throat
    • Odynophagia (pain with swallowing)
    • Fever/chills
    • Tender cervical lymph nodes
    • Enlarged, erythema tonsils with white or yellow exudate
  35. Nursing Diagnoses for Nose, Mouth & Sinuses:
    • Readiness for enhanced management of teeth & gums
    • Risk for aspiration RT decreased gag reflex
    • Risk for infection of gums or tonsillitis
    • Disturbed sensory perception RT smell (CN I) & taste (CN VII & IX)
    • Pain RT sinusitis
    • Impaired Swallowing RT dysphagia
    • Impaired oral mucous membranes

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