Nursing Assessment of the Head and Neck

by Samantha Rhea, MSN, RN

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    00:01 So let's move on to the head and neck of the client.

    00:03 Now just taking a glimpse of our patient here, as you can see, we can see a lot of things of just looking here at the head and neck.

    00:11 We're gonna talk about the patient's face and all the things we need to assess, and their neck as well.

    00:17 So just starting with the top of our head to toe assessment, we're going to talk about the hair.

    00:22 Now, you may think this isn't really that important.

    00:25 But just think about, if you take a quick scan or your patient, you do actually want to check for the distribution, if there's thinness, if there's cleanliness and observe the hair color.

    00:36 Now, all of this can be important because this can tell us really how good maybe the patient can take care of themselves.

    00:43 And also, with all that hair back there, many times as a nurse if a patient's malnourished or their immobile, well, immobile and malnourished and they've been laying in their bed.

    00:54 There could indeed underneath the hair be some pressure ulcers, and we want to make sure we thoroughly assess back here as well.

    01:02 So let's talk about some special considerations when we're talking about the patient's hair.

    01:06 So our patients, some patients is completely normal.

    01:10 But just keep in mind and assess your patient, that sometimes alo patients presented and it's not typical for that patient.

    01:18 It could mean it's an indicator of disease.

    01:21 This could mean extreme stress or even malnourishment.

    01:25 Now, when we're assessing the hair, you may need to assess if there's an infestation of lice or bedbugs.

    01:32 Now, if this is the case, we need to take a step back and maybe consult social worker or case management because we want to assess the patient's living situation and their ability to take care for themselves.

    01:44 Now, also note when we're talking about infestations, this is also important to help protect us as healthcare providers, and consider specific PPE or Personal Protective Equipment.

    01:56 This may come in the form as gowns, hair nets, etc.

    02:00 Because we also don't want to transfer this to other patients that we may see in the day.

    02:06 Now, if at all possible and you're assessing a patient's hair, and it's appropriate, look at their hair shaft as well.

    02:12 Now, if you take a look at their hair shaft, sometimes you can see pustules or something abnormal that can increase the risk for infection.

    02:19 And lastly, with hair, think about signs of anxiety.

    02:23 Now, you may see patches of hair missing.

    02:26 Now, some people with a lot of stress and anxiety, they may pull out their hair, and this is an indicator that we need to have a thorough interview and give any particular consult with our client.

    02:39 Now, moving down from our head, from our hair, down to our eyes, we want to assess here and take note that we're going to look at color, pain or itching, or any odd discharge.

    02:50 This is important to note in our client.

    02:53 Now, you can see that we want to assess the sclera here.

    02:56 In this image, you see how red and irritated that is.

    02:59 That could be from a lot of things.

    03:01 It could be from some sort of excessive dryness or some sort of eye trauma.

    03:06 I can tell you in particular, I've had this issue where I had a contact in. I fell asleep.

    03:11 It ripped and scratched my cornea.

    03:13 My sclera was so red, I had to go to the doctor.

    03:17 And next, don't forget to check the eyelids, the top and the bottom.

    03:20 This is important to check these mucous membranes and look for any abnormalities.

    03:25 And also the ducts of their eyes.

    03:27 If there's any odd discharge here, this could mean infection.

    03:32 Now, you may think, okay, well, these usually aren't a big deal.

    03:36 They are actually usually easy to fix but however, some eye issues if you don't treat them early, they can indeed lead to visual impairment later, if not treated.

    03:48 Now, moving down the head and assessing the patient's ear, we want to check the external canal here and look for any redness, or drainage, or swelling, or even pain.

    03:58 Now, here's one important point to note that many time in nursing can be missed.

    04:03 If your patients wearing oxygen, look at any of those pressure points and check for pressure injuries.

    04:09 Also not, that if someone has an ear infection, be careful when you assess this if you touch it, or you pull it that can be really painful.

    04:19 And sometimes further assessments needed to look at the membranes inside the ears.

    04:23 Now, you need to make sure that use appropriate equipment and you're specifically trained to do so.

    04:30 Now, let's move on down with their nose.

    04:32 Now, this is important to look at the nasal cavity.

    04:35 So, this can be important for swelling, structural deformities, any odd drainage or color abnormalities.

    04:43 Now, this is also going to be important when we talk about structural deformities.

    04:47 So, if a patient has a nasal deviation, for example, we're going to need to note this if the nurse is going to place a nasogastric tube, for example.

    04:57 So, moving down the head, down to the mouth.

    05:00 Now, we want to assess the patient's lips, their teeth and their mucosa.

    05:04 So, when we assess the mouth, you're going to look at all of these areas and check for redness, we're going to make sure we're looking at the lips, see if they're dry and cracked.

    05:12 Look, if there's missing teeth, check the gum lines, and also check all inside the patient's mouth to see if there's any issues here.

    05:20 Now, it's also important when you're looking at the mouth, and this is commonly commonly overlooked.

    05:27 Especially in your patients that are non verbal and not able to take care for themselves.

    05:31 So you really want to take note to look at the palate, the top of their mouth, the back of their throat and their tongue.

    05:38 And here is important to note, any patches, any weird patches, white patches, lesions, abrasions, ulcerations, any sort of splotchiness.

    05:48 So if a patient's not able to self care, many times they develop kind of white coating on their tongue, and we call it thrush.

    05:55 Now, this is a problem because it affects the patient's ability to swallow or eat.

    06:01 So let's ask the question, what is thrush? So if you take a look at this image here, you see the white coating on the images tongue or on the patient's tongue here? This is actually defined as a fungal infection of the mouth, and no present a lot of times like you see here.

    06:19 Now, moving on from the head, we're moving down the assessment to the neck.

    06:24 Here is where we want to assess the patient's trachea and their lymph nodes.

    06:28 Now, here's really important to know that we just want to be very gentle here.

    06:33 We can palpate the lymph node for inflammation.

    06:36 So all we're looking here is checking for signs of swollen lymph nodes.

    06:40 You're going to lightly take your fingers and gently palpate their neck, and if it's swollen or you feel any sort of lumps or swelling, this could just mean there's assignment infection here.

    06:53 Also when we're talking about assessing the trachea, now this just needs to be midline.

    06:57 This is what we're looking for, and there's not any deformities.

    07:01 Now, if it's pushed on one side to the other, this could happen because of abnormal breathing patterns or breathing issues.

    About the Lecture

    The lecture Nursing Assessment of the Head and Neck by Samantha Rhea, MSN, RN is from the course Assessment of the Head and Neck (Nursing).

    Included Quiz Questions

    1. Alopecia
    2. Trichotillomania
    3. Lice infestation
    4. Dandruff
    5. Bed bug infestation
    1. “The white patches on your tongue are called thrush; it is a bacterial infection.”
    2. “It is normal for you to have some pain when I touch your outer ear.”
    3. “It is important that we address your eye concerns promptly to prevent vision loss.”
    4. “I need to adjust your oxygen tubing so I can assess for any skin breakdown.”
    5. "You're talking normally, so that means I do not need to check your mouth or throat"
    1. Tracheal deviation
    2. Oral thrush
    3. Conjunctivitis
    4. Swollen lymph nodes

    Author of lecture Nursing Assessment of the Head and Neck

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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