THE HEAD AND NECK

Odielon C. Filomeno, RN, MPH

 Learning Targets:
At the end of the module, students will be able to
01 Explain the functions of the head and neck;

02 Collect an accurate health history of the head

and neck
03 Perform the physical examination techniqu
es to evaluate the head and neck; and

04 Identify the measures to prevent traumatic

brain
injury.
 COMMON OR CONCERNING SYMPTOMS
OF THE HEAD
Head injury
Head or neck surgery
Traumatic brain injury

Headache
It is one of the most common symptoms in clinical practice, with a lifetime
prevalence of 30% in the general population.
Migraine headaches are by far the most frequent cause of headaches seen in offic
e practice, approaching 80% with careful diagnosis. Nevertheless, every headache w
arrants careful evaluation for life-threatening causes such as meningitis, subdural or i
ntracranial hemorrhage, or tumor.
The OLDCART or PQRST methods can be used in order to obtain the health histor
y of the patient’s headache.
 History Interview (OLDCART)
Onset: When did you first notice the headache?
Location: Where do you feel the headache? Can you point to the area(s)?
Duration: How long has this been going on? Did the headache begin suddenly (in a few minut
es or less than an hour) or gradually (over a few hours or days)? Is it temporary or constant? Wh
en does the pain begin (morning, evening)? Does it wake you at night? How long do the headac
hes last? Are they recurring? Is there a pattern?
Characteristic Symptoms: Describe what it feels like (throbbing, hammering, squeezing). De
scribe the pain on a scale of 1 to 10 with 1 being minimal pain and 10 being the worst pain you e
ver felt.
Relieving Factors: What have you tried to make the headache go away? (e.g. Sleep? Dark r
oom? Cool
compresses? Relaxation techniques?) What has worked the best? What has not worked at all?
Does anything
make it worse? How have the headaches affected your daily life and activities?
Treatment: Has anyone treated you for headaches in the past? (e.g. physician, nurse practitio
ner, or massage therapist). Have you used any medication? If yes, then the name of the medica
tion, dosage, and affect?
 History Interview (OLDCART)
Traumatic brain injury (TBI) is a blow to the head or a piercing head injury that interferes with the fun
ction of the brain.
Not all injuries to the head result in a TBI, and those that occur in span from mild to severe.

Head Trauma or Brain Injury:

Onset: When did this occur? Can you describe what happened? Do you remember when you hurt y
our head?
Precipitating Factors: What happened to cause the traumatic brain injury? (e.g. Lack of protective eq
uipment or helmet? Environmental)?
Location: Can you show me where you hurt your head?
Duration: Did you lose consciousness? If yes, for how long? Did you fall first or lose consciousness
first?
Characteristic Symptoms: Did you experience any symptoms prior to the head injury (headache, s
hortness of breath, chest pain, numbness, or tingling)? Do you have any medical issues (cardiac histor
y, diabetes, seizures)?
Associated Manifestations: Do you experience vision changes; nausea or vomiting; attention span
deficits; drainage from the ears, nose, eyes, or mouth; tremors; seizures; or gait change?
Relieving Factors/Strategies: Prevention of further injur
 COMMON OR CONCERNING SYMPTOMS OF THE
NECK
Swollen lymph nodes or neck lumps
Enlarged thyroid gland
Hoarseness

History Interview (OLDCART)

Onset: When did you first notice the lump?
Location: Where is the lump? Is there more than one lump?
Duration: How long have you had the lump?
Characteristic Symptoms: Has the lump changed (size, tenderness, drainage, shape,
consistency
Associated Manifestations: Do you have difficulty swallowing? Have you had any recent
infections? Trauma? Radiation? Surgery? History of smoking? Drinking alcohol? Chewing
,tobacco?
Relieving Factors: Does anything make the lump smaller? Less tender? Have you tried com
presses on the site?
Treatment: Have you been to a health care provider?
 PHYSICAL ASSESSMENT
Equipment:
Tangential light
Cup of water
Stethoscope

The Hair
Note its quantity, distribution, texture, and pattern of loss, if any. You may see loose flakes of dandruf
f.
The Scalp
Part the hair in several places and look for scaliness, lumps, nevi, or other lesions.
The Skull
Observe the general size and contour of the skull. Note any deformities, depressions, lumps, or tend
erness.
Learn to recognize the irregularities in a normal skull, such as those near the suture lines between th
e parietal and occipital bones.
The Face
Note the patient’s facial expression and contours. Observe for asymmetry, involuntary
movements, edema, and masses.
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The Skin
Observe the skin, noting its color, pigmentation, texture, thickness, hair distribution,
and any lesions.
The Neck
Observe the skin, noting its color, pigmentation, texture, thickness, hair distribution,
and any lesions. Inspect the neck, noting its symmetry and any masses or scars.
Look for enlargement of the parotid or submandibular glands, and note any visible ly
mph nodes.
The Lymph Nodes
Palpate the lymph nodes. Using the pads of your index and middle fingers, move the
skin over the underlying tissues in each area in a circular motion. The patient should
be relaxed, with neck flexed slightly forward and, if needed, slightly toward the side bei
ng examined.
You can usually examine both sides at once. For the submental node, however, it is
helpful to feel with one hand while bracing the top of the head with the other.
 PHYSICAL ASSESSMENT
Sequence of following nodes:
1. Preauricular — in front of the ear
2. Posterior auricular — superficial to the mastoid process
3. Occipital — at the base of the skull posteriorly
4. Tonsillar — at the angle of the mandible
5. Submandibular — midway between the angle and the tip of the mandible. These nodes
are usually smaller and smoother than the lobulated submandibular gland against which the
y lie.
6. Submental — in the midline a few centimeters behind the tip of the mandible
7. Superficial cervical — superficial to the sternomastoid
8. Posterior cervical — along the anterior edge of the trapezius
9. Deep cervical chain — deep to the sternomastoid and often inaccessible to examination
. Hook your thumb and fingers around either side of the sternomastoid muscle to
find them.
10. Supraclavicular — deep in the angle formed by the clavicle and the sternomastoid
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The Trachea and the Thyroid Gland:
Inspect the trachea for any deviation from its usual midline position. Then feel for an
y deviation.
Place your finger along one side of the trachea and note the space between it and th
e sternomastoid.
Compare it with the other side. The spaces should be symmetric.
Inspect the neck for the thyroid gland.
Tip the patient’s head back a bit.
Using tangential lighting directed downward from the tip of the patient’s chin, inspect
the region below the
cricoid cartilage for the gland.
The lower shadowed border of each thyroid gland shown here is outlined by arrows.
PHYSICAL ASSESSMENT
 THE EYES
Odielon C. Filomeno, RN, MPH
 COMMON OR CONCERNING SYMPTOMS IN THE
EYES:
Changes in vision:
o Hyperopia – is a refractive error, which means that the eye does not bend or refract light pr
operly to a single focus to see images clearly. In hyperopia, distant objects look
somewhat clear, but close objects appear more blurred.
o Presbyopia – is when your eyes gradually lose the ability to see things clearly up close.
It is a normal part of aging. In fact, the term “presbyopia” comes from a Greek word which me
ans “old eye”. You may start to notice presbyopia shortly after age 40.
o Myopia – is a common vision condition in which you can see objects near to you clearly, bu
t objects farther away are blurry. It occurs when the shape of your eye causes light rays to
bend (refract) incorrectly, focusing images in front of your retina instead of on your retina.
o Scotomas – is an area of partial alteration in field of vision consisting of a partially diminish
ed or entirely degenerated visual acuity that is surrounded by a field of normal–or relatively w
ell-preserved– vision.
 COMMON OR CONCERNING SYMPTOMS IN THE
EYES:
Double vision or diplopia
Strabismus – is when your eyes are not lined up properly and they point in different
directions
Blurring
Redness
Itching
Discharge
Pain
Tearing
Edema
Lesions
Visual disturbances
Photophobia
Areas of History Interview
• Eye History
• Family History
• Lifestyle Habits
 PHYSICAL ASSESSMENT
The components of the eye examination include:
• Vision tests: distal, near, and peripheral Inspection of the eye, eyebrows, lids, conjunctiva and
sclera, cornea, lens, iris, and pupils Inspection and palpation of the lacrimal apparatus.
• Extraocular movements: assessment of cardinal fields, convergence, corneal light test, cover–u
ncover test.

Equipment for Examination

• Snellen chart or “E” card
• Rosenbaum, near-vision card
• Index card
• Penlight
• Ophthalmoscope
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Visual Acuity
• This is expressed as two numbers (e.g., 20/30): the numerator indicates the distance of the
patient from the chart and this number should always be 20 unless the patient moved closer to see,
and the denominator is the distance at which a normal eye can read the line of letters.
Near Vision
• Testing near vision with a special hand-held card, the Rosenbaum chart, helps identify the need
for reading glasses or bifocals in patients older than 45 years. This card can be utilized to test
visual acuity at the bedside. Held 14 inches from the patient’s eyes, the card simulates a Snellen ch
art. However, patients may choose their own distance.
External Eye Examination
• Position and Alignment of the Eyes. Stand in front of the patient and survey the eyes for position a
nd alignment. If one or both eyes seem to protrude, assess them from above.
• Eyebrows. Inspect the eyebrows, noting their quantity and distribution and any scaliness of the un
derlying skin.
• Eyelids. Note the position of the lids in relation to the eyeballs.
 PHYSICAL ASSESSMENT

Inspect for the following:

• Width of the palpebral fissures — open area between the upper and lower eye
lids
• Edema of the lids
• Color of the lids
• Lesions
• Condition and direction of the eyelashes
• Adequacy with which the eyelids close. Look for this especially when the eyes
are unusually prominent, when
there is facial paralysis, or when the patient is unconscious.
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Internal Eye Examination

• Cornea and Lens. With oblique lighting, inspect the cornea of each eye for op
acities and note any opacity in the lens that may be visible through the pupil.
• Iris. At the same time, inspect each iris. The markings should be clearly
defined. With your light shining directly from the temporal side, look for a cresce
ntic shadow on the medial side of the iris. Because the iris is normally fairly flat
and forms a relatively open angle with the cornea, this lighting casts no shadow.
• Pupils. Inspect the size, shape, and symmetry of the pupils. If the pupils are
large (5 mm), small (<3 mm), or unequal, measure them. A pupil guide with
black circles of varying sizes facilitates measurement.
• Test the pupillary reaction to light. Ask the patient to look into the distance, and
shine a bright light obliquely into each pupil in turn.
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Ophthalmic Examination
• The nurse would examine the patient’s eyes without dilating the pupils. The view is ther
efore limited to the posterior structures of the retina.
• To see more peripheral structures, to evaluate the macula well, or to investigate unexpl
ained visual loss, ophthalmologists dilate the pupils with mydriatic drops unless this is co
ntraindicated.
Extraocular Muscles
• The normal conjugate movements of the eyes in each direction, or any
deviation from normal
• Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus on extre
me lateral gaze are normal.
If you see it, bring your finger in to within the field of binocular vision and look again.
• Lid lag as the eyes move from up to down.
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Special Techniques
• Nasolacrimal Duct Obstruction. This test helps identify the cause of excessive
tearing. Ask the patient to look up. Press on the lower lid close to the medial canthus,
just inside the rim of the bony orbit — this compresses the lacrimal sac. Look for fluid
regurgitated out of puncta into the eye. Avoid this test if area is inflamed and tender.

Health Promotion, Disease Prevention and Education

• Vision screening
• Eye protection
• Care of contact lenses
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Vision Screening
• Changes in vision shift with age. Amblyopia, also known as “lazy eye”, affects approximately 2–4
% or preschool children. This loss of vision is due to an alteration in neural pathways in the developi
ng brain which in turn decreases use of the affected eye.
• Strabismus is eye misalignment; these are found most frequently in infants and children up to 5 y
ears old. Screening tests for detecting strabismus and amblyopia include simple inspection, the cov
er uncover test, corneal light reflex and visual acuity tests.

Eye Protection
• Eye injuries and trauma can occur in the home, during recreational activities, and in the place of e
mployment. Protective eyewear should be utilized when there is a chance of injury to the eye.
• Eye injury can result from numerous causes, for example: chemical splashes from cleaning suppli
es, metal shards or rocks flying when mowing the lawn, sports (e.g., lacrosse) injuries, body fluids e
ntering the eye—the list is endless. The activities and environment in which people work and play s
hould be assessed and precautions taken to avoid eye injury and promote healthy habits.
 PHYSICAL ASSESSMENT
Care of Contact Lenses
• Infections can occur and injure the eye if contact lenses are not taken care of properly.
Patients should remember to wash their hands when inserting or removing lenses, to
wear and remove them as prescribed by the health care provider, and to keep them
clean and not share contacts.
• If patients are using solutions, they should discard unused portions at the expiration
date.

Variations and Abnormalities of the Eyelids

• Ptosis
• Entropion
• Ectropion
• Lid retraction and exophthalmos
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Thank you