Nursing Assessment test 2

Nursing Assessment test 2 - HEAD, FACE, AND NECK; INCLUDING...

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HEAD, FACE, AND NECK; INCLUDING REGIONAL LYMPHATICS I. The Head a. Skull —a rigid bony box that protects brain and special sense organs (includes bones of cranium and face) i. Cranial bones : Frontal, parietal, occipital, temporal 1. Meet at immoveable joints called sutures, which doesn’t ossify until early childhood b. 14 facial bones—all articulate at sutures…except for the mandible c. Glands —salivary, parotid, submandibular, sublingual i. Parotid : in the cheeks over the mandible, anterior to and below the ear ii. Submandibular : beneath mandible at the angle of the jaw iii. Sublingual : lie in the floor of the mouth II. The Neck a. Major neck muscles—sternomastoid and trapezius i. Sternomastoid : arises from sternum and medial part of the clavicle; extends diagonally across neck to mastoid process behind ear 1. Used for rotation and head flexion ii. Trapezius : 2 trap muscles form a trapezoid shape on upper back arise from occipital bone and vertebrae and extend fanning out to scapula and clavicle 1. Move shoulders and extend and turn head b. Thyroid gland—straddles the trachea i. Highly vascular; synthesizes and secretes thyroxine and triiodotyronine hormones that stimulate metabolism III. Lymphatic’s a. Occipital —at base of skull; submental —midline, behind tip of mandible; submandibular —halfway between angle and tip of mandible; jugulodigastric —under angle of mandible; superficial cervical —overlying the sternomastoid muscle; deep cervical —deep under sternomastoid muscle; posterior cervical —posterior triangle along edge of trap muscle; supraclavicular —just above and behind clavicle, at sternomastoid muscle b. Major part of the immune system—detect and eliminate foreign substances from body c. Accessible to exam in only head/neck, arms, axillae, and inguinal region IV. Aging adult —bones are more prominent, and skin sags from decreased elasticity, decreased subcut fat, and decreased moisture. Lower face may look smaller if teeth have been lost V. Subjective Data a. Headache —any frequent or unusually severe headaches? Onset, ever had THIS KIND of headache before?, location, localized or all over? Character (throbbing, aching)? Mild, moderate severe? Course and duration? What brings it on? Associated factors (nausea, vomiting,
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vision changes, etc). any other illnesses? Any medications? What makes it worse? Pattern(family history, frequency). Getting worse/better? What seems to help? How do you cope? i. More meaningful than do you ever have headaches? ii. Red flag for those w a severe headache that’s never happened before iii. Nuchal rigidity and fever are signs of meningitis or encephalitis iv. Hypertension, fever, hypothyroidism, and vasculitis; BC, bronchodilatros, alcohol, nitrates, carbon monoxide inhalation—all produce headaches v. Tension headaches —tend to be occipital, frontal, or w bandlike tightness; viselike pain 1. Anxiety and stress vi. Migraines —supraortibal, retro-orbital, or frontotemporal;
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This note was uploaded on 09/27/2011 for the course NURSING 000 taught by Professor Seckmen during the Spring '11 term at Barnes-Jewish College.

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Nursing Assessment test 2 - HEAD, FACE, AND NECK; INCLUDING...

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