HEAD AND NECK ASSESSMENT I RETURN DEMONSTRATION (Student Nurse)

Summary

In this instructional video, student nurse Shantal Lati demonstrates the proper technique for assessing a patient’s head and neck. The video covers the process of introducing the procedure to the patient, obtaining consent, and performing a thorough examination, including the inspection and palpation of the head, checking facial nerve function, assessing the temporomandibular joint, evaluating the neck for swelling or pain, and palpating the lymph nodes. The nurse also demonstrates how to assess the thyroid gland and provide appropriate health advice, ensuring the patient’s comfort and confidentiality throughout the process.

Takeaways

• 😀 Greet the patient and verify their identity (name, birthday, and age) before starting the assessment.
• 😀 Ensure patient consent to touch specific areas of the head and neck and explain the procedure.
• 😀 Perform hand hygiene and provide privacy for the patient by closing the curtain before starting the exam.
• 😀 Inspect the patient's head for symmetry, roundness, and alignment, checking for any lesions or parasites.
• 😀 Observe facial symmetry and movements, testing facial nerve (Cranial Nerve VII) by asking the patient to perform specific tasks like raising eyebrows and smiling.
• 😀 Palpate the temporal artery while the patient clenches their teeth and check for any abnormalities in the temporomandibular joint (TMJ).
• 😀 Inspect the neck for symmetry and bulging; ask the patient to swallow and assess for any pain or discomfort.
• 😀 Check the range of motion in the cervical spine by having the patient look up, down, and sideways.
• 😀 Palpate the trachea for any abnormalities and auscultate the thyroid gland for abnormal sounds (bruits).
• 😀 Palpate the lymph nodes in various regions (preauricular, postauricular, submental, cervical, and supraclavicular) to check for any tenderness or enlargement.
• 😀 After completing the assessment, inform the patient about the findings, provide health advice, and refer them to their attending physician if necessary.

Q & A

What is the first step in performing the head and neck assessment?

The first step is to introduce yourself, verify the patient's identity, and explain the procedure you will be conducting. This includes informing the patient that you will be assessing their head and neck and asking for consent.

Why is it important to confirm the patient's comfort with the language used during the assessment?

It is important to ensure clear communication and understanding between the nurse and the patient, which helps in building rapport and ensuring the patient is comfortable with the procedure.

What should the nurse check for when palpating the patient's scalp?

The nurse should check for symmetry, roundness, erectness, alignment with the midline, and the absence of lesions, scars, masses, or parasites like lice. Alopecia should also be observed.

What is the purpose of testing the facial nerve (cranial nerve VII)?

Testing the facial nerve is done to assess the symmetry and movement of the patient's face. This includes asking the patient to perform tasks like raising eyebrows, blinking, smiling, and puffing cheeks to check for any abnormalities such as drooping.

How is the temporomandibular joint (TMJ) assessed?

The TMJ is assessed by asking the patient to open and close their mouth, checking for any swelling or clicking sounds that may indicate issues with the joint.

What should be observed when assessing the neck?

When assessing the neck, the nurse should look for symmetry, bulging, or swelling. The patient should also be asked to swallow to check for any abnormal movements or pain.

What is the significance of checking the cervical vertebrae?

The cervical vertebrae should be checked for any irregularities or tenderness during neck movements, such as looking up or turning the head to the sides, which could indicate injury or other issues.

How are the lymph nodes palpated during the assessment?

The lymph nodes are palpated by gently feeling around various areas of the head and neck, including the preauricular, postauricular, occipital, tonsillar, submental, superficial cervical, deep cervical chain, posterior cervical, and supraclavicular nodes.

What is the purpose of auscultating the thyroid gland?

Auscultating the thyroid gland helps detect any abnormal sounds, such as bruits, which could indicate underlying thyroid or vascular issues.

How should the nurse conclude the head and neck assessment?

The nurse should summarize the findings, ensure the patient has no questions or concerns, and provide general health advice such as drinking enough water, eating a balanced diet, and taking vitamins. The nurse should also inform the patient that abnormal findings will be referred to an attending physician.