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    Assessing The Neck

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    Anne Joyce Lara Albios
    The document provides guidance on assessing the neck, including inspection of neck muscles and lymph nodes, palpation of the thyroid gland and trachea, and evaluation of head and neck range of motion. Normal findings include symmetrical neck muscles and nodes that are not palpable, while deviations may indicate masses, injuries, or weaknesses. The assessment evaluates for signs of infection, tumors, or other abnormalities.

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    © All Rights Reserved
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    Assessing The Neck

    Uploaded by

    Anne Joyce Lara Albios
    131 views3 pages
    The document provides guidance on assessing the neck, including inspection of neck muscles and lymph nodes, palpation of the thyroid gland and trachea, and evaluation of head and neck range of motion. Normal findings include symmetrical neck muscles and nodes that are not palpable, while deviations may indicate masses, injuries, or weaknesses. The assessment evaluates for signs of infection, tumors, or other abnormalities.

    Original Description:

    RATIONALE: BASED ON KOZIER AND ERBS FUNDAMENTALS IN NURSING

    Original Title

    Assessing the Neck

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    The document provides guidance on assessing the neck, including inspection of neck muscles and lymph nodes, palpation of the thyroid gland and trachea, and evaluation of head and neck range of motion. Normal findings include symmetrical neck muscles and nodes that are not palpable, while deviations may indicate masses, injuries, or weaknesses. The assessment evaluates for signs of infection, tumors, or other abnormalities.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    131 views3 pages

    Assessing The Neck

    Uploaded by

    Anne Joyce Lara Albios
    The document provides guidance on assessing the neck, including inspection of neck muscles and lymph nodes, palpation of the thyroid gland and trachea, and evaluation of head and neck range of motion. Normal findings include symmetrical neck muscles and nodes that are not palpable, while deviations may indicate masses, injuries, or weaknesses. The assessment evaluates for signs of infection, tumors, or other abnormalities.

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    © All Rights Reserved
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    Assessing the Neck

    ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL

    Neck Muscles
    Muscles equal in size; head Unilateral neck swelling; head tilted to one
    5. Inspect the neck muscles
    centered side (indicates presence of masses, injury,
    (sternocleidomastoid and trapezius) for
    muscle weakness, shortening of
    abnormal swellings or masses. Ask the
    sternocleidomastoid muscle, scars)
    client to hold the head erect.

    6. Observe head movement. Ask client to: Coordinated, smooth movements Muscle tremor, spasm, or stiffness
    with no discomfort

    • Move the chin to the chest. Head flexes 45° Limited range of motion; painful
    Rationale: This determines function of the movements; involuntary movements (e.g.,
    sternocleidomastoid muscle. up-and-down nodding movements
    associated with Parkinson’s disease)

    • Move the head back so that the chin points Head hyperextends 60° Head hyperextends less than 60°
    upward. Rationale: This determines function
    of the trapezius muscle.

    • Move the head so that the ear is moved Head laterally flexes 40° Head laterally flexes less than 40°
    toward the shoulder on each side. Rationale:
    This determines function of the
    sternocleidomastoid muscle.

    • Turn the head to the right and to the left. Head laterally rotates 70° Head laterally rotates less than 70°
    Rationale: This determines function of the
    sternocleidomastoid muscle

    7. Assess muscle strength.

    • Ask the client to turn the head to one side Equal strength Unequal strength
    against the resistance of your hand. Repeat
    with the other side. Rationale: This
    determines the strength of the
    sternocleidomastoid muscle.
    • Ask the client to shrug the shoulders Equal strength Unequal strength
    against the resistance of your hands.
    Rationale: This determines the strength of
    the trapezius muscles
    Lymph Nodes
    Not palpable Enlarged, palpable, possibly tender
    8. Palpate the entire neck for enlarged
    (associated with infection and tumors)
    lymph nodes.

    • Face the client, and bend the client’s head


    forward slightly or toward the side being
    examined. Rationale: This relaxes the soft
    tissue and muscles.

    • Palpate the nodes using the pads of the


    fingers. Move the fingertips in a gentle
    rotating motion.

    • When examining the submental and


    submandibular nodes, place the fingertips
    under the mandible on the side nearest the
    palpating hand, and pull the skin and
    subcutaneous tissue laterally over the
    mandibular surface so that the tissue rolls
    over the nodes.

    • When palpating the supraclavicular nodes,


    have the client bend the head forward to
    relax the tissues of the anterior neck and to
    relax the shoulders so that the clavicles
    drop. Use your hand nearest the side to be
    examined when facing the client (i.e., your
    left hand for the client’s right nodes). Use
    your free hand to flex the client’s head
    forward if necessary. Hook your index and
    third fingers over the clavicle lateral to the
    sternocleidomastoid muscle. &

    • When palpating the anterior cervical nodes


    and posterior cervical nodes, move your
    fingertips slowly in a forward circular
    motion against the sternocleidomastoid and
    trapezius muscles, respectively.

    • To palpate the deep cervical nodes, bend or


    hook your fingers around the
    sternocleidomastoid muscle.

    Trachea
    Central placement in midline of Deviation to one side, indicating possible
    9. Palpate the trachea for lateral deviation.
    neck; spaces are equal on both neck tumor; thyroid enlargement; enlarged
    Place your fingertip or thumb on the trachea
    in the suprasternal notch (see Figure 30–19, sides lymph nodes
    earlier), and then move your finger laterally
    to the left and the right in spaces bordered
    by the clavicle, the anterior aspect of the
    sternocleidomastoid muscle, and the trachea.

    Thyroid Gland
    10. Inspect the thyroid gland. Not visible on Not visible on inspection Visible diffuseness or local enlargement
    inspection Visible diffuseness or local
    enlargement
    • Stand in front of the client.
    • Observe the lower half of the neck
    overlying the thyroid gland for symmetry
    and visible masses

    • Ask the client to extend the head and Gland ascends during Gland is not fully movable with swallowing
    swallow. If necessary, offer a glass of water swallowing but is not visible
    to make it easier for the client to swallow.
    Rationale: This action determines how the
    thyroid and cricoid cartilages move and
    whether swallowing causes a bulging of the
    gland.

    11. Document findings in the client record


    using forms or checklists supplemented by
    narrative notes when appropriate

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