PHYSICAL
EXAMINATION OF NECK
ANATOMY OF NECK
·
It includes muscles,
lymph nodes, trachea, thyroid gland, carotid arteries and jugular veins.
·
Sternocleidomastoid
muscles which divide the neck into two triangles. Anterior and posterior
triangles.
·
The trachea, thyroid
gland, anterior cervical nodes and carotid artery runs parallel to the muscles.
·
The posterior lymph nodes
within the posterior triangle.
·
Lymph nodes in the neck
that collect lymph from the head and neck structures are grouped serially and
referred to as Chains.
Lymph nodes of the
head and neck
Head
·
Occipital At
the posterior base of the skull
·
Post auricular
(mastoid) behind the auricle of
the ear or in front of the mastoid process
·
Preauricular In front of the
tragus of the ear
Floor of the Mouth
·
Submandibular_ Along
the medial border of the lower jaw,
halfway between the triangle of the jaw and chin
·
Submental- Behind the tip of the, mandible in
the midline, under the chin.
Neck
·
Superficial Cervical
Chain Along the anterior to the Sternocleidomastoid
muscle
·
Posterior cervical chain along the anterior aspect of the Trapezius
muscle
·
Deep cervical chain Under Sternocleidomastoid
muscle
·
Supraclavicular The angle between the clavicle
and the sternocleidomastoid
muscle
ASSESSING THE NECK
Assessment of the neck observed during usual care and
may be recorded by persons.
Equipment: none.
1. Explain the procedure to the client
2. Take co-operation from the client.
3. Observe appropriate infection control procedures.
4. Provide client privacy.
Assessment of neck
muscles
Inspect the neck muscles for abnormal swelling or
masses.
Ask the client to hold the head erect.
|
Normal findings:
Muscles equal in size; head centered.
|
Observe the head movement.
Ask the client to move the chin to the chest.
Move the head back so that the chin points upward (to
determine the functions of Trapezius muscles.)
|
Co- ordinated, smooth movements with no discomforts.
Head flexes 45۠
Head laterally Flexes 70۠
|
Assess
the muscle strength.
Ask the client to turn the head to one side against
the resistance of your hand.
Repeat with other side.
|
Equal strength.
|
Shrug the shoulders against the resistance of your
hands
|
Equal strength
|
Assessment
of lymph nodes
|
|
Palpate the entire neck for enlarged lymph nodes
Palpating
neck lymph nodes
·
Face the client, and
bend the client’s head forward slightly or toward the side being examined to
relax the soft tissue and muscles.
·
Palpate the nodes using
the pads of the fingers. Move the fingertips in gentle rotating motion
·
When examining the sub
mental and submandibular nodes, place the finger tips under the mandible on
the side nearest the palpating the hand, and pull the skin and subcutaneous
tissue laterally over the mandibular surfaces so that tissue rolls over the
nodes.
·
Palpate subclavicular
nodes: ask patient to bend forward and relax shoulders. Palpate by hooking
index and third finger over clavicle lateral to sternocleidomastoid muscle
|
Not palpable.
|
Assessment
of Trachea
|
|
Palpate the trachea for lateral deviation. Place
your finger tip or thumb on the trachea in the suprasternal notch, and then
move your finger laterally to the left and right in spaces bordered by the
clavicle, the anterior aspect of the sternocleidomastoid muscle, and the
trachea.
|
Central placement in midline of neck, spaces are
equal on both sides.
|
Assessment
of Thyroid gland
|
|
Inspect
the thyroid gland.
·
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
hyperextend the head and swallow, if necessary, offer a glass of water to
make it easier for the client to swallow.
|
Not visible on inspection.
Gland ascends during swallowing but is not visible.
|
Thyroid gland
Palpate the thyroid gland for smoothness. Note any
areas of enlargement, masses or nodules.
Findings: Lobes may not be palpated.
·
Stand in front of or
behind the client, and the client to lower the chin slightly. Lowering the chin
relaxes the neck muscles, facilitating the palpation.
Posterior
approach:
·
Place hands around the
client’s neck, with your finger tips on the lower half of the neck over the
trachea.
·
Ask the client to swallow
(taking a sip of water if necessary), and feel for any enlargement of the thyroid
isthmus as it raises.
·
To
examine the right thyroid lobe, have the client
lower the chin slightly and turn the head slightly to the right.
·
With your finger displace
the trachea slightly to the right. With the right fingers palpate the right
thyroid lobe.
·
Repeat the last step, in
reverse to examine the left thyroid lobe.
·
If enlargement of the
gland is suspected, auscultate over the thyroid area for a bruit sound created
by turbulent blood flow.
·
Use the bell shaped
diaphragm of the stethoscope.
Normal findings: absence of bruit.
Document the findings in the client record.
Anterior approach
·
Place the tips of your
index and middle fingers over the trachea,
·
Palpate the thyroid isthmus as the client
swallows.
·
To examine the right thyroid lobe, have the
client lower the chin slightly to the right. With the right fingers displace
the trachea slightly to the client’s right.
·
With the left fingers, palpate the right
thyroid lobe. To examine the left thyroid lobe, repeat it other way reverse.
·
If enlargement of the
gland is suspected, auscultate over the thyroid area for a bruit (a soft
rushing sound created by turbulent blood flow) use the bell of the stethoscope.
·
Document findings.
Thorax
and lungs
·
Assessing the thorax and
lungs is frequently critical.
·
To assessing the client’s
aeration status.
·
The client posture is
very important.
·
Health
History: History
of allergies
·
H/o smoking, H/o of lung
disease in family
·
H/o of frequent and
chronic respiratory infections
·
H/o of chest pain or any
trauma
Chest shape and size-
In adults the thorax is oval. Its anteroposterior diameter is half
its transverse diameter. There are
several deformities in the chest.
Pigeon chest
a deformity caused by Rickets. The characteristics of Pigeon chest are:
·
Narrow transverse
diameter,
·
Increased anteroposterior diameter,
·
Protruding sternum
Funnel chest: It
is due to a congenital defect. Characteristics are:
·
Opposite to the pigeon
chest.
·
Sternum is depressed.
·
Narrowing of anteroposterior
diameter.
Barrel chest: It
is seen in clients with thoracic kyphosis and emphysema.
Thoracic kyphosis
is an excessive convex curvature of the thoracic spine. The characteristics
are: The ratio of the anterioposterior diameter to transverse diameter is 1:1.
NORMAL BREATH
SOUNDS
·
Vesicular
·
Broncho- vesicular
·
Bronchial( tubular)
Bronchial breath
sound- Larynx, suprasternal fossa, around 6th,
7th cervical vertebra, 1st, 2nd thoracic vertebra.
Bronchial (tubular)
High-pitched, loud, "harsh” sounds created by air
moving through the trachea. They located in anteriorly over the trachea; not
normally heard over lung tissue. They are louder than vesicular sounds; have a
short inspiratory phase and long expiratory phase (1:2 ratio)
Bronchovesicular
breath sound- 1st, 2nd intercostal space beside of
sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of
lung. Moderate intensity and moderate- pitched “blowing” sounds created by air
moving through larger airway (bronchi). They
locate in between the scapulae and lateral to the sternum at the first and
second intercostal spaces
Characteristics: equal inspiratory and expiratory
phases (1:1 ratio).
Vesicular breath
sound- Most area of lungs. It is soft- intensity, low- pitched,
“Gentle- sighing” sounds created by air moving through
smaller airways (bronchioles and alveoli). They locate over peripheral lung and
also heard t base of lungs. Characteristics: Best heard on inspiration, which
is about 2.5 times longer than the expiratory phase (5:2 ratio)
ASSESSING THE
THORAX
First nurse should examine the posterior chest, then
the anterior chest.
Position:
sitting or lying for anterior chest
examination. Sitting position preferred because it maximizes the chest
expansion. Good lighting is very essential.
EQUIPMENTS
·
Stethoscope
·
Skin marker/pencil
·
Centimeter ruler
Explain the procedure to the client. Wash the hands. Provide
client privacy. In women, drape the anterior chest when is not being examined.
Enquiry the client has any history of the following:
·
Family history of illness
including cancer, Allergies
·
Tuberculosis
·
Lifestyles habits such as smoking
·
occupational hazards
·
Any medications can being
taken, Swelling, wheezing, coughs, pain
Assessment of Posterior
thorax
Inspect the shape and symmetry of the thorax from
posterior and lateral views.
|
Normal findings:
Anteroposterior to transverse diameter in ratio of
1:2
|
Inspect the spinal alignment for deformities.
Have the client stand.
From a lateral position, observe the three normal
curvatures; cervical, thoracic and lumbar
• To assess the lateral deviation of spine
(scoliosis). Observe
the standing client from the rear.
• Have the client bend forward at the waist and
observe from behind.
|
Spine vertically aligned
Spinal column is straight, right and left shoulders
and hips are at same height
|
For clients who have no respiratory complaints,
rapidly assess the temperature and integrity of all chest skin
|
Skin intact; uniform temperature.
|
For clients who do have respiratory problems,
palpate all chest areas for bulges, tenderness or abnormal movements.
Avoid deep palpation for pain full areas, especially
if a fractured rib is suspected.
|
Chest wall intact.
No tenderness.
No masses.
|
Palpate the posterior chest for respiratory
excursion.
Place
the palms of both your hands over the lower thorax with your thumbs adjacent
to the spine and your finger stretched laterally
|
Full and symmetric chest expansion.
|
Ask the client to take deep breath while you observe
the movement of your hands and any lag in movement.
|
When the client takes a deep breath, your thumb
should move apart an equal distance and at the same time;
Normally the thumbs separate 3 to 5 cm during deep
inspiration.
|
Palpate the chest for vocal (tactile) fremitus.
The faintly perceptiable vibration felt through the
chest wall when the client speaks
|
Bilateral symmetry of vocal fremitus.
Fremitus is
heard most clearly at the apex of the lungs.
|
Place the palmar surfaces of your fingertips or the
ulnar aspect of your hand or closed fist on the posterior chest, starting
near the apex of the lungs.
|
Low- pitched voices of males are more readily
palpated than higher pitched voices of females.
|
Palpation
Thoracic expansion-
Massive hydrothorax, pneumonia, pleural
thickening, atelectasis
Vocal fremitus (tactile
fremitus)
Pleural friction
fremitus-Cellulose exudation in pleura due to
pleurisy, Tuberculosis, pleurisy,
uremia, pulmonary embolism
Ask the client to repeat such words as ”blue moon or “One,
two, three.”
Repeat the two steps, moving your hands sequentially
to the base of the lungs. Compare the fremitus on both lungs.
Abnormal findings: Increased fremitus (associated with
consolidated lung tissue, as seen in pneumonia).
Decreased or absent fremitus seen in pneumothorax.
PERCUSSION OF
POSTERIOR THORAX
Percuss diaphragmatic excursion. Complete the findings
at each point with the corresponding point on the opposite side of the chest.
Normal findings: Percussion notes resonate, except
over the scapula.
Lowest point of resonance is at the Diaphragm.
Excursion is 3 to 5 cm bilaterally in women, 5 to 6 cm
in men.
Diaphragm is usually slightly higher on the right
side. By auscultation hear the vesicular
and bronchovesicular breath sounds.
AUSCUTATION OF
POSTERIOR THORAX
Auscultate chest using diaphragm of stethoscope. Used
the systematic Zigzag procedure.
Ask the client to take slow, deep breath through the
mouth. Listen each breath sounds during inspiration and expiration.
ABNORMAL FINDINGS- By auscultation hear the adventitious
breath sounds.
Name
|
Description
|
Cause
|
Location
|
Gurgles (rhonchi)
|
Continuous, low- pitched, coarse gurgling, harsh,
louder sounds with a moaning or snoring quality.
Best heard on expiration but can be heard on both
inspiration and expiration.
|
Air passing through narrowed air passages as a
result of secretion, swelling, tumors.
|
Loud sounds can be heard over most lung areas but
predominate over the trachea and bronchi
|
Friction rub
|
Superficial grating or creaking sounds heard during
inspiration and expiration, not relieved by coughing.
|
Rubbing together of the inflamed pleural surfaces.
|
Heard most often in areas of greatest thoracic
expansion ( lower anterior and lateral chest)
|
Crackles (rales)
|
Fine, short interrupted crackling sounds, alveolar rales are high
pitched. Sound can be stimulated by rolling a lock of hair near the ear. Best
heard on inspiration but can be heard on both inspiration and
expiration. May not be cleared by
coughing.
|
Air passing through fluid or mucous in any air
passage.
|
Most commonly heard in the bases of the lower lung
lobes.
|
Wheeze
|
Continuous, high-pitched, squeaky musical sounds.
Best heard on expiration. Not usually altered by
coughing.
|
Air passing through a constricted bronchus as a
result of secretions, swelling, tumors
|
Heard over all lung fields
|
ASSESSMENT OF
ANTERIOR THORAX
INSPECTION:
·
Breathing patterns
·
Coastal angle
Normal findings:
·
Quiet, rhythmic and
effortless respirations.
·
Coastal angle is less
than 90 degrees.
Palpation of
anterior thorax
Place the palms of both your hands on the lower
thorax.
With your finger laterally along the lower rib cage
and your thumbs along the coastal margins.
Ask the client to take a deep breath while you observe
the movement of your hands. Palpate the
tactile fremitus in the same manner as for the posterior chest.
Normal findings: Full symmetric excursion. Thumbs
normally separate 3 to 5 cm. same as posterior vocal fremitus. Fremitus
normally decreased over heart and breast tissue.
PERCUSSION OF
ANTERIOR CHEST
Begin above the clavicles in the Supraclavicular space,
and proceed downward to the diaphragm. Compare one side of the lung to the
other.
Normal findings
Percussion notes resonate down to the sixth rib at the
level of diaphragm but are flat over areas of heavy muscle and bone. Dull on
areas over the heart and the liver. Tympanic over the underlying stomach.
5. Abnormal sound
Special areas on percussion in moderate hydrothorax
Auscultate the
trachea- Auscultate anterior chest. Use the sequence.
Start from the bronchi between the sternum and the
clavicles. Record the findings in Nurse’s
record.
NORMAL FINDINGS
By Auscultating
trachea hear the Bronchial and tubular breath sounds.
Auscultation of
anterior chest hear the Bronchovesicular and Vesicular breath sounds.
Lateral thorax
Position – sitting. Patient should raise arms to
improve access to lateral thoracic structures
Techniques used- Inspection, palpation, auscultation. Breath
sounds heard are vesicular.
COMMENTS