Weber Health Assessment in Nursing Chapter 15 Assessing

Structure and Function • The Head – Cranium • Frontal; Parietal • Temporal; Occipital

Question Is the following statement true or false? The skull, which is the framework of a head, has two subsections – the cranium and cervical vertebrae. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer False. The skull has two subsections – the cranium and the face. Copyright

Structure and Function • The Head – Face • Maxilla; Zygomatic • Inferior conchae;

The Skull Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question Which bone belongs to the face? a. Parietal b. Temporal c. Palatine d.

Answer c. Palatine Rationale: Palatine is a facial bone that gives shape to the face. Parietal, temporal, and sphenoid are bones of the cranium. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Structure and Function • The Neck – Hyoid bone – Several major blood vessels

Structures of the Neck Copyright © 2014 Wolters Kluwer Health | Lippincott Williams &

Cervical Vertebrae Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question Tell whether the following statement is True or False. The axis is the

Answer False. The axis is the second of the seven cervical vertebrae. Copyright ©

Lymph Nodes Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Traumatic Brain Injury • Presence of transportation accidents involving automobiles, motorcycles, bicycles, and pedestrians • Presence of violence, such as firearm assaults and child abuse or self-inflicted wounds • Falling • Excessive alcohol ingestion • Infants and elderly being cared for by caregivers Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Infant and Toddlers Risk Factors • Environmental risks (for falls) • Lack of parental knowledge of shaken baby syndrome • Caregivers risk of shaken baby syndrome Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Children and Teens Risk Factors • Knowledge and use of protective equipment in sports and bicycle use • Knowledge and use of safety practices when driving Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Adults and Older Adults Risk Factors • Knowledge and use of safety practices when driving • Impairment of physical or mental stability • Potential for maltreatment or domestic violence Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Risk Reduction • Buckling your child in the car using a child safety seat, booster seat, or seat belt (according to the child's height, weight, and age). Know the Stages • Birth Through Age 2 • Between Ages 2 -4/Until 40 lbs • Between Ages 4 -8 or Until 4'9" Tall • After Age 8 and/or 4'9" Tall • Wearing a seat belt every time you drive or ride in a motor vehicle. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Risk Reduction (cont. ) • Never driving while under the influence of alcohol or drugs. • Wearing a helmet and making sure your children wear helmets when: – Riding a bike, motorcycle, snowmobile, scooter, or all -terrain vehicle; – Playing a contact sport, such as football, ice hockey, or boxing; – Using in-line skates or riding a skateboard; – Batting and running bases in baseball or softball; – Riding a horse; or skiing or snowboarding. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Risk Reduction (cont. ) • Making living areas safer for seniors, by: – Removing tripping hazards such as throw rugs and clutter in walkways; – Using nonslip mats in the bathtub and on shower floors; Installing grab bars next to the toilet and in the tub or shower; – Installing handrails on both sides of stairways; and – Improving lighting throughout the home. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Risk Reduction (cont. ) • Maintaining a regular physical activity program, if your doctor agrees, to improve lower body strength and balance. • Making living areas safer for children, by: – Installing window guards to keep young children from falling out of open windows; and – Using safety gates at the top and bottom of stairs when young children are around. – Making sure the surface on your child's playground is made of shock absorbing material, such as hardwood mulch or sand. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Health Assessment: Subjective Data • Interview Approach (COLDSPA) – History of current health problem, past health, family – Lifestyle and health practices Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Headaches • Character: Describe how the headache feels (sharp, throbbing, dull)? • Onset: When did it first begin? • Does it tend to occur with other factors (i. e. , Menstrual cycle, emotional or physical stress, ingestion of alcohol or other certain foods like cheese or chocolate)? • Locations: Where does your headache begin? (Ask client to point to area in head if possible). Does it radiate or spread to other areas? Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Headaches (cont. ) • Duration: How long does it last? How often does it recur? Has there been any change in the duration of your headaches? Explain. • Severity: How severe is the headache? Rate it on a scale of 1 -10 (10 being most severe). Does the headache keep you from doing your usual activities of daily living? Explain. • Pattern: What aggravates it? What makes the pain go away? What pain relievers work best for you? • Associated Factors: Do you have other symptoms with the headache such as nausea, visual changes, dizziness, or sensitivity to noise or light? Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Equipment • Gloves • Penlight or flashlight • Small glass of water • Stethoscope

Physical Assessment: Head • Inspect the size, shape, configuration • Consistency • Involuntary movement

Physical Assessment: Face • Inspect the face – Symmetry – Features – Movement –

Physical Assessment: Face • Palpate – Temporal artery: tenderness and elasticity – Temporomandibular joint (TMJ): range of motion, swelling, tenderness, crepitation Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Physical Assessment: Neck • Inspect movement of neck structures – Cervical vertebrae – Neck

Physical Assessment: Neck • Palpate – Trachea – Thyroid gland • Thyroid cartilage • Cricoid cartilage • Auscultate an enlarged thyroid gland Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Physical Assessment: Neck • Palpate lymph nodes of head and neck – Preauricular – Postauricular – Occipital – Tonsillar – Submandibular Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Physical Assessment: Neck • Palpate lymph nodes of head and neck – Submental – Superficial cervical – Posterior cervical – Deep cervical – Supraclavicular Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Normal and Abnormal Findings • Review and discuss findings of client’s head and neck

Altered Thyroid Function • Increased sensitivity to cold • Constipation • Depression • Fatigue • Heavier menstrual periods • Pale, dry skin, • Thin, brittle hair or nails • Weakness • Unintentional weight gain. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hyperthyroidism • Increased appetite • Sudden weight loss, without changes in appetite and diet • Rapid heartbeat (tachycardia) greater than 100 beats a minute, irregular heartbeat (arrhythmia), or palpitations • Nervousness, anxiety and irritability • Tremor in the hands and fingers • Sweating Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hyperthyroidism (cont. ) • Changes in menstrual patterns • Increased sensitivity to heat • Changes in bowel patterns, more frequent bowel movements • Enlarged thyroid gland (goiter) • Fatigue, insomnia • Muscle weakness Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Headaches • Sinus • Cluster • Tension • Migraine • Tumor related Copyright ©

Abnormal Findings • Acromegly • Cushing’s Syndrome • Scledodema • Hypothryoidism • Bell’s Palsy

Older Adults • Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion • In older clients, facial wrinkles are prominent because subcutaneous fat decreases with age. In addition, the lower face may shrink and the mouth may be drawn inward as a result of resorption of mandibular bone, also an age-related process. • The strength of the pulsation of the temporal artery may be decreased in the older client. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Older Adults (cont. ) • In older clients, cervical curvature may increase because of kyphosis of the spine. Moreover, fat may accumulate around the cervical vertebrae (especially in women). This is sometimes called a “dowager’s hump. ” • Older clients usually have somewhat decreased flexion, extension, lateral bending, and rotation of the neck. This is usually due to arthritis. • If palpable, the older client’s thyroid may feel more nodular or irregular because of fibrotic changes that occur with aging; the thyroid may also be felt lower in the neck because of age-related structural changes. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Validating and Documenting Findings • Health promotion diagnoses • Risk diagnoses • Actual diagnoses • Collaborative problems • Medical problems Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins