Lymph Nodes of the Head and Neck

NODE CENTER Head Occipital LOCATION At the posterior base of the skull Behind the auricle of the ear or in front of the mastoid process In front of the tragus of the ear Along the medial border of the mandible, halfway between the angle of the jaw and the chin AREA DRAINED The occipital region of the scalp and the deep structures of the back of the neck The parietal region of the head and part of the ear The forehead and upper face The chin, upper lip, cheek, nose, teeth, eyelids, part of the tongue and of the floor of the mouth .

Postauricular (mastoid) Preauricular

Floor of Mouth Submandibular (submaxillary)

Submental
Neck Superficial anterior cervical (tonsillar)

Behind the tip of the mandible in the midline, under the chin
Along the medial border of the mandible, anterior to the sternocleidomastoid muscle Along the anterior aspect of the trapezius muscle Under the sternocleidomastoid muscle Above the clavicle, in the angle between the clavicle and the sternocleidomastoid muscle

The anterior third of the tongue, gums, and floor of the mouth
The skin and neck

Posterior cervical Deep cervical Supraclavicular

The posterior and lateral regions of the neck, occiput, and mastoid The larynx, thyroid gland, trachea, and upper part of the esophagus The lateral regions, of the neck and lungs

ASSESSING

THE NECK

PLANNING
Delegation Assessment of the neck is not delegated to UAP. However, many aspects are observed during usual care and may be recorded by persons other than the nurse. Abnormal findings must be validated and interpreted by the nurse.

IMPLEMENTATION
Performance Prior to performing the procedure, introduce self and verify the client's identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Discuss how the results will be used in planning further care or treatments. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the, client has any history of the following: problems with neck lumps; neck pain or stiffness; when and how any lumps occurred; previous diagnoses of thyroid problems; and other treatments provided :(e.g., surgery, radiation). '

ASSESSMENT Neck Muscles 5. Inspect the neck muscles (sternodeidomastoid and trapezius) for abnormal swellings or masses. Ask the client to hold the head erect. 6. Observe head movement. Ask client to: Move the chin to the chest. Rationale: This determines function of the sternocleidomastoid muscle. Move the head back so that the chin points upward. Rationale: This determines function of the trapezius musde. Move the head so that the ear is moved toward the shoulder on each side. Rationale: This determines function of the sternodeidomasod musde.

NORMAL FINDINGS Muscles equal in size; head centered

DEVIATIONS FROM NORMAL Unilateral neck swelling; head tilted to one side (indicates presence of masses, injury, muscle weakness, shortening of sternocleidomastoid muscle, scars) Muscle tremor, spasm, or stiffness Limited range of motion; painful movements; involuntary movements (e.g, up-and-down nodding movements associated with Parkinson's disease) Head hyperextend less than 60.

Coordinated, smooth movements with no discomfort Head flexes 45

Head hyperextend 60

Head laterally flexes 40

Head laterally flexes less than 40

 Turn the head to the right and to the left, Rationale: This determines function of the sternodeidomastoid musde. 7. Assess muscle strength. Ask the client to turn the head to one side against the resistance of your hand. Repeat with the other side. Rationale: This determines the strength of the sternodeidomastoid muscle. Ask the client to shrug the shoulders against the resistance of your hands. Rationale: This determines the strength of the trapezius musdes.

Head laterally rotates 70

Head laterally rotates less than 70

Equal strength

Unequal Strength

Equal strength

Unequal strength

Lymph Nodes
8. Palpate the entire neck for enlarged 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.

Not palpable

Enlarged, palpable, possibly tender (associated with infection and tumors)

 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 clients 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. 1 When palpating the anterior cervical nodes and posterior cervical nodes, move your fingertips slowly in a formid 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 9. Palpate the trachea for lateral deviation. Place your fingertip or thumb on the trachea in the suprasternal notch, 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 Stand in front of the client Observe the lower half of the neck overlying the thyroid gland for symmetry and visible masses.

Central placement in midline of neck; spaces are equal on both sides

Deviation to one side, indicating possible neck tumor; thyroid enlargement; enlarged lymph nodes

Not visible on inspection

Visible diffuseness or local enlargement

 Ask the client to extend the head and swallow. If necessary, offer a glass of water 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. Palpate the thyroid gland for smoothness. Note any areas of enlargement masses, or nodules. Stand in front of or behind the client, and ask the client to lower the chin slightly. Rationale: Lowering the chin reflexes the neck muscles; facilitating palpation.

Gland ascends during swallowing but is not visible

Gland is not-fully movable with swallowing

Lobes may not be Solitary nodules palpated If palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing

Posterior Approach
Place your hands around the client's neck, with your fingertips on the lower half of the neck over the trachea.2 Ask the client to swallow (taking a sip of water, if necessary). and feel for any enlargement of the thyroid isthmus as it rises. The isthmus lies across the trachea, below the cricoid cartilage. To examine the right thyroid lobe, have the client. lower the chin slightly and turn the head slightly to the right (the side being examined), With your left fingers, displace the trachea slightly to the right. With your, right fingers, palpate the right thyroid lobe. Have, the client swallow while you are palpating. Repeat the last step, in reverse, to examine the left thyroid lobe.

Anterior Approach
Place the tips of your index and middle fingers over the trachea. and palpate the thyroid isthmus as the client swallows. To examine the right thyroid lobe, have the client lower the chin slightly and turn the head slightly to the right. With your right fingers, displace the trachea slightly to the client's right (your left). With your left fingers, palpate the right thyroid lobe. 3 To examine the left thyroid lobe, repeat the above step in reverse.

12. If enlargement of Absence of bruit 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. Rationale: The bell transmits this low frequency y sound better than the diaphragm does. 13. Document findings in the client record using forms or checklists supplemented by narrative notes When appropriate.

Presence of bruit

EVALUATION
Perform a detailed follow-up examination of other systems based on findings that deviated from expected or normal for the client. Relate 'findings to previous assessment data if available. Report significant deviations from normal to the primary care provider.