NURSING FOUNDATIONS- EXAM 2 CHEAT SHEET
Neck, Head, Face, Mouth & Related Assessment
• Neck Assessment / Landmarks
• Symmetry
• Head should be midline, erect, and stable.
• Neck muscles (including accessory muscles) should be symmetric.
• Abnormal findings:
o Head tilt → muscle spasm
o Rigid neck → arthritis or inflammation
• Range of Motion (ROM)
o Ask patient to:
▪ Touch chin to chest
▪ Turn head left/right
▪ Touch each ear to shoulder (without shoulder elevation)
▪ Extend head backward
• Normal: smooth, controlled movement
• Abnormal:
• Limited “ratchety” motion → cervical arthritis or inflammation
• Arthritic neck → patient turns entire torso instead of neck
• Cranial Nerve XI (Accessory nerve)
• Test by resisting:
o Shoulder shrug
o Head turning
• Trachea
o Normally midline
o Assess by palpating in sternal notch and comparing both sides
• Tracheal deviation
• Pushes away from affected side:
o Pneumothorax
o Tumor
o Aortic aneurysm
o Unilateral thyroid enlargement
• Pulls toward affected side:
o Atelectasis
o Fibrosis
o Pleural adhesions
• Tracheal tug
• Downward rhythmic movement with systole
• Associated with aortic arch aneurysm
Thyroid Gland
o Normally difficult to palpate
o Located over trachea
• Assessment
, o Check size, symmetry, consistency, nodules
o May use anterior or posterior approach
o Enlarged thyroid → auscultate for bruit (whooshing sound)
o Normal anatomy landmarks
▪ Thyroid cartilage (V notch)
▪ Cricoid cartilage below thyroid cartilage
▪ Isthmus: 2nd–3rd tracheal rings
Facial Structures
• Salivary glands
o Parotid: not normally palpable
o Submandibular: beneath jaw angle
o Sublingual: floor of mouth
Face Assessment- TMJ (temporomandibular joint)
• Located anterior to tragus
• Assess while opening/closing mouth
• Normal: smooth, painless movement
• Abnormal: crepitus, pain, limited ROM
Facial symmetry & expression
• Symmetry of eyebrows, eyes, nasolabial folds, mouth
• Abnormal findings:
o Stroke → lower facial asymmetry
o Bell’s palsy → unilateral facial paralysis
o Parkinson’s → mask-like face
o Cushing’s → moon face, hirsutism
o Acromegaly → enlarged facial features
o Cachexia → sunken eyes, wasted appearance
Lymph Node Assessment
• Technique
o Gentle circular palpation using finger pads
o Compare bilaterally
o Normal nodes- Soft, movable, nontender, discrete
o Abnormal: Lymphadenopathy > 1 cm
• Node locations
o Preauricular: front of ear
o Posterior auricular: behind ear
o Occipital: base of skull
o Submental: under chin midline
o Submandibular: jaw angle
o Jugulodigastric: under mandible angle
o Cervical (superficial/deep/posterior)
o Supraclavicular: above clavicle (high concern if enlarged)
Neck, Head, Face, Mouth & Related Assessment
• Neck Assessment / Landmarks
• Symmetry
• Head should be midline, erect, and stable.
• Neck muscles (including accessory muscles) should be symmetric.
• Abnormal findings:
o Head tilt → muscle spasm
o Rigid neck → arthritis or inflammation
• Range of Motion (ROM)
o Ask patient to:
▪ Touch chin to chest
▪ Turn head left/right
▪ Touch each ear to shoulder (without shoulder elevation)
▪ Extend head backward
• Normal: smooth, controlled movement
• Abnormal:
• Limited “ratchety” motion → cervical arthritis or inflammation
• Arthritic neck → patient turns entire torso instead of neck
• Cranial Nerve XI (Accessory nerve)
• Test by resisting:
o Shoulder shrug
o Head turning
• Trachea
o Normally midline
o Assess by palpating in sternal notch and comparing both sides
• Tracheal deviation
• Pushes away from affected side:
o Pneumothorax
o Tumor
o Aortic aneurysm
o Unilateral thyroid enlargement
• Pulls toward affected side:
o Atelectasis
o Fibrosis
o Pleural adhesions
• Tracheal tug
• Downward rhythmic movement with systole
• Associated with aortic arch aneurysm
Thyroid Gland
o Normally difficult to palpate
o Located over trachea
• Assessment
, o Check size, symmetry, consistency, nodules
o May use anterior or posterior approach
o Enlarged thyroid → auscultate for bruit (whooshing sound)
o Normal anatomy landmarks
▪ Thyroid cartilage (V notch)
▪ Cricoid cartilage below thyroid cartilage
▪ Isthmus: 2nd–3rd tracheal rings
Facial Structures
• Salivary glands
o Parotid: not normally palpable
o Submandibular: beneath jaw angle
o Sublingual: floor of mouth
Face Assessment- TMJ (temporomandibular joint)
• Located anterior to tragus
• Assess while opening/closing mouth
• Normal: smooth, painless movement
• Abnormal: crepitus, pain, limited ROM
Facial symmetry & expression
• Symmetry of eyebrows, eyes, nasolabial folds, mouth
• Abnormal findings:
o Stroke → lower facial asymmetry
o Bell’s palsy → unilateral facial paralysis
o Parkinson’s → mask-like face
o Cushing’s → moon face, hirsutism
o Acromegaly → enlarged facial features
o Cachexia → sunken eyes, wasted appearance
Lymph Node Assessment
• Technique
o Gentle circular palpation using finger pads
o Compare bilaterally
o Normal nodes- Soft, movable, nontender, discrete
o Abnormal: Lymphadenopathy > 1 cm
• Node locations
o Preauricular: front of ear
o Posterior auricular: behind ear
o Occipital: base of skull
o Submental: under chin midline
o Submandibular: jaw angle
o Jugulodigastric: under mandible angle
o Cervical (superficial/deep/posterior)
o Supraclavicular: above clavicle (high concern if enlarged)
