HA LEC

• Accessory Nerve (CN XI)

  • Accessory nerve lesions are often associated with damage to the ninth and tenth nerves and cause ipsilateral sternomastoid weakness (on turning the head away from the affected side) and weakness of the trapezius on shrugging the shoulders
• History of Present Health Concern

  1. Problems with neck lumps

  2. Neck pain or stiffness

  3. When and how any lumps occurred

  4. Any diagnoses of thyroid problems

  5. Any treatments such as surgery or radiation

  
• Lumps and lesions that do not heal or disappear


  May indicate cancer
• Goiter


  An enlarged thyroid gland that may appear as a large swelling at the base of the neck, and may also have a tight feeling in the throat, cough, hoarseness, difficulty swallowing, or a hoarse voice
• Neck pain


  May accompany muscular problems or cervical spinal cord problems
• Stress and tension


  May increase neck pain
• Sudden head and neck pain seen with elevated temperature and neck stiffness


  May be a sign of meningeal inflammation
• Palpating the Lymph Nodes

  1. Palpate the entire neck for enlarged lymph nodes

  2. Face the client, and bend the client's head forward slightly or toward the side being examined

  3. Palpate the nodes using the pads of the fingers, moving the fingertips in a gentle rotating motion

  
• While palpating the lymph nodes

  • Note the size and shape, delimitation, mobility, consistency, tenderness and location

  
• Skin Cancer


  • It occurs in three types: melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC)
  • BCC is the most common skin cancer in Caucasians
  • SCC is the most common in darker skin

  
• Skin cancer is the most common of cancers (US)
• heavily exposed to sunlight, especially in areas of ozone depletion
• Assess Risk Factor


  Sun exposure, especially intermittent pattern with sunburn; risk increases if excessive sun exposure and sunburns began in childhood
• Normal Findings


  • Symmetric or slightly asymmetric; palpebral fissures equal in size; symmetric nasolabial folds
  • No edema
• Abnormal Findings


  • Neurologic disorders - horizontal jerling movement
  • Aortic insufficiency - involuntary nodding
• History of Present Health Concern
• Lumps and lesions that do not heal or disappear may indicate cancer
• A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck
• Neck pain may accompany muscular problems or cervical spinal cord problems
• Palpating the Lymph Nodes

  1. Face the client, and bend the client's head forward slightly or toward the side being examined

  2. Palpate the nodes using the pads of the fingers. Move the fingertips in a gentle rotating motion

  3. 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

  4. 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

  5. Use your hand nearest the side to be examined when facing the client (i.e., your left hand for the client's right nodes)

  6. 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

  7. 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

  8. To palpate the deep cervical nodes, bend or hook your fingers around the sternocleidomastoid muscle
• While palpating the lymph nodes, note the following

  • Size and shape
  • Delimitation
  • Mobility
  • Consistency
  • Tenderness and location
• Iris and Pupil


  • The iris is typically round, flat, and evenly colored. The pupil, round with a regular border, is centered in the iris. Pupils are normally equal in size (3 to 5 mm). An inequality in pupil size of less than 0.5 mm occurs in 20% of clients. This condition, called anisocoria, is normal
  • Arcus senilis - normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision
• Visual Acuity Testing


  1. Position the patient 20 feet or 6 meters from a well-illuminated Snellen Chart

  2. Instruct the patient to occlude one eye using his/her palm or an opaque occluder when available

  3. Ask the patient to read the chart starting at the first line (20/200 pr 6/60 line) proceeding until the smallest line that he can distinguish more than half of the figures

  4. Record the acuity using the ratio or fraction which compares the performance of the patient with an agreed upon standard
• Tympanic Membrane


  • should be pearly, gray, shiny, and translucent, with no bulging or retraction
  • slightly concave, smooth, and intact
  • A cone-shaped reflection of the otoscope light is normally seen at 5 o'clock in the right ear and 7 o'clock in the left ear
• Weber Test


  1. Strike a tuning fork softly with the back of your hand and place it at the center of the client's head or forehead

  2. Centering is the important part. Ask whether the client hears the sound better in one ear or the same in both ears
• Normal Findings


  • Vibrations are heard equally well in both ears. No lateralization of sound to either ear
• Abnormal Findings


  • With conductive hearing loss, the client reports lateralization of sound to the poor ear—that is, the client "hears" the sounds in the poor ear
  • The good ear is distracted by background noise and conducted air, which the poor ear has trouble hearing. Thus the poor ear receives more of the vibrations
• Weber Test


  1. Helps to evaluate the conduction of sound waves through bone

  2. Helps distinguish between conductive hearing and sensorineural hearing
• Conductive hearing


  Sound waves transmitted by the external and middle ear
• Sensorineural hearing


  Sound waves transmitted by the inner ear
• Weber Test


  1. Strike a tuning fork softly

  2. Place it at the center of the client's head or forehead

  3. Ask whether the client hears the sound better in one ear or the same in both ears
• Normal findings of Weber Test

  • Vibrations are heard equally well in both ears
  • No lateralization of sound to either ear
• Abnormal findings of Weber Test with conductive hearing loss

  • Client reports lateralization of sound to the poor ear
• Conductive hearing loss


  Good ear is distracted by background noise and conducted air, poor ear receives most of the sound conducted by bone vibration
• Abnormal findings of Weber Test with sensorineural hearing loss

  • Client reports lateralization of sound to the good ear
• Sensorineural hearing loss


  Limited perception of the sound due to nerve damage in the bad ear, making sound seem louder in the unaffected ear
• Rinne Test


  Compares air and bone conduction sounds
• Rinne Test


  1. Strike a tuning fork

  2. Place the base of the fork on the client's mastoid process

  3. Ask the client to tell when the sound is no longer heard

  4. Move the prongs of the tuning fork to the front of the external auditory canal

  5. Ask the client if the sound is audible after the fork is moved
• Normal findings of Rinne Test

  • Air conduction sound is heard longer than bone conduction sound (AC > BC)
• Abnormal findings of Rinne Test with sensorineural hearing loss

  • Air conduction sound is heard longer than bone conduction sound (AC > BC) if anything is heard at all