Anterior Triangle REMEMBER:

Assessing Head, Neck, o Carotid Lymph nodes are very small beads that are
Breasts, and Lympathic o Submandibular normally not palpable.
System o Submental
o Muscular Lymphadenopathy
- Enlargement of lymph nodes above
Posterior Triangle 1cm
Anatomy and Physiology o Supraclavicular Triangle
o Supraclavicular Triangle
A. Head Most Common Neck and Head Lymph
Muscles and Cervical Vertebrae Nodes
1. Sternocleidomastoid and Trapezius 1. Preauricular
Head
– allow movement and provide 2. Postauricular
- is divided into two parts
o Also known as the facial groups support 3. Occipital
Sternocleidomastoid – rotate and 4. Tonsillar
1. Cranium
flexed the head; biggest neck muscle, 5. Submandibular
2. Face
main muscle of the neck 6. Submental
Trapezius – extends head & move 7. Superficial cervical
Trigeminal Neuralgia (Tic Douloureux)
- facial pain – sharp, shooting, piercing shoulder; form boundaries 8. Posterior cervical
9. Deep cervical – not palpable
facial pains w/c last seconds to
2. XI Cranial Nerve (Accessory) – 10. Supraclavicular node
minutes
muscle movement; permits shrugging
- occurs over the 5th trigeman CN
of shoulders; turning the head against
o Ophthalmic Nursing Health History
o Maxillary the resistance of the
sternocleidomastoid muscles
o Mandibular Subjective data
3. C7 Vertebra Prominence – can
easily be palpated when head is - what the patient tells the doctor
Cranial Bones/Cranium
flexed.
- houses and protects the brain and 1. Focuses on the chief complaint –
the major sensory organs main reason why the patient
Blood Vessels
- bones in the skull are flat bones consulted the doctor
1. Internal Jugular Vein
2. External Jugular Ven 2. History of present illness HPI or
1. Frontal Bone (1) History of present health concerns
3. Internal Carotid Artery
2. Parietal Bone (2) (COLDSPA)
3. Temporal Bone (2) 4. External Carrotid Artery
5. Common Carrotid Artery Character – Describe how it feels
4. Occipital Bone (1) Onset – When did it begin?
5. Ethmoid Bone (1) Location – Does it radiate to the
Note: Avoid bilaterally compressing the
6. Sphenoid Bone (1) back, arms, or shoulders?
carotid arteries when assessing the neck
as bilateral compression ca reduce the Duration – How long does it last?
Cranial bones are joined by immovable Severity – On a scale of 1 to 10, how
blood supply to the brain
sutures: would you rate your pain?
1. Sagittal Pattern – every when does the pain
Thyroid Gland
2. Coronal occur?
o Largest endocrine gland in the body
3. Squamosal Associated factors – Do you have
4. Lambdoid o 2 lobes connected by isthmus
o Contains 4 parathyroid glands limitation of the head, neck, or arms,
posteriorly with this pain?
Facial Bones 3. Past health history
o Produces thyroid hormones (FT3,
1. Maxilla (2) 4. Family history – 1st to 2nd degree
FT4) – req. iodine
2. Palatine Bone (2) 5. Social history (lifestyle and health
3. Zygomatic Bone(2) o Thyroid cartilage (a.k.a Adam’s
Apple) – located below the hyoid practices)
4. Lacrimal Bone (2)
bone, posterior to the thyroid gland.
5. Nasal Bone (2)
o Cricoid cartilage – located below the Physical Examination
6. Inferior Nasal Conchae (2)
thyroid cartilage.
7. Mandible Bone (1)
8. Vomer Bone (1) Objective data
Goiter - enlargement of thyroid gland due - Signs – objective; observed by the
to low iodine diet; difficulty in breathing,
Temporal Artery physical examiner
swallowing, hoarse voice, and cough
Parotid Gland - Symptoms – subjective; what the
Submandibular Gland patient feels or says
Lymph Nodes of the Head and Neck
Note: All of the facial bones are immovable Considerations before conducting
EXCEPT for the mandible at the TMJ Lymph Nodes (0.5 cm; clustered 2-100) physical exam:
which has a free movement. - part of the immune system which • Instruct the patient to remove hair
produces lymphocytes and ornaments
REMEMBER: antibodies against several • Consider cultural norms
Cranium and face are the 2 subsections of/ pathogens. • Ask patient to sit upright, back and
the skull. - are elastic and has rubbery textur shoulders held back and straight
- filters the lymph, remove bacteria and • Keep in mind that normal facial
B. Neck tumor cells from the lymph structures vary
o lymph – a clear substance • Wear gloves (and other PPEs) and
composed of excess tissue fluid prepare stethoscope
Neck
o Flow of the lymph
Composed of:
- Muscles, ligaments, and the cervical § Subclavian artery Physical Examination Techniques
(major BV) 1. Inspection – observing the patient
vertebrae
§ Drained down or goes visually
- Hyoid bone – free bone
back to the venous arc 2. Palpation – clinical touching of body
- Several major blood vessels
o Carotid arteries - main BV areas to assess
of the neck Note: If nodes become overwhelmed 3. Percussion – tapping technique with
(Mononucleosis, an infection), they swell hands to determine the condition of
- Larynx (voice box)
and become painful. If cancer body areas (solid, fluid, orair-filled)
- Trachea (windpipe)
metastasizes, nodes may enlarge but are 4. Auscultation – use of stethoscope to
- Thyroid gland
not painful assess sound
 Inspection: Head and Neck
• Inspect the size, shape, configuration
• Consistency
• Involuntary movement
Equipments for Head and Neck
Examination
1. Gloves
2. Penlight or flashlight
3. Small glass of water
4. Stethoscope
HEAD
• Size, shape, configuration
• Normal findings:
Normocephalic
– symmetric, round, erect,
midline
– no visible lesions.
• Abnormal findings:
1. Microcephaly – abnormal small head
for age
2. Anencephaly – serious birth defect in
which a baby is born without parts of
the brain and skull
3. Acromegaly
– skull and face are larger and
thicker
– endocrine problem; excessive
growth of hormones
4. Paget’s Diseases – acorn-shaped,
enlarged skull
5. Head Bobbing or Nodding
– involuntary movement of head
– aortic insufficiency
FACE
• Symmetry, features, movement,
expression, and skin condition
• Abnormal findings:
1. Stroke
– facial asymmetry
– drooping of eyelid or nasolabial
folds
– one-sided body weakness
2. Bell’s palsy
– Drooping, weakness,
paralysis on one side of the face
– Neurologic condition
– FN 9
3. Parkinson’s Diseases – mask-like
face, hollow cheeks
4. Cushing Syndrome – a moon-shaped
face with reddened cheeks and
increased hair.
NECK
• Position, symmetry, lumps, or masses
• Note for any palpable lymph nodes or
thyroid gland
• Ask patient to swallow and observe
for movement of the thyroid cartilage
• Ask the patient to flex the neck.
Inspect C7.
• Assess ROM of the neck
REMEMBER:
Stiff neck = late symptom of meningitis
• Abnormal findings:
Buffalo’s Hump – a collection of
excess fat behind the neck that
causes the shoulders to develop a
hump like shape.
Palpation: Head and Neck
• Note for consistency of the head and
face
o Hard and smooth without
lesions
• Palpate the temporal artery
• Palpate the TMJ
• Palpate the trachea
• Palpate the thyroid gland
• Palpate the lymph nodes of the neck
Ausculation: Thyroid
Only auscultate if you find an enlarged
thyroid gland during inspection and
palpation
in
• Place the bell of the stethoscope over
the lateral lobes of the ear
• Ask the client to hold his/her breath
• Hyperthyroidism
o There are bruits – soft,
blowing, swishing sounds
heard over the lobes
o Indicate increased blood
flow through the thyroid
arteries
GERIATRIC CONSIDERATION
• Facial wrinkles are prominent –
subcutaneous fat decreases
• Lower face may shrink and the
mouth may be drawn inward – result
of resorption of mandibular bone
• Cervical curvature may increase
because of kyphosis, and fat may
accumulate around the cervical
vertebrae (Dowager’s Hump)
• Thyroid may feel more nodular or
irregular because of fibrotic changes
– May also be felt lower in the neck
• Arthritis or Osteoporosis – neck pain
and decrease range of motion
Anatomy and Physiology
or
C. Breast
External Anatomy
• The female breast enlarges in
response to estrogen and
progesterone released from the
ovaries
• Located on the anterior thoracic wall
o Innervated by the anterior and
lateral cutaneous branches of
the 4th to 6th intercostal nerves
• Functions of the breast:
o Produce and store milk
o Pair with mammary glands
o Aid in sexual stimulation
• Composed of two regions
o Circular body
o Axillary tail of Spence
• Nipple
o Located at the center of the
breast
o Contains tiny openings of
lactiferous duct, which milk
passes
o Composed mainly of smooth
muscle
• Areola
o Pigmented area surrounding the
nipple
o Contains montgomery glands
§ secrete lipid
substance during
lactation
§ prominent when
erect
§ releases oil so
that the nipples
and areola are
not dry
• Mongomery glands – modified sweat
glands that consist of a series of ducts
and secretory lobules (15-20).
o Each lobule consists of
many alveoli drained by a
single lactiferous duct.
These ducts converge at
the nipple like spokes of a
wheel.
Note: Pigmentation of the nipple and
areola increases during pregnancy and
decreases after lactation
• The breast has four quadrants,
namely:
1. Upper outer
o Tail of Spence
o Where most breast tumor
occur
2. Upper inner
3. Lower outer
4. Lower inner
Internal Anatomy
1. Vasculature
– internal thoracic artery
– Also known as the internal
mammary artery
– A branch of the subclavian artery
– The lateral part of the breast that
receives blood from branches of
axillary and anterior intercostal
arteries
2. Lymphatics
– There are three groups of lymph
nodes that receive lymph from
the breast tissue:
a. Axillary nodes – 75%
b. Parasternal nodes – 20%
c. Posterior intercostal nodes
– 5%
Breasts Lymph Nodes
1. Anterior (Pectoral)
2. Posterior (Subscapular)
3. Lateral (Brachial)
4. Central (Midaxillary)
5. Supraclavicular
6. Infraclavicular
Mammary Plexus – superficial vein,
deviation in pattern may indicate tumor.
Three Types of Tissues
1. Glandular tissue
– functional part of the breast
– Allows milk production
– With 15-20 Lobes – where milk
is produced
– Lobules
– Alveoli (acini)
– Mammary ducts – in the alveoli;
converge into a single lactiferous
duct that leaves each lobe and
conveys milk to the nipple
– Lactiferous sinus – slight
enlargement in each duct; where
milk can be stored
– Prolactin – hormone that
creates milk
– Oxytocin – hormone
responsible for milk release or
letdown. Is stimulated by nipple
sucking
– Pituitary gland – where
oxytocin is released
2. Fibrous tissue
– Provide support for glandular
tissue by suspensory
ligaments of cooper
o Attach and secure the
breasts to the dermis
– Connective tissue stroma –
supporting structures which
surrounds the mammary glands
– Pectoral Fascia – flat sheet of
connective tissue. Separate the
breast from the pectoralis major
muscle and the breast tissue.
Acts as attachment point for
suspensory ligaments
3. Fatty tissue
– where glandular tissue is
embedded
– determines the size and shape
of the breast
Note: The functional capability of the
breast is not related to the size, but rather
to the glandular tissue present
Nursing Health History
• Same with the head and neck
Physical Examination
Considerations before conducting
physical exam:
• Explain in detail what is happening
throughout the assessment and
answer any questions that the patient
might have
• Provide privacy
• Have patient sit upright
• Explain that it will be necessary to
expose both breasts to compare for
symmetry during inspection. One
breast may be draped while the other
is palpated.
Inspection: Breast
Observe and inspect breast skin, areolas,
and nipples for size, color, shape, rashes,
dimpling, swelling, asymmetry, retraction,
discoloration, and other unusual findings.
Abnormal findings:
• Peau d’ orange – orange peel texture
of the breast
• Supernumerary nipples – milk line
• Gynecomastia – enlargement of
breast tissues in men May be due to
puberty, hormonal imbalance, drug
abuse, cirrhosis, leukemia, or
thyrotoxicosis
• Paget’s disease – redness, mild
scaling, and flaking of the nipple
• Retracted nipple – suggests
malignancy
REMEMBER:
Dimpling or retraction of the breasts is
usually caused by a malignant tumor.
REMEMBER:
A personal history of breast cancer
increases the risk for recurrence of cancer.
Palpation: Breast
• Palpate breasts and axillary lymph
nodes. Take note for:
o Swelling
o Lumps or masses
o Warmth or inflammation
o Tenderness
• Ask the client to lie down and to place
overhead the arm on the same side as
the breast being palpated. Place a
small pillow or rolled towel under the
breast being palpated
• Use the flat pads of three fingers to
palpate the client’s breasts
• Palpate the breasts using one of the
three different patterns
• Be sure to palpate every square inch
of the breast, from the nipple and
areola to the periphery of the Breast
tissue, and up to the tail of Spence
o Light - superficial
o Medium – mid-level tissue
o Firm – ribs
• Use the bimanual technique if the
client has large breasts. Support the
breast with your nondominant hand
and use your dominant hand to
palpate
GERIATRIC CONSIDERATION
• The older client may notice a
decrease in the size and firmness of
the breast as she ages because of a
decrease in estrogen levels
o Glandular tissue decreases
o Fatty tissue increases.
• The older client often has more
pendulous, less firm, and saggy
breasts.
• The older client’s breasts may feel
more granular, and the inframammary
ridge may be more easily palpated as
it thickens.
Expected Changes in Aging Female
Breasts
1. Decrease in size
2. Decrease in firmness
3. Glandular tissue decreases, whereas
fatty tissue increases
Clinical Correlation
1. Fibrocystic Breast Disease
• Benign cystic lesion
• Round, elastic, defined, tender, and
mobile
• Common to age 30 to menopause
2. Fibroadenoma
• Benign tumor
• Lesions are lobular, ovoid, or round
• Firm, well-defined, singular, and
mobile
• Occur commonly between puberty
and menopause
3. Breast Cancer
• Malignant tumors are most often
found in the upper outer quadrant of
the breast.
• They are usually unilateral, with
irregular, poorly delineated borders.
• They are hard and nontender and
fixed to underlying tissues.
Early Detection of Breast Cancer
40-44 Can have optional mammograms
provided that there is no family
history of breast cancer
45-54 Annual mammography
>55 Mammography every other year
and annual screenings
Note: If there is history of breast cancer in the
family, be sure to start at the age of 35
Breast ultrasound is recommended for young
adults rather than mammogram because they
have dense breasts
Hypothyroidism
o Increased sensitivity to cold
o Constipation
o Depression
o Fatigue
o Heavier menstrual periods
o Pale, dry skin
o Thin, brittle hair or nails
o Weakness
o Unintentional weight gain
Hyperthyroidism
o Sudden weight loss, without changes in
appetite and diet
o Increased appetite
o Rapid heartbeat (tachycardia) greater than
100 beats a minute, irregular heartbeat
(arrhythmia), or palpitations
o Nervousness, anxiety, and irritability
o Tremor in the hands and fingers
o Sweating
o Changes in menstrual patterns
o Increased sensitivity to heat
o Changes in bowel patterns, more frequent
bowel movements
o Enlarged thyroid gland (goiter)
o Fatigue, insomnia
o Muscle weakness
Types Of Headaches
1. Sinus
– deep, constant, throbbing, pressure-
like, face is tender to touch
– occurs with or after cold, sinusitis,
febrile illness
– along eyebrow ridge and below
cheekbone
– lasts until asssoc. Condition is
improved
– moderate severe
– pain worse with sudden movements,
bending forward, lying down, in the
morning, temperature changes
– asssoc w/ sinusitis, congestion, fever,
foul smelling breath
2. Cluster
– stabbing, tearing, eyelid drooping,
reddened eye, runny nose
– sudden onset, precipitated by alcohol
– along the eye
– onset late evening or night
– intense severity
– relieve by moving and walking back
and forth
– occur in young males
3. Tension
– dull, tight, diffuse
– no prodromal; woccur w/ stress,
anxiety, or depression
– frontal, temporal, occipital
– lasts day, months, years
– aching
– relieve by heat, massage, analgesics,
anti-depressants, and muscle
relaxants
– common in women than men
4. Migraine
– accompanied by nausea, vomiting,
and sensitivity to noise and light
– w/ prodromal; emotional
disturbances, anxiety, alcohol,
cheese, chocolate
– one side of face
– last up to 3 days
– throbbing, severe
– relieved by resting
– common in women
5. Tumor Related
– aching, steady, nausea, vomiting
– no prodromal; aggravated by
coughing, sneezing, or sudden
movement of head
– varies with location of tumor
– occur in the morning and lasts for
hours
– varies in intensity
– usually subsides later in the day