Head, Neck, & Nails (Health Assess.)

What is ADPIE?

Assessment, Diagnosis, Planning, Implementation, & Evaluation

4 Types of Assessment

Initial comprehensive = full history + head-to-toe exam

Ongoing/partial = follow-up after initial

Focused/problem-oriented = check 1 concern (like chest pain)

Emergency = quick, life-saving

What is subjective data?

What patient says (symptoms, feelings, beliefs).

What is objective data?

What nurse observes/measures.

4 Steps of Data Collection

Collect subjective, collect objective, validate accuracy, document for care team.

What are the 4 main exam techniques?

Inspection = look at skin color/posture

Palpation = feel for texture/temp

Percussion = tap to hear sound (air vs fluid)

Auscultation = listen with stethoscope

What does pain trigger in the body?

Sympathetic nervous system

Types of Pain

Nociceptive = tissue injury

Neuropathic = nerve damage

Inflammatory = swelling/infection

Somatic = skin/muscles/joints

Visceral = organs

Referred = felt away from source

What scale uses smiley/crying faces for pain?

Wong-Baker Faces scale

What is malnutrition?

Too little (undernutrition) OR too much (overnutrition).

Why is overhydration dangerous?

Can harm people with kidney, liver, or heart disease.

Types of Violence

Physical, psychological, economic, sexual, domestic, child abuse, school violence, hate crimes, human trafficking.

Skin Functions

Protection, temperature regulation, fluid balance, sensation, immunity, vitamin D production.

What are the 3 skin layers?

Epidermis, Dermis, Subcutaneous tissue.

Hair

Made of keratin, grows from follicles.

Types:

Vellus (fine)

Terminal (thick, dark).

Nails

Hard keratin plates.

parts: body, lunula, cuticle.

What tools are used in skin/hair/nail assessment?

Gloves, light, ruler, mirror, magnifier, Wood’s light, Braden scale, PUSH tool.

What does the Braden Scale check?

Risk for pressure ulcers.

Which techniques are always used in skin assessment?

Inspection + Palpation

What are the 3 main types of skin cancer?

Basal cell carcinoma (BCC)

Squamous cell carcinoma (SCC)

Melanoma

ABCDE Rule

For melanoma: Asymmetry, Border, Color, Diameter, Evolving

Which vitamin lowers skin cancer risk?

Vitamin B3

Who tends to be diagnosed later and have worse outcomes?

People with darker skin

What is MRSA?

Antibiotic-resistant staph infection.

Risk factors for MRSA (community)?

Contact sports, sharing items, poor hygiene, recent antibiotics, weak immune system.

How to prevent MRSA spread?

Handwashing, cover wounds, don’t share personal items, finish antibiotics.

Why do older adults sweat less?

Fewer active sweat glands.

What changes in older skin?

Thinner, drier, less elastic, fragile.

What happens to older nails & hair?

Nails = thick, yellow, brittle.

Hair = thinner, slower growth, coarse, women may get chin hair.

Who is at risk for pressure injuries?

Anyone immobile, unconscious, or with poor sensation/mobility.

Pressure Injury Stages

Stage 1 = Red, doesn’t blanch

Stage 2 = Blister/open wound

Stage 3 = Full-thickness skin loss

Stage 4 = Exposed muscle/bone

Unstageable = Covered in slough/eschar

How can pressure injuries be prevented?

Daily skin checks, repositioning, cushions, good nutrition/hydration.

Primary Lesions

Macule, patch, papule, plaque, nodule, tumor, vesicle, bulla, wheal, pustule, cyst.

Secondary Lesions

Erosion, ulcer, scar, fissure.

Vascular Lesions

Petechiae, ecchymosis, hematoma, cherry angioma, spider angioma.

Configurations

Linear, annular, clustered, discrete, nummular, confluent.

What nail finding is linked to psoriasis?

Pitting

What is koilonychia?

Spoon-shaped nails. (iron-deficiency)

What is yellow nail syndrome?

Thick, yellow, curved nails.

What is paronychia?

Nail fold infection (red, swollen).

What does a head & neck assessment focus on?

Cranium, face, thyroid gland, lymph nodes, muscles, ligaments, cervical vertebrae.

The 8 Cranium Bones

Frontal (1)

Parietal (2)

Temporal (2)

Occipital (1)

Ethmoid (1)

Sphenoid (1)

The 14 Face Bones

Maxilla (2)

Zygomatic (2)

Inferior conchae (2)

Nasal (2)

Lacrimal (2)

Palatine (2)

Vomer (1)

Mandible (1 — only movable bone, at TMJ)

Neck Structures

Muscles (sternocleidomastoid, trapezius)

cervical vertebrae (C1–C7)

hyoid bone

carotid arteries

jugular veins

larynx

trachea

thyroid gland

Name the major lymph nodes of head & neck.

Submental

Superficial cervical

Posterior cervical

Deep cervical

Supraclavicular

What tool is used to assess pain?

COLDSPA (Character, Onset, Location, Duration, Severity, Pattern, Associated factors).

What test measures how headaches affect daily life?

HIT-6 (Headache Impact Test).

What are key subjective symptoms to ask about?

Dizziness, lumps, swallowing trouble, blurred vision, weakness, tingling, emotional changes.

What does objective assessment of head & neck include?

Inspect head (size, shape), palpate temporal arteries & TMJ, check trachea & thyroid, palpate lymph nodes, auscultate thyroid only if enlarged.

Why do older adults often have more facial wrinkles?

Loss of subcutaneous fat.

What is a “dowager’s hump”?

Fat accumulation around cervical vertebrae.

How does the thyroid feel in older adults?

May be nodular, irregular, lower in the neck.

Hypothyroidism (Myxedema)

Low thyroid. Symptoms: sleepiness, cold intolerance, weight gain, dry skin, brittle hair, edema (esp. eyes), constipation, slow reflexes.

Hyperthyroidism (Thyrotoxicosis)

Overactive thyroid. Symptoms: nervousness, sweating, weight loss, tachycardia, bulging eyes, insomnia, diarrhea, thyroid enlargement.

Which thyroid disorder causes exophthalmos (bulging eyes)?

Hyperthyroidism

Headache Types

Sinus: pain around eyes/cheeks, worse bending

Cluster: severe, one eye, tearing

Tension: “band-like” pressure

Migraine: throbbing, light/noise sensitive, nausea

Tumor-related: steady, worse with coughing

What are the FAST signs of stroke?

Face droop, Arm weakness, Speech trouble, Time to call 911.

Traumatic Brain Injury (TBI)

Bump, jolt, blow, or penetrating injury. Risk groups: infants, teens, adults >65. Leading causes: falls, vehicle crashes, violence.

How can TBIs be prevented?

Helmets, seatbelts, no DUI, safe environments.

Other Head & Neck Disorders

Acromegaly = enlarged bones of face, hands, feet

Cushing Syndrome = “moon face,” fat neck, thin limbs

Scleroderma = hard, tight skin

Bell’s Palsy = one-sided facial droop