health module: neck and lymph nodes

When auscultating a patient's carotid arteries, you are primarily listening for which abnormal finding?

Bruits

Rationale: You auscultate the carotids to detect the presence of bruits, which are associated with turbulent blood flow. Carotid auscultation is not performed in order to gauge the rate or quality of the pulse; this can be gauged through palpation.

assessment of the neck includes

neck range of motion, lymph nodes, carotid arteries

before a neck and lymph node assessment, ask about

• swollen glands or lumps in the neck

• temperature intolerance or sweating

• ongoing hoarseness

thyroid gland

• largest endocrine gland in the body

• produces thyroid hormones → increase metabolic rate of most body cells

• surrounded by structures that are important to palpate for accurate location of the thyroid gland

  • isthmus: lies across the trachea below the cricoid cartilage

  • lateral lobes of this gland curve posteriorly around the sides of the trachea and esophagus

  • except in the midline, thyroid gland is covered by thin strap-like muscles

    • only sternomastoids are visible

  • 1/3 of the population, there is a third lobe that extends upward from the isthmus or from one of the two lobes

trachea

• air enters the lungs

• composed: C-shaped hyalin cartilage rings

  • cricoid cartilage

    • first upper tracheal ring

    • has a small notch in it

  • thyroid cartilage

    • adam’s apple

    • larger & located above the cricoid cartilage

    • identified by the notch on its superior edge

  • hyoid bone

    • attached to the tongue

    • lies above the thyroid cartilage and under the mandible

what are the two paired muscles that allow movement and provide support to the head and back?

sternomastoid and trapezius

sternomastoid and trapezius muscles form two triangles that provide important landmarks for assessment:

• anterior triangle: located under the mandible, anterior to the sternomatoid muscke

• posterior triangle: located between the trapezius and sternomastoid muscles

sternomastoid muscle function

rotates and flexes the head

in the sternomastoid muscle, the internal jugular veins and carotid arteries are located

bilaterally, parallel and anterior to the sternomastoid muscles

avoid bilaterally compressing the carotid arties when assessing the neck because the bilateral compression can

reduce the blood supply to the brain

the external jugular vein lies _________ over the surface of the sternomastoid muscles

diagonally

trapezius muscle function

extends the head and moves the shoulders

which cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezius muscles and turning the head against resistance by sternomastoic muscles?

11th cranial nerve

11th cranial nerve

• shoulder shrugging → trapezius

• turning head against resistance → sternomastoid muscles

cervical vertebrae

• C1 — C7

• located: posterior neck, support the cranium

• C7: vertebra prominens

  • can be palpated when neck is flexed

  • this landmark will help you locate other vertebrae

lymph nodes characteristics

• clear substance

• composed of excess tissue fluid

• size & shape: vary, most are less than 1 cm long

• buried deep in the connective tissue

• not easily palpable, may feel like small beads

lymph nodes function

• filter lymph after the lymphatic vessels collect it but before it returns to the vascular system

• filtering → removes bacteria & tumor cells from lymph

• produce lymphocytes & antibodies as a defense against invasion by foreign substances

where do lymph nodes appear?

• clusters

• vary in size from 2 to 100 individual nodes

what happens if nodes become overwhelmed by microorganisms?

swell and become painful

what happens if cancer metastasizes to the lymph nodes?

become enlarged, but not painful

what are the most common head and neck lymph nodes?

• preauricular

• posterior auricular

• occipital

• submandibular

• submental

• superficial cervical

• posterior cervical

• deep cervical

• supraclavicular

what do you look for when a malignant or inflammatory lesion is observed?

involvement of the regional lymph nodes that drain it

when a node is enlarged or tender, look for a

source, such as infection in the area that it drains

posterior auricular

superficial to the mastoid process

occipital

base of the skull

submental

midline, under the chin

submandibular

halfway between the angle and the tip of the mandibles

superficial cervical

overlaying the sternomastoid muscle

when inspecting neck, note its

• symmetry

• any masses

• any scars

• enlargement of the parotid or submandibular glands

locate the transverse process of C7 by having patient

tilt head forward towards chest

in older patients, the cervical curvature may increase because of

kyphosis of the spine

what makes the inspection of the cervical vertebrae difficult?

fat accumulated

what can cause stiffness, rigidity, and limited mobility of the neck?

• muscle spasms

• inflammation

• cervical arthritis

what is a late symptom seen in meningitis?

neck stiffness

when palpating lymph nodes, note if any nodes are

• palpable

• unilateral (one sided) or bilateral (both sides)

• size

• shape

• consistency

• fixed or freely movable

normal nodes should be

nonpalpable

you should be able to roll a node in two directions:

• up and down

• side to side

how should nodes feel if the patient has chronic allergies?

• soft

• nontender

• freely movable

in older patients, nodes feel

fibrotic and fatty

when should you be concerned for a lymph node?

• larger than 1 cm

• hard

• fixed to surrounding tissue

if patient has unexplained enlarged or tender nodes, call for:

• reexamination of any regions they drain

• careful assessment of lymph nodes elsewhere

steps for carotid artery assessment:

1. auscultate carotid arteries for bruits (turbulent blood flow)

2. palpate the carotid artery one side at a time

   1. locate the carotid artery by placing your fingers near the upper neck between the sternomastoid & trachea

what happens if you palpate the carotid arteries at the same time?

can impede blood flow to the brain

neck abnormal findings

• pain

• masses

• tenderness

• asymmetric movement

• enlargement of thyroid

• prominence or swellings of vertebrae other than C7

• muscle spasms

• inflammation

• cervical arthritis: may cause stiffness, rigidity, limited mobility of neck

• meningitis: stiff neck, late sign

• trachea pulled to side

  • pulled to affected side in atelectasis, fibrosis, pleural adhesions

  • pushed to unaffected side: tumor, enlarged thyroid lobe, pneumothorax, aortic anuerysm

• neck landmarks deviated from midline / obscured by masses / abnormal growths

neck pain and decreased range of motion in older adults

arthritis or osteoporosis

thyroid abnormal findings

diffuse enlargement

• isthmus and lateral lobes

• no discreetly palpable nodules

• causes include:

  • graves disease

  • hashimoto thyroiditis

  • endemic goiter

enlarged lymph nodes can be a result of

• acute or chronic infection

• autoimmune disorders

• cancers

what is lymphadenopathy?

enlarged lymph nodes greater than 1 cm

what does palpable, tender, warm lymph nodes indicate?

infection:

• anterior cervical nodes: pharyngitis

• posterior cervical nodes: mononucleosis

• posterior auricular nodes: otitis media

• supraclavicular nodes: possible cancer

• virchow node (left supraclavicular): lung and abdominal cancers

• enlarged, tender lymph nodes: pharyngitis

lymphoma

• hard

• rubbery

• irregular

• fixed

• nontender lymph nodes

diffuse lymphadenopathy

• hiv

• aids

A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? (Select all that apply.)

Lethargy, Constipation, Cool skin, Lower systolic blood pressure

Rationale: A patient with hypothyroidism would be likely to experience most of these symptoms, as thyroid difficulty often results in several symptoms 'clustered together.' The exception would be weight loss, which would be unlikely, as hypothyroidism is associated with a slow metabolism which can lead to weight gain or difficulty losing weight.

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to do which of the following?

Swallow a small sip of water

Rationale: Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage, thyroid gland.