Comprehensive Study Notes: Head, Face, Neck, Regional Lymphatics, and Eyes

Chapter 14: Head, Face, Neck, and Regional Lymphatics

Purpose of Study

  • This chapter aims to teach the location and function of structures within the head and neck.
  • It covers how to perform inspection and palpation of the head and neck.
  • It also focuses on accurately recording the assessment findings.

Reading Assignments

  • Required Reading: Jarvis: Physical Examination and Health Assessment, 88th ed., Chapter 1414, pp. 245−274245 - 274 (pages 99−10399 - 103 of the study guide).
  • Suggested Reading: Moriarty, M., & Mallick-Searle, T. (20162016). Diagnosis and treatment for chronic migraine. Nurse Pract, 41(6)41(6), pp. 18−3218 - 32 (pages 99−10399 - 103 of the study guide).

Key Terminology (Glossary Definitions)

  • Bruit: A blowing, swooshing sound heard through a stethoscope over an area of abnormal blood flow.
  • Dysphagia: Difficulty in swallowing.
  • Goiter: An increase in the size of the thyroid gland, typically associated with hyperthyroidism.
  • Lymphadenopathy: Enlargement of the lymph nodes, which can be due to infection, allergy, or neoplasm.
  • Macrocephalic: Refers to an abnormally large head.
  • Microcephalic: Refers to an abnormally small head.
  • Normocephalic: Describes a skull that is round, symmetric, and appropriately related to body size.
  • Torticollis: A head tilt caused by the shortening or spasm of one sternomastoid muscle.
  • Vertigo: An illusory sensation of either the room or one's own body spinning; distinct from general dizziness.

Anatomy of the Head and Neck

  • Muscles: Key muscles include the sternomastoid and trapezius muscles.
  • Triangles of the Neck:
    • Anterior Triangle: Bounded by the sternomastoid muscle, the midline of the neck, and the mandible.
    • Posterior Triangle: Bounded by the sternomastoid muscle, the trapezius muscle, and the clavicle.
  • Facial Symmetry: Important assessment areas include the eyebrows, eyes, ears, nose, mouth, and the symmetry of eye openings.

Lymph Node Assessment

  • Normal Characteristics: Normal cervical nodes are palpable, small (e.g., < 1 cm), soft, and mobile. They are often more easily felt in adults, especially after minor infections.
  • Abnormal Characteristics:
    • Enlarged, tender, mobile, soft nodes: May indicate infection or inflammation.
    • Clumped nodes: Can suggest chronic inflammation or malignancy.
    • Hard, non-tender, fixed, irregular nodes: Are suspicious for malignancy.

Head Assessment in Newborns

  • Fontanels: Normal newborn fontanels should feel firm, slightly concave, and well-defined. They may pulsate visibly.
  • Caput Succedaneum:
    • A swelling of the scalp resulting from birth trauma.
    • It crosses the suture lines of the skull.
    • It is soft and pitting.
    • Typically resolves within a few days.
  • Cephalhematoma:
    • A collection of blood located under the periosteum of the skull.
    • It does not cross the suture lines.
    • It feels firm.
    • May take weeks to resolve.
    • Associated with subperiosteal hemorrhage.
  • Tonic Neck Reflex ("Fencing Position"):
    • When an infant's head is turned to one side, the arm and leg on that side extend, while the opposite arm and leg flex.
    • This reflex is normally present from birth until 4−64 - 6 months of age.
    • The absence of the tonic neck reflex may be noted when suspecting an infant's head is of abnormal size.
  • Assessing Head Size: A measuring tape is used to verify findings of abnormal infant head size.

Specific Conditions and Findings

  • Down Syndrome: Often characterized by a flat nasal bridge, upward slanted eyes, a small, flat nose, a protruding tongue, and low muscle tone. Brushfield spots (small white or gray spots in the iris) are also associated.
  • Salivary Gland Issues: Enlarged, tender, mobile, soft glands can be due to mumps, abscess, tumor, blocked salivary duct, or stones.
  • Headaches:
    • Cluster Headaches: May be precipitated by alcohol and daytime napping.
    • Migraine Headaches: Characterized by throbbing, unilateral pain, often associated with nausea, vomiting, and photophobia.
  • Bell Palsy: Characterized by unilateral paralysis of a complete half of the face.
  • Thyroid Gland Enlargement: If the thyroid gland is enlarged bilaterally, it is appropriate to listen for a bruit over the thyroid lobes.
  • Malignancy Risk Factors: History of radiation therapy to the head, neck, or upper chest; history of using chewing tobacco; and history of large alcohol consumption are all potential indicators. Marked tenderness is least likely to indicate a possible malignancy, as malignant nodes are often non-tender.

Cranial Nerve Assessment

  • Cranial Nerve XI (Spinal Accessory): Tested by providing resistance while the patient shrugs his or her shoulders.

Lymph Node Location Matching

  • Preauricular: In front of the ear.
  • Posterior auricular: Superficial to the mastoid process.
  • Occipital: At the base of the skull.
  • Submental: Behind the tip of the mandible.
  • Submandibular: Halfway between the angle and the tip of the mandible.
  • Jugulodigastric: Under the angle of the mandible.
  • Superficial cervical: Overlying the sternomastoid muscle.
  • Deep cervical: Deep under the sternomastoid muscle.
  • Posterior cervical: In the posterior triangle along the edge of the trapezius muscle.
  • Supraclavicular: Above and behind the clavicle.

Chapter 15: Eyes

Purpose of Study

  • This chapter aims to teach the structure and function of both external and internal components of the eyes.
  • It covers the methods of examining vision, the external eye, and the ocular fundus.
  • It also focuses on accurately recording the assessment findings.

Reading Assignments

  • Required Reading: Jarvis: Physical Examination and Health Assessment, 88th ed., Chapter 1515, pp. 275−316275 - 316 (pages 107−114107 - 114 of the study guide).
  • Suggested Reading: Ossorio, A. (20152015). Red eye emergencies in primary care. Nurse Pract, 40(12)40(12), pp. 47−5347 - 53 (pages 107−114107 - 114 of the study guide).

Key Terminology (Glossary Definitions)

  • Accommodation: Adaptation of the eye for near vision by increasing the curvature of the lens.
  • Anisocoria: Unequal pupil size.
  • Arcus senilis: A gray-white arc or circle around the limbus of the iris, common with aging.
  • Argyll Robertson pupil: A pupil that does not react to light but does constrict with accommodation.
  • Astigmatism: A refractive error of vision due to differences in curvature in the refractive surfaces of the eye (cornea and lens).
  • A-V crossing: Crossing paths of an artery and vein in the ocular fundus.
  • Bitemporal hemianopsia: Loss of both temporal visual fields.
  • Blepharitis: Inflammation of the glands and eyelash follicles along the margin of the eyelids.
  • Cataract: Opacity of the lens of the eye that develops slowly with aging and gradually obstructs vision.
  • Chalazion: An infection or retention cyst of a meibomian gland, presenting as a beady nodule on the eyelid.
  • Conjunctivitis: Infection of the conjunctiva, commonly known as "pinkeye."
  • Cotton wool area: Abnormal soft exudates visible as gray-white areas on the ocular fundus.
  • Cup-to-disc ratio: The ratio of the width of the physiologic cup to the width of the optic disc, normally half or less.
  • Diopter: A unit of strength of the lens settings on the ophthalmoscope that changes focus on eye structures.
  • Diplopia: Double vision.
  • Drusen: Benign deposits on the ocular fundus that appear as round yellow dots and occur commonly with aging.
  • Ectropion: A condition where the lower eyelid is loose and rolls outward.
  • Entropion: A condition where the lower eyelid rolls inward.
  • Exophthalmos: Protruding eyeballs.
  • Fovea: The area of keenest vision at the center of the macula on the ocular fundus.
  • Glaucoma: A group of eye diseases characterized by increased intraocular pressure.
  • Hordeolum (Stye): A red, painful pustule that is a localized infection of a hair follicle at the eyelid margin.
  • Lid lag: An abnormal white rim of sclera visible between the upper eyelid and the iris when a person moves the eyes downward.
  • Macula: A round, darker area of the ocular fundus that mediates vision only from the central visual field.
  • Microaneurysm: An abnormal finding of round red dots on the ocular fundus that are localized dilations of small vessels.
  • Miosis: Constricted pupils.
  • Mydriasis: Dilated pupils.
  • Myopia: Nearsightedness; a refractive error in which near vision is better than far vision.
  • Nystagmus: Involuntary, rapid, rhythmic movement of the eyeball.
  • Optic atrophy: Pallor of the optic disc due to partial or complete death of the optic nerve.
  • Optic disc: The area of the ocular fundus where blood vessels exit and enter.
  • Papilledema: Stasis of blood flow out of the ocular fundus; a sign of increased intracranial pressure.
  • Presbyopia: A decrease in the power of accommodation that occurs with aging.
  • Pterygium: A triangular opaque tissue on the nasal side of the conjunctiva that grows toward the center of the cornea and may affect vision.
  • Ptosis: Drooping of the upper eyelid over the iris and possibly covering the pupil.
  • Red reflex: A red glow that appears to fill the person's pupil when first visualized through the ophthalmoscope.
  • Strabismus (Squint, Crossed Eye): Disparity of the eye axes, which can lead to amblyopia (lazy eye) if not corrected early.
  • Xanthelasma: Soft, raised yellow plaques occurring on the skin at the inner corners of the eyes.

Anatomy and Physiology of the Eye

  • Extraocular Muscles (EOMs) and Cranial Nerve (CN) Innervation:
    • CN III (Oculomotor): Superior rectus, Inferior rectus, Medial rectus, Inferior oblique muscles.
    • CN IV (Trochlear): Superior oblique muscle.
    • CN VI (Abducens): Lateral rectus muscle.
    • All 66 eye muscles that control eye movement are innervated by cranial nerves III, IV, and VI.
  • Eye Layers:
    • Outer Layer:
      • Sclera: White, protective layer.
      • Cornea: Clear and refracts light.
    • Middle Layer (Vascular):
      • Choroid: Vascular layer that supplies blood.
      • Ciliary body: Controls lens shape for focusing.
      • Iris: Colored part that controls pupil size to regulate light entry.
    • Inner Layer:
      • Retina: Nervous tissue containing rods and cones that sense light and color.
  • Fluid-Filled Chambers:
    • Anterior Chamber: Space between the cornea and iris, filled with aqueous humor.
    • Posterior Chamber: Space between the iris and lens, also filled with aqueous humor.
    • Vitreous Body: Large cavity behind the lens, filled with gel-like vitreous humor to maintain eye shape.
  • Image Perception: The image projected onto the retina is upside down and reversed; the brain corrects this for upright and correct orientation perception.
  • Tear Production and Drainage:
    • Lacrimal Gland: Located above the eyes, produces tears.
    • Tears flow across the eyes and drain through the puncta into the nasolacrimal duct.

Eye Reflexes and Functions

  • Pupillary Light Reflex: Pupils constrict when exposed to light.
    • Direct light reflex: Pupils constrict in the same eye that receives the light.
    • Consensual light reflex: Pupils constrict in the opposite eye, even without direct light stimulus.
  • Fixation: The eyes focus on a single target, maintaining a steady image.
  • Accommodation: The eyes adjust to see near objects clearly, involving pupil constriction and convergence (turning inward).

Age-Related Eye Changes

  • Common Changes: Decreased tear production, loss of lens elasticity (leading to presbyopia), smaller pupils, slower light response, decreased night vision, and reduced peripheral vision.
  • Increased Risk for Conditions: Cataracts, glaucoma, macular degeneration, and diabetic retinopathy are more common with aging.

Vision Assessment

  • Visual Acuity (Far Vision): Assessed with the Snellen eye chart. A 20/2020/20 rating means a person can see at 2020 feet what a normal eye can see at 2020 feet.
  • Near Vision: Assessed with a handheld vision card held about 1414 inches away. If the person needs to move it farther away to read, presbyopia is likely present.
  • Peripheral Vision: A patient with normal vision would see a moving finger temporally at approximately 9090 degrees.

Eye Alignment

  • Phoria: A mild weakness where the eye drifts only when fusion is broken.
  • Tropia: A constant, visible misalignment (strabismus).
  • Cover Test: Used to assess for muscle weakness (phoria or tropia).

Scleral Coloration Indications

  • Pallor: May indicate anemia.
  • Cyanosis: May indicate hypoxemia.
  • Jaundice: May indicate liver disease.
  • Redness: May indicate infection or irritation.
  • Subconjunctival Hemorrhage: A bright red patch on the sclera from a small vessel rupture; harmless and resolves in 1−21 - 2 weeks.

Eyelid Examination

  • To check for foreign bodies on the underside of the upper lid: Ask the person to look down, place a cotton swab on the upper lid, gently lift the lashes, and then flip the lid over the swab.

Conjunctival Lesions

  • Pinguecula: Yellowish, small, raised nodules on the conjunctiva, usually harmless, often caused by sun, wind, or dust exposure.
  • Pterygium: A triangular growth of conjunctiva that extends onto the cornea and may affect vision.

Ophthalmoscopic Examination

  • Diopter Lens Settings:
    • Negative (red lens): Focuses on structures farther away.
    • Positive (black lens): Focuses on structures closer.
  • Procedure: When using the ophthalmoscope, remove your own glasses, set the diopter setting at 00, and approach the patient's left eye with your left eye (and patient's right eye with your right eye).
  • Red Reflex: A red glow that fills the pupil, caused by light reflecting from the retina. An interruption of the red reflex indicates opacity in the cornea or lens.
  • Viewable Retinal Structures: The optic disc, retinal vessels, the general background, and the macula.

Pediatric Eye Considerations

  • Epicanthal Fold: An extra fold of skin covering the inner eye corner, common in infants and people of Asian descent. Can cause "pseudostrabismus," which is the appearance of crossed eyes even if they are aligned.
  • Ophthalmia Neonatorum: Purulent eye discharge in a newborn, often caused by gonorrhea, which can lead to blindness if untreated. Critical for early detection and treatment.

Common Eye Conditions

  • Conjunctivitis ("Pinkeye"): Infection/inflammation of the conjunctiva, characterized by redness, discharge, and itchiness. It is contagious but generally not serious.
  • Iritis (Anterior Uveitis): A serious condition presenting with deep, dull eye pain, photophobia, and a small, irregular pupil, requiring urgent medical care.
  • Acute Glaucoma: A medical emergency characterized by sudden eye pain, halos around lights, dilated pupils, a cloudy cornea, and vision loss.
  • Cataract: Thickening and yellowing of the lens due to aging.

Eye Emergency Symptoms

  • Sudden onset of vision change.
  • Sudden eye pain.
  • Halos around lights.
  • Photophobia.

PERRLA Documentation

  • P: Pupils
  • E: Equal
  • R: Round
  • R: Reactive
  • L: to Light
  • A: and Accommodation