N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide patient can help during the exam. • Explain how the results of the exam will be used. • Ask about presence or history of: o Neck stiffness or decreased range of motion (ROM) o Previous neck injuries o Lumps in neck o Thyroid problems • Assess the neck muscles and range of the motion. o Normal: Muscles on each side of the neck are equal in size; head moves smoothly from side to side with no tenderness or pain; patient able to place chin on the chest; patient able to extend head to 60 degrees; patient able to move head side to side (ear toward shoulder) to 40 degrees flexion; patient rotates head to 70 degrees o Deviations from normal: Muscles on each side of the neck unequal in size; head does not move smoothly side to side or patient experiences tenderness or pain; patient not able to place chin on the chest; patient not able to extend head to 60 degrees; patient not able to move the head side to side (ear toward shoulder) to 40 degrees flexion; patient not able to rotate the head to 70 degrees • Assess lymph nodes in the neck: Face the patient and bend his head slightly forward torelax the muscles. Palpate the sides of the neck, under the mandible, and above the clavicles using a gentle rotatingmotion. o Normal: No palpable nodes o Deviations from normal: Enlarged and possibly tender nodes • Assess trachea: Place fingertip on the trachea and move finger to the left andright. o Normal: Trachea in midline of the neck; spaces equal on both sides o Deviations from normal: Trachea deviated to one side • Assess thyroid gland: Face the patient and bend his head slightly forward to relax the muscles. Place the tips of fingers over the thyroid and instruct the patient to swallow. To examine the thyroid lobes, displace the trachea slightly to one side and palpate the thyroid lobe on the other side. Perform the same procedure on the other side. o Normal: Not visible on inspection; on swallow, the thyroid ascends but is not visible; not palpable or, if palpable, the nodes are small and non-tender o Deviations from normal: Generalized enlargement of the gland on inspection; on swallow, the thyroid is not freely movable; solitary, hard nodules; the nodes may be tender Evaluation It is important to compare all findings with previous findings to determine if there are changes to any abnormal neck findings. Record and report any significant deviations from the normal. 2.9 Chest/Thorax To examine the chest, the nurse should have access to the patient's bare thorax. Typically, the patient should be examined in a sitting position to allow full lung expansion. Most clinicians will begin with

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