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Vitals: Pulse - looking for, norm
- (4) · Rate · Rhythm · Amplitude · Contour
- · Normal adult resting pulse rate between 60 to 90 pulsations/min
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Vitals: Respiratory Rate s/b
12-20 per min (verify rate used here)
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Vitals: Temperature s/b
98.6
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Vitals: Blood Pressure s/b
120/80
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Visc Head Inspection: Battle sign - cause
- · Bruising over a mastoid
- Cause: Skull fracture.
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Visc Head Inspection: DeMusette sign - defin, assoc w., indicates
- · Jerking and bobbing of the head.
- · Associated with: Tremor
- Nodding movement synchronized with the pulse indicates aortic insufficiency.
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Visc Head Palp: Temporal arteries – looking for, indicates
- · (2) Thickening or hardness.
- · If thick and hard it is a possible temporal arteritis.
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Visc Head Palp: Hyoid bone – loc
Adj to C3
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Visc Head Palp: Thyroid and cricoid cartilage – loc
- Adj to C4, 5 for thyroid
- Adj to C6 for cricoid
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Visc Head Palp: Head and Neck Lymph Nodes - check for, names, locations
- Palpate for: (4) size; consistency; mobility; condition
- Names: · Occipital · Postauricular · Preauricular · Tonsilar · Submandibular · Submental · Facial · Anterior cervical chain · Posterior cervical chain · Supraclavicular
- Locations: · Occipital nodes at the base of the skull · Postauricular nodes located superficially over the mastoid process · Preauricular nodes located in front of the ear · Tonsillar nodes at the angle of the mandible · Submandibular nodes halfway between the angle and the tip of the mandible · Submental nodes in the midline behind the tip of the mandible. · Facial nodes located in the maxillary region · Anterior cervical chain nodes at the anterior border of the SCM · Posterior cervical chain nodes along the posterior border of the SCM · Supraclavicular nodes located just above the clavicle
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z Visc Head Palp: Tracheal tug – perform, feel for, indicates
· Use the thumb and 2nd finger to palpate each side of the trachea just below the thyroid isthmus. If a downward tug sensation is felt with a synchronous pulse, this is evidence of an aortic aneurysm.
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z Visc Head Palp: Thyroid gland – feel for
· (7) nodules, tenderness, size, shape, configuration, consistency, and tenderness.
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z Visc Head Palp: Patient swallowing s/b, difficulty may indicate
· Thyroid cartilage movement should be smooth, painless, symmetrical and midline. · It should be smooth and rhythmic. There should be no need to swallow twice. · Difficulty in swallowing may be an enlarged thyroid gland or a space-occupying lesion in the anterior spine.
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