Hi, I'm Meris, and in this video, I'm going to be talking to you about assessing your patient's neck, including their lymph nodes and vessels. I'm going to be following along using our Health Assessment flashcards, which are available on our website, Level Up RN, as both physical hard cards that you can get your hands on if you want a nice set too, or our digital Flashables, which are available and in your possession immediately after purchasing. So if you have these or you want them, I would go ahead and pull them along, and follow along with me. All right. Let's get started.
So when we talk about assessing your patient's neck, there are, of course, a few things that we're going to be assessing all the time, such as symmetry, looking for any sort of unusual deviations from the norm in terms of scars or lumps or bumps, but some other things that we're going to be assessing here are specific to the neck.
So one of them is going to be looking for tracheal deviation. As an ER nurse, this matters to me very much. Tracheal deviation tells me that there is a problem underneath related to the lungs. That perhaps we have one lung that is collapsed if it has pulled the trachea over to the unaffected side. This is a late finding, however. So this is not something that I would expect to see on somebody presenting with an initial collapsed lung. This is going to be multiple hours into having this tension pneumothorax, okay? So tracheal deviation is a possible finding associated with neck assessment.
What else am I going to be looking for here though? I'm going to be looking for range of motion of the neck. And we do this with any kind of a joint space in the body, but this is a really important ability for your patient to have.
To be able to turn their head completely to both sides. To be able to hyperextend and hyperflex chin to chest, right?
All of these things are going to be important when we are assessing range of motion for your patients, and that's how you would do it for the neck assessment.
We may also be assessing cranial nerve 11, spinal accessory, and you can watch the full video on cranial nerves, but cranial nerve 11, spinal accessory we're going to do by putting our hands on our patient's shoulders and having them try to shrug their shoulders against resistance.
We're making sure that there is an even response, that they are strong on both sides, and that my patients are able to move both sides when I'm doing the spinal accessory assessment here.
Another thing we're going to assess that is unique to the neck is the thyroid gland. Now, as you may be able to tell, you shouldn't be able to see my thyroid, right? My thyroid should be nice and flat. It should not be visible in the average person.
How do you assess a thyroid, though? Great question. I'm so glad you asked. The correct way to assess a thyroid is going to be from the posterior, meaning that I might be standing to my patient's side, and have my hand brought around the back of their neck, and I'm going to have them take a sip of water or swallow.
Swallowing is going to pop that thyroid gland up and out so that I can assess it posteriorly while my patient is swallowing.
Now, what other structures do we need to be concerned about assessing when we're talking about the neck?
Well, a big one that I want to bring up would be lymph nodes. Lymph nodes, we have many of them in our whole body, but we have a bunch that are localized to the head and neck.
And in these lymph nodes, we are looking to feel-- first of all, can we feel them at all? Are they swollen? Are they enlarged? Where are they? Is one side larger than the other, right?
If I'm feeling my lymph nodes, I say, "Ooh, this one is really swollen, but this one I can't palpate at all." That's going to be a unique finding here, right?
But what is a normal lymph node? A normal lymph node is going to be movable, meaning I can literally move it around under the skin. It's not fixed in place. It's going to be soft, so it's not firm or hard. It's going to be nontender, meaning if I touch it, I'm not expecting there to be any kind of painful stimuli associated with this. And I'm also expecting that it is less than 1 cm in diameter.
Those things, movable, soft, nontender, and less than 1 cm in diameter, are going to be considered normal findings associated with the lymph nodes.
Now, let's talk about where to assess for these lymph nodes because there are a lot of them in your neck. Now, when we are talking about assessing the lymph nodes of the neck, there are multiple different locations that you are responsible for assessing, and you need to know where they are. We have a great image here for you of the different locations of the lymph nodes, and there's a few that I want to point out to you. So pre- and postauricular, right? So we're going to have preauricular before the ear, postauricular, behind the ear, after the ear, right?
We're going to have jugulodigastric. So jugulodigastric is going to be right around where that jugular vein is going to be passing through.
Submandibular. So sub- meaning beneath or below, and mandible meaning the jaw. So submandibular, we're talking here, right?
Submental, beneath the chin. Ment- means chin. So right here, submental is going to be beneath the chin.
Then we have some cervical chain lymph nodes. So we have superficial cervical. These are going to be the ones that are closest to the surface, superficial. We have posterior cervical, meaning more towards the back of the neck.
And then we have also-- sorry, got to remind myself, the deep cervical. Deep cervical is going to be more anterior. However, as the name may suggest, they're going to be deeper to the surface. They're not going to be as close to the surface.
And then, of course, we have supraclavicular, so on top of the clavicle.
Now, we also have some on the back of our head, occipital. All of these are going to be part of what you are assessing when you are feeling for lymphadenopathy.
Lymphadenopathy is the state or condition of having swollen lymph nodes. Lymphadenopathy. So we're going to assess fully all of these lymph nodes, and we are going to ensure that they are soft, movable, nontender, and less than 1 cm in diameter.
Now, lastly, I want to talk to you about assessing the vasculature of the neck. So let's talk about the vessels in the neck and what we should be assessing when we are looking at this. One of the things that I see with some frequency as an ER nurse is something called jugular venous distention, and let's break this down. It is distension, so widening, largening, a bulging of the jugular vein.
And the jugular vein is going to come right here, and it is draining the blood back to the heart from the brain, the head, the scalp, the face. All of this blood is going to come down through the jugular vein, and it is going to dump back into the right atrium of the heart.
Why do I see jugular venous distention? I see that when there is some variety of a traffic jam. And think about how close the jugular vein is to the heart, right? That I'm going to see the backup of traffic. I'm going to see that traffic jam blood flow happening pretty quickly when it's so close to the affected organ.
So jugular venous distension, how am I going to look for this? I'm going to position my patient at a 30- to 45-degree angle, so 30- to 45-degree head of the bed. And I'm going to let them rest there for a minute.
And then I'm going to look and see, does the jugular vein stick out at all? And when I'm talking about sticking out, I want you to imagine a bodybuilder and they're bearing down like, "Grr," right? When they do that, you see this jugular vein pop out. You know what I'm talking about. You have seen this before. That's a normal finding when somebody is bearing down, pushing, flexing, doing something like that. That's a normal finding.
But if I see that jugular vein popping out when my patient is at rest and relaxed at 30 to 45 degrees, that is an abnormal finding, my friends, and you need to be aware of that.
Now, what else can I do? I can actually auscultate the vasculature of the neck, and I'm going to do that using the bell of my stethoscope. The bell is going to be that smaller portion of the stethoscope, and I'm going to place it on one side and then the other. I'm going to be listening to the carotid arteries.
Now, remember, the carotid arteries are taking blood away from the heart to the head, brain, scalp, face, neck, etc.
So here, I'm going to be listening for anything called a bruit. B-R-U-I-T is bruit. A bruit is sort of like a whooshing, turbulent sort of sound, and this is an abnormal finding. I should not hear this. I should just be able to hear nice, normal blood flow on either side. But if I listen with the bell of that stethoscope and I hear that turbulent [phhshhww], right, some kind of bruit noise in there, I'm concerned that we either have a plaque buildup, maybe we have some sort of stenosis in the carotid artery, or perhaps there's some other problem at play, but this is an abnormal finding.
Not only am I going to listen to the sounds, though, I'm also going to palpate for the pulse in the carotid artery. Now, notice what I did. I did this one, and then I did this one.
I did not do this because if you take both of your hands and place them to feel your patient's pulse and you push in too hard, you will occlude the blood flow to their brain, and you may cause your patient to have a syncopal event. So remember, we always, always, always assess one carotid pulse and then the other.
All right. I hope you've stayed to the end because I have some quiz questions for you to test your knowledge of key facts we provided in this video, and I've got a great story about the thyroid, so stay tuned.
Which four terms describe findings associated with normal lymph nodes?
Those would be movable, soft, nontender, and less than 1 cm in diameter.
At what angle should the patient be positioned to assess for jugular venous distention, JVD?
At a 30- to 45-degree angle.
How can the nurse assess cranial nerve 11, spinal accessory?
By asking the patient to shrug their shoulders against resistance.
All right. That is it for those quiz questions. Please let me know in the comments how you did. I want to hear. And since you stayed to the end, I do have a story for you.
So there was a TikToker who existed in the world who-- I don't know what he does, but he was just doing his TikTok thing, and people started leaving him comments.
And they would say, "Hey, man. I'm not trying to diagnose you. I'm not a doctor. Whatever. However, I can see your thyroid gland, and I had thyroid cancer, or a thyroid nodule, or this, that, or the other thing, and I know it's not normal to be able to see your thyroid at baseline.
So forgive me if I'm overstepping, however, I just wanted to bring it to your attention in case you didn't know."
Well, sure enough, he didn't know, and he started getting a bunch of these comments.
And he went to his doctor, where they discovered that he indeed had thyroid cancer.
So I love this story because I got to watch it unfold in real time, but also because it shows how when you are medical and when you are learning how to assess people, you can't turn it off.
You assess people all the time, whether that's somebody that you're seeing on TikTok, somebody at the grocery store, your partner, your kids sitting on the couch, whatever it may be. You can't turn those assessment skills off.
So just a story to remind you that it is abnormal to be able to see the butterfly-shaped thyroid gland in a person at rest who doesn't have a known condition that would cause that.
