Headache

A headache is a common type of pain that patients experience in everyday life and a major reason for missed time at work or school. Headaches range greatly in severity of pain and frequency of occurrence. For example, some patients experience mild headaches once or twice a year, whereas others experience disabling migraine headaches more than 15 days a month. Severe headaches such as migraines may be accompanied by symptoms of nausea or increased sensitivity to noise or light. Primary headaches occur independently and are not caused by another medical condition. Migraine, cluster, and tension-type headaches are types of primary headaches. Secondary headaches are symptoms of another health disorder that causes pain-sensitive nerve endings to be pressed on or pulled out of place. They may result from underlying conditions including fever, infection, medication overuse, stress or emotional conflict, high blood pressure, psychiatric disorders, head injury or trauma, stroke, tumors, and nerve disorders such as trigeminal neuralgia, a chronic pain condition that typically affects the trigeminal nerve on one side of the cheek.^[1]

Not all headaches require medical attention, but some types of headaches can signify a serious disorder and require prompt medical care. Symptoms of headaches that require immediate medical attention include a sudden, severe headache unlike any the patient has ever had; a sudden headache associated with a stiff neck; a headache associated with convulsions, confusion, or loss of consciousness; a headache following a blow to the head; or a persistent headache in a person who was previously headache free.^[2]

Concussion

A concussion is a type of traumatic brain injury caused by a blow to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement causes the brain to bounce around in the skull, creating chemical changes in the brain and sometimes damaging brain cells.^[3] See Figure 7.14^[4] for an illustration of a concussion.

A person who has experienced a concussion may report the following symptoms:

• Headache or “pressure” in head
• Nausea or vomiting
• Balance problems or dizziness or double or blurry vision
• Light or noise sensitivity
• Feeling sluggish, hazy, foggy, or groggy
• Confusion, concentration, or memory problems
• Just not “feeling right” or “feeling down”^[6]

The following signs may be observed in someone who has experienced a concussion:

• Can’t recall events prior to or after a hit or fall
• Appears dazed or stunned
• Forgets an instruction, is confused about an assignment or position, or is unsure of the game, score, or opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows mood, behavior, or personality changes^[7]

Anyone suspected of experiencing a concussion should immediately be seen by a health care provider or go to the emergency department for further testing.

Head Injury

Head and traumatic brain injuries are major causes of immediate death and disability. Falls are the most common cause of head injuries in young children (ages 0–4 years), adolescents (15–19 years), and the elderly (over 65 years). Strong blows to the brain case of the skull can produce fractures resulting in bleeding inside the skull. A blow to the lateral side of the head may fracture the bones of the pterion. If the underlying artery is damaged, bleeding can cause the formation of a hematoma (collection of blood) between the brain and interior of the skull. As blood accumulates, it will put pressure on the brain. Symptoms associated with a hematoma may not be apparent immediately following the injury, but if untreated, blood accumulation will continue to exert increasing pressure on the brain and can result in death within a few hours.^[8]

See Figure 7.15^[9] for an image of an epidural hematoma indicated by a red arrow associated with a skull fracture.

Sinusitis

Sinusitis is the medical diagnosis for inflamed sinuses that can be caused by a viral or bacterial infection. When the nasal membranes become swollen, the drainage of mucous is blocked and causes pain.

There are several types of sinusitis, including these types:

• Acute Sinusitis: Infection lasting up to 4 weeks
• Chronic Sinusitis: Infection lasting more than 12 weeks
• Recurrent Sinusitis: Several episodes of sinusitis within a year

Symptoms of sinusitis can include fever, weakness, fatigue, cough, and congestion. There may also be mucus drainage in the back of the throat, called postnasal drip. Health care providers diagnose sinusitis based on symptoms and an examination of the nose and face. Treatments include antibiotics, decongestants, and pain relievers.^[10]

Pharyngitis

Pharyngitis is the medical term used for infection and/or inflammation in the back of the throat (pharynx). Common causes of pharyngitis are the cold viruses, influenza, strep throat caused by group A streptococcus, and mononucleosis. Strep throat typically causes white patches on the tonsils with a fever and enlarged lymph nodes. It must be treated with antibiotics to prevent potential complications in the heart and kidneys. See Figure 7.16^[11] for an image of strep throat in a child.

If not diagnosed as strep throat, most cases of pharyngitis are caused by viruses, and the treatment is aimed at managing the symptoms. Nurses can teach patients the following ways to decrease the discomfort of a sore throat:

• Drink soothing liquids such as lemon tea with honey or ice water.
• Gargle several times a day with warm salt water made of 1/2 tsp. of salt in 1 cup of water.
• Suck on hard candies or throat lozenges.
• Use a cool-mist vaporizer or humidifier to moisten the air.
• Try over-the-counter pain medicines, such as acetaminophen.^[12]

Epistaxis

Epistaxis, the medical term for a nosebleed, is a common problem affecting up to 60 million Americans each year. Although most cases of epistaxis are minor and manageable with conservative measures, severe cases can become life-threatening if the bleeding cannot be stopped.^[13] See Figure 7.17^[14] for an image of a severe case of epistaxis.

The most common cause of epistaxis is dry nasal membranes in winter months due to low temperatures and low humidity. Other common causes are picking inside the nose with fingers, trauma, anatomical deformity, high blood pressure, and clotting disorders. Medications associated with epistaxis are aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs, and anticoagulants.^[15]

To treat a nosebleed, have the victim lean forward at the waist and pinch the lateral sides of the nose with the thumb and index finger for up to 15 minutes while breathing through the mouth.^[16] Continued bleeding despite this intervention requires urgent medical intervention such as nasal packing.

Cleft Lip and Palate

During embryonic development, the right and left maxilla bones come together at the midline to form the upper jaw. At the same time, the muscle and skin overlying these bones join together to form the upper lip. Inside the mouth, the palatine processes of the maxilla bones, along with the horizontal plates of the right and left palatine bones, join together to form the hard palate. If an error occurs in these developmental processes, a birth defect of cleft lip or cleft palate may result.

Cleft lip is a common developmental defect that affects approximately 1:1,000 births, most of which are male. This defect involves a partial or complete failure of the right and left portions of the upper lip to fuse together, leaving a cleft (gap). See Figure 7.18^[17] for an image of an infant with a cleft lip.

A more severe developmental defect is a cleft palate that affects the hard palate, the bony structure that separates the nasal cavity from the oral cavity. See Figure 7.19^[18] for an illustration of a cleft palate. Cleft palate affects approximately 1:2,500 births and is more common in females. It results from a failure of the two halves of the hard palate to completely come together and fuse at the midline, thus leaving a gap between the nasal and oral cavities. In severe cases, the bony gap continues into the anterior upper jaw where the alveolar processes of the maxilla bones also do not properly join together above the front teeth. If this occurs, a cleft lip will also be seen. Because of the communication between the oral and nasal cavities, a cleft palate makes it very difficult for an infant to generate the suckling needed for nursing, thus creating risk for malnutrition. Surgical repair is required to correct a cleft palate.^[19]

Poor Oral Health

Despite major improvements in oral health for the population as a whole, oral health disparities continue to exist for many racial, ethnic, and socioeconomic groups in the United States. Healthy People 2020, a nationwide initiative geared to improve the health of Americans, identified improved oral health as a health care goal. A growing body of evidence has also shown that periodontal disease is associated with negative systemic health consequences. Periodontal diseases are infections and inflammation of the gums and bone that surround and support the teeth. Red, swollen, and bleeding gums are signs of periodontal disease. Other symptoms of periodontal disease include bad breath, loose teeth, and painful chewing.^[20] In 2020, the Centers for Disease Control and Prevention (CDC) reported that 42% of U.S. adults have some form of periodontitis, and almost 60% of adults aged 65 and older have periodontitis. See Figure 7.20^[21] for an image of a patient with periodontal disease. Nurses may encounter patients who complain of bleeding gums, or they may discover other signs of periodontal disease during a physical assessment.

Because many Americans lack access to oral care, it is important for nurses to perform routine oral assessment and identify needs for follow-up. If signs and/or symptoms indicate potential periodontal disease, the patient should be referred to a dental health professional for a more thorough evaluation.^[22]

Thrush/Candidiasis

Candidiasis is a fungal infection caused by Candida. Candida normally lives on the skin and inside the body without causing any problems, but it can multiply and cause an infection if the environment inside the mouth, throat, or esophagus changes in a way that encourages fungal growth.^[23] See Figure 7.21^[24] for an image of candidiasis.

Candidiasis in the mouth and throat can have many symptoms, including the following:

• White patches on the inner cheeks, tongue, roof of the mouth, and throat
• Redness or soreness
• Cotton-like feeling in the mouth
• Loss of taste
• Pain while eating or swallowing
• Cracking and redness at the corners of the mouth^[25]

Candidiasis in the mouth or throat is common in babies but is uncommon in healthy adults. Risk factors for getting candidiasis as an adult include the following:

• Wearing dentures
• Diabetes
• Cancer
• HIV/AIDS
• Taking antibiotics or corticosteroids including inhaled corticosteroids for conditions like asthma
• Taking medications that cause dry mouth or have medical conditions that cause dry mouth
• Smoking

The treatment for mild to moderate cases of candidiasis infections in the mouth or throat is typically an antifungal medicine applied to the inside of the mouth for 7 to 14 days, such as clotrimazole, miconazole, or nystatin.

“Meth Mouth”

The use of methamphetamine (i.e., meth), a strong stimulant drug, has become an alarming public health issue in the United States. A common sign of meth abuse is extreme tooth and gum decay often referred to as “Meth Mouth.” See Figure 7.22^[26] for an image of Meth Mouth.

Signs of Meth Mouth include the following:

• Dry Mouth. Methamphetamines dry out the salivary glands, and the acid content in the mouth will start to destroy the enamel on the teeth. Eventually this will lead to cavities.
• Cracked Teeth. Methamphetamine can make the user feel anxious, hyper, or nervous, so they clench or grind their teeth. You may see severe wear patterns on their teeth.
• Tooth Decay. Methamphetamine users crave beverages high in sugar while they are “high.” The bacteria that feed on the sugars in the mouth will secrete acid, which can lead to more tooth destruction. With methamphetamine users, tooth decay will start at the gum line and eventually spread throughout the tooth. The front teeth are usually destroyed first.
• Gum Disease. Methamphetamine users do not seek out regular dental treatment. Lack of oral health care can contribute to periodontal disease. Methamphetamines also cause the blood vessels that supply the oral tissues to shrink in size, reducing blood flow, causing the tissues to break down.
• Lesions. Users who smoke methamphetamine may present with lesions and/or burns on their lips or gingival inside the cheeks or on the hard palate. Users who snort may present with burns in the back of their throats.^[27]

Nurses who notice possible signs of “Meth Mouth” should report their concerns to the health care provider, not only for a referral for dental care, but also for treatment of suspected substance abuse.

Dysphagia

Dysphagia is the medical term for difficulty swallowing that can be caused by many medical conditions. Nurses are often the first health care professionals to notice a patient’s difficulty swallowing as they administer medications or monitor food intake. Early identification of dysphagia, especially after a patient has experienced a cerebrovascular accident (i.e., stroke) or other head injury, helps to prevent aspiration pneumonia.^[28] Aspiration pneumonia is a type of lung infection caused by material from the stomach or mouth entering the lungs and can be life-threatening.

Signs of dysphagia include the following:

• Coughing during or right after eating or drinking
• Wet or gurgly sounding voice during or after eating or drinking
• Extra effort or time required to chew or swallow
• Food or liquid leaking from mouth
• Food getting stuck in the mouth
• Difficulty breathing after meals^[29]

The Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) is an example of a simple, evidence-based bedside screening tool that can be used by nursing staff to efficiently identify swallowing impairments in patients who have experienced a stroke. See internet resource below for an image of the dysphagia screening tool. The result of the screening test is recorded as a “fail” if any of the five items tested are abnormal (Glasgow Coma Scale < 13, facial/tongue/palatal asymmetry or weakness, or signs of aspiration on the 3-ounce water test) or “pass” if all five items tested were normal. Patients with a failed screening result are placed on nothing-by-mouth (NPO) status until further evaluation is completed by a speech therapist. For more information about using the Glasgow Coma Scale, see the “Assessing Mental Status” section in the “Neurological Assessment” chapter.

Enlarged Lymph Nodes

Lymphadenopathy is the medical term for swollen lymph nodes. In a child, a node is considered enlarged if it is more than 1 centimeter (0.4 inch) wide. See Figure 7.23^[30] for an image of an enlarged cervical lymph node.

Common infections such as a cold, pharyngitis, sinusitis, mononucleosis, strep throat, ear infection, or infected tooth often cause swollen lymph nodes. However, swollen lymph nodes can also signify more serious conditions. Notify the health care provider if the patient’s lymph nodes have the following characteristics:

• Do not decrease in size after several weeks or continue to get larger
• Are red and tender
• Feel hard, irregular, or fixed in place
• Are associated with night sweats or unexplained weight loss
• Are larger than 1 centimeter in diameter

The health care provider may order blood tests, a chest X-ray, or a biopsy of the lymph node if these signs occur.^[31]

Thyroid

The thyroid is a butterfly-shaped gland located at the front of the neck that controls many of the body’s important functions. The thyroid gland makes hormones that affect breathing, heart rate, digestion, and body temperature. If the thyroid makes too much or not enough thyroid hormone, many body systems are affected. In hypothyroidism, the thyroid gland doesn’t produce enough hormone and many body functions slow down. When the thyroid makes too much hormone, a condition called hyperthyroidism, many body systems speed up.^[32]

A goiter is an abnormal enlargement of the thyroid gland that can occur with hypothyroidism or hyperthyroidism. If you find a goiter when assessing a patient’s neck, notify the health care provider for additional testing and treatment. See Figure 7.24^[33] for an image of a goiter.