Cagayan de Oro College-PHINMACollege of Nursing

A Case Study of

‘Deep Neck Abscess’Submitted to:

Mr. Arsenio S. Poral, Jr., RN, MAN (c)

Submitted by:Carmelli Mariae H. Calugay

February 20, 2015I. INTRODUCTION

a. Overview

A neck abscess is a collection of pus from an infection in spaces between the structures of the neck. As the amount of pus increases, the soft tissue spaces expand and push against the structures in the neck, such as the throat, tongue, and, in extreme cases, the trachea (windpipe). Neck abscesses are sometimes called cervical abscesses or deep neck infections.

There are several types of neck abscesses, including the following:

Retropharyngeal abscess. An abscess that forms behind the pharynx (back of the throat) often following an upper respiratory infection. In children, the lymph nodes in this area can become infected and break down, forming pus. Retropharyngeal abscesses are most common in young children, because these lymph nodes atrophy (get smaller) by the time a child reaches puberty.

Peritonsillar abscess (quinsy abscess). An abscess that forms in the tissue walls beside the tonsils (the lymph organs in the back of the throat). Peritonsillar abscesses are most common in adolescents and young adults and are rarely seen in young children.

Submandibular abscess (Ludwig's angina). An abscess beneath the tissues in the floor of the mouth. Pus collects under the tongue, pushing it upwards and toward the back of the throat, which can cause breathing and swallowing problems. Ludwig's angina is not common in young children but may occur in older adolescents, especially after a dental infection.

What causes a neck abscess?A neck abscess occurs during or just after a bacterial or viral infection in the head or neck such as a cold, tonsillitis, sinus infection, or otitis media (ear infection). As an infection worsens, it can spread down into the deep tissue spaces in the neck or behind the throat. Pus collects and builds up in these spaces forming a mass. Sometimes, a neck abscess occurs following an inflammation or infection of a congenital (present at birth) neck mass such as a branchial cyst or thyroglossal duct cyst.

What are the symptoms of a neck abscess?The following are the most common symptoms of a neck abscess. However, each child may experience symptoms differently. Symptoms may include:

- Fever- Red, swollen, sore throat, sometimes just on one side- Bulge in the back of the throat- Tongue pushed back against throat- Neck pain and/or stiffness- Ear pain- Body aches- Chills- Difficulty swallowing, talking, and/or breathing

The symptoms of a neck abscess may resemble other neck masses or medical problems. Always consult a physician for a diagnosis.

How is a neck abscess diagnosed?Generally, diagnosis is made by physical examination. In addition to a complete medical history and physical examination, diagnostic procedures for a neck abscess may include the following:

Throat culture. A procedure that involves taking a swab of the back of the throat and monitoring it in the laboratory to determine the type of organism causing an infection.

Blood tests. To measure the body's response to infection

Biopsy. A procedure in which tissue samples are removed (with a needle or during surgery) from the body for examination under a microscope.

X-ray. A diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

Computed tomography scan (also called a CT or CAT scan). A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays.

Treatment of a neck abscessSpecific treatment of a neck abscess will be determined by a physician based on:

o Age, overall health, and medical historyo Extent of the conditiono Tolerance for specific medications, procedures, or therapieso Expectations for the course of the conditiono Your opinion or preference

Treatment may include:

Antibiotic medications (to treat the infection). Often, antibiotics must be given intravenously (in the vein) and hospitalization may be required.

Drainage of the abscess using a needle. This procedure may require hospitalization.

b. Objective of the Study

The objective of this study is to be able to:

1. Acquire knowledge about the disease process.

2. Discuss thoroughly the disease process.

3. Formulate realistic and appropriate nursing care plans.

4. Identify and learn more about the treatment and modalities of the said disease.

5. Apply the nursing process and appreciate its significance in nursing practice.

c. Scope and Limitation of the Study

This study covers about facts related to patient’s condition. It includes the nature, causes,

signs and symptoms, pathophysiology, prognosis, treatment and the nursing interventions

appropriate for his condition. A nursing care plan is also provided which serves as a guide for the

interventions to be applied to the patient to aid in recovery and it will also serve as basis for the

evaluation of client care outcomes. Health teachings including referrals were also imparted to the

patient.

It is limited only to the case of our client. For the completion of this study, some information

was taken from significant others. The assessment and so with the interventions rendered to the

patient were also limited due to time constraint, with a total of 2 days, dated February 9 and 10 of

2015. Thus, we’ve supplemented our study with facts from various references.

d. Patient’s Profile

Name: E.T.C.

Address: Purok 3, Tablon, Cagayan de Oro City, Misamis Oriental

Sex: Female

Age: 95 years old

Birth date: December 26, 1920

Place of Birth: Jimenez, Misamis Occidental

Occupation: None

Civil status: Widowed

Nationality: Filipino

Religion: Roman Catholic

Date of Admission: February 7, 2015

Time of Admission: 10:00 pm

Chief Complaint: Right Lateral Neck Mass

Admitting Diagnosis: Deep Neck Abscess

Attending Physician: Dr. Caayupan

e. Medical History

Patient E.T.C. was admitted at Northern Mindanao Medical Center in the year 2010 for the first

time because of pneumonia. With unknown hypertension and diabetes mellitus.

f. Social History

The patient is reasonably sociable. She’s easy to get along with, and has positive attitude towards

others.

g. Family History

There is no family history of hypertension and diabetes mellitus.

h. History of Present Illness

This is the case of patient E.T.C., who was admitted in Northern Mindanao Medical Center

at their ENT/Optha ward last February 7, 2015.

One week prior to admission, she had onset of erythema and pain at the right side of the

neck. No medications given. No consultation.

Three days prior to admission, patient noted to have increase mass size at the lateral

neck. This was associated with odynophagia. No consultation done.

One day prior to admission, the patient had increase in mass size of 8 x 10 cm, associated

with odynophagia, dysphagia, fever, and generalized body malaise. Resistance of symptoms

prompted consultation and subsequent admission.

i. Chief Complaint

The patient complains of having right lateral neck mass.

j. Diagnosis/Impression

She was then diagnosed to have deep neck abscess.

II. GROWTH AND DEVELOPMENT

Developmental theories of learning have to do with the additional learning tasks individuals

can accomplish as they mature mentally, emotionally, and physically. Although this maturation

actually progresses in slow, continuous fashion, it is often described as proceeding in stages.

Many names are associated with developmental research. The following people and their

stages of development are important in the field of development theory

FREUD’S PSYCHOSEXUAL THEORY

Genital Stage: 13 yrs and above

Freud’s advanced a theory of personality development that centered on the effects of the

sexual pleasure drive on the individual psyche. At particular points in the developmental process,

he claimed, a single body part is particularly sensitive to sexual, erotic stimulation.

Based on Sigmund Freud’s Psychosexual Stages of development our client belongs to the

genital Stage. Characteristics of this stage are that energy of a person is directed toward full

sexual maturity and function and development of skills needed to cope with environment as well as

its demands. The patient is able to achieve independence and able to practice decision-making.

But this condition of the patient needs support from family in activities of daily living as well as

decision making to her present condition.

PIAGET’S COGNITIVE DEVELOPMENT THEORY

Formal Operations Phase: 11- 15 and above

In this developmental theory, our patient belongs to FORMAL-OPERATIONAL wherein

logical reasoning processes are applied to abstract ideas as well as concrete objects. This is the

time when people are most capable of forming new concepts and shifting their thinking in order to

solve problems and general concepts are related to specific situations and alternatives are

considered.

III. ANATOMY AND PHYSIOLOGY

Neck Anatomy

The neck is the part of the body that separates the head from the torso. The Latin-derived term cervical means "of the neck." The neck supports the weight of the head and is highly flexible, allowing the head to turn and flex in different directions.

The midline in front of the neck has a prominence of the thyroid cartilage termed the laryngeal prominence, or the so-called "Adam's apple."

Between the Adam’s apple and the chin, the hyoid bone can be felt; below the thyroid cartilage, a further ring that can be felt in the midline is the cricoid cartilage. Between the cricoid cartilage and the suprasternal notch, the trachea and isthmus of the thyroid gland can be felt.

The quadrangular area is on the side of the neck and is bounded superiorly by the lower border of the body of the mandible and the mastoid process, inferiorly by the clavicle, anteriorly by a midline in front of the neck, and posteriorly by the trapezius muscle.

The cervical spine is made of 7 cervical vertebrae deemed C1 to C7. The cervical portion of the spine has a gentle forward curve called the cervical lordosis. Certain cervical vertebrae have atypical features and differ from the general form of a typical vertebra.

The main arteries in the neck are the common carotids, and the main veins of the neck that return the blood from the head and face are the external and internal jugular veins. Quadrangular AreaA quadrangular area can be delineated on the side of the neck. This quadrangular area is subdivided by an obliquely prominent sternocleidomastoid muscle into an anterior cervical triangle and a posterior cervical triangle.

Anterior cervical triangle

The anterior cervical triangle is bounded by the midline anteriorly, mandible superiorly, and sternocleidomastoid muscle inferolaterally. This triangle is subdivided into 4 smaller triangles by the 2 bellies of the digastric muscle superiorly and the superior belly of the omohyoid muscle inferiorly.

Submandibular triangle

The submandibular triangle is bounded by the mandible and 2 bellies of the digastric muscle. It contains the submandibular salivary gland, hypoglossal nerve, mylohyoid muscle, and facial artery.

Carotid triangle

The carotid triangle is bounded by the sternocleidomastoid muscle, posterior belly of the digastric muscle, and superior belly of the omohyoid muscle. It contains the carotid arteries and branches, internal jugular vein, and vagus nerve.

Muscular or omotracheal triangle

The muscular or omotracheal triangle is bounded by the midline, hyoid bone, superior belly of the omohyoid muscle, and sternocleidomastoid muscle. It includes the infrahyoid musculature and thyroid glands with the parathyroid glands.

Submental triangle

The submental triangle is located beneath the chin, bounded by the mandible, hyoid, and anterior belly of the digastric muscle.

Posterior cervical triangle

The posterior cervical triangle is bounded by the clavicle inferiorly, sternocleidomastoid muscle anterosuperiorly, and trapezius muscle posteriorly. The inferior belly of the omohyoid divides this triangle into an upper occipital triangle and a lower subclavian triangle.

Occipital triangle

The occipital triangle is bounded anteriorly by the sternocleidomastoid muscle, posteriorly by the trapezius, and inferiorly by the omohyoid muscle. The contents include the accessory nerve, supraclavicular nerves, and upper brachial plexus.

Subclavian triangle

The subclavian triangle is smaller than the occipital triangle and is bounded superiorly by the

inferior belly of the omohyoid muscle, inferiorly by the clavicle, and anteriorly by the

sternocleidomastoid muscle. The contents include the supraclavicular nerves, subclavian vessels,

brachial plexus, suprascapular vessels, transverse cervical vessels, external jugular vein, and

nerve to the subclavius muscle.

Osteology: The Cervical Spine

The cervical spine is made of 7 cervical vertebrae deemed C1 to C7. The cervical portion of the spine has a gentle forward curve called the cervical lordosis. Certain cervical vertebrae have atypical features and differ from the general form of a typical vertebra. C1 is also called the atlas because it bears the head, "the globe." It has 2 concave superior facets that articulate with the occipital condyles of the skull. This important articulation provides 50% of the flexion and extension

of the neck. C1 has no vertebral body and no spinous process.

C2, otherwise called the axis, has a conelike projection from the vertebral body that articulates within the atlas. This atlantoaxial articulation is responsible for 50% of the rotation in the neck.

The C2 to C7 vertebrae have foramina in each of the transverse processes and bifid spinous processes except for C7, which has a nonbifid and a prominent posterior spinous process that can be felt distinctly at the base of the neck.

The vertebral artery travels in the foramina of the transverse processes. The spinal cord travels in the spinal canal about 17 mm in diameter formed by the vertebral arches behind the body.

Myology

The muscles of the neck can be grouped according to their location. Those immediately in front and behind the spine are the prevertebral, postvertebral, and lateral vertebral muscles and on the side the neck are the lateral cervical muscles. In addition, a unique superficial muscle, the platysma, exists.

Superficial muscle

The platysma muscles are paired broad muscles located on either side of the neck. The platysma arises from a subcutaneous layer and fascia covering the pectoralis major and deltoid at the level of the first or second rib and is inserted into the lower border of the mandible, the risorius, and the platysma of the opposite side. It is supplied by the cervical branch of the facial nerve. The platysma depresses the lower lip and forms ridges in the skin of the neck and upper chest when the jaws are "clenched" denoting stress or anger. It also serves to draw down the lower lip and angle of the mouth in the expression of melancholy.

Sternocleidomastoid

The sternocleidomastoid is the prominent muscle on the side of the neck. It arises from the sternum and clavicle by 2 heads. The medial or sternal head arises from the upper part of the anterior surface of the manubrium sterni and is directed upward, lateralward, and backward.

The lateral or clavicular head, which is flatter, arises from the superior border and anterior surface of the medial third of the clavicle; it is directed almost vertically upward. The 2 heads are separated from each other at their origins by a triangular interval, but they gradually blend, below the middle of the neck, into a thick, rounded muscle. It is inserted by a strong tendon into the lateral surface of the mastoid process, from its apex to its superior border, and by a thin aponeurosis into the lateral half of the superior nuchal line of the occipital bone. It is supplied by the accessory nerve and branches from the anterior rami of the second and third cervical nerves.

When only one side of the muscle acts, it draws the head toward the shoulder of the same side and rotates the head toward the opposite side. Acting together from their sternoclavicular attachments, the muscles flex the cervical part of the vertebral column. If the head is fixed, the 2 muscles assist in elevating the thorax in forced inspiration.

Trapezius

The trapezius arises from the spinous processes of the cervical and thoracic vertebrae and inserts on the spine of the scapula and acromion; it is innervated by the spinal accessory nerve and branches from the third and fourth cervical roots. Its upper fibers shrug the shoulder and aid in

suspension of the shoulder girdle (see the image below).

Anterior cervical muscles.

Anterior cervical muscles

Muscles in the front of the neck are the suprahyoid and infrahyoid muscles and the anterior vertebral muscles (see the images below).

The suprahyoid muscles are the digastrics, stylohyoid, mylohyoid, and geniohyoid.

The infrahyoid muscles are the sternohyoid, sternothyroid, thyrohyoid, and omohyoid.

Muscles in the front of the neck.

The anterior vertebral muscles.

Suprahyoid muscles

The suprahyoid muscles perform 2 very important actions. During the act of swallowing they raise the hyoid bone and, with it, the base of the tongue; when the hyoid bone is fixed by its depressors, they depress the mandible. During the initial phase of swallowing, when the food is shifted from the mouth into the pharynx, the hyoid bone and with it the tongue are carried upward and forward by the anterior bellies of the digastrics, the mylohyoids, and geniohyoids.

In the next phase, when the food passes through the pharynx, the direct elevation of the hyoid bone takes place by the combined action of all the muscles; after the food has passed, the hyoid bone is carried upward and backward by the posterior bellies of the digastrics and the stylohyoids, which assist in preventing the return of the food into the mouth.

The digastric muscle consists of 2 fleshy bellies united by an intermediate tendon. It lies below the body of the mandible and extends, in a curved form, from the mastoid process to the symphysis menti. The posterior belly, longer than the anterior, arises from the mastoid notch of the temporal bone and passes downward and forward. The anterior belly arises from the inner side of the lower border of the mandible, close to the symphysis, and passes downward and backward. The 2 bellies end in an intermediate tendon that perforates the stylohyoideus muscle and is held in connection with the side of the body and the greater cornu of the hyoid bone by a fibrous loop.

The stylohyoid muscle is a slender muscle lying in front of and above the posterior belly of the digastric muscle. It arises from the back and lateral surface of the styloid process, near the base; passing downward and forward, it is inserted into the body of the hyoid bone at its junction with the greater horn and just above the omohyoid. It is perforated, near its insertion, by the tendon of the digastric muscle.

The mylohyoid muscle is flat and triangular and is situated above the anterior belly of the digastric, and it forms, with its fellow of the opposite side, a muscular floor for the oral cavity. It arises from the whole length of the mylohyoid line of the mandible, extending from the symphysis in front to the last molar tooth behind. The posterior fibers pass medialward and slightly downward to be inserted into the body of the hyoid bone. The middle and anterior fibers are inserted into a median fibrous raphe extending from the symphysis menti to the hyoid bone, where they join at an angle with the fibers of the opposite muscle. This median raphe is sometimes wanting; the fibers of the 2 muscles are then continuous.

The geniohyoid muscle is a narrow muscle, situated above the medial border of the mylohyoideus. It arises from the inferior mental spine on the back of the symphysis menti and runs backward and slightly downward to be inserted into the anterior surface of the body of the hyoid bone; it lies in contact with its fellow of the opposite side.

The mylohyoid branch of the inferior alveolar nerve supplies the mylohyoid and anterior belly of the digastric muscle. The facial nerve supplies the stylohyoid and posterior belly of the digastric. C1 fibers that travel with the hypoglossal nerve supply the geniohyoid muscle.

Infrahyoid muscles

The sternohyoid muscle is a thin, narrow muscle, which arises from the posterior surface of the medial end of the clavicle, posterior sternoclavicular ligament, and upper and posterior part of the manubrium sterni. Passing upward and medialward, it is inserted, by short, tendinous fibers, into the lower border of the body of the hyoid bone.

The infrahyoid muscles are supplied by branches from the first 3 cervical nerves via the ansa cervicalis. These muscles depress the larynx and hyoid bone, after they have been drawn up with the pharynx in the act of deglutition. The omohyoids not only depress the hyoid bone but also carry it backward and to one or the other side.

The sternothyroid muscle is shorter, wider, and deeper than the sternohyoid. It arises from the posterior surface of the manubrium sterni, below the fibers of the sternohyoid, and from the edge of the cartilage of the first rib. It is inserted into the oblique line on the lamina of the thyroid cartilage.

The thyrohyoid muscle is a small, quadrilateral muscle that arises from the oblique line on the lamina of the thyroid cartilage and is inserted into the lower border of the greater horn of the hyoid bone.

The omohyoid muscle consists of 2 fleshy bellies united by a central tendon. It arises from the upper border of the scapula. From this origin, the inferior belly forms a flat, narrow fasciculus, which inclines forward and slightly upward across the lower part of the neck, being bound down to the clavicle by a fibrous expansion; it then passes behind the sternocleidomastoid, becomes tendinous, and changes its direction, forming an obtuse angle.

The omohyoid muscle ends in the superior belly, which passes almost vertically upward, close to the lateral border of the sternohyoideus, to be inserted into the lower border of the body of the hyoid bone, lateral to the insertion of the sternohyoid. The central tendon of this muscle varies a great deal in length and form, and it is held in position by a process of the deep cervical fascia, which sheaths it, and extends downward to be attached to the clavicle and first rib; it is by this means that the angular form of the muscle is maintained.

Anterior vertebral muscles

The anterior vertebral muscles are the longus colli, longus capitis, rectus capitis anterior, and rectus capitis lateralis.

The longus colli muscle is situated on the anterior surface of the vertebral column, between the atlas and the third thoracic vertebra. It is broad in the middle, narrow and pointed at either end, and consists of 3 portions: superior oblique, an inferior oblique, and a vertical.

The superior oblique portion arises from the anterior tubercles of the transverse processes of the third, fourth, and fifth cervical vertebrae and, ascending obliquely with a medial inclination, is inserted by a narrow tendon into the tubercle on the anterior arch of the atlas. The inferior oblique portion, the smallest part of the muscle, arises from the front of the

bodies of the first 2 or 3 thoracic vertebrae and, ascending obliquely in a lateral direction, is inserted into the anterior tubercles of the transverse processes of the fifth and sixth cervical vertebrae The vertical portion arises , below, from the front of the bodies of the upper 3 thoracic and lower 3 cervical vertebrae and is inserted into the front of the bodies of the second, third, and fourth cervical vertebrae.

The longus capitis is broad and thick above, narrow below, and arises by 4 tendinous slips, from the anterior tubercles of the transverse processes of the third, fourth, fifth, and sixth cervical vertebrae, and ascends, converging toward its fellow of the opposite side, to be inserted into the inferior surface of the basilar part of the occipital bone.

The rectus capitis anterior is a short, flat muscle, situated immediately behind the upper part of the longus capitis. It arises from the anterior surface of the lateral mass of the atlas and from the root of its transverse process, and passing obliquely upward and medialward, it is inserted into the inferior surface of the basilar part of the occipital bone immediately in front of the foramen magnum.

The rectus capitis lateralis is a short, flat muscle, which arises from the upper surface of the transverse process of the atlas and is inserted into the undersurface of the jugular process of the occipital bone.

The rectus capitis anterior and the rectus capitis lateralis are supplied from the loop between the first and second cervical nerves; the longus capitis, by branches from the first, second, and third cervical; the longus colli, by branches from the second to the seventh cervical nerves.

The longus capitis and rectus capitis anterior are the direct antagonists of the muscles at the back of the neck, serving to restore the head to its natural position after it has been drawn backward. These muscles also flex the head, and from their obliquity, rotate it, so as to turn the face to one or the other side. The rectus lateralis, acting on one side, bends the head laterally. The longus colli flexes and slightly rotates the cervical portion of the vertebral column.

Lateral vertebral muscles

The lateral vertebral muscles are the scalenus anterior, scalenus medius, and scalenus posterior.

Scalenus anterior lies at the side of the neck, behind the sternocleidomastoid. It arises from the anterior tubercles of the transverse processes of the third, fourth, fifth, and sixth cervical vertebrae, and descending, almost vertically, is inserted by a narrow, flat tendon into the

scalene tubercle on the inner border of the first rib and into the ridge on the upper surface of the rib in front of the subclavian groove.

Scalenus medius the largest and longest of the three scaleni, arises from the posterior tubercles of the transverse processes of the lower 6 cervical vertebrae, and descending along the side of the vertebral column, is inserted by a broad attachment into the upper surface of the first rib, between the tubercle and the subclavian groove.

Scalenus posterior, the smallest and most deeply seated of the 3 scaleni, arises, by 2 or 3 separate tendons, from the posterior tubercles of the transverse processes of the lower 2 or 3 cervical vertebrae and is inserted by a thin tendon into the outer surface of the second rib, behind the attachment of the serratus anterior. It is occasionally blended with the scalenus medius.

The scaleni are supplied by branches from the second to the seventh cervical nerves.

When the scaleni act from above, they elevate the first and second ribs, and are, therefore, inspiratory muscles. Acting from below, they bend the vertebral column to one or other side; if the muscles of both sides act, the vertebral column is slightly flexed.

Suboccipital muscles

The suboccipital group comprises the rectus capitis posterior major, rectus capitis posterior minor, obliquus capitis inferior, and obliquus capitis superior.

Rectus capitis posterior major (rectus capitis posticus major) arises by a pointed tendon from the spinous process of the axis, and, becoming broader as it ascends, is inserted into the lateral part of the inferior nuchal line of the occipital bone and the surface of the bone immediately below the line. As the muscles of the 2 sides pass upward and lateralward, they leave between them a triangular space, in which the recti capitis posteriores minores are seen.

Rectus capitis posterior minor (rectus capitis posticus minor) arises by a narrow pointed tendon from the tubercle on the posterior arch of the atlas, and, widening as it ascends, is inserted into the medial part of the inferior nuchal line of the occipital bone and the surface between it and the foramen magnum.

Obliquus capitis inferior (obliquus inferior), the larger of the 2 oblique muscles, arises from the apex of the spinous process of the axis and passes lateralward and slightly upward to be inserted into the lower and back part of the transverse process of the atlas.

Obliquus capitis superior (obliquus superior), narrow below, wide and expanded above, arises by tendinous fibers from the upper surface of the transverse process of the atlas, joining with the insertion of the preceding. It passes upward and medialward and is inserted into the occipital bone, between the superior and inferior nuchal lines, lateral to the semispinalis capitis.

The deep muscles of the back and the suboccipital muscles are supplied by the posterior primary rami of the spinal nerves.

The 2 recti draw the head backward. The rectus capitis posterior major, owing to its obliquity, rotates the skull, with the atlas, around the odontoid process, turning the face to the same side.

The obliquus capitis superior draws the head backward and to its own side. The obliquus inferior rotates the atlas, and with it the skull, around the odontoid process, turning the face to the same side.

Suboccipital triangle

Between the obliqui and the rectus capitis posterior major is the suboccipital triangle. It is bounded, above and medially, by the rectus capitis posterior major; above and laterally by the obliquus capitis superior; and below and laterally by the obliquus capitis inferior. It is covered by a layer of dense fibro-fatty tissue, situated beneath the semispinalis capitis. The floor is formed by the posterior atlanto-occipital membrane and the posterior arch of the atlas. The vertebral artery and the first cervical or suboccipital nerve are in the groove on the upper surface of the posterior arch of the atlas.

Arteries of the NeckThe main arteries in the neck are the common carotids arising differently, one on each side (see the images below). On the right, the common carotid arises at the bifurcation of the brachiocephalic trunk behind the sternoclavicular joint; on the left, it arises from the highest point on arch of the aorta in the chest.

Dissection of the side of the neck showing the major arteries.

The internal carotid and vertebral arteries.

Common carotid arteries

The common carotid arteries ascend in the neck and divide at the level of upper border of the thyroid cartilage into 2 branches, the external and internal carotid arteries. The external carotid artery supplies the exterior of the head; the face and the neck and the internal carotid artery supplies the cranial and intraorbital contents.

The common carotid arteries lie on either side of the trachea. The common carotid artery, the internal jugular vein, and the vagus nerve are enclosed in a fibrous sheath called the carotid sheath, which is part of the deep cervical fascia. Within this sheath, the vein lies lateral to the artery and nerve between and behind the vessels.

Descending in front of its sheath is the superior root of the ansa cervicalis, which accompanies the hypoglossal nerve below the skull to the level of the greater horn of the hyoid bone. In the lower part of the neck, the common carotid artery is covered by the sternocleidomastoid muscle. As it ascends, only the medial border of this muscle covers it. It is crossed by the thyroid vessels at the level of the thyroid gland.

Behind and medial to the carotid artery lie the sympathetic trunk, the longus colli and longus capitis, and, directly posteriorly, the transverse processes of the cervical vertebrae, successively. Medial to the artery are the esophagus, the trachea, and the thyroid gland. The recurrent laryngeal nerve is interposed higher up between the trachea and esophagus. Lateral to the artery lies the internal jugular vein. Within the angle of bifurcation of the common carotid artery is a reddish-brown oval body, known as the carotid body.

External carotid artery

The external carotid artery begins at the level of the upper border of the thyroid cartilage, and taking a slightly curved course, it passes upward and forward and then inclines backward to the space behind the neck of the mandible, where it divides into the superficial temporal and maxillary arteries. It rapidly diminishes in size in its course up the neck, owing to the number and large size of the branches given off from it — namely, the superior thyroid, lingual, facial, occipital, posterior auricular, ascending pharyngeal, superficial temporal, and maxillary.

Internal carotid artery

The internal carotid artery begins at the bifurcation of the common carotid, at the level of the upper border of the thyroid cartilage, and runs upward, in front of the transverse processes of the upper 3 cervical vertebrae, to the carotid canal in the petrous portion of the temporal bone. It lies behind the sternocleidomastoid and lateral to the external carotid. It passes below the parotid gland and is crossed by the hypoglossal nerve, the digastrics and stylohyoid muscles, and the occipital and posterior auricular arteries.

Behind the artery lies the longus capitis, the superior cervical ganglion of the sympathetic trunk, and the superior laryngeal nerve; lateral to it lie the internal jugular vein and vagus nerve. Medial to it lie the pharynx, superior laryngeal nerve, and ascending pharyngeal artery. At the base of the skull, the glossopharyngeal, vagus, accessory, and hypoglossal nerves lie between the artery and the internal jugular vein. The cervical portion of the internal carotid gives off no branches.

Veins of the Neck

The main veins of the neck that return the blood from the head and face are the external and internal jugular veins.

External jugular vein

The external jugular vein receives blood from the exterior of the cranium and the deep parts of the face and is formed by the posterior division of the retromandibular vein joining with the posterior auricular vein. It begins in the substance of the parotid gland, on a level with the angle of the mandible, and runs down in the neck, in the direction of a line drawn from the angle of the mandible to the middle of the clavicle at the posterior border of the sternocleidomastoid muscle. It is separated from the sternocleidomastoid by the superficial layer or investing layer of the deep

cervical fascia and is covered by the platysma, the superficial fascia, and the integument.

This vein receives the occipital occasionally, the posterior external jugular, and, near its termination, the transverse cervical, suprascapular, and anterior jugular veins; in the substance of the parotid, a large branch of communication from the internal jugular may join it.

Internal jugular vein

The internal jugular vein collects the blood from the brain, from the superficial parts of the face, and from the neck. It is directly continuous with the sigmoid sinus and begins in the posterior compartment of the jugular foramen, at the base of the skull. It runs down the side of the neck in a vertical direction, lying at first lateral to the internal carotid artery and then lateral to the common carotid; at the root of the neck, it unites with the subclavian vein to form the brachiocephalic vein. Behind it lies the internal carotid artery, and the vagus descends between and behind the vein and the artery in the same sheath; the accessory runs obliquely backward, superficial or deep to the vein.

This vein receives in its course the inferior petrosal sinus; the common facial, lingual, pharyngeal,

superior, and middle thyroid veins; and sometimes the occipital. The thoracic duct on the left side

and the right lymphatic duct on the right side open into the angle of union of the internal jugular and

subclavian veins.

NECK DEEP DISSECTION

IV. PATHOPHYSIOLOGY

a. Definition

In the past, infections of the deep neck abscess were associated with high rates of morbidity and mortality. The overwhelming complication rate of the past has been reduced with the advent of modern microbiology and hematology, the development of sophisticated diagnostic tools (eg, CT, MRI), the effectiveness of modern antibiotics, and the continued development of medical intensive care protocols and surgical techniques.

Infections of the deep neck spaces present a challenging problem for the following reasons:

Complex anatomy: The anatomy of the deep neck spaces is highly complex and can make precise localization of infections in this region difficult. Deep location: The deep neck spaces are located deep within the neck. This makes diagnosis of infections difficult because they are often covered by a substantial amount of unaffected superficial soft tissue. Deep neck infections may be difficult to palpate and impossible to visualize externally. Access: Superficial tissues must be crossed to gain surgical access to the deep neck spaces, placing all of the intervening neurovascular and soft tissue structures at risk of injury. Proximity: The deep neck spaces are surrounded by a network of structures that may become involved in the inflammatory process. Neural dysfunction, vascular erosion or thrombosis, and osteomyelitis are just a few of the potential sequelae that can occur with involvement of surrounding nerves, vessels, bones, and other soft tissue. Communication: The deep neck spaces have real and potential avenues of communication with each other. Infection in one space can spread to adjacent spaces, thus gaining access to increasingly larger portions of the neck. In addition, certain deep neck spaces extend to other portions of the body (eg, mediastinum, coccyx), placing areas outside of the head and neck at risk of involvement when these spaces are involved.

b. Precipitating and Predisposing Factors

Causes of deep neck infections include the following:

Tonsillar and pharyngeal infections Dental infections or abscesses Oral surgical procedures or removal of suspension wires Salivary gland infection or obstruction Trauma to the oral cavity and pharynx (eg, gun shot wounds,

pharynx injury caused by falls onto pencils or Popsicle sticks, esophageal lacerations from ingestion of fish bones or other sharp objects)

Instrumentation, particularly from esophagoscopy or bronchoscopy Foreign body aspiration Cervical lymphadenitis Branchial cleft anomalies Thyroglossal duct cysts Thyroiditis Mastoiditis with petrous apicitis and Bezold abscess Laryngopyocele IV drug use Necrosis and suppuration of a malignant cervical lymph node or

mass

c. Pathophysiological Diagram

V. MEDICAL MANAGEMENT

A. Doctor’s Order

Progress Notes Doctor’s Order Implication

2-7-2015

10:00 pm

BP = 140/100

T= 37.0°C

HR = 85

RR = 20

Please admit under ENT dept.

Secure consent

Vital signs every 4 hours

Low fat, low salt, diabetic client with strict aspiration precaution

LABS:o CBC with PC

o U/A,

o Chest x-ray – PAL,

Neck APLo ECG

o RBS, Na, K, Crea

o FBS, Lipid profile in AM

Start IVF: PNSS iL @ 30 gtts/min

MEDS:1. Clindamycin 600g IVTT

loading dose then 300g IVTT q6H ANST

2. Ceftazidine 2 grams IVTT loading dose then 1 gram IVTT q8H ANST

3. Paracetamol 500g i tab P.O. q4H PRN for fever

Refer accordingly

Refer to IM for co-management

> Admit the pt. to an appropriate department for care; for management

> Agreement that the patient will submit to the care; for legal purposes

> Monitors vital signs, normal and abnormal values

> Appropriate diet for the patient

> To check for possible cause of illness/ relation to disease condition

> For fluid and electrolyte balance

> Pharmacologic management

> For proper management and to provide necessary intervention

> For co-management

2-8-2015

9:00 am

Diagnosticso CBC with PC, U/A, Na,

K, Crea, BUN, FBS, lipid profile, chloride

Insert NGT and NPO temporarily

Advice endotracheal intubation

Refer accordingly

> To check for improvement and for abnormalities

> For nutrition; appropriate feeding

> For maintaining patent airway

> For proper management and to provide necessary intervention

2-8-2015

4:30 am

BP = 170/90

8:30am

T = 39.3°C

CBG = 613

BP = 150/80

Give Captopril 25 g i tab SL now

Ff. up referral to IM pls.

Shift paracetamol to 300 g IVTT q4H RTC

CBG now

CBG monitoring q6H

Give 10 “u” of regular insulin IVTT now and 10 “u” S, rpt. CBG after 1 hour

> Pharmacologic management; to treat hypertension

> For co-management

> For fever; faster effect

> To check for blood glucose

> To monitor blood glucose

> To lower blood glucose

B. Laboratory result

Date: 2-8-15

Result Normal Range Interpretation

Blood Sugar(FBS, RBS)

High – 562.5 mg/dl 60-110 g/dl Diabetes Mellitus

BUN High - 75.19 mg/dl 10-50 Increased no. may be a sign of possible kidney problem

Creatinine High – 2.43 mg/dl 0.6 – 1.2 Increased no. may be a sign of possible kidney problem

Magnesium Low - 2.07 mg/dl 2.5 - 3.5 Decreases no. may be a sign of hypoparathyroidism

C. Drug Study

GENERIC NAME Paracetamol

BRAND NAME Perfalgan

CLASSIFICATION Analgesic, Antipyretic

DOSAGE 300 mg IVTT q 6 hours

GENERIC NAME Ceflazidime

BRAND NAME Tozidime

CLASSIFICATION Antibiotic, Anti-Infective

DOSAGE 1 gram IVTT q 8 hours

MECHANISM OF ACTION Inhibits cell wall synthesis promoting osmotic

instability

INDICATION Lower respiratory tract infection

SIDE EFFECTS Headache, dizziness, nausea and vomiting

ADVERSE REACTION Diarrhea, abdominal cramps, rashes

CONTRAINDICATION Hypersensitivity to drug or other cephalosphorin.

NURSING CONSIDERATION Allergies to penicillin and cephalosphorin. If large doses are given, therapy is prolonged,

monitor signs and symptoms of superinfection.

MECHANISM OF ACTION Binds to non-opioid receptors

INDICATION Management of pain and fever.

SIDE EFFECTS Headache, dizziness, nausea

ADVERSE REACTION Abdominal pain, dry mouth

CONTRAINDICATION Use cautiously with CVD and hepatic conditions.

NURSING CONSIDERATION Patient dependent with opioids must use this cautiously.

GENERIC NAME Clindamycin

BRAND NAME Cleocin

CLASSIFICATION Antibiotic, Anti-InfectiveDOSAGE 300 mg IVTT q 6 hours

MECHANISM OF ACTION Inhibits bacterial protein synthesis.

INDICATION Infections caused by sensitive staph, strep.

SIDE EFFECTS Headache, nausea, flatulence

ADVERSE REACTION Abdominal pain, rash, diarrhea

CONTRAINDICATION Hypersensitivity to drug or lincomycin.

NURSING CONSIDERATION Assess patient’s infection before and regularly throughout therapy.

Use cautiously in patients with renal, or hepatic disease, asthma, history of GI disease.

NURSING ASSESSMENT

Complete Physical Assessment

Time Assessed: 3:00 P.M.Initial Vital Signs:Temperature: 37.0 degree CPulse Rate: 85 bpmRespiratory Rate: 20 cpmBlood Pressure: 140/80 mmHgGeneral Appearance:• The pt. is lying on bed, stuporous with an IVF of PNSS regulated @ 50cc/hr @350ml level infusing well @ left hand.• With Nasogastric Tube inserted.• With Foley catheter inserted.• With oxygen @ 4 lpm via nasal cannula

BODY PART FINDINGS IMPLICATIONHead/ Skull Proportional to the size of the

body, round, with prominence in the frontal area anteriorly & the occipital area posteriorly, symmetrical in all planes, gently curved. But has a scar in the parietal area

Normal

Scalp/ Hair No areas of tenderness upon palpation; hair is gray

Normal

Face Oblong shaped, symmetrical, smooth & no involuntary muscle

Normal

movementsEyes/ Vision Eyes are parallel & evenly placed,

symmetrical and non-protruding, with scant amount of secretions, both eyes black & clear.

Sclera is white. eyebrows are black, symmetrical, and thick, can raise both symmetrically & without difficulty, evenly distributed & parallel with each other; eyelashes are evenly distributed & turned outward.

Upper eyelids cover a large portion of the iris, cornea & the sclera when the eyes are open, when the eyes are closed the lids meet completely, symmetrical & the color is the same as the surrounding skin.

Lid margins are clear, without scaling or secretions.

Lower palpebral conjunctivas are shiny, moist, transparent & salmon pink in color.

Both irises are proportional to the size of the eye, round & symmetrical.

Pupils are from pinpoint to almost the size of the iris, round, symmetrical, constricts with increasing light & accommodation.

Able to move eyes in full range of direction.

Cannot open eyes completely

Ears/ Hearing Ears are parallel, symmetrical, proportional to the size of the head, bean-shaped, helix is in line with the outer canthus of the eye, and skin is the same color as the

Normal

surrounding area & cleans.

Ear canal is pinkish, clean, with scant amount of cerumen & a few cilia.

Able to hear whisper spoken 2 feet away.

1 piercing are found in both earNose Nose is in midline, symmetrical,

patent.

Internal nares are clean, dark pink with few cilia

With NGT in placed, inserted in the right nostril.

Normal

Mouth/ Lips Lips are pinkish ,asymmetrical; has lower lip laceration. Gums are pinkish, Tongue is pinkish, slightly rough on top, smooth along the lateral margins, moist, shiny & freely movable .Soft palate is pinkish, smooth & moist. Hard palate is slightly pinkish.

Lower lip laceration

NECK Proportional to the size of the body & head, asymmetrical, has palpable lump, mass or area of tenderness on the right lateral neck.

Right lateral neck mass

THORAX & LUNGS

Chest contour is symmetrical, spine is straight

Normal

HEART No abnormal pulsations, pulsations are palpable & visible in apical area.

Normal

ABDOMEN Abdominal skin is blemished, no bruises, abdomen is rounded with symmetric movements caused by respiration; umbilicus is concave.

Normal

UPPER EXTREMITIES

Symmetrical, with visible veins, fine hair evenly distributed, warm, dry & elastic upon palpation.

Bruises due to injections and IV insertions

Palms are pinkish, warm, soft & elastic.

Nails are transparent, smooth & convex with light pink nail beds & white translucent tips.

5 fingers in each hand.

Left shoulder, arm, elbow, hand & wrist can be moved in different range of motion with relative ease while weak on the right and limited range of motion.

With marks of bruises

With IVF in left handLOWER EXTREMITIES

Skin is smooth, fine hair is evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical, 5 toes in each foot, sole & dorsal surface is smooth with pink nail beds & white translucent tips.

Both legs, knees, ankles, & toes can be moved in limited range of motion with relative ease

bruises on both patellar surface.

With bruises

VI. NURSING MANAGEMENT

A. IDEAL NURSING CARE PLAN

ASSESSMENTSUBJECTIVE:

“Galisod siyag ginhawa” as verbalized by the son of the patient.

OBJECTIVE: Nose flaring Dyspnea Pale skin

NURSING DIAGNOSISImpaired gas exchange related to altered oxygen supply

EXPECTED OUTCOMEAfter 15 minutes of nursing intervention, the client will be able to breathe easily via nasal cannula.

PLANNING/INTERVENTION RATIONALEIndependent:1. Assess respirations: quality, rate, pattern, depth and breathing effort.

> Rapid, shallow breathing and hypoventilation affect gas exchange by affecting CO2 levels. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention.

2. Assess for life-threatening problems. (i.e. respiratory arrest, flail chest, sucking chest wound).

> Absence of ventilation, asymmetric breath sounds, dyspnea with accessory muscle use, dullness on chest percussion and gross chest wall instability (i.e. flail chest or sucking chest wound) all require immediate attention.

3. Assess for signs of hypoxemia > Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia.

4. Monitor vital signs. > Initially with hypoxia and hypercapnia blood pressure (BP), heart rate and respiratory rate all increase. As the condition becomes more severe BP may drop, heart rate continues to be rapid with arrhythmias and respiratory failure may ensue.

5. Assess skin color for development of cyanosis, especially circumoral cyanosis.

> Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia.

Dependent:1. Treat the underlying injuries with appropriate interventions.

> Treatment needs to focus on the underlying problem that leads to the respiratory failure.

EVALUATIONAt the end of 8 hours nursing intervention, the client is free of signs of distress.

ASSESSMENT

SUBJECTIVE:

“Ga ngut-ngot man na panagsa iyang liog” as verbalized by the son of the patient.

OBJECTIVE: Pain scale: 7 out of 10 Sleep Disturbance Facial Grimace

NURSING DIAGNOSISAcute Pain related to Post Surgery

EXPECTED OUTCOMEAfter 30-45 minutes of nursing intervention, the client will be able to reduce pain from 7 to 5 out of 10.

PLANNING/INTERVENTION RATIONALEIndependent:1. Accept patient’s description of pain. > Pain is subjective experience.2. Observe non-verbal cues. > Observations may/may not be congruent to verbal

respond.3. Monitor vital signs. > Usually altered when in pain.4. Provide comfort measures. > For non-pharmacological pain management.5. Encourage adequate rest period. > To prevent fatigue.Dependent:1. Administer analgesics as indicated per doctor’s order.

> To maintain acceptable level of pain.

EVALUATIONAt the end of 8 hours nursing intervention, the client was able to reduce pain from 7 to 4 out of 10.

ASSESSMENTSUBJECTIVE:“Luya man siya” as verbalized by the son of the patient.

OBJECTIVE: Restlessness Fatigue

NURSING DIAGNOSISRisk for infection related to inadequate primary defenses

EXPECTED OUTCOMEAfter 15 minutes of nursing intervention, the client will be able to maintain normal vital signs.

PLANNING/INTERVENTION RATIONALEIndependent:1. Assess for presence of risk factors: open wounds, abrasions; indwelling catheters; drains; artificial airways; and venous access devices.

> Represent a break in body’s first line of defense.

2. Monitor white blood count (WBC). > Normal WBC is 4-11 mm3. Rising WBC indicates the body’s attempt to combat pathogens.

3. Monitor incisions, injured sites and exit sites of tubes, drains and catheters for signs of infection.

> Redness, swelling, increased pain, or purulent drainage is suspicious of infection and should be cultured.

4. Monitor temperature and the presence of sweating and chills.

> In the first 24-48 hours fever up to 38 degrees C (100.4F) is related to the stress of surgery. After 48 hours fever above 37.7C (99.8F) suggests infection. High fever with sweating and chills suggests septicemia.

5. Monitor the color of respiratory secretions. > Yellow or yellow-green sputum indicates a respiratory infection.

Dependent:1. Administer and teach the use of antimicrobial drugs as ordered.

> All agents are either toxic to the pathogens or retard the pathogen’s growth. Ideally medications should be selected based on a culture from the infected area. A broad-spectrum agent may be started until culture reports are available.

EVALUATIONAt the end of 16 hours nursing intervention, the client’s WBC within normal limits. No further infections noted.

B. ACTUAL NURSING CARE PLAN

S No subject cues. The patient is unable to speak.O Restlessness, facial grimace, sleep disturbanceA Acute Pain related to Post surgery as evidenced by facial grimaceP Short term: At the end of 30 minutes, the patient will be able show cues of reduced pain.

Long term: At the end of 8 hours, the patient will be able to show less stressful and relieved from pain that she was experiencing.

I 1. Monitored the patient closely by taking vital signs- This is to check the patient’s status to prevent any complication and to know if there progress of the status of the patient.2. Encouraged adequate rest periods.- To prevent fatigue3. Provided comfort measures.- To lessen pain and promotes relaxation.4. Provided diversional activities, like encouraging expressing the feeling in other form of communication through actions to lessen the feeling of having the pain.5. Administered medication as ordered by the attending physician- This is for the treatment of the present illness of the patient

E At the end of 30 minutes the patient shows gestures and facial expressions that indicates no pain.

S No subject cues. The patient is unable to speak.

O Nose flaring, dyspnea, pale skinA Impaired gas exchange related to altered oxygen supplyP Short term: After 15 minutes, the patient will be able to maintain normal vital signs.

Long term: At the end of 8 hours, the patient will maintain high oxygen supply.I 1. Monitored the patient closely by taking vital signs

- This is to check the patient’s status to prevent any complication and to know if there progress of the status of the patient.2. Assessed for signs of hypoxemia.- Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia.3. Provided a quiet and comfortable place for patient to have adequate rest.4. Assessed skin color for development of cyanosis.- Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia.5. Administered oxygen as ordered by the attending physician- This is to improve oxygen supply of the patient.

E At the end of 15 minutes, the patient maintains normal vital signs.

VII. HEALTH TEACHINGS

MEDICATIONS Instructed complete procurement of stocks of medicine and take it

on right time, dosage, and route as prescribed. Emphasized the

importance of following proper protocol and consideration upon

taking the medicine.

A. Antibiotic

B. Oral hypoglycemic

EXERCISE Encouraged to have range of motion exercises to promote blood

circulation throughout the body.

Encouraged also to have adequate balance between sleep and

daily exercise to prevent further stress that can more complicate

the situation.

TREATMENT Instructed to follow what has been ordered by the doctor and

stressed the importance of strict compliance of all the medications

and treatment prescribed by the physician.

OUT-PATIENT

(Check-up)

With patient’s critical case. She should see the doctor regularly for

check-up. Doing so will help foresee probable readmission and

management. Proper compliance to every instruction given before

discharge will help prevent untoward complications, and help

patient live a normal life again.

DIET Eat well-balanced diet for proper nutrition; nutritious foods like

fruits and green leafy vegetables (eg. pechay, Malunggay, and

oranges, apple, banana, etc.)

Instructed to avoid foods that are high in cholesterol, fats, and

sodium.

SEXUAL/SPIRITUAL Encourage patient and significant others to pray to God for healing

and strengthen faith. Encourage to have positive outlook.

VIII. RECOMMENDATION

Patient E.T.C. will be referred to a doctor after discharge persistence of chief complaints

reoccurs and complicates. Schedules for follow-up visits should not be overlooked to evaluate

progress of the patient’s health condition after termed medical and nursing management. She

should have check up at the nearest hospital a week after discharge as scheduled by her

physician. The physician also ordered to continue on using all the medications prescribed.

IX. CONCLUSION

I, therefore conclude, that deep neck abscess may lead to complications that may threaten life and

cause death to individual, especially with old age. People who are old have less tolerance to pain

and unable to recover easily with such diseases. It is important to take good care of our health and

to refrain from things that can lead to diseases. Also, family support is very important, aside from

medical management.

X. PROGNOSIS

CRITERIA GOOD PROGNOSIS POOR PROGNOSIS

A.) Onset of Illness /

B.) Duration of Illness /

C.) Precipitating Factor /

D.) Attitude and Willingness

toward taking medication and

treatment

/

E.) Family Support /

On the criteria listed above, it shows only 2 out of 5 criteria falls under good prognosis

therefore the client’s prognosis is poor.

XI. BIBLIOGRAPHY

Brunner and Suddarth Textbook of Medical-Surgical Nursing, 11th Edition by Johnson

Pocket Guide Nursing Diagnosis with Interventions, 3rd Edition by M. Doenges

Nursing 2010 Drug Handbook, 20th Anniversary Edition by Davis drug guide

Medical Surgical Nursing, 7th Edition by Black and Hawks

Manual of Nursing Practice, 7th edition, Volume 1, Lippincott

I. DOCUMENTATION

I wasn’t able to take any pictures with the patient due to confidentiality purposes.