Saint Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences

College of Nursing

HEAD-TO-TO PHYSICAL ASSESSMENT

STUDENT’S COPY

ASSESSMENT OF THE HEAD AND NECK

A. Learning Objectives
Students will:
 Evaluate the client’s current physical condition
 Detect early signs of developing health problems
 Establish a baseline for future comparison
 Evaluate the client’s responses to medical or nursing interventions

B. Equipment/Supplies
 Small cup
 Stethoscope
 Examination gown or drape

C. Procedure

Evidence to be produced Rationale

1. Introduce self to patient To establish rapport, and gain trust of patient.
2. Identify the client using the 2 identifiers. Ensures correct patient to be examined.
3. Explain the procedure. Discuss what it is, why it is Enhances comfort and cooperation.
necessary and how can s/he cooperate.
4. Gather supplies/equipment necessary for the Facilitate convenience in performing the examination.
procedure.
5. Provide comfortable examination area. Well-lighted Promotes comfort.
and at room temperature.
6. Observe infection control measures - hand washing, Reduces transmission of microorganisms.
hand hygiene. Wear clean gloves as necessary.
7. Provide client privacy. Promotes comfort and respect.
8. Prepare the client for examination. Facilitate convenience in performing the examination.
a. Assess for toileting needs.
b. Ask patient to wear examination gown/drape.
c. Place the patient in sitting position.
9. Review Complete Health History of patient Abnormalities are often detected in client’s history.
- complains of pain, headache, dizziness,
lightheadedness, difficulty moving moving head and
neck
- head and neck problems (surgery, radiation therapy,
etc)
Assessment of the Head and Face
10. Inspect head for size, shape and configuration To detect unusual head condition that may indicate
medical problems.
11. Inspect for involuntary movement
12. Palpate the skull
13. Inspect the face for features, movement,
expression, and skin condition.
14. Inspect the face for symmetry
Ask client to:
- elevate eyebrows
- frown
- lower eyebrows
- close eyes tightly
- puff the cheeks
- smile and show teeth
15. Palpate the temporal artery
16. Palpate the temporo-mandibular joint To detect signs of TMJ dysfunction.
Assessment of the Neck
17. Inspect the neck.
Ask client to hold his/her head erect.
18. Inspect movement of neck structures.
Ask the client to swallow a small sip of water.
19. Inspect the cervical vertebrae and range of motion. To detect adequacy of ROM.
Ask the client to:
- flex the neck to chin
- flex the ear to shoulder
- twist neck right to left & vice versa
- flex neck forward and backward
20. Palpate the lymph nodes. To detect swelling, enlargement and tenderness which
- pre-aurical nodes indicates infection.
- post-aurical nodes
- occipital nodes
- tonsillar nodes
- submandibular nodes
- submental nodes
-superficial cervical nodes
- posterior cervical nodes
- deep cervical chain nodes
- superclavicular nodes
21. Palpate the trachea. To detect lateral deviation that may indicate a medical
- Place your finger in the sternal notch. condition.
- Feel each side of the notch and palpate the
tracheal rings
22. Palpate the thyroid gland To assess for smoothness of the thyroid gland.

Posterior Approach:
- Locate key landmarks with your index finger
and thumb.
- hyoid bone
- thyroid cartilage (Adam’s apple)
- cricoid cartilage
- Stand behind the client.
- Ask him/her to lower the chin to the chest and
turn the neck slightly to the right.
- Place thumbs on the nape of the client’s neck
with the fingers of left hand to push the trachea
slightly to the right.
- Curve right fingers between the trachea and
sternocleidomastoid muscle
- Retract it slightly.
- Ask the patient to take a sip of water and
swallow.
- Reverse the procedure for the left side.
23. If enlargement is detected during inspection and To detect signs of increased of vascularity which is
palpation indicative of hyperthyroidism.
- Auscultate over thyroid for bruit.
Use the bell side of the stethoscope.
Thank patient.
Ensure patient’s safety and comfort. Provide safety and comfort after the procedure.
Remove gloves (as necessary). Prevents transmission of microorganisms.
Perform medical asepsis. Cleanses soiled hands and prevents transmission of
microorganisms.
Document over-all finding, report for any unusual Record purposes and retrieval of data in the
findings. management of care.

References:

Jarvis, Carolyn. (2004). Pocket Companion for Physical Examination and Health Assessment. 4th Ed. St.
Louis, Missouri, Saunders

Weber, J. et al. (2014). Health Assessment in Nursing. 5th. Ed. Philadelphia, Lippincott