RIVERA, ZYRENE MAY C

BSN 1

NECK ASSESSMENT

Begin the head and neck assessment by asking focused interview

questions to determine if the patient is currently experiencing any
symptoms or has a previous medical history related to head and neck
issues

Inspection
Begin by inspecting the head for skin color and symmetry of facial
movements, noting any drooping. If drooping is noted, ask the patient
to smile, frown, and raise their eyebrows and observe for symmetrical
movement. Note the presence of previous injuries or deformities.
Inspect the nose for patency and note any nasal drainage.
Inspect the oral cavity and ask the patient to open their mouth and
say “Ah.” Inspect the patient’s mouth using a good light and tongue
blade.
Note oral health of the teeth and gums.
If the patient wears dentures, remove them so you can assess the
underlying mucosa.
Assess the oral mucosa for color and the presence of any
abnormalities.
Note the color of the gums, which are normally pink. Inspect the gum
margins for swelling, bleeding, or ulceration.
Inspect the teeth and note any missing, discolored, misshapen, or
abnormally positioned teeth. Assess for loose teeth with a gloved
thumb and index finger, and document halitosis (bad breath) if
present.[2]
Assess the tongue. It should be midline and with no sores or coatings
present.
Assess the uvula. It should be midline and should rise symmetrically
when the patient says “Ah.”
Is the patient able to swallow their own secretions? If the patient
has had a recent stroke or you have any concerns about their ability
to swallow, perform a brief bedside swallow study according to agency
policy before administering any food, fluids, or medication by mouth.
See a sample bedside swallow study in Chapter Resources A.
Inspect the neck. The trachea should be midline, and there should not
be any noticeable enlargement of lymph nodes or the thyroid gland.
Note the patient’s speech. They should be able to speak clearly with
no slurring or garbled words.
If any neurological concerns are present, a cranial nerve assessment
may be performed. Read more about a cranial nerve assessment in the
“Neurological Assessment” chapter.

Auscultation
Auscultation is not typically performed by registered nurses during a
routine neck assessment. However, advanced practice nurses and other
health care providers may auscultate the carotid arteries for the
presence of a swishing sound called a bruit.

Palpation
Palpate the neck for masses and tenderness. Lymph nodes, if palpable,
should be round and movable and should not be enlarged or tender. See
the figure illustrating the location of lymph nodes in the head and
neck in the “Basic Concepts” section earlier in this chapter. Advanced
practice nurses and other health care providers palpate the thyroid
for enlargement, further evaluate lymph nodes, and assess the presence
of any masses.

Video for head and neck assessment:

https://youtu.be/MkqCjH-BlMo