Republic of the Philippines

Laguna State Polytechnic University

Province of Laguna
College of Nursing and Allied Health

Espina, Ribecca Andrhea F.

BSN-1A

PHYSICAL ASSESSMENT OF HEAD AND NECK

Abnormalities that cannot be directly observed in the physical appearance of the head
and neck are often detected in the client’s history. When discussing the client’s head
and neck structure, recognize that the appearance of these structures often has a great
influence on the client’s self-image

PURPOSE
To observe for signs of head and neck disease or illness.

EQUIPMENTS
● Penlight or Flashlight
● Small glass of water
● Stethoscope
● Gloves

Nursing Interview Guide to Collect Subjective Data From the Client

Questions Rationale
Current Symptoms
1.Lumps or lesions on the head Lumps and lesions that do not heal may indicate
or neck that do not heal or suspected benign or malignant tumors that can be
disappear. worsened if no further laboratory tests and
procedures which will help to formulate an
appropriate plan to the patient.
2. Difficulty moving head or To check for any musculoskeletal related problems
neck. such as tension muscles, vertebral joint dysfunction,
and other disorders of the head and neck may limit
mobility and affect activities of daily function.
3. Facial or neck pain or Trigeminal neuralgia (tic douloureux) is manifested by
frequent sharp, shooting, piercing facial pains that last from
Headaches. seconds to minutes. Pain occurs over the division of
the fifth trigeminal cranial nerve (the ophthalmic,
maxillary, and mandibular areas).

Neck pain may accompany muscular problems or

cervical spinal cord problems. Stress and tensions
may increase the neck pain. Sudden head and neck
pain seen with elevated temperature and neck
stiffness maybe a sign of meningeal inflammation

4. Dizziness, light-headedness, Sudden trouble seeing or visual disturbances in one

spinning sensation, or loss of or both eyes or sudden trouble walking, dizziness, or
consciousness. loss of balance or coordination may be a sign of an
impending stroke. It could be caused by ear problems
which may affect the balance of the patient. In the
worst scenario, the patient also gets dizziness and
loss of consciousness due to lesions in the brain and
trauma on the head.

Past History
1.Previous head or neck Previous head and neck trauma, medical procedures
problems/ trauma/ injury such as chemotherapy, repetitive injuries, etc. May
(surgery, medication, physical cause acute pain in the head and limitation of
or radiation therapy) results. movement or even cognitive issues due to the
affectations of the specific brodmann areas of the
brain or nerves

Family History
1.Family history of head and/or Genetic predisposition is a risk factor related to head
neck cancer. and neck conditions such as cancer.
2. Family of migraine Migraine headaches commonly have familial
headaches. association.

Lifestyle and Health Practices

 1.Do you smoke or chew Tobacco use increases the risk of having head and
tobacco? neck cancer. Eighty five percent of head and neck
Amount? Secondhand smoke? cancers are linked to tobacco use (smoking and
smokeless tobacco)

2. Do you wear a helmet or Failure to use safety precautions, increases the risk
hard hat? for head and neck injury due to vehicular accident.

3. Typical posture when Prolonged static posture manifested by faulty posture

relaxing, during sleep, and or body malalignments can exacerbate head and neck
when working. discomfort.

4. Types of recreational Contact or aggressive sports or activities may

activities. increase the risk for head or neck injury.

Photo Documentation
Physical Assessment Guide to Collect Objective Client Data
Questions Rationale Photo Documentation
1.Gather equipment All equipment is highly
(gloves, penlight or organized and
flashlight, magnifying prepared in the table
glass, small glass of to save time and effort.
water, stethoscope).

2. Explain procedure to The procedure is well

client. explained to the client
for her comfortability
and awareness.

Head and Face

1.Inspect head for size, To inspect the client’s
shape, and configuration. head symmetry, shape
and size, or if it is
erect, and in midline

2. Palpate head for To inspect for lesions

consistency while wearing or lumps that can
gloves. indicate trauma or a
sign of cancer.

3. Inspect for face To inspect for any

symmetry, features, drooping, weakness,
movement, expression, or paralysis in the face
and skin condition. of the client. These
symptoms indicate
paralysis or stroke.

4. Palpate for temporal To inspect for the

artery for tenderness and inflammation of
elasticity temporal artery that
can cause temporal
arteritis which can lead
to blindness
5. Palpate the To inspect for the
temporomandibular joint range of motion,
for a range of motion, swelling, tenderness
swelling, tenderness, or that can indicate TMJ
crepitation by placing syndrome.
index finger over the front
of each and asking client
to open mouth.

Neck
1.Inspect the neck while it
is in a slightly extended
position (and using a light)
for position, symmetry,
and presence of lumps
and masses).
2. Inspect movement of
thyroid and cricoid
cartilage and thyroid gland
by having client swallow a
small sip of water.
To inspect for swelling
or if there are enlarged
masses or nodules
that may indicate an
enlarged thyroid gland,
inflammation of lymph
nodes or a tumor.
To inspect if the thyroid
and cricoid cartilage
has no abnormalities
in rising and falling.
Asymmetric movement

3. Inspect cervical To inspect for swelling

vertebrae by having client of C7.
flex neck.

4. Inspect neck range of To inspect for muscle

motion by having client
turn chin to right and left
shoulder, touch ear to the
shoulder, touch chin to
chest, and lift chin to
ceiling.
spasm, inflammation,
or cervical arthritis that
can cause stiffness,
rigidy, and limited
mobility of the neck
which may affect daily
functioning.

5. Palpate trachea by To inspect if the

placing your finger in the trachea is in midline
sternal notch, feeling to
each side, and palpating
the tracheal rings.
6. Palpate the thyroid To inspect if the thyroid
gland. gland is positioned
midline.

To inspect for enlarged

or tender glands that
indicated thyroiditis.
7. Auscultate thyroid To inspect for soft,
gland for bruits if the blowing, swishing
gland is enlarged (use bell sounds that indicates
of the stethoscope). increase in blood flow
through the thyroid
arteries.

8. Palpate lymph nodes To inspect for any

for size/shape, enlarged nodes that
delimitation, mobility, can indicate head and
consistency, and neck cancers includes
tenderness (refer to cancers of the mouth,
display on nose, sinuses, salivary
characteristics of lymph glands, throat, and
nodes). lymph nodes
A. Preauricular nodes
(front ears)
B. Postauricular nodes
(behind the ears)
C. Occipital nodes
(posterior base of skull)
D. Tonsillar nodes (angle
of the mandible,
on the anterior edge of the
sternocleidomastoid
muscle)
E. Submandibular nodes
(medial border of
the mandible); do not
confuse with the
lobulated submandibular
gland.
F. Submental nodes (a
few centimeters
behind the tip of the
mandible); use one
hand.
G. Superficial cervical
nodes (superficial to
the sternomastoid muscle)
H. Posterior cervical
nodes (posterior to
the sternocleidomastoid
and anterior to the
trapezius in the posterior
triangle)

Analysis of Data
1. Formulate nursing to communicate the
diagnosis (wellness, health care needs of
risk, actual) individuals and
aggregates among
members of the
healthcare team
2. Formulate to detect onset or
collaborative change in status and
problems. manage using
medically-prescribed and
nursing-prescribed
interventions to prevent
or minimize the
complication
3. Make necessary if the patient needs
referrals. further treatment and
investigations on his/her
condition/s by the
specialists.

Reference
Health Assessment in Nursing 6th Edition by Janet R. Weber and Jane H. Kelley
Lab Manual for Health Assessment in Nursing 5th Edition by Janet R. Webber, Jane H.
Kelley, and Ann D. Sprengel