ADVENTIST MEDICAL CENTER COLLEGE

BRGY. SAN MIGUEL, ILIGAN CITY

SCHOOL OF NURSING

HEALTH ASSESSMENT
Related Learning Experience
Second Semester, AY 2022 - 2023

Assessment of Head and Neck

Name______________________________________ Section ______ Date______ Score _____

I. Collecting Subjective Data: The Nursing Health History

Preliminaries
1. Gather equipment (gloves, penlight, glass or small cup of
water, stethoscope, pen, and assessment form with
clipboard).

2. Demonstrate courtesy, introduce self, and verify client’s

identity. Explain to the client what you are going to do ,
why it is necessary, and how he or she can participate.
Explain to the client that after the nursing health history,
you will proceed to the physical assessment or physical
examination.

3. Do hand hygiene and observe other infection prevention

procedures.

4. Provide a quiet environment.

5. Be sure that the room is having a comfortable temperature.

6. Ensure that during the interview, there are no interruptions

and distractions.

7. Provide privacy.

8. Ask questions in a straightforward manner, be sensitive, and

avoid being judgmental.

HISTORY OF PRESENT HEALTH CONCERN

Questions Findings
Pain
1. Do you experience neck pain? (14 points)
Use COLDSPA to further explore any neck pain. Be sure to
ask about precipitating events (illness or injury) severity,
and associated symptoms.
a. Character: Describe how it feels.
b. Onset: Did it begin after some strenuous activity, exercise,
accident, or a direct injury.
c. Locations: Does it radiate to the back, arms, or shoulders?
d. Duration: How long does it last? Does it come and go?
e. Severity: Are you able to continue your daily schedule and

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 sleep at night?
f. Pattern: Does it tend to occur more with exercise or stress?
Are there any activities that relieve it to make it worse?
g. Associated Factors: Do you have any limitation of
movement
of your head or neck or arms with this pain?
Do you have any numbness or tingling with it?
2. Do you experience headaches? (2 pts)
Use COLDSPA to further explore the symptoms of
headache. Be sure to include assessment of severity,
location, and aggravating factors.
3. Have the client complete the Headache Impact Test at
www.bash.org.uk/wp-content/uploads/2012/07/English.pdf
and share the results with primary care provider. (14 pts)
a. Character: Describe how the headache feels (sharp,
throbbing, and dull)?
b. Onset: When did it first begin? Does it tend to occur with
other factors (e.g., menstrual cycle, emotional or
physical stress, ingestion of alcohol or certain other
foods like cheese or chocolate)?
c. Locations: Where does your headache begin? (Ask client to
point area in head if possible.) Does it radiate or spread
to other areas?
d. Duration: How long does it last? How often does it recur?
Has there been any change in the duration of your
headaches? Explain.
e. Severity: How severe is the headache? Rate it on a scale of
0 – 10 (10 being the most severe). Does the headache keep
you from doing your usual activities of daily living? Explain.
f. Pattern: What aggravates it? What makes the pain go
away? What pain relievers work best for you?
g. Associated factors: Do you have other symptoms with the
headache such as nausea, visual changes, dizziness, or
sensitivity to noise or light?

4. Do you have any facial pain? Describe. (2 pts)

Other Symptoms

5. Do you have any difficulty moving your head or neck?

(2 pts)

6. Have you noticed any lumps or lesions on your head or

neck that do not heal or disappear? Describe their
appearance. Do you have a cough or any difficulty
swallowing? (2 pts)

7. Have you experienced any dizziness, light-headedness,

spinning sensation, blurred vision, or loss of
consciousness? Describe. (2 pts)

8. Have you noticed a change in the texture of your skin,

hair, or nails? Have you noticed changes in your energy
level, sleep habits, or emotional stability? Have you

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 experienced any palpitations? (2 pts)

9. Have you had any weakness or numbness in your face,

arms, or legs or on either side of your body? (2 pts)

PAST HEALTH HISTORY

Questions

10. Describe any previous head and neck problems (trauma,

injury, falls) you have had. What were the results? (2 pts)

11. Have you ever undergone radiation therapy for a problem

in your neck region? (2 pts)

FAMILY HISTORY
Questions

12. Do you find that you have headaches when you take any
of the following medications? (2 pts) Refer to p. 285 of your
book.
Oral contraceptives and hormone therapy(menopause), Blood
thinning medicines or stopping of blood clot (warfarin, aspirin,
enoxaparin; leads to stroke or heart attack)

Caffeine, Antihypertensives(heart & blood pressure), Medications

for erectile dysfunction (when necessary) Corticosteroids (asthma,
COPD, and rheumatologic diseases), Ergotamine (cluster headaches
and migraines) Immunosuppressants (autoimmune diseases, organ
transplant, bone or stem cell transplant, Fat-soluble vitamins (vit.
A,D,E K), Chemotherapeutic agents (decreases cancer)

13. Is there a history of head or neck cancer in your family?

(2 pts)

14. Is there a history of migraine headaches in your family?

(2 pts)

LIFESTYLE AND HEALTH PRACTICES

Questions
15. Do you smoke or chew tobacco? If yes, how much? (2 pts)

16. Do you use alcohol or recreational drugs? Describe the

type used and how much? (2 pts)

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17. Do you wear a helmet when riding a horse, bicycle,
motorcycle, or other open sports vehicle (e.g., four-wheel,
go-cart)? Do you wear a hard hat for hazardous
occupations? (2 pts)

18. In what kinds of recreational activity do you participate?

Describe the activity. (2 pts)

19. What is your typical posture when relaxing, during sleep,

and when working? (2 pts)
20. Have any problems with your head or neck interfered with
your relationships with others or the role you occupy at
home or at work? (2 pts)

Initial Score: 64 points

A. Collecting Objective Data: Physical Examination

Findings
Head and Face
INSPECTION AND PALPATION
1. Inspect head size, shape, and facial appearance and
configuration and involuntary movement. (2 pts)
2. Palpate the head for consistency, while wearing gloves. (2pts)

3. Inspect face for symmetry, features, movement, expression

and skin condition. (2 pts)
4. Palpate temporal artery for tenderness and elasticity. (2 pts)

5. Palpate the temporo-mandibular joint (TMJ) for range of

motion, swelling and tenderness, or crepitation by placing
index fingers over the TM and palpating the joint as the
patient opens and closes his/ her mouth. (2 pts)
Neck
INSPECTION
6. Inspect neck while it is in neutral, slightly extended position
for position, symmetry, presence of lumps and masses.
(2 pts)
7. Inspect movement of thyroid and cricoid cartilage and
thyroid gland by having client swallow a small sip of
water. (2 pts)
8. Inspect cervical vertebrae by having client flex neck (chin to
chest). (2 pts)
9. Inspect neck range of motion by having client turn chin to
right and left shoulder touch each ear to the shoulder,
touch chin to chest, and lift chin to ceiling. (2 pts)
10.Palpate the trachea by placing your finger in the sternal
notch, feeling to each side, and palpating the tracheal rings.
11. Palpate the thyroid gland. (4 pts)

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 11.1. ( anterior approach)
Right lobe - by sliding fingers to the right and displace the
trachea to the right and palpate the gland as patient
swallow
Left lobe- by sliding fingers to the left gently displace the
trachea to the left, and palpate gland as patient swallows.
11.2. (posterior approach) (4 pts)
Right lobe- have the patient tilt head to the right and
displace the trachea to the right and palpate the gland
as patient swallow.
Left lobe- have the patient tilt head to the left and
displace the trachea to the left and palpate the gland
as patient swallow.
AUSCULTATION
12. Auscultate thyroid gland for bruits if the gland is enlarged/
palpable (use bell of the stethoscope). (2 pts)

PALPATION
13. Lightly palpate the neck for: (11 pts)
a. (occipital nodes) - the back of the head at the base of the
skull
b. (posterior auricular nodes) - behind the ears,
c. (preauricular nodes) - in front of the ears
d. (tonsillar nodes) - under the mandible
e. (submandibular nodes) - in the angle of the jaw
f. (submental nodes) - under the tip of the chin,
g.(superficial cervical nodes) - upper portion of the sternocleido –
mastoid muscle
h. (posterior cervical nodes) - in the posterior triangle behind
the sternocleidomastoid muscle
i. (deep cervical nodes) - in the sternocleidomastoid muscle
j. (supraclavicular) - above the clavicle
k. (Infraclavicular) - below the clavicle.

Initial Score: 39 points

Total Score: 103 points

Assessed by:

_________________________________________
Signature over Printed Name of Clinical Instructor

/rsp
4/26/21

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