HEAD AND NECK ASSESSMENT

Name: Sex: Age:

ID # : Date:
NO PROCEDURE STEP YES NO COMMENT
A Current Symptoms
a) Lumps or leions on head or neck that do not heal
or disappear.
b) Difficulty moving head or neck
c) Fcaial or neck pain or frequent headaches
d) Dizziness, lightheadedness, spinning sensation or
loss of consciousness.
B Past History
a) Previous head or eck problems/trauma/injury
(surgery, medication, physical or radiation therapy)
results.
C Family History
a) Family history of head and/or neck cancer.
b) Family history of migraine headaches.
D Lifestyle and Health Practices
a) Do you smoke or chew tobacco? Amount?
Secondhand smoke?
b) Do you wear a helmet or hard hat?
c) Typical posture when relaxing, during sleep, and
when working?
d) Types of recreational activities
e) Satisfaction with appearance
E Preparation
a) Gather equipment ( celan gloves, cup of water,
stethoscope, penlight
b) Provide comfortable environment
c) Explain procedure to client
d) Provide privacy
e) Wash hands
F Procedure
1. Head and Face
a) Inspect the size, shape, configuration, and
involuntary movement of the head.
b) Palpate the Head.
c) Inspect for symmetry, features, movement,
expression, and skin condition of the face.
d) Palpate the temporal, which is located between
the top of the ear and the eye.
e) Ask the patient to open the mouth and place your
index finger over the front of each ear and palpate
for the temporomandibular joint.
2. The Neck
a) Inspect the neck. Observe the client's slightly
extended neck for position, symmetry, and lumps or
masses. Shine a penlight from the side of the neck
across to highlight any swelling.
b) Inspect movement of the neck structure. Ask the
client to swallow a small sip of water. Observe the
movement of the thyroid cartilage and thyroid gland.
c) Ask the patient to flex the neck (chin to chest) to
inspect the cervical vertebrae.
d) Inspect the range of motion. Ask the client to
turn the head to the right and the left (chin to
shoulder), touch each ear to the shoulder, touch chin
to chest, and lift the chin to the ceiling.
e) Palpate the trachea. Place your finger in the
sternal notch. Feel each side of the notch and
palpate the tracheal rings.
3. Palpate the Thyroid Gland from behind
a) Stand behind the client and ask the client to
lower the chin to the chest and turn the neck slightly
to the right.
b) Place the fingers of both hands on the patient's
neck so that the index fingers are just below the
cricoid.
c) Adjust the patient's neck extension to avoid
tightened neck muscles.
d) Ask the patient to sip and swallow water and
feel for any glandular tissue rising under the finger
pads
e) Ask the client to set up right, lower the chin and
turn the head slightly to the right.
f) Use the fingers of the left hand to push the
trachea to the right.
h) Palpate with and without swallowing
i) Reverse the technique to palpate the left lobe of
the thyroid.
i) If the thyroid gland is enlarged listen over the
lateral lobes with a stethoscope to detect a bruit)
4. Lymph Nodes of the Neck and Head
a) Auscultate the thyroid only if you find an
enlarged thyroid gland during inspection or
palpation.
b) Ask the client to hold their breath (to obscure any
tracheal breath sounds while you auscultate).
c) Palpate Lymp Nodes
d) Palpate the preauricular nodes (in front of the
ear), postauricular nodes (behind the ears), and
occipital nodes (at the posterior base of the skull).
e) Palpate the tonsillar nodes at the angle of the
mandible on the anterior edge of the sternomastoid
 muscle
f) Palpate the submandibular nodes located on the
medial border of the mandible
g) Palpate the submental nodes, which are a few
centimeters behind the tip of the mandible.
h) alpate the superficial cervical nodes in the area
superficial to the sternomastoid muscle.
i) Palpate the posterior cervical nodes in the area
posterior to the sternomastoid and anterior to the
trapezius in the posterior triangle.
j) Palpate the deep cervical chain nodes deeply
within and around the sternomastoid muscle.
k) Palpate the supraclavicular nodes by hooking
your fingers over the clavicles and feeling deeply
between the clavicles and the sternomastoid
muscles
G Procedure Termination
a) Put patient in comportable according to health
status
b) Provide patient with reassurance
c) Return back equipment
d) Wash Hands
H ANALYSIS OF DATA FINDINGS
Formulate nursing diagnose ( wellness, risk, actual.)
Formulate collative problems
Make necessary referrals