NCM 101: HEALTH ASSESSMENT

CRYSTAL A. ARIETA
Professor: CHONA LIM, RN
Second Semester | A.Y. 2023-2024

HEAD AND NECK ASSESSMENT

 Head and neck assessment focuses on the All of the facial bones are immovable except for the
cranium, face, thyroid gland, and lymph node mandible, which has free movement joint.
structures contained within the head and neck. The face also consists of many muscles that
produce facial movement and expressions.
􏰀Skull – the framework of the head. Temporal artery, a major artery, is located
between the eye and the top of the ear.
The Head Subsections of the Skull Two other important structures located in the
1. Cranium facial region are the parotid and submandibular
2. Face salivary glands.
Subsections of the Skull Parotid glands
1. Cranium – houses and protects the brain and – located on each side of the face anterior and
major sensory organs - consists of 8 bones inferior to the ears and behind the mandible
> frontal (1)
> parietal (2) Submandibular glands
> temporal (2) – located inferior to the mandible underneath the
> occipital (1) base of the tongue.
> ethmoid (1)
> sphenoid (1) THE NECK
The structure of the neck is composed of
In adults, the cranial bones are joined together muscles, ligaments, and the cervical vertebrae.
by immovable sutures. Contained within the neck are the hyoid bone,
Sutures that joined the cranial bones: several major blood vessels, the larynx, trachea,
1. Sagittal and the thyroid gland, which is the anterior
2. Coronal triangle of the neck.
3. Squamosal
4. Lambdoid Muscles and Cervical Vertebrae
Two major muscles of the neck:
Subsections of the Skull 1. Sternomastoid ( sternocleidomastoid) muscles
2. Face – facial bones give shape to the face. 2. Trapezius muscles
- the face consists of 14 bones o Sternomastoid (sternocleidomastoid)
> Maxilla (2) > Zygomatic (2) muscle – rotates and flexes the head
> Inferior conchae (2) > Nasal (2) o Trapezius muscle
> Lacrimal (2) > Palatine (2) - extends the head and moves the shoulder.
> Vomer (1) > Mandible (1)
 NCM 101: HEALTH ASSESSMENT
CRYSTAL A. ARIETA
Professor: CHONA LIM, RN
Second Semester | A.Y. 2023-2024
The eleventh cranial nerve is responsible for
muscle movement that permits shrugging of the
shoulders by the trapezius muscles and turning the
head against resistance by the sternomastoid
muscles.
Two major muscles that form two triangles that
provide important landmarks for assessment:
1. Anterior triangle – located under the mandible
2. Posterior triangle – located between the
trapezius and sternomastoid muscle.
The cervical vertebrae (C1 through C7) are located
in the posterior neck and support the cranium.
 The vertebra prominens is C7, which can
easily be palpated when the neck is flexed .
 􏰀 Using C7 as landmark will help you locate
other vertebrae.
Blood Vessels
􏰀 The internal jugular veins and carotid arteries
are located bilaterally, parallel and anterior to the
sternomastoid muscles.
􏰀 The external jugular vein lies diagonally over the
surface of these muscles.
It is important to avoid bilaterally compressing the
carotid arteries when assessing the neck, as
bilateral compression can reduce the blood supply
to the brain.
Thyroid Gland
 􏰀 The largest endocrine gland in the body.
 􏰀 It produces thyroid hormones that
increases the metabolic rate of most body
cells.
 The trachea, through which air enters the
lungs, is composed of C-shaped hyaline
cartilage rings.
 The first upper tracheal ring, called the
cricoid cartilage, has a small notch in it.
 The thyroid cartilage (Adam’s apple) is
larger and located just above the cricoid
cartilage.
 The hyoid bone, which is attached to the
tongue, lies above the thyroid cartilage and
under the mandible.
Lymph Nodes of the Head and Neck
 Several lymph nodes are located in the
head and neck.
 Lymph nodes filter lymph, a clear
substance composed mostly of excess tissue
fluid, Filtering removes bacteria and tumor
cells from lymph. The lymph nodes
produce lymphocytes and antibodies as a
defense against invasion by foreign
substances.
 The size and shape of lymph nodes vary
but most are less than 1 cm long and are
buried deep in the connective tissue.
 Normally lymph nodes are either not
palpable or they may feel like very small
beads.
 Lymph nodes usually appears in clusters
that vary in size from 2 to 100 individual
nodes.
 If the nodes become overwhelmed by
microorganisms, as happens with an
infection such as mononucleosis, they swell
and become painful.
 If cancer metastasizes to the lymph nodes,
they may enlarge but not painful.
The Most Common Head and Neck Lymph
Nodes
􏰀 Preauricular
􏰀 Postauricular
􏰀 Tonsillar
􏰀 Occipital
􏰀 Submandibular
􏰀 Submental
􏰀 Superficial cervical 􏰀 Posterior cervical 􏰀 Deep
cervical
􏰀 Supraclavicular
 Preauricular - located infront of the ear
 Postauricular – located behind the ear
 Occipital – located at the posterior base of
the skull
 Tonsillar – located at the angle of the
mandible on the anterior edge of the
sternomastoid muscle
 Submandibular – located at the medial
border of the mandible
 Submental – located a few centimeters
behind the tip of the mandible
 Superficial cervical – located in the area
superficial to the sternomastoid muscle
 Posterior cervical – located in the area
posterior to the sternomastoid and anterior
to the trapezius in the posterior triangle
 NCM 101: HEALTH ASSESSMENT
CRYSTAL A. ARIETA
Professor: CHONA LIM, RN
Second Semester | A.Y. 2023-2024

 Deep cervical – located deeply and around 􏰀 Stethoscope

the sternomastoid muscle
 Supraclavicular – can be palpated by
hooking your fingers over the clavicles
feeling deeply between the clavicles and the
sternomastoid muscles
ASSESSMENT
o Collecting Subjective Data: The Nursing
Health History
Abnormalities that cannot be directly observed
in the physical appearance of the head and neck
are often detected in the client’s history.
o Collecting Objective Data: Physical
Examination
 Assessment of both the head and the neck
assists the nurse to detect enlarged or tender
lymph nodes.
Thyroid enlargement, nodules, masses, or
tenderness may be detected by palpating the
thyroid gland.
ASSESSMENT PROEDURE
Head and Face Inspection and Palpation
􏰀 Inspect the head.
􏰀 Inspect for size, shape, and
configuration
Head and Face Inspection and Palpation
Normal Findings:
 􏰀 Head size and shape vary, especially in
accord with ethnicity.
 􏰀 Usually the head is symmetric, round,
erect, and in midline and appropriately
related to body size (normocephalic).
 􏰀 No lesions are visible.
Abnormal Findings:
􏰀 An abnormally small head is called microcephaly.
 􏰀 The skull and facial bone are larger and
thicker in acromegaly.
 􏰀 Acorn-shaped, enlarged skull bones are
seen in Paget’s disease of the bone.

Palpation may also detect abnormalities of the MICROCEPHALY

neck and facial muscles. The assessment steps and
findings to be described provide parameters for the
examination.

Preparing The Client

􏰀 Prepare the client for the head and neck
examination by instructing him or her to remove
any wig, hat, hair ornaments, pins, rubber bands,
jewelry, and head or neck scarves.

Cultural Considerations
􏰀 Take care to consider cultural norms for touch
when assessing the head. Some cultures (e.g.
Southeast Asian) prohibit touching the head or
touching the feet before touching the head (Purnell
& Paulanka,2008).

 Ask the client to sit in an upright position

with the back and shoulders held back and
straight.
 Explain the importance of remaining still
during most of the inspection and palpation
of the head and neck.
 Explain the need for the client to move and
bend the neck for examination of muscles
and for palpation of the thyroid gland.
 Be aware that some clients may be anxious
as you palpate the neck for lymph nodes,
especially if they have a history of cancer
that caused lymph node enlargement.
 Tell the client what you are doing and share
your assessment findings.

Preparing The Client Equipment

􏰀 Small cup of water
 NCM 101: HEALTH ASSESSMENT
CRYSTAL A. ARIETA
Professor: CHONA LIM, RN
Second Semester | A.Y. 2023-2024

Acromegaly  􏰀 Head tilted to one side may indicate

unilateral vision or hearing deficiency or
shortening of the sternomastoid muscle.
Head and Face Inspection and Palpation
􏰀 Palpate the head
􏰀 Note consistency
􏰀 (wear gloves to protect yourself from possible
drainage)
Normal Findings:
􏰀 The head is normally hard and 􏰀 smooth without
lesions
Abnormal Findings:
􏰀 Lesions or lumps of the head may indicate recent
trauma or a sign of cancer

Inspect the face

􏰀 Inspect for symmetry, features, movement,
expression and skin condition

Head and Face Inspection and Palpation

Normal findings:
􏰀 The face is symmetric with a round, oval,
elongated. or square appearance.
􏰀 No abnormal movements noted.

ABNORMAL FINDINGS:
􏰀 Asymmetry in front of the earlobes occurs with
parotid gland enlargement from an abscess or
tumor.

Head and Face Inspection and Palpation

􏰀 Viral infections such as mumps, flu, and others
can cause swelling of the salivary glands. Swelling
happens in parotid glands on both sides of the face,
giving the appearance of "chipmunk cheeks."

Paget’s Disease

Assessment Procedure
Head and Face Inspection and Palpation
􏰀 Inspect for involuntary movement

Head and Face Inspection and Palpation

Abnormal Findings:
 􏰀 Neurologic disorders may cause a
horizontal jerking movement.
 􏰀 An involuntary nodding movement may
be seen in patients with aortic insufficiency.
 NCM 101: HEALTH ASSESSMENT
CRYSTAL A. ARIETA
Professor: CHONA LIM, RN
Second Semester | A.Y. 2023-2024

Head and Face Inspection and Palpation
ABNORMAL FINDINGS:
􏰀 Unusual or asymmetric orofacial movements may
be from an organic disease or neurologic problem,
which should be referred for medical follow-up.
ABNORMAL FINDINGS:
􏰀 Drooping, weakness, or paralysis on one side of
the face may result from a stroke (cerebrovascular
accident) and usually is seen with paralysis or
weakness of other parts on that side of the body.
to droop or become stiff on that side. It's caused by
some kind of trauma to the seventh cranial nerve.
Abnormal Findings:
􏰀 A “mask-like” face marks Parkinson’s disease, a
sunken face with depressed eyes and hollow cheeks
is typical of cachexia (emaciation or wasting); and a
pale, swollen face may result from nephrotic
syndrome.
 Cachexia is loss of weight, muscle atrophy,
fatigue, weakness and significant loss of
appetite in someone who is not actively
trying to lose weight.

Nephrotic syndrome is a kidney disorder caused by

damage to the clusters of small blood vessels in
your kidneys that filter waste and excess water from
your blood.

ABNORMAL FINDINGS:
 􏰀 Drooping, weakness, or paralysis on one
side of the face may also result from a
neurologic condition known as Bell’s palsy.

Bell's palsy is a condition in which the muscles on

one side of your face become weak or paralyzed. It
affects only one side of the face at a time, causing it
 NCM 101: HEALTH ASSESSMENT
CRYSTAL A. ARIETA
Professor: CHONA LIM, RN
Second Semester | A.Y. 2023-2024

Palpate the Temporal Artery Abnormal Findings:

 which is located between the top of the ear and
the eye.
Normal Findings:
􏰀 The temporal artery is elastic and
not tender.
􏰀 (the strength of the pulsation of the temporal
artery may be decreased in older client)
Abnormal Findings:
􏰀 The temporal artery is hard, thick and tender with
inflammation as seen with temporal arteritis
(inflammation of the temporal arteries that may lead
to blindness).
 Palpate the Temporomandibular Joint
(TMJ).
 􏰀 To assess the TMJ, place your index
finger over the front of each ear as you ask
the client to open the mouth.
􏰀 Asymmetric movement or generalized enlargement of
the thyroid gland is considered abnormal.
Inspect the Cervical Vertebrae.
􏰀 Ask the client to flex the neck (chin to chest).
Normal Findings:
 􏰀 C7 (vertebrae prominens) is usually visible
and palpable.
 􏰀 (In older clients, cervical curvature may
increase because of kyphosis of the spine.
Moreover fat may accumulate around the
cervical vertebrae especially in women). This is
sometimes called “dowager’s hump.
The Neck Inspection
􏰀 Kyphosis is an exaggerated curvature of the upper
(thoracic) spine that creates a hunchback appearance.

Normal Findings:
 􏰀 Normally there is no swelling,
tenderness, or crepitation with movement.
 􏰀 Mouth opens and closes fully (3 to 5 cm
between upper and lower teeth).
 􏰀 Lower jaw moves laterally 1 to 2 cm in
each direction.
Abnormal Findings:
􏰀 Limited range of motion, swelling,
tenderness, or crepitation may
indicate TMJ syndrome.
(when assessing TMJ syndrome, be sure to explore
the client’s history of headaches, if any). 􏰀 Dowager’s hump - An abnormal outward
The Neck Inspection curvature of the thoracic vertebrae of the upper
􏰀 Inspect the Neck back.
 􏰀 Observe the client’s slightly extended
neck for position, symmetry, and lumps or
masses.
 􏰀 Shine a light from the side of the neck
across to highlight any swelling.

The Neck Inspection

Normal Findings:
􏰀 Neck is symmetric, with head centered and
without bulging masses.
Abnormal Findings:
􏰀 Swelling, enlarged masses – or nodules – may
indicate an enlarged thyroid gland, inflammation of
lymph nodes, or a tumor.
Inspection
 􏰀 Inspect Movement of the Neck
Structures.
 􏰀 Ask the client to swallow a small sip of
water.
 􏰀 Observe the movement of the thyroid
cartilage, thyroid gland.

ASSESSMENT PROCEDURE
The Neck Inspection
Normal Findings: Abnormal Findings:
􏰀 The thyroid cartilage, cricoid cartilage move upward
􏰀 Prominens or swellings other than C7 vertebrae
symmetrically as the client swallows.
may be abnormal.
Inspection
􏰀 Inspect Range of Motion.
 NCM 101: HEALTH ASSESSMENT
CRYSTAL A. ARIETA
Professor: CHONA LIM, RN
Second Semester | A.Y. 2023-2024

􏰀 Ask the client to turn the head to the right and to

the left (chin to shoulder), touch each ear to the
shoulder, touch chin to chest, and lift the chin to the
ceiling.
Normal Findings:
􏰀 Normally neck movement should be smooth and
controlled with 45-degree flexion, 55-degree
extension, 40-degree lateral abduction, and 70-
degree rotation.
Abnormal Findings:
 􏰀 Muscle spasms, inflammation, or cervical
arthritis may cause stiffness, rigidity, and
limited mobility of the neck, which may
affect daily functioning.
 􏰀 A stiff neck is often a late symptom seen
in meningitis.

The Neck Palpation

􏰀 Palpate the Trachea Cricoid cartilage – smaller upper tracheal ring
􏰀 Place your finger in the sternal notch. Feel each under the thyroid cartilage.
side and palpate the tracheal rings. The upper ring
above the smooth tracheal rings is the cricoid
cartilage.
Normal Findings:
􏰀 Trachea is midline
Abnormal Findings:
 􏰀 The trachea may be pulled to the affected
side in cases of lung atelectasis, fibrosis or
pleural adhesions.
 􏰀 The trachea is pushed to the unaffected
side in cases of a tumor, enlarged thyroid
lobe, pneumothorax, or with an aortic
aneurysm.
 􏰀 Palpate the Thyroid Gland
􏰀 Locate key landmarks with your index
finger and thumb.

Neck Landmarks
􏰀 Hyoid bone – arch shaped bone that does not
articulate directly with any other bone; located
high in anterior neck.

The Neck Palpation

􏰀 Thyroid cartilage – under the hyoid bone; the
area that widens at the top of the trachea, also
known as the “Adam’s apple”.
 􏰀 To palpate the thyroid use a posterior
approach.
 􏰀 Stand behind the client and ask the client
to lower the chin to the chest and turn the
neck slightly to the right (this will relax the
client’s neck muscles).
 􏰀 Then place your thumbs on the nape of
the client’s neck with your other fingers on
either side of the trachea below the cricoid
cartilage.
 􏰀 Use your left fingers to push the trachea
to the right.
 􏰀 Then use your right fingers to feel deeply
in front of the sternomastoid muscle.
Normal Findings:
􏰀 Landmarks are positioned midline.
Normal Findings:
 NCM 101: HEALTH ASSESSMENT
CRYSTAL A. ARIETA
Professor: CHONA LIM, RN
Second Semester | A.Y. 2023-2024
 􏰀 Unless the client is extremely thin with a
long neck, the thyroid gland is usually not
palpable.
 􏰀 The isthmus may be palpated, the lobes
are smooth, firm, and nontender.
 􏰀 The right lobe is often 25% larger than
the left lobe.
Older Adult Consideration
􏰀 If palpable, the older client’s thyroid gland may
feel more nodular or irregular because of fibrotic
changes that occur with aging; the thyroid may also
be felt lower in the neck because of age related
structural changes.
Abnormal Findings:
􏰀 Landmarks deviate from midline or are obscured
because of masses or abnormal growths.
Abnormal Findings:
 􏰀 In cases of diffuse enlargement ; such as
hyperthyroidism, Grave’s disease, or an
endemic goiter, the thyroid gland may be
palpated.
 􏰀 An enlarged, tender gland may result
from thyroiditis.
 􏰀 Multiple nodules of the thyroid may be
seen in
metabolic processes.
 􏰀 Rapid enlargement of a single nodule
suggests a malignancy and must be
evaluated further.
The Neck Palpation
􏰀 Palpating the Thyroid
􏰀 Ask the client to swallow as you
palpate the right side of the gland.
􏰀 Reverse the technique to palpate the left lobe of
the thyroid.
Normal Findings:
􏰀 Glandular thyroid tissue may be felt rising
underneath your fingers.
􏰀 Lobes should feel smooth, rubbery, and free of
nodules.
Abnormal Findings:
􏰀 Coarse tissue or irregular consistency may
indicate an inflammatory process. Nodules should
be described in terms location, size and consistency.
The Neck Auscultation
 􏰀 Auscultate the thyroid only if you find
an enlarged thyroid gland during
inspection or palpation.
 􏰀 Place the bell of the stethoscope over the
lateral lobes of the thyroid gland.
 􏰀 Ask the client to hold his/her breath (to
obscure any tracheal breath sounds while
you auscultate).
The Neck Auscultation
Normal Findings:
􏰀 No bruits are auscultated
Abnormal Findings:
􏰀 A soft, blowing, swishing sound auscultated over
the thyroid lobes is often heard in hyperthyroidism
because of an increase in blood flow through the
thyroid arteries.
Lymph Nodes of the Head and Neck Palpate the
Lymph Nodes
􏰀 Preauricular nodes – infront of the ears
􏰀 Postauricular nodes – behind the ears
􏰀 Occipital nodes – at the posterior base of the
skull
􏰀 Tonsillar nodes – at the angle of the mandible on
the anterior edge of the sternomastoid muscle.
􏰀 Submandibular nodes – located on the medial
border of the mandible
􏰀 Submental nodes – which are a few centimeters
behind the tip of the mandible.
􏰀 Superficial cervical nodes – in the area
superficial to the sternomastoid
muscle
Lymph Nodes of the Head and Neck Palpate the
Lymph Nodes
 􏰀 Posterior cervical nodes – in the area
posterior to the sternomastoid and
anterior to the trapezius in the posterior triangle
 􏰀 Deep cervical chain nodes – deeply
within and around the
sternomastoid muscle
 􏰀 Supraclavicular nodes – by hooking your
fingers over
the clavicles and feeling
deeply between the clavicles and the sternomastoid
muscle
Normal Findings:
􏰀 There is no swelling or enlargement and no
tenderness is present
Abnormal Findings:
 􏰀 Head and neck cancer includes cancer of
the mouth, nose, sinuses, salivary glands,
throat, and lymph nodes in the neck.
 􏰀 Enlarged nodes are abnormal
 􏰀 Swelling, tenderness, immobility are
abnormal
 􏰀 Enlargement and tenderness are
abnormal
Lymph Nodes of the Head and Neck Palpate the
Lymph Nodes
Abnormal Findings:
􏰀 An enlarged, hard, nontender node, particularly
on the left side, may indicate a metastasis from a
malignancy in the abdomen or thorax.
Validating and Documenting Findings
 􏰀 Validate the head and neck assessment
data that you have collected.
 􏰀 This is necessary to verify that the data
are reliable and accurate.
 􏰀 Document the assessment data following
the health care facility or agency policy.
Analysis of Data: Diagnostic Reasoning
􏰀 After collecting the assessment data, identify
abnormal findings and client’s strengths using
diagnostic reasoning. Then, cluster the data to
reveal any significant patterns or abnormalities.
 NCM 101: HEALTH ASSESSMENT
CRYSTAL A. ARIETA
Professor: CHONA LIM, RN
Second Semester | A.Y. 2023-2024