Chapter 15
Assessing Head and Neck
Health Assessment: Subjective Data
• Interview Approach (COLDSPA)
– History of current health problem
• Pain
• Headaches
• Facial pain
• Other symptoms – movement, lumps, lesions, cough,
difficulty swallowing, dizziness, lightheadedness, vision, LOC,
changes in texture of skin, hair or nails, loss of energy, sleep
habits, emotional stability, palpations, weakness, numbness
in face, arms or legs, either side of body.
Copyright © 2018 Wolters Kluwer · All Rights Reserved
– Past health history
• Previous head or neck problems, thyroid problems,
radiation therapy
– Family health history
• Headaches
• Head/neck cancer in family
• Migraines in family
Copyright © 2018 Wolters Kluwer · All Rights Reserved
• Lifestyle and health practices
– Smoke, ETOH, recreations drugs
– Helmet or hard hat usage
– Recreational activity
– Interfere with life?
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Equipment for Head and Neck
Examination
• Gloves
• Small glass of water
• Stethoscope
• Good light source, penlight
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Hypothyroidism
• Increased sensitivity to cold
• Constipation
• Depression
• Fatigue
• Heavier menstrual periods
• Pale, dry skin
• Thin, brittle hair or nails
• Weakness
• Unintentional weight gain
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Hyperthyroidism
• Sudden weight loss, without changes in appetite and diet
• Increased appetite
• Rapid heartbeat (tachycardia) greater than 100 beats a
minute, irregular heartbeat (arrhythmia), or palpitations
• Nervousness, anxiety, and irritability
• Tremor in the hands and fingers
• Sweating
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Hyperthyroidism (cont.)
• Changes in menstrual patterns
• Increased sensitivity to heat
• Changes in bowel patterns, more frequent bowel
movements
• Enlarged thyroid gland (goiter)
• Fatigue, insomnia
• Muscle weakness
Copyright © 2018 Wolters Kluwer · All Rights Reserved
General Routine Screening
• Inspect head & neck
• Palpate temporal arteries, TMJ, trachea, thyroid, lymph
nodes
• Auscultate thyroid only if enlarged
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Physical Assessment: Head
• Inspect the size, shape, configuration
• Involuntary movement
• Palpate head
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Physical Assessment: Face
• Inspect the face
– Symmetry
– Features
– Movement
– Expression
– Skin condition
• Palpate the temporal artery
• Palpate the TMJ
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Physical Assessment: Neck
• Inspect the neck
• Inspect movement of neck structures
– Cervical vertebrae
– Neck ROM
• Palpate
– Palpate trachea
– Palpate thyroid gland – only auscultate if enlarged
– Palpate lymph nodes – see figure 15-5 & assessment
guide 15-1
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Validating & Documenting Findings
• Validate by asking more questions, look at testing,
comparing objective & subjective data
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Analyzing Date to Make Informed Clinical
Judgments
• Collect data
• Cluster cues to ID patterns or abnormalities
• Make informed clinical judgment
• Possible concerns: opportunity to improve health, risk for
client concerns, actual client concerns
• Refer if needed
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Types of Headaches
• Sinus
• Cluster
• Tension
• Migraine
• Tumor related
• See abnormal findings 15-1
Copyright © 2018 Wolters Kluwer · All Rights Reserved