HEALTH ASSESSMENT (NCMA111)
WEEK 7: HEAD AND NECK ASSESSMENT │2ND SEMESTER
STRUCTURE AND FUNCTION
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Head and neck assessment focuses on the
cranium, face, thyroid gland, and lymph nodes
contained within the head and neck and the
sensory organs (eyes, ears, nose, and mouth)
Kapag ang baby ay kapapanganak palang
malambot pa ang skull nito kasi yung mga sutures
ay
nagkakaroon ng overlapping para
maaccomodate sa puerta ng nanay

General Survey
Level of Consciousness:
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1.
THINGS TO REMEMBER
I.
II.
III.
Positioning:
 Individual sits upright with arms at side
(Best position is SITTING POSITION)
 Perform all exams on the undressed
individual
while
preserving
the
individual’s modesty
 Classically, the exam is performed from
the right side of the individual (The nurse
should be on the right side of the patient
because you can easily perform most of
the assessment since most of the patient
is on the right side.)
Environment:
 Ensure good lighting, privacy, and
hygiene
 Drape the individual with a towel or
sheet
Initial steps:
 Explain the exam steps to the individual and
obtain consent
 Obtain vital signs including pulse oximetry
(oxygen saturation)
Ask the individual to indicate areas of tenderness
to avoid exacerbating pain
Alert: Normal response
Confused: Disoriented to surroundings
Lethargic: Drowsy, needs stimulation to initiate a
response
Obtunded: Slowly responding, needs repeated
stimulation to maintain attention
Stuporous: Minimal response to stimulation
Comatose/Unresponsive:
No
response
to
stimulation
Skull and scalp
- Close inspection of the scalp by moving the hair is
pertinent to a good exam: (Start parting the hair
by 1 cm and expose the scalp using the pinky
finger)
o Start at an area and move the hair in small
pieces to inspect the scalp
o Systemically go through the entire scalp
Note: Skin cancers can be missed if the exam is not done
properly
A. Notice any:
 Asymmetries
 Deformities
 Lacerations
 Signs of trauma
B. Skull shapes:
Skull shape varies by:
 Age
 Gender
 Race
Malformation causes:
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Congenital disorders
Trauma
Brain tumors
Scalp swelling
Hematomas
Skin cancer of the scalp
HEALTH ASSESSMENT (NCMA111)
WEEK 7: HEAD AND NECK ASSESSMENT │2ND SEMESTER
 Hydrocephalus
HEAD
Normal Findings
1.Inspect/
Palpate the head
 Inspect for
size, shape,
and
configurati
on
-
Round and is
of normal size
or
head
circumferenc
e
In proportion
with
gross
body
structure
Smooth skull
contour
Normocepha
lic
(proportion
head)
Bulging fontanelle
(There is pressure
and may cause
vomiting to the
baby)
Sunken fontanelle
(The baby is
dehydrated)
Deviation from
normal
- An
abnormally
small head is
called
microcephal
y
- The skull and
facial bones
are
larger
and thicker
in
acromegaly
- Abnormal
increase in
head size in
young child:
may indicate
hydrocephal
us
- Depressed
skull
(fracture)
- The
first
suture
to
develop
is
the posterior
suture
(triangle
shaped
suture)
2.Inspect for
involuntary
movement
FACE
-
Head
should be
held still
and
upright
Neurologic
disorders may
cause
a
horizontal
jerking
movement. An
involuntary
nodding
movement
may be seen in
patient with
aortic
insufficiency
- Head tilted to
one side may
indicate
unilateral
vision
or
hearing
deficiency or
shortening of
the
sternomastoid
muscle
Deviation from
normal
- Asymmetry,
drooping,
weakness, or
paralysis on
one side of the
face
-
Normal
findings
3. Inspect
- The face is
for
symmetric
symmetry,
with a
features,
round,
movement,
oval,
expression,
elongated,
and skin
or square
condition
appearance
- No
abnormal
movements
noted
Normal: Raise or lower both eyebrows, blink both eyes, close
both eyes tightly, smile and show the teeth, frown, puff the
cheeks
HEALTH ASSESSMENT (NCMA111)
WEEK 7: HEAD AND NECK ASSESSMENT │2ND SEMESTER
 Facial nerve or the 7th cranial nerve is
responsible for the muscle movement for facial
expression and movement
 There is drooping if there is paralysis in
the eye (any part of the face) cause by
stroke or Bell’s palsy (temporary and
can be fixed by physical therapy)
 During the inspection you should check for
drooping or weakness in the patient’s face. If
the patient can’t smile there might be paralysis
 If the stroke is in the right side, the brain that
has a problem is the left side (vise-versa)
opposite
 Nasolabial fold - the creases in the skin from
both sides of the nose to the corners of the
mouth
 When the patient is raising his arms check if
the other arm is higher than the other because
this may be also a sign of arm weakness
4. Palpate the head
 Note:consistency
 Start
palpating
the
head
from front to back
5. Palpate the tempooral artery,
which is located
between the top
of the ear and the
eye
The
head is
normally
hard
and
smooth
Without
lesions
-
The
temporal
artery is
elastic
and not
tender
Lesions or
lumps
on
the
head
may
indicate
recent
trauma or a
sign
of
cancer
The temporal
artery is hard,
thick,
and
tender with
inflammation,
as seen with
temporal
arteritis
(inflammation
of th temporal
arteries that
may lead to
blindness
6.
Palpate
- the
Normally
temporomandibular
joint
there is no
(TMJ)
swelling,
 To assess the
tenderness,
TMJ,
place
or
your
index
crepiitation
finger over the
with
front of ear as
movement
you ask the - Mouth
client to open
opens and
the mouth
closes fully
(3-6
cm
between
upper and
lower
teeth).
Lower jaw
moves
laterally 1-2
cm in each
direction
NECK
Normal
findings
-
Limited
range
of
motion,
swelling,
tenderness,
or
crepitation
may
indicate
TMJ
syndrome
Deviation from
normal
HEALTH ASSESSMENT (NCMA111)
WEEK 7: HEAD AND NECK ASSESSMENT │2ND SEMESTER
1. Inspect the - Neck
is
- Swelling,
neck
symmetric,
enlarged
- Check also
with
head
masses or
for
the
centered
nodules –
Jugular vein
and without
may
- Observe the
bulging
indicate an
client’s
masses
enlarged
slightly
- No Jugular
thyroid
extended
Vein
gland,
neck
for
Distension
inflammatio
position,
(JVD)
n of lymph
symmetry,
nodes, or a
and lumps or
tumor
masses
- Distended
neck vein
2.
Inspect
- The thyroid
- Asymmettric
movement of
cartilage,
movement
the
neck
cricoid
or
structures
cartilage
generalized
 Ask
the
move
enlargement
client to
upward
of
the
swallow a
symmetricall
thyroid gland
small sip of
y as the client
is considered
water.
swallows
abnormal
Observe
the
movement
of
the
thyroid
cartilage,
thyroid
gland
(moving
upward
and
downward
normally)
3. Inspect the
- C7 is usually
- Prominence
cervical
visible and
or swellings
vertebrae.
palpable
other than
Ask the client
the
C7
to flex the
vertebrae
neck (chin to
may
be
chest)
abnormal
 The patient uses the sternocleidomastoid
muscle when having difficulty in breathing


(Typically called upon by NS to elevate the ribs
in ordder to get more oxygen into the lungs
The Spinal Accessory Nerve or 11th cranial nerve is
responsible for the muscle movement that allows
shrugging of the shoulders
C7 is the one that is being checked when assessing the
head of the patient because its easy to palpate when the
neck is flexed
4. Inspect range - Smooth and - Stiffness,
of motion
controlled
rigiddity,
 Ask the
with;
limited
client to:
mobility
 45◦
1. Turn the
Flexion
head to
 55◦
the right
extension
and to the
 40◦ lateral
left (chin
abduction
to
 70◦
shoulder)
rotation
2. Touch
each ear
to
the
shoulder
3. Touch chin
to chest
4. Lift
the
chin to the
ceiling
5. Palpate the
- Trachea
is - The
trachea
may be pulled
trachea.
midline
to the affected
- Place
your
finger in the
sternal notch.
Feel each side
of the notch
and plapte the
tracheal rings.
The
first
uppering ring
above
the
smooth
tracheal rings
is the cricoid
cartilage
side in cases of
large
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
HEALTH ASSESSMENT (NCMA111)
WEEK 7: HEAD AND NECK ASSESSMENT │2ND SEMESTER
6.
Palpate
the - Landmarks - Landmarks
thyroid gland.
are
deviate
from
 Locate
key
positioned
midline or are
landmarks with
midline
obscured
your
index
because
of
finger
and
masses
or
thumb
abnormal
growths
7. Auscultate the - No
bruits - A soft, blowing,
thyroid (only if you
are
swishing sound
find an enlarged
auscultated
auscultated
thyroid gland during
over the thyroid
inspection
or
lobes is often
palpation)
heard
in
 Place the
hyperthyroidism
bell of the
because of an
stethoscope
increase
in
over
the
blood
flow
lateral lobes
through
the
of
the
thyroid arteries
thyroid
gland. Ask
the client to
hold his or
her breath
8. Palpate the lymph - There is no - Swelling,
nodes
swelling or
enlargement
enlargement
and tenderness
and
tenderness
 When assessing the thyroid gland to check if there’s any
enlargement of the thyroid gland, position yourself on the
side and not at the back to avoid discomfort for the
patient.