Head and neck assessment focuses on the cranium, face, thyroid gland, and lymph node structures contained within the head and neck.
History of present health concern
Assess for pain
Do you experience neck pain?
Do you experience headaches? Describe.
Do you have any facial pain? Describe.
Do you have any difficulty moving your head or neck?
Other symptoms
Have you noticed any lumps or lesions on your head or neck that do not heal or disappear? Describe their appearance and location.
Have you experienced any dizziness, lightheadedness, spinning sensation, or loss of consciousness? Describe.
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 experienced any palpitations, blurred vision, or changes in bowel habits?
Past health history
This portion of the health history focuses on questions related to the client’s past, from the earliest beginnings to the present.
Describe any previous head or neck problems you have had. How were they treated? What were the results?
Have you ever undergone radiation therapy for a problem in your neck region?
Family history
Is there a history of head and neck cancer in your family?
Is there a history of migraine headaches in your family?
Lifestyle and health practices
This is a very important section of the health history because it deals with the client’s human responses.
Do you smoke or chew tobacco? If yes, how much?
Do you wear a helmet when riding a horse, bicycle, motorcycle, or other open sports vehicle? Do you wear a hard hat for hazardous occupations?
What is your typical posture when relaxing, during sleep, and when working?
In what kinds of recreational activities do you participate? Describe the activity.
Have any problems with your head or neck interfered with your relationships with others or the role you occupy at home or at work?
Head and Face
Inspection
Inspect the head. Inspect for size, shape, and configuration.
Inspect for involuntary movement. Head should be held still and upright.
Inspect the face. Inspect for symmetry, features, movement, expression, and skin condition.
Palpation
Palpate the head. Palpate for consistency; the head is normally hard and smooth without lesions.
Palpate the temporal artery. This should be located between the top of the ear and the eye.
Palpate the temporomandibular joint. To assess the temporomandibular joint, place your index finger over the front of each ear as you ask the client to open your mouth.
Neck
Inspection
Inspect the neck. 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.
Inspect the movement of the neck structures. Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage and thyroid gland.
Inspect the cervical vertebrae. Ask the client to flex the neck (chin to chest, ear to shoulder, twist left to right and right to left, and backward and forward.
Inspect range of motion. 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.
Palpation
Palpate the trachea. Place your finger in the sternal notch. Feel each side of the notch and palpate the tracheal rings. The first upper ring above the smooth tracheal rings is the cricoid cartilage.
Palpate the thyroid gland. Locate key landmarks with your index finger and thumb; ask the client to swallow as you palpate
Auscultation
Auscultate the thyroid gland 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 breath (to obscure any tracheal breath sounds while you auscultate).