HEAD AND NECK ASSESSMENT

OBJECTIVES
 Discuss head assessment
 Discuss eye assessment

 Discuss ear assessment

 Discuss mouth assessment

 Discuss neck assessment

SUBJECTIVE DATA
Present history:
 Head injury.

 Lumps/lesion that don’t heal- indicators of cancer.

 Headaches- onset, duration, location.

 Associated symptoms e.g. nausea and vomiting.
 Precipitating factors e.g. stress alcohol.

 Stiff neck/neck pain due to injury, strain or swelling of

the neck.
 Thyroid problems e.g. swelling.

 Facial pain.

 Dizziness, lightheadedness, loss of consciousness and

spinning sensation.
Past medical history:
 Previous head and neck trauma and how it was managed.

 Surgery for tumors.

 Seizure disorder.

 Thyroid dysfunction or surgery.

 Radiation therapy- has been linked to cancer thyroid.

Family history:
 Thyroid dysfunction.

 Headaches (headaches).

 Head or neck cancer in the family.

Lifestyle and health practices:
 Taking of alcohol and chewing of tobacco.

 Wearing of helmet when riding a horse, bicycle, motor

cycle.
 Posture when relaxing, during sleep and when working.

 Recreation activities.
OBJECTIVE DATA
Client preparation:
 Explain to the client the need to remove any items that
would interfere with the assessment e.g. jewelry, hair
pins, wigs.
 Ask the client to sit in an upright position with the back
and shoulders held back and straight.
 Explain what the procedure entails.
HEAD AND FACE
Inspection:
 Size, shape and configuration of the head- normally head
is symmetric, round, erect and in midline. No lesions are
visible.
 Involuntary movements- head should be held still and
upright. Abnormal findings- tremors.
 Symmetry features, movement, expression and skin
condition of the face- normally face is symmetric with a
round, oval, elongated or square appearance and no
abnormal movements are noted.
 Abnormal findings- drooping (stroke), mask like
(Parkinson’s disease).
Palpation:
 Head for consistency- normally hard and smooth without
lesions. Lesions or lumps may indicate recent trauma or
cancer.
 Temporal artery- normally elastic and non tender.
Abnormal findings- hard, thick and tender with
inflammation ( temporal arteritis)
 Temporal-mandibular joint- place the index finger over
the joint as the client opens the mouth. Normally no
swelling, tender or crepitation.
 Mouth opens and closes fully 3-6cm between the upper
and lower teeth. Lower jaw moves laterally 1-2 cm in
each direction.
 Abnormal findings- limited range of motion, swelling,
tenderness or crepitation.
Auscultation
 Temporal artery for any bruits using the bell of the
stethoscope.
EYE
 Discharge (thickness, color, odor]
 History of infection

 Pruritus

 Lacrimation/ excessive tearing

 Pain in eye ball
 Spots/ floaters

 Swelling

 Cataracts, glaucoma
 Twitching
 Vision changes

 Diplopia/ double vision

 Blurred vision

 Photophobia

 Interference with activities of daily living

SUBJECTIVE DATA
Current symptoms:
 Pain

 Vision difficulty- blurring. Blind spots, decreased acuity.

 Redness.

 Swelling

 Any discharge or watering.

 Itching.
Past history:
 History of eye problems or vision.

 Any eye surgery.

 Past treatments because the client may be satisfied with

this treatments
Family history:
 History of eye problems or vision loss in the family-
many eye disorders have familial tendency e.g. allergies,
refraction errors.
Lifestyle and health practices:
 Exposure to conditions/ substances in the work place or
home that may harm the eyes e.g. chemicals, smoke,
dust.
 Use of safety glasses to avoid exposure to harmful
substances.
 Use of sunglasses during exposure to sun---- exposure to
ultraviolet radiation puts the client at risk of cataracts
(opacities of the lenses).
 Type of medications mostly used as some of medications
have ocular side effects e.g. corticosteroid.
 Last eye examination- usually once in every 2 yrs for
healthy individuals.
OBJECTIVE DATA
Client preparation:
 Should be seated comfortably.

 Client participation during the examination is very

important therefore the test should be thoroughly
explained to guarantee accurate results.
 During the examination of the internal eye using the
ophthalmoscope the examiner must move very close to
the client’s face therefore explain to the client that this
may be slightly uncomfortable.
 To ease any client anxiety, explains in detail what you
will be doing and answer any questions that the client
may have.
Equipment and supplies:
 Snellen chart / E- card-used to test distant visual acuity.
It consists lines of different letters.
 The letters are large at the top and decrease in size from
top to bottom.
 The chart is placed on the wall or the door at eye level in
a well light area.
 Hand- held Snellen chart/ near vision screener/
rosenbaum chart
 Penlight

 Opaque cards

 Ophthalmoscope

 Gloves
VISION TESTS
Distant visual acuity test –
 use of the Snellen chart.

 Client is positioned 20feet/ 6M from the chart and client

covers one eye with an opaque card.
 The client reads line of letters until he/she can no longer
distinguish them.
 The test results are recorded as a fraction e.g. 6/6; 20/20
 top/first number indicates the distance of the client from
the chart
 second/bottom number indicates the last full line the
client could read and repeat the test for the other eye.
 The clinician needs to indicate if the client wore glasses
during the examination.
 Normal distant visual acuity- 20/20 or 6/6.

 Abnormal findings- myopia (impaired far vision).

 The higher the second number the poorer the vision;
hesitancy; squinting; leaning forward; misreading the
letters.
 If the vision is poorer than 20/30 refer to
ophthalmologist. O.D- right eye; O.S-left eye.
Near visual acuity
 use of a hand- held Snellen chart to hold 14 inches from
the eye.
 Have the client cover one eye with the opaque card and
read the chart from the top to bottom.
 Repeat the test for the other eye.
 Normal findings- 14/14 meaning that the client can read
what the normal eye can read at 14 inches.
 Abnormal findings- presbyopia (impaired near vision)
caused by decreased accommodation.
 This condition is suggested when the client moves the
card further away.
Visual fields test for gross peripheral vision
 done by confrontation test.

 Position yourself 2 ft away from the client at eye level.

 Have the client cover his left eye while you cover your
right eye.
 Look directly at each other with your uncovered eyes.
 Next fully extend your left arm at midline and slowly
move the one finger/ pencil from below until the client
sees it.
 Ask the client to say now/ yes when they see the finger/
pencil
 . Test the inferior, superior, temporal and nasal visual
fields.
 Normal findings- the client should see the examiner’s
finger/ pencil at the same time the examiner sees it.
 Normal visual fields are; inferior-70 degrees; superior-50
degrees; temporal 90 degrees; nasal- 60 degrees.
 Abnormal finding- reduced peripheral vision; delayed or
absent perception of the examiner’s finger.
INSPECT THE EXTRA OCULAR MUSCLE
FUNCTION
Corneal light reflex test
 this test assesses the parallel alignment of the eyes.

 Hold a penlight about 30cm from the client’s face.

 Shine the light towards the bridge of the nose while the
client stares straight ahead.
 Note the light reflection on the corneas.
 Normally the reflection of the light on the corneas
should be on the exact same spot on each eye which
indicate parallel alignment.
 Abnormal finding- asymmetric position of the light
reflex indicates deviated alignment of the eyes which
may be due to muscle weakness or paralysis.
Cover test/ uncover test
 ask the client to stare straight ahead and focus on a
distant object.
 Cover one of the client’s eyes with an opaque card while
you observe the uncovered eye for any movements.
 Then remove the opaque card and observe the previously
covered eye for any movement.
 Repeat the test on the other eye.

 Normally, uncovered eye should remain fixed straight

ahead while the covered eye should also remain fixed
straight ahead after being uncovered.
 Abnormal findings- the uncovered eye will move to
establish focus when the opposite eye is covered; when
the covered eye is uncovered it moves to re-establish
focus.
Testing the six cardinal fields of gaze
 instruct the client to focus on an object that you are
holding about 30cm from the clients face.
 Move the object through the 6 cardinal positions of gaze
in a clock wise direction and observe the client’s eye
movements
 . Normally the eye movements should be smooth and
symmetric throughout the 6 directions.
 Abnormal findings- failure of the eyes to follow the
movements which indicate a weakness in one or more
muscles; nystagmus- shaking movement of the eye.
EXTERNAL EYE STRUCTURES
 Eyebrows- should be present bilaterally, move
symmetrically as the facial expression changes and have
no lesions or scaling.
 Inspect eyelids and eyelashes- note for any discharge;
ability of the eyelids to close; width and position of
palpebral fissures; turning; color; swelling; lesions.
 Inspect eyeball - observe the position and alignment of
the eyeball in the eye socket. Normally symmetrically
aligned in the socket without protruding or sinking.
 Inspect the bulbar conjunctiva and sclera- have the
client keep his head straight while looking from side to
side and then up towards the ceiling and observe for
color, clarity and texture. Normally the bulbar
conjunctiva is clear, moist and smooth. The sclera is
white in color.
 Inspect the palpebral conjunctiva- inspect the inner parts
of the lower and upper eyelids for color, swelling or
lesions. Normally pink and free of swellings or lesions.
Abnormally- pallor, swellings, lesions.
 Inspect the Lacrimal apparatus- inspect the areas over
the lacrimal glands (lateral aspect of the upper eyelid
and the puncta (medial aspect of the lower eyelid) for
any swelling or lesions.
 Palpate the Lacrimal apparatus- palpate the
nasolacrimal duct to assess for blockage. Use one finger
and palpate just inside the lower orbital rim. Normally
no discharge should be noted from the puncta during
palpation. Abnormally- expressed drainage from the
puncta indicates duct blockage.
 Inspect the pupils- for size, shape. Normally they are
round and equal in size and shape. Test the papillary
light reflex by darkening the room and asking the client
to focus on a distant object and shine the light in from
the client side into the eye while observing for direct
papillary response( response in the eye that you are
shining the light) and consensual response( simultaneous
reaction in both eyes)..
 Test for accommodation by asking the client to focus on
a distant object- this dilates the pupils; ask the client to
shift the gaze to a near object e.g. your finger/ pen- the
pupils constrict. Record these tests as PERRLA- Pupils
Equal, Round, React to Light, and Accommodation.
 Cornea and the lens- shine the light from the side across
the cornea and check for smoothness and clarity
INTERNAL STRUCTURES
Use of the ophthalmoscope to inspect the inner eye.
Darken the room to help dilate the pupils.
 Red reflex- this is the red glow filling the person’s pupil
(it is reflection of light off the retina). Normally you will
see no shadows or dots interrupting the reflex.
Abnormally, absence of the red reflex indicates cataracts.
 Optic disc- the most prominent landmark. Explore the
following characteristics; color-creamy yellow-orange to
pink; shape- round or oval; margins- distinct and sharply
demarcated; physiologic cup- brighter yellow to white
and is 1/3rd of the disc diameter.
 Retinal vessels- follow a paired artery and vein out to the
periphery in the 4 quadrants and note the following;
color- arteries are brighter red than the veins; number- a
paired artery and vein pass to each quadrant; any
pulsations.
 General background- color and integrity.
SPECIAL CONSIDERATIONS
Infants
 Eye movement is poorly coordinated at birth.

 Eye function is limited.

 Most neonates are far-sighted (80%) but decreases

gradually after 7-8yrs.
Elderly
 Poor vision.
EAR
SUBJECTIVE DATA
Current symptoms:
 Earaches/otalgia.

 Infection.

 Discharge.
 Hearing loss.
 Tinnitus/ ringing sensations.

 Dizziness/ loss of balance.

 Trauma to the ear.

Past history:
 History of trauma or infections of the ear.

 Past treatments for ear problems e.g. ototoxic drugs like

antibiotics, aspirin, quinine.
 Ear surgery.
Family history
 History of hearing loss in the family.

 Lifestyle and health practices.

 Working or living in areas that have continuous loud
noise- machinery, music, explosives.
 Use of ear guards in noisy environment.
 Ear care/ ear cleaning.

 Spending lots of time swimming or in water- swimmers

ear i.e. infection due to contaminated water being left in
the ear therefore recommend use of era plugs to keep
water out of the ears.
OBJECTIVE DATA
Client preparation
 Seated position.

 Explain the tests to enhance client participation.

Equipments
 Watch with a second hand.

 Turning fork

 Otoscope
EXTERNAL EAR STRUCTURES
 The external ear and the tympanic membrane can be
assessed by direct inspection and otoscope.
 However, the middle and inner ear cannot be directly
inspected but are assessed by testing hearing acuity and
conduction of sound.
Inspect the auricle, Tragus, and the lobule
 noting the size, shape and position.

 Ears are equal in size bilaterally; the auricle aligns with

the corner of each eye.
 Abnormally. Low set ears or very small ear < 4cm or
very large ears > 10cm.
 Inspect for lesions, discolorations and discharge.
 Palpate the auricle and mastoid process. Usually non-
tender. Tenderness indicate infection.
Otoscopic examination
Used for inspection of the external auditory canal. Note
the following traits
 lesions; foreign bodies; swellings

 color and consistency-should be pink and smooth

without nodules
 any discharge- usually none
 color and consistency of the cerumen- may be yellow,
orange, red, brown. Gray or black, and is soft, moist, dry,
abnormally- foul smelling yellowish, purulent, bloody
discharge;
 Inspect the tympanic membrane and note the :
 color, shape, consistency and landmarks = it is gray, shiny and
translucent without bulging or retraction; its concave (flat and
slightly pulled at the center) , smooth and intact.
 A cone reflection of the otoscope light is normally seen at 5
o’clock in the right ear and 7 o’clock in the left.
HEARING AND EQUILIBRIUM TESTS
Whisper test:
 It tests the hearing acuity of high frequency sounds or
gross hearing.
 Stand 1-2 ft behind the client so that the/she cannot read
your lips.
 Ask them to occlude on ear with one finger on the
tragus.
 Whisper a simple phrase and ask the client to repeat the
phrase.
 The client should be able to repeat the phrase correctly.

 Inability to do so may indicate a loss of ability to hear

high frequency sounds.
Weber’s test:
 Is valuable when a person reports hearing better with one
ear than the other.
 Place a vibrating tuning fork in the midline of the
persons skull and ask if the tone sounds the same in both
ears or better in one ear.
 It assesses sound conduction via bone. Normally the
person should hear the tone by bone conduction through
the skull and it should sound equally loud in both ears
i.e. no lateralization of the sound.
 With conductive hearing loss there is lateralization of
sound in the poorer ear while in sensorineural hearing
loss there is lateralization of sound to the better/ good
ear.
Rinne test:
 It compares air conduction (AC) and bone conduction
(BC).
 Place the stem of the vibrating tuning fork on the
person’s mastoid process and ask him/ her to signal
when the sound goes away.
 Quickly invert the fork so that the vibrating end is near
the ear canal.
 The person should still hear the sound.
 Normally the sound is heard twice as long by AC (next
to the ear canal) as by BC (through the mastoid process).
i.e. AC> BC in a normal situation.
 In conductive hearing loss BC>/= AC while in
sensorineural loss AC> BC.
Romberg test:
 Done to test the client’s equilibrium or balance.

 Ask the client to stand with feet together and arms at the
sides and eyes closed.
 Client maintains position for 20secs without swaying or
with minimal swaying.
 Abnormally, the client moves feet apart to prevent falls
or starts to fall from loss of balance and this may
indicate a vestibular disorder.
NOSE, SINUS, MOUTH AND
THROAT
NOSE AND SINUS
 Discharge [characteristics]
 Epistaxis

 Allargies

 Pain over sinuses

 Postnasal drip

 Sneezing

 General olfactory ability

MOUTH AND THROAT
 Sore throat [characteristics]
 Tongue or mouth lesions

 Bleeding gums

 Hoarseness
 Voice changes
 Altered taste

 Chewing difficulty

 Swallowing difficulty

 Pattern of dental hygiene

SUBJECTIVE DATA
MOUTH
Present history:
 Mouth lesions/ sores.

 Tongue sores/ lesions.

 Pain.

 Dental problems.

 Gum bleeding, redness, swelling or pain.

 Change in ability to taste.

 Difficulty in chewing.
Past history
 Systemic diseases e.g. diabetes.

 Trauma to the mouth previously.

 Any surgery.

Family history
 Allergies.

 Hereditary diseases.
Lifestyle and health practices
 Use of tobacco/ smoking.

 Alcoholism.

 Oral hygiene on both the teeth, gums and tongue.

OBJECTIVE DATA
Equipment
 Gloves.

 Tongue depressor.

 Penlight.
Inspection:
 Lips for color and consistency- normally they are smooth
and moist without lesions or swellings. Lips are pink in
color.
 Teeth- note the number, color, condition and alignment.
Normally 32 in number; whitish in color; smooth
surfaces and edges; no missing teeth.
 Gums for color and consistency- pink, moist and firm
with no lesions or swellings. Red, swollen gums that
bleed easily indicate gingivitis or scurvy( vitamin C
deficiency).
 Buccal mucosa- use a penlight and tongue depressor to
retract the lips and the cheeks to check for color and
consistency. Pink in color; smooth; moist; no lesions or
swellings. Abnormally, whitish, curd like patches
indicate thrush/ Candida albicans.
 Inspect and palpate the tongue- ask the client to stick out
the tongue while you note the color, moisture, size, and
texture.
 Palpate any lesions present. Tongue should be pink,
moist with papillae and no lesions. The ventral surface is
smooth, shiny and pink.
 Hard (anterior) and soft(posterior) palate- ask the client
to open the mouth wide while you use a penlight to look
at the roof for color and integrity. Hard palate is pale or
whitish with firm transverse rugae while the soft palate
is pink.
 Uvula- for color, location and mobility. Is pink, midline
location and moves when the client says aaah.
 Odor- any unusual four odor.


THROAT
Present history:
 Sore throat.

 Voice hoarseness.

 Mouth breathing.

 Difficulty swallowing.

Past history
 Frequently documented streptococcal infection.

 Tonsillectomy.
OBJECTIVE DATA
Equipment
 Tongue depressor.

 Penlight.


Inspection
 Tonsils- for color, size and presence of exudates or
lesions. Normally they may be present or absent; are
pink in color and symmetric and may be enlarged to
+1(visible) in healthy individuals.
 No exudates, swellings or lesions present. Abnormally,
they are red, enlarged to +2(midway between the uvula
and Tonsillar pillar), +3(touch the uvula), +4(touch each
other) and covered with exudates in tonsillitis.
Posterior pharyngeal wall-
 shines the penlight on the back of the throat and note the
color, any exudates or lesions.
 Pink without any lesions or exudates. Abnormally, a
bright red throat with white or yellow exudates indicates
pharyngitis.
NOSE
Present history
 Nasal discharge

 Nose bleeding

 Foreign body

 Sneezing

 Nasal congestion
 Inability to smell
 Itching of the nasal mucosa.

 Nasal obstruction

 Difficulty breathing in one or both nostrils.

 Mouth breathing.
Past history
 Trauma to the nose.

 Surgery.

 Chronic nose bleeds.

 Use of nasal sprays- overuse may cause irritation and

nose bleeds.
OBJECTIVE DATA
Equipment
 Otoscope.

Inspection
 Inspect and palpate the external nose- note the color,
shape, tenderness and patency of airflow. Color is same
as the rest of the face; no tenderness.
Inspect the internal nose-
 use of otoscope with a short wide tip attachment.

 Insert the speculum into the nostril without touching the

sensitive septum.
 View the nasal mucosa, nasal septum, inferior and
middle turbinate’s.
 The mucosa is dark pink, moist and free of exudates.
 The septum is intact and free of ulcers or perforations.

 Turbinates are dark pink/ redder than the mucosa and

moist free of lesions.
 Abnormally the mucosa is swollen, pale pink, ulcers,
lesions.
SINUSES
Present history
 Pain over the sinuses.

Past history
 Repeated sinusitis.

 Chronic paranasal drip.

Family history
 Allergies.
OBJECTIVE DATA
Equipment
 Penlight.

Assessment
 Palpate the sinuses- using the thumbs on the frontal and
maxillary sinuses.
 Normally no tenderness. Tenderness indicates infection.
 Percuss the sinus- for tenderness. Normally, non-tender
on percussion.
 Transilluminate the sinuses- done by holding the light
under the eyebrows and using the other hand to shield
the light a red glow transluminates the frontal sinus
indicating it is normal and air filled Vs absence of the
glow indicate sinus filled with fluid or pus.
 For maxillary sinuses hold the light on the maxillary
sinuses (over the inner corner of the eye) and ask the
client to open the mouth wide open red glow on the hard
palate.
 Many healthy sinuses normally will not transilluminate.
NECK
Inspection
 Skin color, symmetry, lumps, masses and shape- neck is
symmetric with head centered and without bulging
masses.
 Movement of neck structures- ask the client to swallow a
small sip of water and observe the movement of the
thyroid gland. Normally the thyroid gland moves
upwards symmetrically as the client swallows.
 Cervical vertebrae- ask the client to flex the neck chin to
chest. C7 is usually visible and palpable. Any other
prominence/ swelling is abnormal.
 Neck range of motion- ask the client to turn 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.

 Normally movements are smooth.
 Abnormal findings- stiffness due to inflammation,
limited movements.
 Carotid arteries and jugular veins.
Palpation
 Trachea- place your index finger on the trachea in the
sternal notch and slip it off to the side/ put two fingers
(thumb and index) on the trachea and follow it down to
the sternal notch..
 Note any deviations.

 Normally trachea is midline. Abnormal findings- may be

pulled to one side in cases of a tumor, thyroid gland
enlargement.
Thyroid gland-
 use a posterior approach.

 Stand behind the client then place thumbs the client’s

nape of the neck while your other fingers are on either
side of the trachea.
 Use your left fingers to push the trachea to the right.

.
 Then use your right fingers to feel deeply for the right
lobe of 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.
 Thyroid gland is non-palpable normally unless the client
is extremely thin.
 If palpable the lobes are smooth, firm and non- tender

 Auscultation
 Thyroid gland if enlarged for a bruit by using the bell of
the stethoscope.
PALPATION OF THE LYMPH NODES
 Head

 Pre-auricular nodes- in front of the ears.

 Post- auricular nodes- behind the ears.

 Occipital nodes- posterior base of the skull.

Neck
 Tonsillar nodes- at the angle of the mandible.

 Sub- mandibular nodes- on the medial border of the

mandible.
 Sub- mental- behind tip of the mandible.

 Cervical nodes- along the Sternomastoid muscle.

 Supraclavicular- over the clavicles.

 Assess the size and shape, mobility (are mobile),
consistency (normally soft) , tenderness and location.
 Compare lymph nodes that occur bilaterally.

 Normally in adults they are non-palpable.

SPECIAL CONSIDERATIONS
Infants and children.
 Measure the size of the head at each visit up to 2 yrs.

 Suture lines and fontanels are inspected and palpated.

 Lymph nodes palpable in this group