Skill 3-4

Assessing the Head and Neck

Examination of the head and neck region includes the assessment of multiple structures and body systems. The eyes, ears, nose, mouth, and throat are located within the facial structures. Anterior neck structures include the trachea, esophagus, and the thyroid gland as well as the arteries, veins, and lymph nodes. Posterior neck areas involve the upper portion of the spine. Assessment of the size and consistency of the thyroid gland is performed by advanced practice professionals. Refer to information on a health assessment text for details.

Delegation Considerations

Assessment of the patient's head and neck should not be delegated to assistive personnel (AP). However, the AP may notice some items while providing care. The nurse must then validate, analyze, document, communicate, and act on these findings, as appropriate. Depending on the state's nurse practice act and the organization's policies and procedures, the licensed practical/vocational nurses (LPN/LVNs) may perform some or all the parts of assessment of the patient's head and neck. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Stethoscope
Gloves
Additional PPE, as indicated
Bath blanket or other drape
Lighting, including a penlight
Tongue blades
Visual acuity chart

Assessment

Complete a health history, focusing on the head and neck. Identify risk factors for altered health by asking about the following:

Changes with aging in vision or hearing
History of use of corrective lenses or hearing aids
History of allergies
History of disturbances in vision or hearing
History of chronic illnesses, such as hypertension, diabetes mellitus, or thyroid disease
Exposure to harmful substances or loud noises
History of smoking, chewing tobacco, or cocaine use
History of eye or ear infections
Presence of body piercings and/or tattoos
Oral and dental care practices

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Impaired Swallowing
Impaired Dentition
Impaired Hearing

Outcome Identification and Planning

The expected outcome to achieve in performing an examination of the structures in the head and neck region is that the assessment is completed without the patient experiencing anxiety or discomfort, the findings are documented, and the appropriate referral is made to the other health care professionals, as needed, for further evaluation. Other outcomes may be appropriate, depending on the specific diagnosis or patient problem identified for the patient.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
3. Close the curtains around the bed and close the door to the room, if possible. Explain the purpose of the head and neck examination and what you are going to do. Answer any questions.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates cooperation.
4. Inspect the head for size and shape. Inspect the face for color, symmetry, lesions, and distribution of facial hair. Note facial expression. Palpate the skull.	In general, the shape of the head is normocephalic and symmetric. Abnormal findings include a lack of symmetry or unusual size or contour of the head, which may be a result of trauma or disease. Facial expression is appropriate. The skull should be mobile and nontender.
5. Inspect the external eye structures (eyelids, eyelashes, eyeball, and eyebrows), cornea, conjunctiva, and sclera. Note color, edema, symmetry, and alignment.	Inspection detects abnormalities, such as ptosis, styes, conjunctivitis, or scleral color. Some abnormalities are associated with systemic disorders.
6. Examine the pupils for equality of size and shape (Figure 1). Examine the pupillary reaction to light: Darken the room. Ask the patient to look straight ahead. Bring the penlight from the side of the patient's face and briefly shine the light on the pupil (Figure 2). Observe the pupil's reaction; it normally constricts rapidly (direct response). Note pupil size. Repeat the procedure and observe the other eye; it too normally will constrict (consensual reflex). Repeat the procedure with the other eye.	Testing pupillary response to light and accommodation assesses cranial nerve III, the oculomotor nerve. The pupils are normally black, equal in size, round, and smooth. The normal and consensual pupillary response is constriction.
7. Test for pupillary accommodation: Hold the forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 inches) from the bridge of the patient's nose. Ask the patient to first look at the object, then at a distant object, and then back to the object being held. The pupil normally constricts when looking at a near object (Figure 3A) and dilates when looking at a distant object (Figure 3B).	Testing pupillary response to light and accommodation assesses cranial nerve III, the oculomotor nerve. The normal pupillary response is constriction when focusing on a near object.
8. Assess extraocular movements. Ask the patient to hold the head still and follow the movement of your forefinger or a penlight with the eyes as you move the patient's eyes through the six cardinal positions of gaze. Keeping your finger or penlight about 1 ft from the patient's face, move it slowly through the cardinal positions: up and down, right and left, diagonally up and down to the left (Figure 4A), diagonally up and down to the right (Figure 4B).	This evaluates the function of each of the six extraocular eye muscles (EOMs) and tests cranial nerves III, IV, and VI (oculomotor, trochlear, and abducens nerves). Normally, both eyes move together, are coordinated, and are parallel.
9. Test convergence: Hold your finger about 6 to 8 inches from the bridge of the patient's nose. Move your finger toward the patient's nose (Figure 5). The patient's eyes should normally converge (assume a cross-eyed appearance).	The patient's eyes should normally converge; converging eyes normally follow the object to within 5 cm of the nose (assume a cross-eyed appearance).
10. Test the patient's visual acuity with a Snellen chart. Have the patient stand 20 ft from the chart and ask the patient to read the smallest line of letters possible, first with both eyes and then with one eye at a time (with the opposite eye covered). Note whether the patient's vision is being tested with or without corrective lenses (Figure 6).	Evaluates the patient's distance vision and function of cranial nerve II (optic nerve). Additional tools are used to test for color perception.
11. Inspect the external ear bilaterally for shape, size, and lesions. Palpate the ear and mastoid process. Inspect the visible portion of the ear canal. Note cerumen (wax), edema, discharge, or foreign bodies.	Inspection may reveal abnormalities, such as uneven color, size, drainage, or lesions; inflammation (edema) or infection; nodules, lesions, or tenderness. Cerumen may normally be dark orange, brown, yellow, gray, or black and soft, moist, dry, or hard.
12. Use a whispered voice as a general hearing screening test. Stand about 1 to 2 ft away from the patient out of the patient's line of vision. Ask the patient to cover the ear not being tested. Determine whether the patient can hear a whispered sentence or group of numbers from 1 to 2 ft. away. Perform the test on each ear.	Provides a gross assessment of cranial nerve VIII (acoustic nerve) and provide clues to the need for further evaluation. The patient should repeat what has been said.
13. Put on gloves. Inspect and palpate the external nose (Figure 7).	Gloves prevent contact with blood and body fluids. These actions assess for the color, shape, consistency, and tenderness of the nose.
14. Palpate over the frontal and maxillary sinuses (Figure 8).	Sinus palpation is used to elicit tenderness, which may indicate sinus congestion or infection. Normally, the sinuses are not painful when palpated.
15. Occlude one nostril externally with a finger while patient breathes through the other; repeat for the other side.	This technique checks the patency of the nasal passages.
16. Inspect each anterior naris and the turbinates by tipping the patient's head back slightly and shining a light into the nares. Examine the mucous membranes for color and the presence of lesions, exudate, or growths.	This technique can detect edema, inflammation, and excessive drainage. The nasal mucosa is moist and darker red than the oral mucosa.
17. Inspect the lips, oral mucosa, hard and soft palates, gingivae, teeth, and salivary gland openings. Ask the patient to open the mouth wide and use a tongue blade and penlight to visualize structures.	Evaluates the condition of the oral structures and hydration level of the patient. The lips should be pink, moist, and smooth. The gums should be pink and smooth. The teeth should be regular and free of cavities or have dental restoration. The tonsils, if present, are small, pink, and symmetric in size.
18. Inspect the tongue. Ask the patient to stick out the tongue. Place a tongue blade at the side of the tongue while patient pushes it to the left and right with the tongue. Inspect the uvula by asking the patient to say “ahh” while sticking out the tongue (Figure 9). Palpate the tongue for muscle tone and tenderness. Remove gloves. Sticking out the tongue evaluates the function of cranial nerve XII (hypoglossal nerve). Saying “ahh” checks for movement of the uvula and soft palate.	The tongue and mucous membranes are normally pink, moist, and free of swelling or lesions. The uvula is normally centered and freely movable. The tongue should feel soft with positive muscle tone and be nontender.
19. Inspect and palpate the lymph nodes (Figure 10) for enlargement, tenderness, and mobility, using the fingerpads in a slow, circular motion (Figure 11).	Palpation can determine size, shape, mobility, consistency, and/or tenderness of enlarged lymph nodes.
20. Inspect and palpate (Figure 12A) the left and then the right carotid arteries. Palpate only one carotid artery at a time. Note the strength of the pulse and grade it as with peripheral pulses. Use the bell of the stethoscope to auscultate the carotid arteries (Figure 12B).	This is part of the assessment of the peripheral vascular system in Skill 3-10. However, some health care providers include this assessment here for organizational convenience and time management. Palpation of this area assesses flow of blood through the arteries. Palpating both arteries at once can reduce blood flow to the brain, potentially causing dizziness or loss of consciousness (Jensen, 2019). Auscultation can detect a bruit.
21. Inspect and palpate the trachea (Figure 13).	Inspection and palpation of the trachea evaluate its midline position.
22. Assess the thyroid gland with the patient's neck slightly hyperextended. Observe the lower portion of the neck overlying the thyroid gland (Figure 14). Ask the patient to swallow. Observe the area while the patient swallows. Offer a glass of water, if necessary, to make it easier for the patient to swallow. Assess for symmetry and visible masses.	Abnormal findings include asymmetry, enlargement, lumps, and bulging. These findings may indicate the presence of enlargement of the thyroid (a goiter), inflammation of the thyroid (thyroiditis), or cancer of the thyroid.
23. Inspect the ability of the patient to move the neck. Ask the patient to touch chin to chest and to each shoulder, each ear to the corresponding shoulder, and then tip the head back as far as possible.	These actions assess neck ROM, which is normally smooth and controlled.
24. Remove any additional PPE, if used. Perform hand hygiene. Continue with assessments of specific body systems, as appropriate or indicated. Initiate appropriate referral to other health care providers for further evaluation, as indicated.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Additional assessments should be completed, as indicated, to evaluate the patient's health status. Intervention by other health care providers may be indicated to evaluate and treat the patient's health status.

Evaluation

The expected outcomes have been met when the patient has participated in head and neck assessment; the assessment has been completed without the patient experiencing anxiety or discomfort; the findings have been documented; and the appropriate referrals have been made to the other health care professionals, as needed, for further evaluation.

Documentation

Guidelines

Describe specific findings. For the head and face, document symmetry, coloration, and presence of lesions or edema. Note visual acuity, pupillary reaction, and condition of the external eye. Document results of tests for accommodation, convergence, and extraocular muscles. Describe condition of the ear, noting any lesions or discharge. Document results of any hearing tests. Note condition of the nose and sinuses. Describe condition of lips, gums, tongue, and buccal mucosa. Document quality of carotid pulse. Note position of trachea and any enlargement of the thyroid. Describe quality of any lymph nodes palpable. Note ROM of the neck. Document presence of pain or discomfort.

Sample Documentation

6/10/25

1545 Head and neck examination completed. Patient denies history of any sensory changes or sensory difficulties, but states, “I have some sores in my mouth.” Overall skin coloring consistent, with pink undertones. Head symmetric and normal in size. Eyes are symmetric. No lesions or redness noted. Pupils equal and reactive to light; positive accommodation and convergence. Visual acuity 20/20 in both eyes. Eyes move smoothly through six fields of gaze. External ears and canal free of discharge, lesions, or tenderness. Whisper test negative for hearing loss. Nose and sinuses nontender. Minimal clear discharge present in the nostrils; nostrils patent. Lips free of lesions. Multiple white lesions approximately 1 cm in diameter noted on buccal mucosa and tongue. Uvula rise normal. No palpable lymph nodes. Carotid pulse strong bilaterally. Trachea midline. Thyroid does not appear enlarged.

—B. Gentzler, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

While you are testing a patient's visual acuity, the patient states that he can't see anything without his glasses: Stop the test. Instruct the patient to put on his glasses, and then resume testing.
While performing an examination of the regional lymph nodes in the neck area, you palpate a lymph node that feels hard and fixed: Ask the patient if he has felt this node before and, if so, for how long it has been present and if it is painful. Refer the patient to a primary health care provider for follow-up care.

Special Considerations

General Considerations

A patient who wears corrective lenses should have them on when visual acuity is being tested.
A Snellen picture chart or Snellen E-chart can be used to test vision in children and in patients who are unable to read English. The E-chart uses the capital letter E in varying sizes pointing in different directions. The patient points their fingers in the direction the legs of the E are pointing.
Near vision is tested with a handheld vision screen with varying sizes of print. A Jaeger card can be used for this measurement. The patient holds the card 14 inches from the eyes. Ask the patient to read the smallest line of letters possible, with one eye at a time (with the opposite eye covered), and corrective lenses in place, if used. The results are recorded as a fraction and written as 14 over the smallest line read by the patient. A normal result is 14/14.

Infant and Child Considerations

When examining the neck of an infant or child, the preferred approach to assess ROM of the neck is to assess one movement at a time, rather than a full rotation of the neck, to avoid dizziness on movement.
When examining the head of an infant, inspect and gently palpate the fontanels and sutures.
Keep in mind that an infant's nose is usually slightly flattened.
For a child younger than age 8 years, do not assess the frontal sinuses; they are usually too small to assess.
Be aware that lymph nodes may be palpable in children younger than age 12 years, which is considered a normal variation.
Note the number of teeth in a child; a child may have up to 20 temporary teeth.

Older Adult Considerations

Look for a thin, grayish ring in the cornea (arcus senilis). This may be a normal finding in an older adult.
When evaluating the older adult patient, expect to find normal age-related changes, such as a decrease in vision, hearing, smell, and taste.
If the patient wears dentures, ask them to remove them for inspection of the gums and roof of the mouth.

Cultural Considerations

Exophthalmos, protrusion of the eyeball, can be a normal finding in patients of African American heritage.

EVIDENCE FOR PRACTICE

Screening for Hearing and Visual Impairment

Hearing impairment (hearing loss) is a common age-associated change in older adults. Despite being considered part of the normal aging process, age-related sensory impairment can have significant impact on the quality of life and functional status of older adults. These impacts are exacerbated when hearing impairment co-occurs with other conditions, such as visual or cognitive impairment (Meyer & Hickson, 2020). How can nurses best support older adults with hearing impairments and improve patient outcomes?

Related Evidence

Meyer, C., & Hickson, L. (2020). Evidence-based practice guideline. Nursing management of hearing impairment in nursing facility residents. Journal of Gerontological Nursing, 46(7), 15-25. DOI: 10.3928/00989134-20200605-04

This guideline provides a summary of the evidence about the impacts of hearing impairment and the factors that are associated with increased risk of hearing impairment. The guideline also offers evidence-based assessment criteria for measuring impairment as well as evidence-based nursing interventions for the management of hearing impairment in older adults.

Relevance to Nursing Practice

Sensory impairment can have negative effects on communication and the functional abilities of older adults. Nurses and caregivers play a key role in recognizing sensory impairment in older adults and implementing interventions to support and improve their quality of life.

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Skill 3-4

EVIDENCE FOR PRACTICE