Republic of the Philippines

President Ramon Magsaysay State University

(formerly Ramon Magsaysay Technological University)
Iba, Zambales, Philippines
Tel/Fax No.: (047) 811-1683

COLLEGE OF NURSING
Name:________________________________Section/Group:_______________Date:____________

Rating
5 Correctly and independently performs procedure and states complete rationale
4 Performs procedure and states rationale with minimal guidance
3 Satisfactorily performs procedure with moderate guidance
2 Procedure incorrectly done without rationale
1 Procedure not performed

Assessing the Neck

PROCEDURE 5 4 3 2 1
1. Introduce yourself and verify the client’s identity. Explain to the
client what you are going to do, why it is necessary, and how she
can cooperate.
2. Perform hand hygiene and observe other appropriate infection
control procedure
3. Provide client privacy
4. Inquire if the client has any history of the following:
 Any problem with neck lumps
 Neck pain or stiffness
 When and how any lumps occurred
 Any diagnoses of thyroid problems
 Any treatments such as surgery and radiation
5. Inspect the neck muscles (sternocleidomastoid and trapezius) for
abnormal swelling mass.
 Ask the client to hold head erect.
6. Observe head movement.
Ask the client to:
 Move chin to the chest. (Determines function of the
sternocleidomastoid muscle)
 Move head back so that the chin points upward. (Determines
function of the trapezius muscle.)
 Turn head to the right and the left. (Determines function of the
sternocleidomastoid muscle.)
7. Assess muscle strength.
Ask the client to:
 Turn head to one side against the resistance of your hand. Repeat
with other side.
 Shrug the shoulders against the resistance of your hands.
Lymph Nodes
8. Palpate the entire neck for enlarged lymph nodes.
9. Palpate the trachea for lateral deviation.
 Place your fingertip or thumb on the trachea in the suprasternal
notch, then move your finger laterally to the left and the right in
spaces bordered by the clavicle, the anterior aspect of the
sternocleidomastoid muscle, and trachea.
10. Insect the thyroid gland.
 Stand in front of the client.
 Observe the lower half of the neck overlying the thyroid gland for
symmetry and visible masses.
 Ask the client to hyperextend head and swallow. If necessary,
 Republic of the Philippines
President Ramon Magsaysay State University
(formerly Ramon Magsaysay Technological University)
Iba, Zambales, Philippines
Tel/Fax No.: (047) 811-1683

COLLEGE OF NURSING
offer a glass of water to make it easier for the client to swallow.
11. Palpate the thyroid gland for smoothness.
 Note any areas of enlargement, masses, or nodules.
12. If enlargement of the gland is suspected:
 Auscultate over the thyroid area for a bruit.
 Use the bell-shaped diaphragm of the stethoscope.
13. Document findings in the client record

Actual Score Actual Score

Computation: ×60+ 40= ×60+ 40=Grade
Total Score ❑
Grade:_______________
Remarks:_________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________

Evaluated by:

___________________
Clinical Instructor

Conforme:

___________________
Signature of Student