Lesson 5

Assessing Head and Neck
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Head
Figure 13.1 Bones of the Head
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Kozier & Erb's Fundamentals of Nursing, Tenth Edition, Global Edition
Pearson Education Limited
Audrey Berman | Shirlee Snyder | Geralyn Frandsen
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Head
• The skin, muscles, and bones of

the face provide landmarks for
assessment, as do the bones of
the skull.
• The muscles of the scalp, face,
and neck play a major role in
expressing emotions through facial
expressions. They also contribute
to movement of the head and
neck.
Facial Landmarks
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Head
• Facial bones provides structure for the face and

cavities for the eyes, nose, and mouth. The bones
also allow movement of the mandible at the
temporomandibular joint (TMJ).
• The TMJ allows a person to open and close the
mouth, protract and retract the chin, and slide the
lower jaw from side to side. These actions are used
for chewing and speaking.
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NECK
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Neck
• Muscles
• Lymph nodes
 Chains
• Trachea
• Thyroid gland
• Carotid arteries
• Jugular veins
Photo credit: www.healthtap.com
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Neck
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Neck
• For the anterior triangle: the
mandible above, the
sternocleidomastoid laterally, and
the midline of the neck medially.
• For the posterior triangle: the
sternocleidomastoid muscle, the
trapezius, and the clavicle. Note
that a portion of the omohyoid
muscle crosses the lower portion of
this triangle and can be mistaken
for a lymph node or mass.
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Figure 30–19 Structures of the neck.
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Table 30–6 Lymph Nodes of the Head and Neck
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Special Considerations
Psychosocial Considerations:
• Stressors may affect the health status of a patient and result
in symptoms such as headaches, neck pain, or mouth
ulcers.
• Additional signs of stress or systemic conditions include pain
in the TMJ because of unconscious clenching of the jaw
during sleep or stressful situations. Chronic TMJ syndrome
may eventually result in a wearing down of the teeth.
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Psychosocial Considerations
• Other indications of psychosocial disturbances include tics (involuntary
muscle spasms), hair twisting or pulling, lip biting, and excessive blinking.
Cultural and Environmental Considerations
• Cultural beliefs and practices about modesty may influence patient
behaviors.
• Environmental impacts on the health status of the components of the
head and neck include the patients’ physical environment and access to
food and other nutrients.
• Thyroid disease is common in areas where iodine is limited and may lead
to deficiency disorders including goiter (enlarged thyroid) and
hypothyroidism.
Collecting Subjective Data
• Abnormalities that cannot be directly observed in the physical
appearance of the head and neck are often detected in the client’s
history.
• A thorough nursing history is needed to detect the cause of possible
underlying systemic problems.
• Provides an opportunity for you to evaluate activities of daily living
that may affect the condition of the client’s head and neck.
• Appearance often has a great influence on the client’s self-image.
The Nursing Health History
Common or Concerning COLDSPA Mnemonic

Symptoms of the Head Character
• Headache Onset
 COLDSPA method Location
• Head injury Duration
• Head or neck surgery Severity
• Traumatic brain injury Pattern
Associated factors/How it
affects the client
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Have you experienced head trauma or brain injury in the past?
Onset: When did this occur? Can you describe what happened? Do you
remember when you hurt your head? Precipitating Factors: What happened to
cause the TBI?
Location: Can you show me where you hurt your head?
Duration: Did you lose consciousness? If yes, for how long?
Characteristic symptoms: Did you experience any symptoms prior to the head
injury (headache, shortness of breath, chest pain, numbness, or tingling)?
Associated manifestations: Do you experience vision changes; nausea or
vomiting; attention span deficits; dizziness, confusion, drainage from the ears,
nose, eyes, or mouth; tremors; seizures; or gait changes?
Relieving factors/strategies: Prevention of further injury
Traumatic Brain Injury
RISK ASSESSMENT
Risk Factors: Age Related
• Age newborn to 4 years old
• Teenagers, especially between 15- and 19-years
• Adults over 65 years
Risk Factors: Other
• Presence of transportation accidents involving automobiles,
motorcycles, bicycles, and pedestrians
• Presence of violence, such as firearm assaults and child abuse or
self-inflicted wounds
• Falling
• Excessive alcohol ingestion
• Infants and elderly being cared for by caregivers
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Infants and Toddlers Adults and Older
• Environmental risks (for falls) Adults
• Lack of parental knowledge of • Knowledge and use
shaken baby syndrome of safety practices
• Caregivers’ risk of shaken baby when driving
syndrome • Impairment of
Children and Teens physical or mental
stability
• Knowledge and use of protective
equipment in sports and bicycle • Potential for
use maltreatment or
domestic violence
• Knowledge and use of safety
practices when driving
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Client Education
• Buckling your child in the car using a child safety seat,
booster seat, or seat belt (according to the child’s
height, weight, and age). Know the stages:
 Birth through age 2
 Between ages 2 and 4/until 40 lb
 Between ages 4 and 8 or until 4’ 9” tall
 After age 8 and/or 4’ 9” tall
• Wearing a seat belt every time you drive or ride in a
motor vehicle
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• Never driving while under the influence of alcohol or
drugs
• Wearing a helmet and making sure your children wear
helmets when:
 Riding a bike, motorcycle, snowmobile, scooter, or all-
terrain vehicle
 Playing a contact sport, such as football, ice hockey, or
boxing
 Using in-line skates or riding a skateboard
 Batting and running bases in baseball or softball
 Riding a horse
 Skiing or snowboarding
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• Making living areas safer for seniors, by:
 Removing tripping hazards such as throw rugs
and clutter in walkways
 Using nonslip mats in the bathtub and on
shower floors
 Installing grab bars next to the toilet and in the
tub or shower
 Installing handrails on both sides of stairways
 Improving lighting throughout the home
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• Maintaining a regular physical activity program, if your
doctor agrees, to improve lower body strength and
balance
• Making living areas safer for children, by:
 Installing window guards to keep young children from
falling out of open windows
 Using safety gates at the top and bottom of stairs when
young children are around
 Making sure that the surface on your child’s playground
is made of shock-absorbing material, such as hardwood
mulch or sand.
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COLLECTING SUBJECTIVE DATA
1. History of Present Health Concern

a. Assess pain: neck pain, headaches, facial pain.
b. Other symptoms: difficulty moving head/neck;
lumps/lesions; dizziness; lightheadedness; spinning
sensation; weakness and numbness in face, arms or
legs
2. Past Health History
a. Previous head or neck problems (trauma, injury, falls)
b. Undergone radiation therapy
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3. Family History
a. Headache after taking any medications
b. Hx of head and neck cancer in family
c. Hx of migraine headache in family
4. Lifestyle and Health Practices
a. Smoke or chew tobacco
b. Alcohol or recreational drug
c. Wearing helmet
d. Recreational activity participation, typical posture
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Collecting Objective Data
 Equipment needed  Preparing the client

includes:  Remove wig, hair ornaments,
 Examination gown scarves
 Clean, nonsterile  sit in an upright position
examination gloves  Explain what you are doing
 Glass of water  share your assessment
 Stethoscope findings
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General Routine Screening Versus Focused Specialty
Assessment
General Routine Screening
Focused Specialty
• Inspect head for size, shape, and
configuration
Assessment
• Palpate temporal arteries • Assess and determine type
• Palpate TMJ for swelling, tenderness, or
of headache client is
crepitation experiencing
• Inspect neck for movement, position, • Assess signs of thyroid
symmetry, lumps, or masses dysfunction
• Palpate trachea for position • Assess signs of Bell palsy
• Palpate thyroid for enlargement, lumps, or
masses
• Palpate for any enlarged or tender lymph
nodes
• Auscultate for bruits over thyroid if enlarged
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Skill 30–5 Assessing the Skull and Face
continued on next slide

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Skill 30–5 (continued) Assessing the Skull and Face
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Lifespan Considerations Assessing the Skull and Face
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Lifespan Considerations Assessing the
Neck
OLDER ADULTS
• facial subcutaneous fat decreases
• Skin may sag and wrinkle across the forehead, surrounding
the eyes, at the tip of the nose, and on the cheeks, altering
facial appearance.
• Skin lesions are more likely
• Hypothyroidism is very common
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Skill 30–10 Assessing the Neck

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Skill 30–10 (continued) Assessing the Neck

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Photo credit: www.drugs.com
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32
Video credit: Stanford Medicine 25
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Video credit: Jessica Nishikawa
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Video credit: Warwick Medical School
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ASSESSMENT TOOL
Recognizing Symptoms of Stroke
Recognize the signs of stroke and ACT F.A.S.T.:
Face drooping
Arm weakness
Speech difficulties
Time to call: Time loss is brain loss
OTHER SYMPTOMS OF STROKE BEYOND FAST
Sudden NUMBNESS or weakness of face, arm, or leg, especially
on one side of the body
Sudden CONFUSION, trouble speaking or understanding speech
Sudden TROUBLE SEEING in one or both eyes
Sudden TROUBLE WALKING, dizziness, loss of balance or
coordination
Sudden SEVERE HEADACHE with no known cause
SYMPTOMS OF STROKE IN THE POSTERIOR CIRCULATION
Vertigo, feels like the room is spinning
Imbalance
One-sided arm or leg weakness
Slurred speech or dysarthria
Double vision or other vision problems
A headache
Nausea and/or vomiting
If these symptoms are present, call for emergency care immediately.
Adapted with permission from American Heart Association. Stroke symptoms.
www.stroke.org/en/about-stroke/stroke-symptoms. ©2021 American Heart Association, Inc.
Head
• Skull and face

 Normocephalic
• Normal head size according to
standard size tables
 Exophthalmos
• Protrusion of eyeballs
• May result from hyperthyroidism
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• Microcephaly – abnormally
small head.
• Acromegaly – the skull and
facial bones are larger and
thicker.
• Moon face – increased adrenal
hormone production or
administration can cause a
round face with reddened
cheeks.
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• Bell’s Palsy
A unilateral facial mus
cle paralysis of sudden
onset
• Myxedema – severe
form of
hypothyroidism
• Parkinson’s Disease
• Down syndrome
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Eyes
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Figure 30–13 Anatomic structures of the right eye, lateral view.
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1. History of Present Health Concern

a. Visual problem: recent visual difficulties or changes,
spots or floaters, blind spots, halos or rings around
lights, trouble seeing at night, double vision
b. Other Symptoms: eye pain or itching; redness or
swelling; excessive tearing or watering; eye discharge
2. Personal Health History
a. Eye surgery, past treatments (laser, surgery
corrective lenses), medications, last eye examination
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3. Family History
a. Hx of eye problems/vision loss
4. Lifestyle and Health Practices
a. Exposed to conditions or substances in the workplace
or home. Wear safety glasses?
b. Wear sunglasses during exposure to sun
c. Vision loss, visual aids used to assist with visual loss
d. Smoking
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• Eyes and vision
 Visual acuity
 Visual fields
 Common refractive errors of
lens
• Myopia (nearsightedness)
• Hyperopia (farsightedness)
• Presbyopia (loss of elasticity and
seeing close objects)
• Astigmatism (uneven curvature)
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• Eyes and vision
 Conjunctivitis
• Inflammation of bulbar
and palpebral conjunctiva
 Dacryocystitis
• Inflammation of lacrimal
sac
 Hordeolum (sty)
• Hair follicle and glands at
eyelid edge
 Iritis continued on next slide
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• Eyes and vision
 Cataracts
• Opacity of lens generally
occurring in individuals over
65 years old
 Glaucoma
• Disturbance in circulation of
aqueous fluid that causes
increase in intraocular
pressure
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• Eyes and vision
 Mydriasis
• Enlarged pupils
 Miosis
• Constricted pupils
 Anisocoria
• Unequal pupils
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Lifespan Considerations Assessing the Eyes and Vision

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Lifespan Considerations (continued) Assessing the Eyes and
Vision
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Skill 30–6 Assessing the Eye Structures and Visual Acuity

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Skill 30–6 (continued) Assessing the Eye Structures and Visual
Acuity

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Acuity

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Acuity

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Acuity

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Acuity

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Acuity

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Acuity

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Acuity

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Acuity

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Acuity

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Acuity

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Acuity

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Acuity
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Assessing Head and Neck

• The skin, muscles, and bones of

• Facial bones provides structure for the face and

Photo credit: www.healthtap.com

Common or Concerning COLDSPA Mnemonic

1. History of Present Health Concern

 Equipment needed  Preparing the client

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Photo credit: www.drugs.com

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Video credit: Stanford Medicine 25

• Skull and face

1. History of Present Health Concern

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