HEALTH ASSESSMENT - Head to Neck

Physical Assessment Procedures

Assessing Appearance and Mental Status (General Survey)

		Normal Findings	Deviation from Normal
1.	Observe body build, height, and weight in relation to the client’s age, lifestyle, and health.	Proportionate, varies with lifestyle	Excessively thin or obese
2.	Observe the client’s posture and gait, standing, sitting, and walking.	Relaxed, erect posture, coordinated movement	Tense, slouched, bent posture, uncoordinated movement, tremors, dirty, unkempt
3.	Observe the client’s overall hygiene and grooming. Relate these to the person’s activities prior to the assessment.	Clean, neat	Dirty, unkempt
4.	Note body and breath odor in relation to activity level.	No body/breath odor or minor body odor relative to work or exercise	Foul body odor, ammonia odor, acetone breath odor, foul breath
5.	Observe for signs of distress in posture or facial expression.
6.	Note obvious signs of health or illness.	Healthy appearance	Pallor, weakness, obvious illness
7.	Assess the client’s attitude.	Cooperative	Negative, hostile, withdrawn
8.	Note the client’s affect/mood; assess the appropriateness of the client’s responses.	Appropriate to situation	Inappropriate to situation
9.	Listen for quantity, quality, and organization of speech.	Understandable, moderate pace, exhibits thought association	Rapid or slow pace, overly loud or soft, uses generalizations, lacks association
10.	Listen for relevance and organization of thoughts.	Logical sequence, makes sense, has sense of reality	Illogical sequence, flight of ideas, confusion

Assessing the Skin

		Normal Findings	Deviation from Normal
1.	Inspect skin color.	Varies from light to deep brown, from ruddy pink to light pink	Pallor Cyanosis Jaundice Erythema
2.	Inspect uniformity of skin color.	Generally uniform except in areas exposed to sun; areas of lighter pigmentation in dark skinned	Areas of either Hyperpigmentation or Hypopigmentation
3.	Assess edema, if present.	No edema	Edema
4.	Inspect, palpate, and describe skin lesions. Apply gloves if lesions are open or draining. Describe lesions according to location, distribution, color, configuration, size, shape, type, or structure.	Freckles, some birth marks, some flat and raised nevi, no abrasion or other lesion	Various interruption in skin integrity; irregular, multicolored, or raised nevi
5.	Observe and palpate skin moisture.	Moisture in skin folds and the axillae, affected by different factors	Excessive moisture or dryness
6.	Palpate skin temperature. Compare the two feet and the two hands, using the backs of your fingers.	Uniform; within normal range	Generalized/ Localized hyperthermia/ hypothermia
7.	Note skin turgor by lifting and pinching the skin on an extremity.	When pinched, skin springs back to previous state	Skins stays pinched or tented or moves back slowly

• Pallor

§ Decrease in color of the skin, caused by lack of oxyhemoglobin.

§ A result of anemia or decreased arterial perfusion

§ Best observed around fingernails, lips and oral mucosa

§ In dark-skinned, best observed on the palms of hands and soles of feet

• Cyanosis

§ A bluish discoloration of the skin and mucous membrane

§ Peripheral Cyanosis

§ Central Cyanosis

• Jaundice

§ Icterus

§ Yellowness of the skin, sclera, mucous membranes, and excretions

• Erythema

§ Redness of the skin due to congestion of the capillaries

Evaluation of edema. Palpate for edema over the tibia as shown here and behind the medial malleolus, and over the dorsum of each foot.

Four point-scale for grading edema:
            1+        barely detectable
            2+        2 to 4 mm
            3+        5 to 7 mm
            4+        more than 7 mm

Skin Turgor

• Indicative of status of hydration of the body

• Done by pinching skin

• In a healthy person, pinched skin immediately returns to its normal position when released.

• The skin turgor test is not as valid in elderly people as in younger people because skin elasticity decreases with age

• Best measured by pinching the skin over sternum, inner aspects of thigh or forehead.

To assess skin turgor, a small fold of skin is picked up and then released to return to its normal shape. Difficulty in lifting a skin fold may indicate presence of edema.

Assessing the Hair

		Normal Findings	Deviation from Normal
1.	Inspect the evenness of growth over the scalp.	Evenly distributed hair	Patches of hair loss (alopecia)
2.	Inspect hair thickness or thinness.	Thick hair	Very thin hair (in hypothyroidism)
3.	Inspect hair texture and oiliness.	Silky, resilient hair	Brittle hair; excessively oily or dry hair
4.	Note presence of infections or infestations by parting the hair in several areas and checking behind the ears and along the hairline at the neck.	No infection or infestation	Flaking, sores, lice, nits, and ringworms
5.	Inspect the amount of body hair.	Variable	Hirsutism in women; naturally absent or sparse leg hair (poor circulation)

Assessing the Nails

		Normal Findings	Deviation from Normal
1.	Inspect fingernail plate shape to determine its curvature and angle.	Convex curvature; angle between nail and nail bed usually 160°	Less: spoon shaped More: clubbing
2.	Inspect fingernail and toenail texture.	Smooth texture	Excessive thickness or thinness or presence of grooves or furrows; Beau’s line
3.	Inspect fingernail and toenail bed color.	Highly vascular and pink in light skinned; dark skinned may be brown or black	Bluish or purplish tint; pallor
4.	Inspect tissues surrounding nails.	Intact epidermis	Hangnails; paronychia; koilonychia
5.	Perform blanch test of capillary refill. Press two or more nails between your thumb and index finger; look for blanching and return of pink color to nail bed.	Prompt return or pink or usual color, less than four seconds	Delayed return of pink or usual color

Assessing the Skull & Face

		Normal Findings	Deviation from Normal
1.	Inspect the skull for size, shape, and symmetry.	Rounded (normocephalic and symmetrical, with frontal, parietal and occipital prominences); smooth skull contour	Lack of symmetry; increased skull size with more prominent nose and forehead; longer mandible
2.	Palpate the skull for nodules or masses and depressions. Use a gentle rotating motion with the fingertips. Begin at the front and palpate down the midline, then palpate each side of the head.	Smooth, uniform consistency; absence of nodules or masses	Sebaceous cysts; local deformities from trauma
3.	Inspect the facial features.	Symmetric or slightly assymetric facial features	Increased facial hair; thinning of eyebrows; exophthalmos; myxedema facies; moonfacies
4.	Inspect the eyes for edema and hollowness.	No edema	Periorbital edema; sunken eyes
5.	Note symmetry of facial movements. Ask the client to elevate the eyebrows, frown, or lower the eyebrows, close the eyes tightly, puff the cheeks, and smile and show teeth.	Symmetric facial movements	Asymmetric facial movements, drooping of lower eyelid and mouth, involuntary facial movement

Assessing the Eye Stuctures & Visual Acuity

	*External Eye Structures*	Normal Findings	Deviation from Normal
1.	Inspect the eyebrows for hair distribution and alignment, and for skin quality and movement.	Hair evenly distributed; skin intact Symmetrically aligned; equal movement	Loss of hair; scaling and flakiness of skin Unequal alignment and movement of eyebrow
2.	Inspect the eyelashes for evenness of distribution and direction of curl.	Equally distributed; curled slightly outward	Turned inward
3.	Inspect the eyelids for surface characteristics, position in relation to the cornea, ability to blink, and frequency of blinking. Inspect the lower eyelids while the client’s eyes are closed.	Skin intact; no discharge; no discoloration Lids close symmetrically 15-20 blinks/min, involuntarily, bilateral	Redness, swelling, flaking, crusting, plaques, discharge, nodules, lesions;Lids close asymmetrically, incompletely, or painfully; Rapid, monocular, absent or infrequent blinking
4.	Inspect the bulbar conjunctiva for color, texture, and the presence of lesions.	Transparent, capillaries sometimes evident	Jaundiced sclera, excessively pale sclera, reddened sclera; lesions or nodules
5.	Inspect the palpebral conjunctiva by everting the lids.	Shiny, smooth, and pink or red	Extremely pale, extremely red, nodules or other lesions
7.	Inspect and palpate the lacrimal gland. Using the tip of your index finger, palpate the lacrimal gland. Observe for edema between the lower lid and the nose.	No edema or tenderness over lacrimal gland.	Swelling or tenderness over lacrimal gland
8.	Inspect and palpate the lacrimal sac and nasolacrimal duct. Observe for evidence of increased tearing. Using the tip of your index finger, palpate inside the lower orbital rim near the inner canthus.	No edema or tearing	Evidence of increased tearing, regurgitation of fluid on palpation of lacrimal sac
9.	Inspect the cornea for clarity and texture. Ask the client to look straight ahead. Hold a penlight at an oblique angle to the eye, and move the light slowly across the corneal surface.	Transparent, shiny, and smooth; details of iris are visible	Opaque, surface not smooth
10.	Perform the corneal sensitivity (reflex) test to determine the function of the fifth (trigeminal) cranial nerve. Ask the client to keep both eyes open and look straight ahead. Approach from behind and beside the client, and lightly touch the cornea with a corner of the gauze.	Client blinks when the cornea is touched, indicating that the trigeminal nerve is intact.	One or both eyelids fail to respond
11.	Inspect the anterior chamber for transparency and depth. Use the same oblique lighting used when testing the cornea.	Transparent No shadows of light on iris Depth of about 3 mm	Cloudy Crescent-shaped shadows on far side of iris Shallow chamber (possible glaucoma)
12.	Inspect the pupils for color, shape, and symmetry of size.	Black in color, equal in size; normally 3 to 7 mm in diameter; smooth border	Cloudiness, mydriasis, miosis, anisocoria
13.	Assess each pupil’s direct and consensual reaction to light. Partially darken a room. Ask the client to look straight ahead. Using a penlight and approaching from the side, shine a light on the pupil. Observe the response. The pupil should constrict (direct response). Shine the light on the pupil again, and observe the response of the other pupil. It should also constrict (consensual response).	Illuminated pupil constricts; non-illuminated constricts	Neither pupil constricts Unequal responses Absent responses
14.	Move the penlight or pencil toward the client’s nose. The pupils should converge.	Pupils converge when near object is moved towards the nose	One or both pupils fail to converge
15.	Assess peripheral visual fields.	When looking straight ahead, client can see objects in periphery	Visual field smaller than normal; one half vision in one or both eyes
16.	Assess six ocular movements to determine eye alignment and coordination.	Both eyes coordinated, move in unison, with parallel alignment	Eye movements not coordinated or parallel; one or both eyes fail to follow a penlight in specific directions; nystagmus
17.	Assess near vision by providing adequate lighting and asking the client to read from a magazine or newspaper.	Able to read newsprint	Difficulty reading newsprint unless due to aging process
18.	Assess distance vision by asking the client to wear corrective lenses unless they are used for reading only. • Ask the client to sit or stand 6 meters (20 ft) from Snellen’s chart, cover the eye not being tested, and identify the letters or characters. • Take three readings: right eye, left eye, and both eyes.	20/20 vision on Snellen Chart	Denominator of 40 or more on Snellen Chart with corrective lenses

· The normal pupil constricts when focused on a near object and dilates when focused on a far object. This is called accommodation.

· To record normal assessment of the pupils, use the abbreviation PERRLA (Pupils Equally Round, Reactive to Light and Accomodation)

• To test the temporal field of the left eye, extend and move your right arm in from the client’s right periphery. Temporally, peripheral objects can be seen at right angles to the central point of vision.

• To test the upward field of the left eye, extend and move the right arm down from the upward periphery. The upward field of vision is normally 50 degrees because the orbital edge is in the way.

• To test the downward field of the left eye, extend and move the right arm up from the lower periphery. The downward field of vision is normally 70 degrees because the cheekbone is in the way.

• To test the nasal field of the left eye, extend and move your left arm in from the periphery. The nasal field of vision is normally 50 degrees away from the central point because the nose is in the way.

Assessing the Ears and Hearing

		Normal Findings	Deviation from Normal
1.	Inspect the auricles for color, symmetry of size, and position. To inspect position, note the level at which the superior aspect of the auricle attaches to the head with relation to the eye.	Color same as facial skin; Symmetrical; Aligned with outer canthus or eye, about 10^º from vertical	Bluish color or earlobes (cyanosis), pallor, excessive redness; Asymmetry; Low set ears
2.	Palpate the auricles for texture, elasticity, and areas of tenderness.	Mobile, firm, and not tender; pinna recoils after folded	Lesions, tenderness when moved or pressed
3.	Assess the client’s response to normal voice tones. If the client has difficulty hearing the normal voice, proceed with the following tests.	Normal voice tones audible	Normal voice tones not audible
4.	Perform the watch tick test.	Able to hear ticking in both ears (watch tick test)	Unable to hear ticking in one or both ears
5.	Perform Weber test. • Hold the tuning fork at its base. Activate it by tapping the fork gently against the back of your hand near the knuckles or by stroking the fork between your thumb and index finger • Place the base of the vibrating fork on top of the client’s head and ask whether the client hears the noise.	Sound is heard in both ears or is localized at the center of head (Weber negative)	Sensorineural disturbance (Weber positive)
6.	Conduct Rinne test. · Ask the client to block the hearing in one ear intermittently by moving a fingertip in and out of the ear canal. · Hold the handle of the activated tuning fork on the mastoid process of one ear until the client states that the vibration no longer can be heard. · Immediately hold still the vibrating fork prongs in front of the client’s ear canal. If necessary, push aside the client’s hair. Ask whether the client now hears the sound.	AC>BC (Positive Rinne)	BC> AC or BC = AC (Negative Rinne)

Assessing the Nose and Sinuses

1.	Inspect the external nose for any deviations in shape, size, or color and flaring, or discharge from the nares.	Symmetric and Straight; No discharge or flaring; Uniform color; Not tender, no lesions	Asymmetric; Discharge from nares; Localized area of redness/skin lesions; Tenderness on palpation
2.	Lightly palpate the external nose to determine any areas of tenderness, masses, or displacements of bone and cartilage.	No tender; no lesions	Tenderness on palpation; presence of lesions
3.	Determine patency of both nasal cavities. Ask the client to close the mouth, exert pressure on one naris, and breathe through the opposite naris. Repeat the procedure to assess patency of the opposite naris.	Air moves freely as client breathes through the nares	Air movement is restricted to one or both nares
4.	Observe for the presence of redness, swelling, growths, and discharge.	Mucosa pink Clear, watery discharge No lesions	Mucosa red, edematous Abnormal discharge Presence of lesions
5.	Inspect the nasal septum between the nasal chambers.	Intact and in midline	Deviated to the left or to the right
6.	Palpate the maxillary and frontal sinuses for tenderness.	Not tender	Tenderness in one or more sinuses

· The frontal sinuses are palpated by gently pressing upward on the bony prominences above each eye.

· The maxillary sinuses are palpated by applying gentle pressure on the bony prominences of the upper cheek.

Assessing the Mouth and Oropharynx

		Normal Findings	Deviation from Normal
1.	Inspect the outer lips for symmetry of contour, color, and texture. Ask the client to purse lips as if to whistle.	Uniform pink color; Soft, moist, smooth texture; Symmetry of contour; Ability to purse lips	Pallor; cyanosis Blisters; generalized or loc. Swelling; fissures, crusts or scales Inability to purse lips
2.	Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture, and the presence of lesions.	Uniform pink color Moist, smooth, soft, glistening, and elastic texture	Pallor; white patches Excessive dryness Mucosal cysts; irritations from dentures; abrasions, ulcerations; nodules
3.	Inspect the teeth and gums while examining the inner lips and buccal mucosa.	32 adult teeth Smooth, white, shiny tooth enamel. Pink gums Moist, firm texture to gums.	Missing teeth; ill-fitting dentures Brown or black discoloration of the enamel. Excessively red gums Spongy texture; bleeding; tenderness Receding, atrophied gums; swelling that partially covers the teeth.
4.	Inspect the surface of the tongue for position, color, and texture. • *Ask the client to protrude the tongue and move it from side to side.*	Tongue in central position; Pink color, moist, slightly rough; thin whitish coating;	Deviated from center Smooth red tongue
5.	Inspect tongue movement. • Ask the client to roll the tongue upward and move it from side to side.	Moves freely; no tenderness	Restricted mobility
6.	Inspect the base of the tongue, the mouth floor, and the frenulum. • *Ask the client to place the tip of his tongue against the roof of the mouth.*	Smooth tongue base with prominent base	Swelling; ulceration
7.	Palpate the tongue and floor of the mouth for any nodules, lumps, or excoriated areas. • *Use a piece of gauze to grasp the tip of the tongue and, with the index finger of your other hand, palpate the back of the tongue, its borders, and its base.*	Smooth with no palpable nodules	Swelling nodules
8.	Inspect salivary duct openings for any swelling or redness	Same as color of buccal mucosa and floor of mouth	inflammation
9.	Inspect the hard and soft palate for color, shape, texture, and the presence of bony prominences. • *Ask the client to open mouth wide and tilt head backward. Then, depress tongue with a tongue blade as necessary, and use a penlight for appropriate visualization.*	Light pink, smooth, soft palate; Lighter pink hard palate, more irregular texture	Discoloration Palates the same color Irritations Bony growths growing from hard palate
10.	Inspect the uvula for position and mobility while examining the palates. • *To observe the uvula, ask the client to say “ah” so that the soft palate rises.*	Positioned in midline of soft palate	Deviation to one side from tumor or trauma; immobility
11.	Inspect the oropharynx for color and texture. • Inspect one side at a time to avoid eliciting the gag reflex. To expose one side of the oropharynx, press a tongue blade against the tongue on the same side about halfway back while the client tilts head back and opens mouth wide. Use a penlight for illumination, if needed.	Pink and smooth posterior wall	Reddened or edematous; presence of lesions, plaques, or drainage
12.	Inspect the tonsils for color, discharge, and size.	Pink and smooth No discharge Of normal size or not visible Grade 1	Inflamed Presence of discharge Swollen Grade 2 Grade 3 Grade 4
13.	Elicit the gag reflex by pressing the posterior tongue with a tongue blade.	Present	Absent

Grading System for Tonsillitis:

• Grade 1 – The tonsils are behind the tonsillar pillars (Normal)

• Grade 2 – between the pillars and the uvula

• Grade 3 – tonsils touch the uvula

• Grade 4 – one or both tonsils extend to the midline of the oropharynx

Assessing the Neck

		Normal Findings	Deviation from Normal
1.	Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal swellings or masses. • *Ask the client to hold head erect.*	Muscles equal in size; head centered	Unilateral neck swelling; head tilted to one side
2.	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.)* • *Move head so that the ear is moved toward the shoulder on each side. (Determines function of the sternocleidomastoid muscle.)* • *Turn head to the right and to the left. (Determines function of the sternocleidomastoid muscle.)*	Coordinated, smooth movements with no discomfort Head flexes 45 Head hyperextends 60 Head laterally flexes 40 Head laterally rotates 70	Muscle tremor, spasm, or stiffness Limited ROM Less than 60 Less than 70 Less than 70
3.	Assess muscle strength. • *Ask the client to:* • *Turn head to one side against the resistance of your hand. Repeat with the other side.* • *Shrug shoulders against the resistance of your hands.*	Equal strength Equal strength	Unequal strength Unequal strength
4.	Palpate the entire neck for enlarged lymph nodes.	Not palpable	Enlarged, palpable, possibly tender
5.	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 the trachea.	Central placement in midline of neck; spaces are equal on both sides	Deviation to one side, indicating possible neck tumor; thyroid enlargement; enlarged lymph nodes
6.	Inspect 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, offer a glass of water to make it easier for the client to swallow.*	Not visible on inspection Gland ascends during swallowing but it is not visible	Visible diffuseness or local enlargement Gland is not fully movable with swallowing
7.	Palpate the thyroid gland for smoothness. • *Note any areas of enlargement, masses, or nodules.*	Lobes may not be palpated If palpated, lobes are small, smooth, centrally located, painless, rise freely with swallowing	Solitary nodules