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Subjective Assessment

Begin the head and neck assessment by asking focused interview questions to determine if the patient is currently experiencing any symptoms or has a previous medical history related to head and neck issues.

Table 7.4a Interview Questions for Subjective Assessment of the Head and Neck

Interview Questions Follow-up
Have you ever been diagnosed with a medical condition related to your head such as headaches, a concussion, a stroke, or a head injury? Please describe.
Have you ever been diagnosed with a medical condition related to your neck such as a thyroid or swallowing issue? Please describe.
Are you currently taking any medications, herbs, or supplements for headaches or for your thyroid? Please describe.
Have you had any symptoms such as headaches, nosebleeds, nasal drainage, sinus pressure, sore throat, or swollen lymph nodes? If yes, use the PQRSTU method to gather additional information regarding each symptom.
Specific oral assessment questions[1]:

  • Are you having any pain, bleeding, or other problems with your teeth or gums?
  • Do you have any loose or sensitive teeth?
  • Do you experience bleeding after brushing or flossing your teeth?
  • Are you wearing dentures? Do they fit properly?
  • Are you experiencing bad breath that won’t go away?
  • Have your eating patterns changed due to mouth pain or discomfort with chewing?

Life Span Considerations

Infants and Children

For infants, observe head control and muscle strength. Palpate the skull and fontanelles for smoothness. Ask the parents or guardians if the child has had frequent throat infections or a history of cleft lip or cleft palate. Observe head shape, size, and symmetry.

Older Adults

Ask older adults if they have experienced any difficulties swallowing or chewing. Document if dentures are present. Muscle atrophy and loss of fat often cause neck shortening. Fat accumulation in the back of the neck causes a condition referred to as “Dowager’s hump.”

Objective Assessment

Use any information obtained during the subjective interview to guide your physical assessment.

Inspection

  • Begin by inspecting the head for skin color and symmetry of facial movements, noting any drooping. If drooping is noted, ask the patient to smile, frown, and raise their eyebrows and observe for symmetrical movement. Note the presence of previous injuries or deformities.
  • Inspect the nose for patency and note any nasal drainage.
  • Inspect the oral cavity and ask the patient to open their mouth and say “Ah.” Inspect the patient’s mouth using a good light and tongue blade.
    • Note oral health of the teeth and gums.
      • If the patient wears dentures, remove them so you can assess the underlying mucosa.
      • Assess the oral mucosa for color and the presence of any abnormalities.
      • Note the color of the gums, which are normally pink. Inspect the gum margins for swelling, bleeding, or ulceration.
      • Inspect the teeth and note any missing, discolored, misshapen, or abnormally positioned teeth. Assess for loose teeth with a gloved thumb and index finger, and document halitosis (bad breath) if present.[2]
    • Assess the tongue. It should be midline and with no sores or coatings present.
    • Assess the uvula. It should be midline and should rise symmetrically when the patient says “Ah.”
    • Is the patient able to swallow their own secretions? If the patient has had a recent stroke or you have any concerns about their ability to swallow, perform a brief bedside swallow study according to agency policy before administering any food, fluids, or medication by mouth.
  • Inspect the neck. The trachea should be midline, and there should not be any noticeable enlargement of lymph nodes or the thyroid gland.
  • Note the patient’s speech. They should be able to speak clearly with no slurring or garbled words.

If any neurological concerns are present, a cranial nerve assessment may be performed. Read more about a cranial nerve assessment in the “Neurological Assessment” chapter.

Auscultation

Auscultation is not typically performed by registered nurses during a routine neck assessment. However, advanced practice nurses and other health care providers may auscultate the carotid arteries for the presence of a swishing sound called a bruit.

Palpation

Palpate the neck for masses and tenderness. Lymph nodes, if palpable, should be round and movable and should not be enlarged or tender. See the figure illustrating the location of lymph nodes in the head and neck in the “Head and Neck Basic Concepts” section earlier in this chapter. Advanced practice nurses and other health care providers palpate the thyroid for enlargement, further evaluate lymph nodes, and assess the presence of any masses.

See Table 7.4b for a comparison of expected versus unexpected findings when assessing the head and neck.

Table 7.4b Expected Versus Unexpected Findings on Adult Assessment of the Head and Neck

Assessment Expected Findings Unexpected Findings (to document and notify provider if new finding*)
Inspection Skin tone is appropriate for ethnicity, and skin is dry.

Facial movements are symmetrical.

Nares are patent and no drainage is present.

Uvula and tongue are midline.

Teeth and gums are in good condition.

Patient is able to swallow their own secretions.

Trachea is midline.

If dentures are present, there is a good fit, and the patient is able to appropriately chew food.

 Skin is pale, cyanotic, or diaphoretic (inappropriately perspiring).

New asymmetrical facial expressions or drooping is present.

Nares are occluded or nasal drainage is present.

Uvula and/or tongue is deviated to one side.

White coating or lesions on the tongue or buccal membranes (inner cheeks) are present.

Teeth are missing or decay is present that impacts the patient’s ability to chew.

After swallowing, the patient coughs, drools, chokes, or speaks in a gurgly/wet voice.

Trachea is deviated to one side.

Dentures have poor fit and/or the patient is unable to chew food contained in a routine diet.
Palpation No unusual findings regarding lymph nodes are present. Cervical lymph nodes are enlarged, tender, or nonmovable. Report any concerns about lymph nodes to the health care provider.
*CRITICAL CONDITIONS to report immediately New asymmetry of facial expressions, tracheal deviation to one side, slurred or garbled speech, signs of impaired swallowing, coughing during or after swallowing, or a “wet” voice after swallowing.
  1. Bencosme, J. (2018). Periodontal disease: What nurses need to know. Nursing, 48(7), 22-27. https://doi.org/10.1097/01.nurse.0000534088.56615.e4 ↵
  2. Bencosme, J. (2018). Periodontal disease: What nurses need to know. Nursing, 48(7), 22-27. https://doi.org/10.1097/01.nurse.0000534088.56615.e4 ↵

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