7.6 Checklist for Head and Neck Assessment
Open Resources for Nursing (Open RN)
Use the checklist below to review the steps for completion of a “Head and Neck Assessment.”
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: penlight, tongue blade, and nonsterile gloves.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs.
- Inspect the head and facial expressions for symmetrical movement.
- Inspect the nose with a penlight for drainage and occlusion.
- Inspect the oral cavity for lesions, tongue position, movement of uvula, and oral health using a penlight.
- Inspect the throat and note any enlargement of the tonsils.
- Palpate the lymph nodes of the head and neck, including submaxillary, anterior cervical, posterior cervical, and preauricular.
- Ask the patient to swallow their own saliva and note any signs of difficulty swallowing.
- Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- Ensure five safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Perform hand hygiene.
- Document the assessment findings and report any concerns according to agency policy.
