Assess of Head and Neck

Assess	Document: assessment, interventions, outcomes
Appearance: Inspect Pt’s overall appearance.	■ Hygiene, state of well-being, nutrition status. ■ Level of consciousness, emotional status, speech patterns, affect, posture, gait, coordination, and balance. ■ Any gross deformities.
Skin: Inspect and palpate exposed skin.	■ Warmth, moisture, color, texture, lesions. ■ Scars, body piercings, tattoos.
Hair and Nails: Inspect hair, hands, and nails.	■ Hair color, fullness, and distribution, noting any signs of malnutrition (thinning). ■ Infestation or disease. ■ Clubbing, deformity, abnormalities of hands.
Head: Inspect and palpate face and scalp.	■ Facial symmetry. ■ Scalp tenderness, lesions, or masses.
Eyes: Inspect conjunctiva, sclera, and pupils.	■ Color and hydration of conjunctiva and sclera. ■ PERRLA: Pupils equal, round, reactive to light and accommodation.
Ears: Inspection.	■ Hearing impairment. ■ Use of hearing aids. ■ Pain, inflammation, and drainage.
Nose: Inspection.	■ Congestion, drainage, and sense of smell. ■ Patency/equality of nostrils, nasal flaring. ■ Septal deviation.
Throat and Mouth: Inspect teeth, gums, tongue, mucous membranes, and oropharynx.	■ Color and hydration of mucous membranes. ■ Gingival bleeding or inflammation. ■ Condition of teeth (any missing, severe decay), dentures. ■ Difficult or painful swallowing. ■ Presence or absence of tonsils. ■ Oral hygiene and the presence of odor.
Neck: Inspect and palpate neck. Test range of motion (ROM).	■ Jugular vein distention (JVD), tracheal alignment (deviation), and retractions. ■ Swollen lymph nodes. ■ Decreased ROM, stiffness, or pain.