Checklist for Head and Neck Assessment

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.

1. Gather supplies: penlight, tongue blade, and nonsterile gloves.
2. 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.
3. Inspect the head and facial expressions for symmetrical movement.
4. Inspect the nose with a penlight for drainage and occlusion.
5. Inspect the oral cavity for lesions, tongue position, movement of uvula, and oral health using a penlight.
6. Inspect the throat and note any enlargement of the tonsils.
7. Palpate the lymph nodes of the head and neck, including submaxillary, anterior cervical, posterior cervical, and preauricular.
8. Ask the patient to swallow their own saliva and note any signs of difficulty swallowing.
9. Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
10. Ensure 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)
11. Perform hand hygiene.
12. Document the assessment findings and report any concerns according to agency policy.