When assessing the face which are is best for assessing symmetry of facial features?

This article will explain how to assess the head and neck as a nurse. This assessment is part of the nursing head-to-toe assessment you have to perform in nursing school and on the job.

During the head and neck assessment you will be assessing the following structures:

• Head
  • includes- face, hair, eyes, nose, mouth, ears, temporal artery, sinuses, temporomandibular joint, cranial nerves
• Neck
  • includes-lymph nodes, carotid artery, cranial nerves, thyroid gland, trachea

Video Demonstration on Head and Neck Assessment

Inspect the face and hair:

• Inspect the overall appearance of the face (are the eyes and ears at the same level)?
• Is the head an appropriate size for the body?
• Is the face symmetrical…. no drooping of the face on one side (eyes or lips). This can happen in Bell’s palsy or stroke.

• Are the facial expressions symmetrical (no involuntary movements)?
• Any lesions?
• Test cranial nerve VII…facial nerve: have the patient close their eyes tightly, smile, frown, puff out cheek. Can they do this will ease?

Palpate the cranium and inspect the hair for infestations, hair loss, skin breakdown or abnormalities:

• Palpate for any masses or indentations
• Skin breakdown (especially on the back of the head in immobile patients)?
• Inspect the hair for any infestations: lice, alopecia areata (round abrupt balding in patches), nevus on the scalp etc.
  

Palpate the temporal artery bilaterally

Test Cranial Nerve V…..trigeminal nerve: This nerve is responsible for many functions and mastication is one of them.

• Have the patient bite down and feel the masseter muscle and temporal muscle
• Then have the patient try to open the mouth against resistance

Palpate the temporomandibular joint for grating or clicking: Have the patient open and close the mouth and feel for any grating sensation or clicking.

Palpate the frontal and maxillary sinuses for tenderness: patient will pressure but should not feel pain

Eyes:

Inspect the eyes, eye lids, pupils, sclera, and conjunctiva

• Is there swelling of the eye lids?
• Is the sclera white and shiny?…not yellow as in jaundice

• Is the conjunctiva pink NOT red and swollen?
• Look for Strabismus and Aniscoria:
  • Strabismus: Do the eyes line up with another?
  • Aniscoria: Are the pupils equal in size…or is one pupil larger than the other?

• Are the pupils clear…not cloudy?
  • Normal pupil size should be 3 to 5 mm and equal

Test cranial nerves III (oculomotor), IV (trochlear), VI (abducens)

• Have the patient follow your pen light by moving it 12-14 inches from the patient’s face in the six cardinal fields of gaze (start in the midline)
  • Watch for any nystagmus (involuntary movements of the eye)
• Reactive to light?
  • Dim the lights and have the patient look at a distant object (this dilates the pupils)
  • Shine the light in from the side in each eye.
    • Note the pupil response: The eye with the light shining in it should constrict (note the dilatation size and response size (ex: pupil size goes from 3 to 1 mm) and the other side should constrict as well.
  • Accommodation?
    • Make the lights normal and have patient look at a distant object to dilate pupils, and then have patient stare at pen light and slowly move it closer to the patient’s nose.
      • Watch the pupil response: The pupils should constrict and equally move to cross.

If all these findings are normal you can document PERRLA.

Ears:

Inspect the ears for:

• Drainage (ear wax) or abnormalities

• Ask the patient if they are experiencing any tenderness and palpate the pinna and targus.
• Palpate the mastoid process for swelling or tenderness.

Tests cranial nerve 8 VIII…vestibulocochlear nerve:

• Test the hearing by occluding one ear and whispering two words and have the patient repeat them back. Repeat this for the other ear.

Inspect the tympanic membrane:

• Use an otoscope to look at the tympanic membrane. It should appear as a pearly gray, translucent color and be shiny. Remember for an adult: pull up and back and for a child down and back on the pinna.
• Also, the cone of light should be at the 5:00 position in the right ear and 7:00 position in the left ear.

Nose:

Inspect nose

• Symmetrical (midline, look at septum for any deviation)
• Drainage (ask patient if they are having any discharge)
• Use a penlight to shine inside the nose and look for any lesions, redness, or polyps
• Then have the patient close one nostril and have the patient breathe out of it and do the same for the other…are they patent?

Test cranial nerve I..….olfactory nerve: Have the patient close their eyes and place something with a pleasant smell under the nose and have them identify it.

Mouth:

Inspect lips (lip should be pink NOT dusky or blue/cyanotic or cracked, and free from lesions)

Inspect the inside of the mouth:

• Color of mucous membranes and gums should be pink and shiny. The teeth should be white and free from cavities. Note: any broken or loose teeth too.

Inspect tongue:

• Should be moist and pink (NOT dry or cracked or beefy red (pernicious anemia)
• Underneath the tongue should be no lesions or sores

Inspect hard and soft palate and tonsils (no exudate on tonsils) and uvula should be midline

Test cranial nerve XII….hypoglossal: have patient stick tongue out and move it side to side

Test cranial nerve IX (glossopharyngeal) and X (vagus) have patient say “ah”…the uvula will move up (cranial nerve IX intact) and if the patient can swallow with ease and has no hoarseness when talking, cranial nerve X is intact.

Neck:

Inspect the trachea

• Is it midline, are there any lesions, lumps (goiter), or enlarged lymph nodes (have patient extend the neck up so you can access it better)?

Test cranial nerve XI….accessory nerve: Have the patient move head from side to side and up and down and shrug shoulders against resistance.

Inspect for jugular vein distention

• Place the patient in supine positon at 45 degree angle and have them turn the head to the side and note any enlargement of the jugular vein.

Palpate the lymph nodes with the pads of fingers and feel for lumps, hard nodules, or tenderness:

• Preauricular, postauricular, occipital, parotid, jugulodiagastric (tonsillar), submandibular, submental, superficial cervical, deep cervical chain, posterior cervical, supravclavicular

Palpate the tracheaand confirm it is midline

Palpate thyroid gland from the back: note for nodules, tenderness or enlargement…normally can’t palpate it.

Palpate the carotid artery (one side at a time) and grade it (0 to 4+….2+ is normal)

Auscultate for bruits at the carotid artery with BELL of stethoscope (listen for a swooshing sound which is a bruit)…have patient breathe in and out and hold it while listening.

You may be interested in watching a complete head-to-toe assessment.