Nama : Karina Chania dan Amalia Lenanda

Kelas/Prodi : 2B/D3 Keperawatan

TOPIC 5

PATIENT ASSESSMENT (HEAD, FACE, NECK)

Conversation

Nurse : Good Morning

Patient : Good Morning, nurse

Nurse : How are you?

Patient : I’m good

Nurse : Okay, I’m nurse Karina of Faletehan Serang, How are you doing today?

Patient : Doing just fine thank you

Nurse : I’m here to assess your head, face, neck.

Patient : okay nurse

Nurse : I’m going to start by asking a couple of questions do you smoke or chew tobacco?

Patient : No

Nurse : Do you have any cold recently?

Patient : No

Nurse : Any problems with your mouth, your face that you’re aware of?

Patient : No

Nurse : Any problems with your thyroid?

Patient : No

Nurse : Okay, all right so we’re just going to proceed then I’m going to start out by looking at your
head and your face.

Patient : Yes nurse

Nurse : So I’m looking at the shape and size of your head which is appropriate for your size of person
and we call that normal cephalic.

Patient : Okay
Patient : And then I’m going to palpate your whole scalp here your head and what I’m checking for is
any lumps, bumps, protrusions and then tensions, anything hurt?

Patient : Nothing

Nurse : I see nothing abnormal and so while palpating to put my hands rights here and I’m going to ask
you to open and close your mouth?

Patient : Aaaaaaa (Open mouth)

Nurse : Okay,and close the temple mandibular joint and I’m checking for any clicking or crepitus or any
pain, any pain with that?

Patient : No

Nurse : All right and then I’m moving on just inspecting your face and I’m looking for symmetry of the
face, so when I’m looking symmetry, I’m looking at the eyebrows, the eyes, the labial folds here
and the sides of the mouth it should all be symmetrical.

Patient : Okay nurse

Nurse : I want you to rise your eyebrows

Patient : Yes

Nurse : Please close your eyes tightly

Patient : (close eyes)

Nurse : So If there is one side of the face that was drooping it would indicate possibly a stroke or
possibly a problem with cranial nerve number seven or Bell’s palsy, so we’re looking for any
swelling of the parotid glands on the sides of the cheeks in the projection not for any swelling
right here of salivary glands and any swelling here at the base of the neck for the thyroid gland
all right that’s good.

Patient : Okay nurse

Nurse : So I want you to puff out your cheeks.

Patient : (doing instruction)

Nurse : Alright that’s good, and then you can look straight at me and we’re going to continue with
assessment of your range of motion of your neck.

Patient : Yes nurse

Nurse : Please put your chin up and then put your chin down to your chest and then turn it side to side

Patient : (doing instruction)

Nurse : And then put your ear to shoulder and put your ear to your other shoulder

Patient : (doing instruction)

Nurse : alright, so your range of motion on your neck is normal. Now I’m going to check the function of
cranial nerve number 11, so can you shrug your shoulders?

Patient : Yes nurse

Nurse : alright good relax, and turn your head to the right and turn your head to the left.

Patient : (doing instruction)

Nurse : OK, Fine. That’s it.