MALATE, JENILYN A.

BSN 1-B APRIL 18,2022 GROUP 4

NCM 101 HEALTH ASSESSMENT MS. MA. MELANDA V. SOSING

Nursing Assessment in Tabular Form: HEAD AND NECK

A. PEDIATRIC CLIENT

NAME: JACOB E. MALATE AGE: 6 YRS. OLD GENDER: MALE

BIRTHDATE: AUGUST 28, 2015 ADDRESS: BRGY. CANRAMOS TANAUAN, LEYTE

Assessment Normal Findings Client’s Findings

Integumentary
 Skin When skin is pinched it goes to previous state It has fair complexion. No hyperpigmentation or scars.
immediately (2 seconds). The skin immediately goes to previous state after being
With fair complexion. pinched. And do not have dry skin.
With dry skin
No hyperpigmentation, mole or scarring
 Hair Light blond to black and gray with alterations caused His hair is black. No exposures from dye. Straight, shiny
by rinses, dyes and permanents. and soft. When held, his hair doesn’t fall off.
Coarse or fine, curly or straight, shiny, smooth and
resilient.
• Nails Variations of pink with varying opacity His nails are smooth and flat with white spots and has
White spots uniform thickness. It is firm and the edges of his nails are
Smooth and flat/convex with edges smooth and smooth and round. Properly groomed.
 round
Clean and neat
Hard and smooth with uniform thickness
Firm

Skull Rounded (norm cephalic and symmetrical with His skull is symmetrical with frontal, parietal and occipital
frontal, parietal and occipital prominences.) prominences. Do not have any nodules or masses
Smooth and uniform consistency present. Consistent and smooth.
Absence of nodules and masses

Face Symmetric / slightly asymmetrical facial features Cheeks rises when smiling, no deformities and does not
have a hard time to make facial expressions. Complete
facial features and can control muscles in the face.
Eyes and Vision
 Eyebrows Evenly distributed His eyebrows are evenly distributed. No signs of hair
loss. Black in color, no scars or inflammations present.
 Eyelashes Evenly distributed Same with his eyebrows. But his eyelashes curls up and
do not give any complications to the vision of the eye.
 Eyelids Pinkish His eyelids are pinkish and do not have any mucus,
scales or lumps. It fits smoothly against the eyeball.
 Bulbar conjunctiva Transparent It is equally white and transparent in both eyes and the
Capillaries are evident capillaries are evident.
 Palpebral Conjunctiva Shiny or smooth They are shiny
Pink or red No signs of swelling and blur surface. Pinkish in color
 Sclera Sclera appears white and yellowish in dark clients His sclera are white and do not show signs of change in
color.
 Lacrimal gland, Lacrimal No edema and tearing No tearing, eyes are somewhat shows moisture and do
sac, Nasolacrimal duct not have edema.
Cornea
  Clarity and texture Translucent, smooth and avascular. His cornea are translucent and do not have any tearing
and signs of inflammation. It is smooth and avascular.
 Corneal sensitivity Client blinks (trigeminal intact) His cornea are still intact even after he blinks. There are
no extra movement of the pupil and the cornea also.
Pupils Black in color His pupil has equal size and black in color. Do not have
Equal in size deformities in shape and is round.
Round smooth border
Visual Fields Illuminated pupil constricts (direct response) He can see clearly as anyone in the center and around
Should be sharp and clear the edges of the visual field. Can see sharp and clear.
Can see
Visual Acuity Pupil constricts when looking at near objects Can see objects and letters clearly or well when looking
Dilates when looking at far objects at near and far objects. It has the ability to dilate and
constricts when looking on objects.
Ear and Hearing
 Auricles There should be no signs of abnormalities or His auricles do not have any signs of swelling. No scars
deformities and inflammation. It is skin tone in color.
No scars, swelling or inflammation
 External Ear Canal Skin-colored and has small hairs It is skin-colored and has small hairs. The eardrum is
pearly white.
 Hearing Acuity Test The sound is heard midline He clearly hear sounds and both of his ears functions
Air conduction is heard better than bone conduction well. He can identify which side of the ear the sound was
played.
 Watch Tick Test Able to identify the distance of the watch from the ear He can identify the distance of the sound if it is near or far
(far or near) from him.
Nose and sinuses
 External Nose Symmetrical with no discoloration and swelling or His nose is symmetrical to his face. It has no swelling,
malformation. malformation and discoloration. His nose is smooth and
do not have any rashes or inflammation present.
 Nasal Cavity Pinkish red with no discharge/ bleeding. His nasal cavity is pinkish red. Do not obtain any foreign
 No swelling, malformations, or foreign objects objects. Not swelling and do not have discharge of blood
or bleeding.
Mouth and Oropharynx
 Teeth Complete set of teeth He has a complete set of teeth. Some of the teeth he has
Gums are normally pink or red are damaged. There are teeth that are deformed and not
in proper position.
 Tongue and floor of the Should be midline and no sore or coatings present His tongue is midline. Do not show signs of swelling, not
mouth sore and pinkish red in color.
 Tongue movement Can control the movement of tongue He can move his tongue, can curl it up, lift from up, down
Can curl up the tongue and side to side. He can also move his tongue out.
Uvula Midline, rises symmetrically when the patient say ‘ah' His uvula rises symmetrically as he says ‘ah'. It is not
swollen and do not show inflammation and infection. Its
color it pinkish red.
Gag Reflex Can speak with no slurring or garbled words He can speak without slurring or garbled words. Can
swallow without any problem. After swallowing,
everything is normal and do not have coughs .
Neck Trachea should be midline His trachea is on midline and do not show any
No enlarged lymph nodes or thyroid gland are abnormalities. No lump, scars, and inflammation is
noticeable present and lymph modes are not noticeable, including
the thyroid gland. He can control his neck and turn his
head from left to right, up and down, or even rotate it.
Head movement Can control its movement He can control his muscles present on his neck and
Can rotate it counter clockwise and clockwise control the movement of its head. He can turn his head
left to right, up and down without any problem.
Muscle strength Holds the head straight His muscles present on his neck enables him to hold his
head up straight and can hold it stable.
Lymph Nodes Barely perceptible They are barely perceptible.
Feels like elastic marbles
 Thyroid Gland Rises along with thyroid and cricoid cartilage when When swallowing the thyroid and cricoid cartilage rises
 swallowing along with the thyroid gland. He can swallow without any
Palpable problem. And it is palpable.

B. ADULT CLIENT

NAME: WILMA A. MALATE AGE: 49 YRS. OLD GENDER: FEMALE

BIRTHDATE: NOVEMBER 22, 1973 ADDRESS: BRGY. CANRAMOS TANAUAN, LEYTE

Assessment Normal Findings Client’s Findings

Integumentary
 Skin When skin is pinched it goes to previous state The client’s skin is fair and light. She has
immediately (2 seconds). hyperpigmentation in her face but it is not dry. It
With fair complexion. also go back to its previous state when pinched.
With dry skin No mole or scars. Just hyperpigmentation.
No hyperpigmentation, mole or scarring
 Head Hair is black with whit alterations which is caused
Light blond to black and gray with alterations
caused by rinses, dyes and permanents. by aging, rinses, and dyes. Hair is straight shiny
Coarse or fine, curly or straight, shiny, smooth and and smooth. When touched, hair strands doesn’t
resilient.
fall off. Scalp has no inflammation or signs of
infection.
 Nails Variations of pink with varying opacity Nails has deformities thought the edge of the nails
 White spots are smooth and round. It is clean and properly
Smooth and flat/convex with edges smooth and groomed. It is hard with uniform thickness. Some
round of the nails are yellowish in color and some has
Clean and neat white spots.
Hard and smooth with uniform thickness
Firm

Skull Rounded (norm cephalic and symmetrical with Skull is prominent smooth and has uniform
frontal, parietal and occipital prominences.) consistency. No presence of lump, nodules and
Smooth and uniform consistency masses present. It is symmetric and don’t have
Absence of nodules and masses any deformities.

Face Symmetric / slightly asymmetrical facial features Face do not have any inflammation and it is
symmetrical and do not have any deformation. Her
facial features are symmetrical. No missing facial
features. The cheeks rises when smile. No
wrinkles visible yet. The under eyes’ color slightly
changes.
Eyes and Vision
 Eyebrows Evenly distributed Eyebrows are light in color and has gaps because
of hair loss due to the application of beauty
product. Hair on the eyebrow is not that visible for
it has a light color of black.
 Eyelashes Evenly distributed Eyelashes are evenly distributed and curls up not
interfering the sight. There are no fall off of hair on
the lashes.
 Eyelids Pinkish The eyelids are fits perfectly against the eyeball
and are skin colored. Do not show any
abnormalities or inflammation.
  Bulbar conjunctiva Transparent There is no swelling and foreign objects present
Capillaries are evident on it. And is transparent.
 Palpebral Conjunctiva Shiny or smooth It is pink and moist. Also it is not swelling. Do not
Pink or red have any foreign objects and lesions.
 Sclera Sclera appears white and yellowish in dark clients Sclera is white and do not contain any foreign
objects in the eyes. There is no signs of
discoloration.
 Lacrimal gland, Lacrimal sac, No edema and tearing No enlargement, swelling or redness of lacrimal
Nasolacrimal duct apparatus
Cornea
 Clarity and texture Translucent, smooth and avascular Cornea is moist and shiny. There is no discharge
cloudiness and irregularities.
 Corneal sensitivity Client blinks (trigeminal intact) Can blink eyes without problem and cornea still
intact. No abnormalities can be observed.
Pupils Black in color Pupils are black in color. Equal in sight and has
Equal in size round and smooth border. It also responds to light
Round smooth border and accommodation.
Visual Fields Illuminated pupil constricts (direct response) Can see objects clearly from the center and
Should be sharp and clear around the visual fields.
Can see
Visual Acuity Pupil constricts when looking at near objects Cannot see small object clearly. Needs glasses
Dilates when looking at far objects when reading letters in small fonts. Sight is not
sharp and clear.
Ear and Hearing
 Auricles There should be no signs of abnormalities or No infection, inflammation, scars and swelling.
deformities There is no abnormalities and deformities on
No scars, swelling or inflammation auricles structure.
 External Ear Canal Skin-colored and has small hairs It has no abnormalities. It is skin colored and has
small hairs. The color of the eardrum is pearly

 Hearing Acuity Test
 Watch Tick Test
Nose and sinuses
 External Nose
 Nasal Cavity
Mouth and Oropharynx
 Teeth
 Tongue and floor of the mouth
 Tongue movement
Uvula
The sound is heard midline
Air conduction is heard better than bone
conduction
Able to identify the distance of the watch from the
ear (far or near)
Symmetrical with no discoloration and swelling or
malformation.
Pinkish red with no discharge/ bleeding.
No swelling, malformations, or foreign objects
Complete set of teeth
Gums are normally pink or red
Should be midline and no sore or coatings present
Can control the movement of tongue
Can curl up the tongue
Midline, rises symmetrically when the patient say
white with the presence of yellowish wax on the
surface of the ear canal.
Can hear sounds clearly. Can easily identify where
the sound comes from, can hear sound midline
and can identify loud and quiet sounds.
Can hear sounds and identify sounds from being
far or near. She can hear sounds clearly.
Her nose do not have any swelling and
discoloration. It is symmetrical and does not show
signs of abnormalities. No infection and
malformation.
Nasal cavity do not have foreign objects present
and do not have discharge and bleeding. There is
no swelling and inflammation.
Teeth are a bit yellow. The color of the gums are
slightly pinkish. She has complete set of teeth and
some of them are deformed and not in lined with
other teeth. There are also damaged part of the
teeth.
Her tongue is in midline and do not have sore or
coatings present. Pinkish red in color and do not
have any infection or inflammation present.
She can move her tongue without problem and
can curl it up. She can also stick her tongue out.
She don't have any problem on the control in the
movement of her tongue.
Her uvula is not swollen and pinkish in color.
 ‘ah' When she create vibration using her pharynx it
responds to it. When she says ‘ah' it rises midline.
Gag Reflex Can speak with no slurring or garbled words Can speak without any slurring or garbled words
and has no problem on swallowing. No after
reaction when finished swallowing.
Neck Trachea should be midline Trachea is in midline and no enlarged lymph node
No enlarged lymph nodes or thyroid gland are and thyroid glands are noticeable. No lump or
noticeable nodules present. Do not show any abnormalities.
Head movement Can control its movement She can control her head movement and can
Can rotate it counter clockwise and clockwise rotate it counterclockwise and clockwise. She can
also turn her head left and right, up and down.
Muscle strength Holds the head straight She can hold her head up straight and lean over
her head from front to back and left to right.
Lymph Nodes Barely perceptible Lymph nodes are bare perceptible.
Feels like elastic marbles
 Thyroid Gland Rises along with thyroid and cricoid cartilage when When swallowing the thyroid and cricoid cartilage
swallowing rises together. She can swallow without any
Palpable problem.
Palpable

C. GERIATIC CLIENT

NAME: WILFREDO ARCEO SR. AGE: 76 YRS. OLD GENDER: MALE

BIRTHDATE: DECEMBER 17,1945 ADDRESS: BRGY. CANRAMOS TANAUAN, LEYTE
 Assessment Normal Findings Client’s Findings
Integumentary
 Skin When skin is pinched it goes to previous state His skin has dry skin. Got patches of rashes. His
immediately (2 seconds). skin color is a bit brown and has
With fair complexion. hyperpigmentation. And is wrinkled.
With dry skin
No hyperpigmentation, mole or scarring
 Head His hair is a bit gray and straight. It is dull and
Light blond to black and gray with alterations
caused by rinses, dyes and permanents. brittle. When touched his hair falls off.
Coarse or fine, curly or straight, shiny, smooth and
resilient.
 Nails Variations of pink with varying opacity Nails are dull and the edges of the nails are not
White spots smooth and round. Deformities are visible but it is
Smooth and flat/convex with edges smooth and neat and clean. Its color is a bit yellowish and it is
round not already thick and hard.
Clean and neat
Hard and smooth with uniform thickness
Firm

Skull Rounded (norm cephalic and symmetrical with Nodules and masses are not visible. The scalp
frontal, parietal and occipital prominences.) has signs of irritation. His skull is rounded and is
Smooth and uniform consistency symmetrical with frontal, parietal and occipital
Absence of nodules and masses prominences.

Face Symmetric / slightly asymmetrical facial features Facial features are complete and symmetrical. The
skin is hyper pigmented.
Eyes and Vision
 Eyebrows Evenly distributed Eyebrows are evenly distributed and the hair is
black in color and is not really that visible.
  Eyelashes Evenly distributed Eyelashes are curled up and do not give any
problem with sight and do not irritate the eye. It is
evenly distributed and the color of the hair is black.
Some of the lashes falls off due to aging.
 Eyelids Pinkish Eyelids are pinkish and do not show signs of
inflammation and swelling. Do not show
abnormalities.
 Bulbar conjunctiva Transparent Capillaries are evident and there is no foreign
Capillaries are evident object and swelling present on it.
 Palpebral Conjunctiva Shiny or smooth Do not have foreign objects and lesions. No
Pink or red swelling and signs of irritation and inflammation in
it. It is pinkish in color.
 Sclera Sclera appears white and yellowish in dark clients There are signs of discoloration. Sclera is
yellowish in color. But there are no foreign objects.
 Lacrimal gland, Lacrimal sac, No edema and tearing No enlargement, tearing and edema in lacrimal
Nasolacrimal duct apparatus.
Cornea
 Clarity and texture Translucent, smooth and avascular There are some part of it that shows cloudiness in
the cornea and irregularities.
 Corneal sensitivity Client blinks (trigeminal intact) The surface of the cornea thickens and the eye
becomes watery when exposed to light.
Pupils Black in color Pupil is black in color, uneven and do not
Equal in size immediately responds to light.
Round smooth border
Visual Fields Illuminated pupil constricts (direct response) Cannot see clearly on the other fields of the visual
Should be sharp and clear but only in the center of eye. Has blurry vision.
Can see
Visual Acuity Pupil constricts when looking at near objects Visual acuity is low.
Dilates when looking at far objects
Ear and Hearing
 Auricles There should be no signs of abnormalities or Auricles show signs of irritation and swelling. Got
deformities some scars.
No scars, swelling or inflammation
 External Ear Canal Skin-colored and has small hairs Skin colored and has small hairs.
 Hearing Acuity Test The sound is heard midline Cannot hear sounds clearly. Only loud noises can
Air conduction is heard better than bone be heard. Cannot identify what which or where the
conduction sound is coming from.
 Watch Tick Test Able to identify the distance of the watch from the Cannot hear the sound of the tick of the watch.
ear (far or near) Cannot identify sounds that are far and near.
Nose and sinuses
 External Nose Symmetrical with no discoloration and swelling or Nose is symmetrical and has no discoloration,
malformation. swelling or malformation.
 Nasal Cavity Pinkish red with no discharge/ bleeding. Pinkish red with no discharge or bleeding. And do
No swelling, malformations, or foreign objects not contain any foreign objects.
Mouth and Oropharynx
 Teeth Complete set of teeth Gums are pink and do not have signs of
Gums are normally pink or red inflammation and infection. Loss of teeth due to
aging. Positions of the teeth are not equal. Its color
is yellow.
 Tongue and floor of the mouth Should be midline and no sore or coatings present There are no signs of abnormalities. The tongue
do not have any swelling and deformation. Not
sore and do not have coatings. It is midline and
pinkish red in color.
 Tongue movement Can control the movement of tongue Can stick the tongue out and move it from side to
Can curl up the tongue side. Can also curl the tongue and straight.
Uvula Midline, rises symmetrically when the patient say Uvula do not show signs of infection or
‘ah' inflammation. It is midline and rises when the client
said ‘ah'. Its color is pinkish red and responses to
 vibration caused by the vocal chords and pharynx.
Gag Reflex Can speak with no slurring or garbled words Can speak but with a little bit slurring and coughs
after being asked to swallow.
Neck Trachea should be midline The trachea is midline. There are no signs of
No enlarged lymph nodes or thyroid gland are nodules, masses or lump in the neck. Wrinkled
noticeable and has scar. There are some scratches .
Head movement Can control its movement Can control the movement of his head. He is able
Can rotate it counter clockwise and clockwise to rotate his head counterclockwise and clockwise.
As well as moving his head from left to right and
up to down.
Muscle strength Holds the head straight The muscles present on the head hold the head
up straight and stable. Can control it and flex it.
Lymph Nodes Barely perceptible They are barely perceptible
Feels like elastic marbles
 Thyroid Gland Rises along with thyroid and cricoid cartilage when Thyroid gland are not palpable and when
swallowing swallowing the thyroid gland rises along with the
Palpable (not palpable) cricoid cartilage.