Nurse: Good Afternoon, Ma’am.

Before we proceed, I would like to introduce myself first, I am (Name) from Far
Eastern University, your Student Nurse for today and you are?.

Nurse: How would you like me to call or address you?

Nurse: Okay, (name) Let me first verify your personal information. Can I get your Fullname?

Nurse: Age?

Nurse: Birthday?

Nurse: Address?

Nurse: Before getting any further, I would like to inform you that I will be assessing your head, face, neck, eyes,
nose, ears, mouth, and sinuses as part of the head to neck assessment. It is essential to perform this procedure
to identify if you have any problems relating to your head to neck. For me to assess those parts, there is a need
for me to touch certain parts of my body. Will that be fine with you, ma’am?

Nurse: Okay, so I will now be performing my hand hygiene for safety procedures. Please be informed also that I
will be wearing gloves.

Nurse: There is also a need for you to answer questions and follow certain procedures while the assessment is
taking place. Is it alright?

Nurse: Rest assured that all the information that will be gathered will be kept with the utmost confidentiality and
will only be accessible to other healthcare professionals.

Nurse: Okay, thank you (name). If ever you will feel uncomfortable while the assessment is ongoing, don't
hesitate to interrupt me.

Nurse: Okay, to continue po, I would like to show you the equipment that I will be needing for today. First, the
gloves, penlight, glass of water, stethoscope, tongue depressor, otoscope, cardboard, the snellen chart.

Nurse: I will now be closing the curtains for privacy. To proceed, you can now sit, straighten your back and hold
your head still.

Nurse: Before anything po, I will first be asking questions about your health history relating to the assessment.
May napapansin po ba kayong lumps, lesions and scars sa inyong head to neck?

Nurse: How about when moving it po, do you encounter any difficulties?

Nurse: In terms of pain naman po, nakakexperience po kayo ng frequent head aches, or may narerecall po ba
kayong instance kung saan nahilo kayo or nawalan ng malay?

Nurse: Moving on to your past health history, do you have any previous head or neck problems like trauma and
injury?

Nurse: Did you undergo any operation po in your head and neck before?
Nurse: In terms of family history po did anyone in your family experience cancer relating to the head and neck?

Nurse: Mayroon po bang may migraine sa family niyo?

Nurse: Moving on to your lifestyle and health practices po, Do you smoke or chew tobacco? How about hats and
helmets po, do you wear them often?

Nurse: To start, I will first focus on your head and face. I will first be inspecting your head and face by checking
the shape, color distributionand consistency. (Observe, observe) As to what I have noticed po, the shape of the
head is round, symmetric, erect and it is in midline. Its size is also appropriate to the bodysize of the client and it
can be classified as a normocephalic. Its consistency is smooth. There are also no lesions, scars or any masses
visible.

Nurse: Moving on ma’am, I will now be checking your cranial nerve number 7. Please perform the things that I
will tell you. Can you smile? Okay, show me your teeth. Now, blow out your cheeks. Raise your eye brows. Close
yur eyes tightly. As to what I have noticed, there are no problems in terms of the face because there are no
drooping that occured and there are no abnormal movements that manifested.

Nurse: To proceed ma’am, I will be testing your cranial nerve 5 through touching certain parts of your face. To
test, please indicate where you feel it is that fine? (Hawakan ang mga bahagi ng mukha ng client) As per the
findings, I can see that wala naman pong problema dahil tama naman lahat ng inindicate niyo and nagmatch
naman siya sa hinawakan ko.

Nurse: Now, I will be palpating your temporal artery which is found in the sides of your eyes and ears. (Pinduting
ang sentido) How does it feel, maam? Okay, as I have noticed your temporal artery is non-tender and elastic. I
will now proceed to palpating your temporomandibular joint. (baba ng onti ng temporal artery, sa bandang bibig)
Can you please open your mouth po? (Ask to close and open) Does it hurt when you do it po? As to what I have
noticed, wala naman pong swelling, tenderness and crepatation of movement.

Nurse: For the next part po, we will now be proceeding to your neck so allow me to inspect it first po. (Inspect
eme eme) As per my observation po, the neck is symmetric, centered and there are no lesions, bulging and
masses.

Nurse: To check the movement naman po, may you please swllow a small sip of water from the glass of water.
May naexperience po ba kayong pain or tenderness while swallowing? Okay as I have noticed po, nagmove
naman po upward yung thyroid and cricoid cartilage.

Nurse: We will now be proceeding po to inspecting your cervical vertebrae, to do that, you need to flex your nek
po by moving your head and chest sideways. Okay, so as I have notice po, your C7 vertebrae is visible and
palpable.

Nurse: To continue po, i will now be checking your neck’s range of motion. Can you turn your head to the right?
And touch your chin to your shoulder? Turn your head to the left, And touch your chin to your shoulder? Then
look at me po. Now touch your right ear to your right shoulder, then your left ear to your left shoulder. Now, chin
to the chest, then eye into the cieling. Do you feel any tenderness or pain po while moving your neck in different
directions? Okay, as I have noticed, your movement of the neck is smooth naman po and you also have control.
Nurse: Moving on po, I will now be palpating your trachea, to do that, i will now place my finger in the sternal
notch. (In the middle of the two bones on the down part of the lalamunan) As I have noticed, it is in the midline.

Nurse: Now I will be palpating the thyroid gland through my index finger and thumb. (Galawin ang lalamunan
tapos pakiramdaman) As to what I have noticed, there are no enlargement and swelling evident naman po. There
i no need to auscultate since hindi naman po siya enlarged.

Nurse: I will now be proceeding to palpating your lymph nodes, ma’am. I will first be checking your preauricular
nodes (icheck ang unahan ng ears) and then the postauricular nodes(icheck ang likod ng ears). I will now palpate
the tonsillar nodes then the submandibular nodes, and then the supraclavicular nodes. As to what I have noticed,
wala naman pong swelling, tenderness or enlargement.

Nurse: After the assessment of the neck, we will now be proceeding to the eyes. We will first test your visual
distant acuity. You can now sit 20 feet away from the snellen chart and reach each letter from your direction from
top to bottom. If you have a prescription glass po, you can wear it. So, you may first read it with both eyes. You
may now cover your right eye. You may now cover your left eye.

(If a client has glasses, perform the test with and without glasses.)

Nurse: To proceed, I will now check your near visual acuity which involves reading the Rosenbaum eye chart
again. You can now hold it 14 inches away from you. If you have a prescription glass po, you can wear it. You
may read it first with both of your eyes. You may now cover your right eye. You may now cover your left eye.

(If a client has glasses, perform the test with and without glasses.)

Nurse: We will now be testing your visual fields for gross peripheral vision. In this case po, please cover your
eyes with the cardboard and look straight into me. I will be putting my hands in different directions po and ehn
you see it, please stop. We will first start with your right eye. We will now proceed to your left eye.

(The fingers should be placed in the inferior, superior, nasal and temporal.)

Nurse: I will now be testing your corneal light reflex ma’am. I will be using a penlight here ma’am. All you have to
do is stare at a distant object.

(Hold a penlight approximately 12 inches from the client’s face. Shine the light toward the bridge of the nose while the
client stares straight ahead. Note the light reflected on the corneas.)

Nurse: As to what I have noticed, there is an alignment of light in both eyes and symmetry in your eyes which is
good to know. For the next one, we will now proceed to the cover test, first cover your right eye ma'am, while you
stare at me and then cover the left eye while you stare at me.

(Perform the test)

Nurse: As to what I have noticed, your gaze is fixed, steady and there is no weak eye muscle.

Nurse: We will now be proceeding to the positions test and to do this, we will be using the six cardinal gaze of
the field. Can you please follow the pen using your eyes?
(Move the pen to the primary and secondary directions and let the client follow it.)

Nurse: I will now be moving on to inspecting the eye’s external structures. I will be inspecting your eyelids,
eyelashes and eyebrows. So as to what I have noticed, all the structures of the eye are in place and I did not
notice any drooping. There are no abnormalities in terms of your eyelashes, eyelids, and eyebrows. Your
eyelashes are evenly distributed and symmetrical. In terms of the eyeballs, it is globe, firm and there are no
tenderness, lesions, redness or swelling. Can you close your eyes? Okay, as to what I have noticed, the upper
and lower eyelids close easily and meet completely when they are closed.

Nurse: Okay, maam, I will now be inspecting the bulbar conjunctiva

as well as the sclera, to do that, i will be touching your eyelid. You
need to look side by side for me to evaluate it.

Nurse: Okay, as to what I have noticed, the bulbar conjunctiva is

clear, smooth and moist. The sclera is white and the underlying
structures are visible. To proceed, I will now be inspecting the
palpebral conjunctiva. Now, I will be everting the eyelids.

Nurse: As to what I have noticed, the palpebral conjunctiva is free

from swelling, foreign bodies, or trauma.

Nurse: Now, I will be inspecting and palpating the lacrimal apparatus.

Nurse: As to what I have noticed, there are no swelling or redness in the lacrimal
apparatus. When I palpated it, there are no drainage noted.

Nurse: We will now be proceeding to inspect the cornea and lens.

(Shine a light from the side of each eye of the client.)

Nurse: As to what I have noticed, the lens and cornea are free from opacities.

Nurse: So, I will now be inspecting Iris and pupil.

(Shine a light from the side of each eye of the client.)

Nurse: I have noticed that the iris is round, flat and evenly colored. The pupil is also round, with a regular border
and it is located at the center of the iris.

Nurse: So we will now proceed to pupillary reaction to light as well as the consensual response. I’ll just turn off
the lightYou can now focus on a distant object.

(Itapat ulit ang light sa tigisang mata. )

Nurse: Okay, As i have noticed the pupils are both constricted.

Nurse: I will now test the accommodation of the pupils. Can you please stare at this pen and as soon as I move
it, follow it with only your eyes.

(move the pen papalapit sa client and then papalayo sa client)

Nurse: As to what I have seen, the pupil constricts and converges as the pen gets near.

Nurse: Okay, so we are now done with the eye assessment and we will now proceed to assessing the ears. First,
I will inspect the auricle, tragus and lobule. Okay, As I have noticed there are no lumps and lesions. Also, the
color of the ears is consistent with the facial color. The ears are equal in size. The auricle is aligned with the
corner of each eye and the earlobes are properly attached. There are also no discharge present.

Nurse: I will now palpate the auricle and mastoid process. As to what I have noticed, there is no tenderness.

Nurse: I will now inspect the external auditory canal using an otoscope. As to what I have noticed, there is only a
small amount of odourless cerumen which is normal.

Nurse: I will now be inspecting the tympanic membrane. As per my observation, it is pearly grey and semi
transparent. It is also slightly concave and intact.

Nurse: To proceed, i will now be performing the whisper test, I will now be standing 2 feet behind you and I will
be whispering words. You can repeat after me if you hear the word I will say.

Nurse: Next, I will be performing the Weber’s test, I will strike the tuning fork and place it on your forehead’s
center.

(perform)

Nurse: Did you hear the same volume in both ears?

Nurse: Next, we will be performing the Rinne’s test where I will be using the tuning fork. Tell me if you stopped
hearing the sound. (Strike the tuning fork and then place it in the client’s mastoid process). Tell me if the sound is
audible after the tuning fork is moved.

Nurse: I will now be performing the Romberg’s test which will determine your equilibrium. Can you please stand
up, feet together, arms at the sides with eyes open. Same position, with eyes closed. Maintain the position for 20
seconds.

Nurse: We are now done with the assessment of the ears, we can now proceed with the nose assessment. First,
I will be inspecting and palpating the external nose. As per my observation, the color consistency is the same as
the face. The nasal structure is symmetric and smooth. As per the client, there is no tenderness.

Nurse: I will now be checking the patency of air flow through the nostrils. Can you please use one finger to cover
one hole of your nose and then sniff. Okay, have you had any problems with your sense of smell?

Nurse: To proceed, I will now inspect the internal nose using my penlight. Now, I have noticed that the nasal
mucosa is pink, moist and free of perforations. There are also no lesions.
Nurse: To continue, I will now focus on your sinuses, I will first palpate your sinuses.

Nurse: I will now be percussing the sinuses. Let’s start with the frontal sinuses. Then, I will now percuss the
maxillary sinuses.

Nurse: Okay, I will now move on to the mouth and throat assessment since we are done with assessing the
sinuses. To start, I will first inspect the lips. I noticed that the lips are smooth, moist and without lesions or
swelling. Now, can you open your mouth so that I can see your teeth. Okay, Open it bigger. Say Ah. Okay, As I
have noticed, there are 32 teeth that are whitish and have smooth edges and surfaces with no decay or missing
teeth. I will now touch your lips so that I can inspect the gums. I noticed that there are no lesions. The gums are
pink, moist and firm.

Nurse: I will now check your buccal mucosa through a tongue depressor and a penlight. Okay, I noticed that it is
pink.

Nurse: I will now inspect and palpate the tongue as well as its ventral surface and the wharton’s duct. Can you
stick it out for a second? Okay, then point it up. Okay, so I noticed that it is pink, moist and in moderate size.
There is no lesions present. In terms of the ventral surface, It is smooth, pink with visible veins and no lesions. In
terms of the Wharton's duct, it is visible and there is no swelling or redness.

Nurse: I will now be observing the sides of the tongue. Allow me to use a square gauze pad to hold the tongue
so that I can palpate for lesions and nodules.

(Use a square gauze pad to hold the client’s tongue.)

Nurse: As I have noticed, there are no lesions, ulcers or nodules present.

Nurse: I will now be checking the tongue’s strength. To do that, push the sides of your cheeks and try to resist
my fingers on your cheeks.

(Do this on the left and right side.)

Nurse: To proceed, I will now inspect the hard and soft palate as well as the uvula. Okay, as I have noticed the
hard palate is whitish with a firm transverse rugae and soft palate is pinky and movable. Aside from that, I also
noticed that there is no foul odor in terms of the client’s mouth.

Nurse: I will now be proceeding to the assessment of the uvula and tonsils through the tongue depressor and
penlight as well. Can you please open your mouth and say ah? I have noticed that it is fleshy, solid and hangs in
the midline. In terms of the tonsils, it is present, its color is pink, and there are no lesions or swelling evident.

Nurse: I will now be inspecting the pharyngeal wall. (lalamunan) I noticed that it is normally pink and there are
also no lesions.

Nurse: I will now document the important findings that I noted during the assessment. Before I end, do you have
any questions, clarifications or anything you would like to add?

Nurse: Okay, once again, thank you for your cooperation. Stay safe.