ASSESSING HEAD TO NECK

• HELLO, I AM CLAIRE LIBAT, STUDENT NURSE AND I WILL BE PERFORMING HEAD TO

NECK ASSESSMENT ON A CLIENT
• I WILL NOW GATHER THE EQUIPMENT SUCH AS GLOVES, PENLIGHT, SMALL GLASS OF
WATER, TONGUE DEPRESSOR, SNELLEN CHART, SMELLING SCENTS, TUNING FORK, AND
STETHOSCOPE
• SO FIRST, IDENTIFY THE PATIENT AND EXPLAIN THE PROCEDURE “HELLO, I AM CLAIRE
LIBAT, YOUR STUDENT NURSE FOR TODAY, I WILL JUST IDENTIFY YOU, MAY I KNOW
YOUR NAME AND BIRTHDAY? OKAY, SO MS. PATIENT, I WILL BE PERFORMING A HEAD
TO NECK ASSESSMENT ON YOU AND THE PURPOSE OF THIS IS TO OBSERVE AND
INSPECT FOR ANY UNUSUAL FINDINGS AND INFORM IT TO THE HEALTH CARE
PROVIDER. TO ASSESS YOU PO, I WILL BE PALPATING AND TOUCHING CERTAIN PARTS
OF YOUR BODY AND I’LL BE NEEDING YOUR COOPERATION PO. DON’T WORRY ALL OF
THE INFORMATION THAT I WILL GATHER WILL REMAIN CONFIDENTIAL, SO IS THAT
OKAY PO?
• I WILL NOW PERFORM HAND HYGIENE AND APPLY GLOVES. SO, I WILL FIRST INSPECT
YOUR HEAD FOR SIZE, SHAPE, AND CONFIGURATION AND I WILL BE PALPATING YOUR
HEAD, IS THAT OKAY WITH YOU?
• DO YOU FEEL ANY PAIN IN THIS PART? OKAY THAT’S GOOD. THEN I WILL INSPECT YOUR
FACE FOR ANY SYMMETRY, FEATURES, ANY ABNORMAL MOVEMENTS, EXPRESSION,
AND SKIN CONDITION. AS I OBSERVE THE PATIENT, I DO NOT SEE ANY ABNORMAL
MOVEMENTS AND THE PATIENT’S FACE IS SYMMETRICAL AND NORMAL.
• NEXT IS PALPATE THE TEMPORAL ARTERY FOR TENDERNESS “DO YOU FEEL ANY PAIN IN
THIS PART?”
• ALSO THE TEMPOROMANDIBULAR JOINT, “DO YOU FEEL ANY PAIN RIGHT HERE?” OKAY, SO
DO YOU HAVE ANY HISTORY OF HEADACHES?
• SO NEXT IS I WILL BE ASSESSING YOUR CRANIAL NERVE V, THE TRIGEMINAL NERVE IN
WHICH I WILL BE USING A WISP OF COTTON BALL TO YOUR FACE AND YOU WILL TELL ME IF
YOU CAN FEEL IT OR NOT. AND ALSO A SHARP OBJECT.
• ALSO TEST THE CORNEAL REFLEX WHICH I WILL TOUCH YOUR CORNEA WITH A WISP OF
COTTON
• ANOTHER THING TO ASSESS THIS CRANIAL NERVE TO HAVE THE PATIENT OPEN HER MOUTH
AGAINST RESISTANCE.
• THEN AFTER THAT, I WILL ASSESS YOUR CRANIAL NERVE VII WHICH IS THE FACIAL NERVE.
CAN I ASK YOU CLOSE YOUR EYES TIGHTLY AND OPEN THEM, SMILE, FROWN, AND PUFF
OUT YOUR CHEEKS. OKAY THAT’S GREAT!”
• NEXT IS ASSESSING THE EYES, I WILL JUST CHANGE MY GLOVES SINCE I WILL BE PALPATING
YOUR LACRIMAL APPARATUS TO PREVENT IRRITATOIN. I WILL INSPECT THE EYELIDS AND
EYELASHES FOR ANY SWELLING, COLOR, OR LESIONS AND ALSO THE POSITIONING OF THE
EYEBALLS.
• MAKE THE PATIENT LOOK UP TO OBSERVE FOR ANY REDNESS OF CONJUNCTIVA AND
SCLERA
• “THEN I PALPATE THE LACRIMAL APPARATUS AND TELL ME IF YOU FEEL ANY PAIN”
• NEXT IS I WILL ASSESS YOUR CRANIAL NERVE II, THE OPTIC NERVE AND TEST YOUR VISUAL
ACUITY AND PERIPHERAL VISION
• SO TO TEST YOUR VISUAL ACUITY, I WILL BE NEEDING A SNELLEN CHART AND THE PATIENT
SHOULD BE 20 FT AWAY FROM IT. ANG GAGAWIN PO DITO IS BABASAHIN NYO PO YUNG
ROW NG PINAKAMALIIT NA LETTERS NA KAYA NYONG BASAHIN. SO MAGSTART PO MUNA
TAYO SA RIGHT EYE, THEN LEFT EYE, THEN BOTH.
• FOR PERIPHERAL VISION, COVER PO NATIN ANG ONE EYE NATIN, THEN TITINGIN
LANG PO KAYO SA MATA KO, AND I WILL NUMBER MY FINGERS AND WHAT YOU’LL
DO IS TO IDENTIFY HOW MANY FINGERS DO YOU SEE IN YOUR PERIPHERAL VISION.
• NEXT I WILL DO IS TO ASSESS YOUR CRANIAL NERVE 3,4, AND 6 (OCCULOMOTOR,
TROCHLEAR, AND ABDUCENS) SO I WANT YOU TO KEEP YOUR HEAD STEADY AND
YOU WILL FOLLOW THE PENLIGHT, CAN YOU DO THAT?
• “AND I WANT YOU TO FOCUS ON A DISTANT OBJECT OR ON A WALL AND I WILL DIM
THE LIGHTS AND SHINE MY PENLIGHT ON YOUR EYES TO OBSERVE YOUR PUPIL’S
REACTION TO LIGHT”. “I WILL ALSO INSPECT YOUR PUPIL AND IRIS USING PENLIGHT
TO ASSESS THE SHAPE AND SIZE
• NEXT TO ASSESS IS YOUR EARS, I WILL INSPECT YOUR EARS AND OBSERVE FOR THE
SHAPE, LESIONS, OR DISCHARGE. I WILL ALSO PALPATE THE MASTOID PROCESS. DO
YOU FEEL ANY TENDERNESS OR PAIN? OKAY GOOD!
• THEN I WILL ASSESS YOUR CRANIAL NERVE 8, THE VESTIBULOCOCHLEAR, WHICH I
WILL PERFORM A WHISPER TEST, AND TELL ME WHAT YOU HEAR.
• NEXT IS WEBER TEST, USING A TUNING FORK, I WILL MAKE A SOUND IN IT AND
PLACE ON YOUR FOREHEAD AND TELL ME KUNG NARIRINIG MO SA BOTH EARS O
ONE EAR LANG.
• NEXT IS THE RINNE TEST, I WILL ALSO MAKE A SOUND ON A TUNING FORK AND
PLACE IT SA HARAP NG EARS AND SUNOD AY ILALAGAY KO SA MASTOID BONE AND
TELL ME PAG HINDI MO NA NARIRINIG YUNG SOUND.
• OKAY SO ANG PURPOSE NG MGA PROCEDURE NA YON IS TO ASSESS IF YOU HAVE
HEARING LOSS AND LUCKILY YO DO NOT HAVE HEARING ISSUES.
• NEXT IS ASSESSING YOUR NOSE, ALLOW ME TO INSPECT AND PALPATE YOUR NOSE
FOR ANY PAIN OR TENDERNESS AND I WILL ALSO PALPATE YOUR SINUSES FOR
TENDERNESS AND PAIN
• SO TO CHECK THE PATENCY OF AIRFLOW, I WILL CLOSE YOUR ONE NOSTRIL THEN
YOU WILL INHALE, THEN ALSO THE OTHER ONE.
• NEXT IS ASSESSING CRANIAL NERVE 1 (OLFACTORY), MAY IPAPAAMOY AKO SAYONG
SCENT AND SABIHIN MO KUNG ANO YON, IS THAT OKAY?
• ANG NEXT KO PONG IIINSPECT IS YOUR MOUTH, LIPS, AND TONGUE, SO I WILL JUST
CHANGE MY GLOVES AGAIN. OKAY, CAN YOU OPEN YOUR MOUTH SO I CAN
OBSERVE FOR THE SIZE, SHAPE, AND COLOR OF YOUR TONGUE, AND YOUR TEETH,
TONSILS USING A TONGUE DEPRESSOR. AND CAN YOU SAY “AH” SO I CAN OBSERVE
THE MOVEMENT OF YOUR UVULA. OKAY, SO I CAN SEE WALA NAMAN PONG
PROBLEMA
• OKAY NEXT PO AY IINOM PO KAYO NG TUBIG PARA PO MAOBSERVE KO YUNG
PAGSWALLOW NYO PO SA THROAT NYO PO. WALA NAMAN PONG MASAKIT PAG
NALUNOK KAYO? OKAY PO
• SO IN THOSE PROCEDURES, I ASSESSED YOU CRANIAL NERVE IX AND X
(GLOSSOPHARYNHEAL AND VAGUS NERVE) AND IT IS INTACT AND NO PROBLEM
• NEXT IS I WILL ASSESS YOUR CRANIAL NERVE XI (ACCESSORY NERVE), SO I WANT YOU
TOMOVE YOUR HEAD SIDE TO SIDE AND UP AND DOWN, AND SHRUG YOUR
SHOULDERS, CAN YOU DO THAT?
• OKAY THAT’S GOOD, THEN I WILL PALPATE YOUR NECK, TRACHEA, AND THYROID
GLAND
• THEN I WILL AUSCULTATE YOUR CAROTID ARTERY
• LAST TO ASSESS IS YOUR LYMPH NODES, I WILL PALPATE FOR THE SIZE, SHAPE AND
TELL ME IF YOU FEEL ANY PAIN OR TENDERNESS WHEN I PALPATE IT. IS IT OKAY?
• A. PREAURICULAR
• B. POSTAURICULAR
• C. OCCIPITAL
• D. TONSILLAR
• E. SUBMANDIBULAR
• F. SUBMENTAL
• SUPERFICIAL CERVICAL
• POSTERIOR CERVICAL
• DEEP CERVICAL
• SUPRACLAVICULAR (DEEPLY BET. CLAVICLES)
• AFTER COMPLETELY ASSESSING THE HEAD TO NECK, YOU WILL DOCUMENT AND
ANALYZE ALL THE DATA AND REPORT FOR ANY ABNORMALITIES.