FAR EASTERN UNIVERSITY

Institute of Health Sciences and Nursing (IHSN)

PERFORMANCE EVALUATION TOOL

HEALTH ASSESSMENT OF HEAD TO NECK

Name : Score: Date:

Sec/Grp:

DIRECTION: Rate the Learner based on the competencies listed below.

KEY:
3 – Acceptable Demonstrates expected procedure/behavior correctly.
2 – Moderately Acceptable Demonstrates expected procedure/behavior with minimal error.
1 – Slightly Acceptable Demonstrates expected procedure/behavior with many errors.
0 – Unacceptable Missed procedure or procedure done but entirely incorrect.

ASSESSMENT PROCEDURES SCRIPT

PREPARATION
1. Introduce yourself and verify the client’s Hello po mam/sir ako po si sean dinoso 1st yr nursing
identity. Explain to student from feu. Ngayon po we will assess you from head
the client what you are going to do, why it is to neck to know if may complications po ba o wala naman.
This is for your betterment po and sana po mag cooperate
necessary, and how the client can cooperate.
po tayo para mapadali at maging effective po ito.
2. Perform hand hygiene and observe other ”I will wash my hands and put alcohol “
appropriate
infection control procedures.
3. Assemble equipment Now all the equipment are assembled
4. Provide for client privacy We can provide privacy by closing the door and curtains
and closing the windows if necessary
HEAD & FACE
5. Inspect the head Tignan mo lang ang head
“The client’s head is oval in shape and symmetrical, no
abnormalities are noted.
6. Inspect the face Tignan lang ang face “The face of the client has no lesions
and all is normal”
7. Palpate the head The head is normally hard and smooth,without lesions
8. Palpate the temporal artery

9. Palpate the temporomandibular joint (TMJ).
NECK
10. Inspect the neck
11. Inspect movement of the neck structures
12. Inspect the cervical vertebrae
13. Inspect range of motion
14. Palpate the trachea
15. Palpate the thyroid gland.
16. Auscultate the thyroid only if you find an
enlarged thyroid
gland during inspection or palpation.
“No tenderness noted it is elastic and pulse is noted”
“no sound heard. Normally, there is no swelling,
tenderness or crepitation with movement, Mouth opens
and closes fully (3-6 cm between upper and lower teeth).
Lower jaw moves laterally 1-2 cm in each direction.”
TIGNAN LANG sabihin lumunok sya
NORMAL FINDINGS: The thyroid cartilage, cricoid
cartilage move upward symmetrically as the client
swallows.
TIGNAN LANG
NORMAL FINDINGS: The neck has a definite and
normal structure
TIGNAN LANG
TIGNAN LANG
“Trachea is slightly tilted to the right. As a result, the
clavicular insertion of the right Sternomastoid is slightly
more prominent and the space between trachea and
sternomastoid is smaller compared to left.”
“The Thyroid gland is palpable and rises along with
thyroid and cricoid cartilage during swallowing,”
NO ENLARGEMENT OF THYROID IS NOTED
17. Palpate the lymph nodes.

“There is no palpation. enlargement or tenderness noted on

the lymph nodes”
 ASSESSMENT PROCEDURES SCRIPT
EYES
18. Test distant visual acuity.

Test distant visual USE THE CHART

acuity - Normal distant visual
acuity is 20/20 with or
without corrective
lenses.
19. Test near visual acuity.

Test near visual

acuity. - Normal near visual
acuity is 14/14 (with or
without corrective
lenses).
20. Test visual fields for gross peripheral vision.

With normal peripheral

vision, the client should
see the examiner’s finger
at the same time the
examiner sees it. Normal
visual field degrees are
approximately as follows:
• Inferior: 70 degrees
• Superior: 50 degrees
• Temporal: 90 degrees
• Nasal: 60 degrees
21. Perform Corneal Light reflex test.

“the corneas are in the exact same spot on each eye,

which indicates parallel alignment.”
22. Perform cover test.

”When you remove the cover, there must be no lateral

motion of the covered eye. The uncovered eye should
also remain straight ahead and fixed. The covered eye
must also remain straight ahead and fixed after being
uncovered
23. Perform Positions Test.

“Eye movement is smooth and symmetric

throughout all six directions”
24. Inspect the eyelids and eyelashes.

”The upper lid margin are in between the upper margin

of the iris and the upper margin of the pupil”
25. Assess ability of eyelids to close. Sir paki close and open po mata ninyo

”The upper and lower lids close easily and meet

completely when closed”
26. Note the position of the eyelids in comparison with .”
the eyeballs
27. Observe eyelids for redness, swelling, discharge or
lesions.
28. Observe eyelids for the position and alignment of the
eyeball
in the eye socket.
29. Inspect the bulbar conjunctiva and sclera.
30. Inspect the palpebral conjunctiva.
31. Evert the upper eyelid.
32. Inspect the lacrimal apparatus.
33. Palpate the lacrimal apparatus.
34. Inspect the cornea and lens.
35. Inspect the iris and pupil.
36. Test pupillary reaction to light (Pupillary Light Reflex).
37. Assess Consensual Response
38. Test accommodation of pupils.
EARS
39. Inspect the auricle, tragus and lobule. 0 23
40. Inspect the external auditory canal 0 23
41. Palpate the auricle and mastoid process 0 23
42. Perform whisper test 0 23
43. Perform Weber’s Test 0 23
44. Perform the Rinne’s Test 0 23
45. Perform the Romberg Test 0 23
NOSE
46. Inspect and palpate the external nose 0 23
47. Check the patency of airflow through the nostrils 0 23
48. Inspect the internal nose 0 23
 ASSESSMENT PROCEDURES RATING REMARKS
SINUSES
49. Palpate the sinuses 0 1 2 3
50. Percuss the sinuses 0 1 2 2
MOUTH & THROAT
51. Inspect the lips. 0 1 2 3
52. Inspect the teeth and gums 0 1 2 3
53. Inspect the buccal mucosa. 0 1 2 3
54. Inspect and palpate the tongue. 0 1 2 3
55. Assess the ventral surface of the tongue 0 1 2 3
56. Inspect for Wharton’s ducts 0 1 2 3
57. Observe the sides of the tongue. 0 1 2 3
58. Check the strength of the tongue. 0 1 2 3
59. Inspect the hard (anterior) and soft (posterior) palates and
0 1 2 3
uvula.
60. Note the odor while the mouth is wide open 0 1 2 3
61. Assess the uvula 0 1 2 3
62. Inspect the tonsils 0 1 2 3
63. Inspect the posterior pharyngeal wall 0 1 2 3

TOTAL

Signature of Student Name & Signature of Faculty