HEAD AND NECK

 First, I will knock on the door for the patient to be aware that there’s someone coming inside
her room.
 Good afternoon ma’am. I’m TRISHA SALVADOR, your student nurse for today from
Northeastern College.
 Let me just perform hand hygiene to avoid cross contamination of microorganisms.
 So ma’am, may I ask what’s your name? May I also check your wristband ma’am? Ok TY.
 To provide privacy, I would like to close the door and curtains. Would it be fine with you
ma’am?
 So today I will be assessing your head and neck. We do this to ensure that everything is
normal and if we ever find out any abnormalities we are going to document that to prevent any
further complications. Rest assured ma’am that all documentations and findings will be
confidential with me.
 Before we start with the assessment, I just wanna ask you some questions.
Q: Are there any lumps and lesions on your head and neck that do not heal and disappear?
Q: How about any previous head and neck problems, trauma or injuries?
 So do you have questions for me before we begin? But if you do have, you can ask it
throughout the assessment.
 So let’s get started with the assessment.
 First, we are going to assess your head. So as I am looking for your skin color, your skin color
is nice and it ranges from light-deep brown.
 We’re also going to make sure that your head is the same size and shape as how it should be
for the body. And it is naman po.
 We’ll also look for any abnormal movements or twitching of your face that you can’t control. So
as I am assessing my client, I don’t see anything.
 We also want to make sure that the face is symmetrical and there’s no drooping on one side.
As I am assessing my client, it seems that her face is symmetrical and there’s no drooping on
the either side of her face. Drooping on the face can be seen in in the patient with Bell’s Palsy
and stroke.
 Next, we will look for the eyes and ears if they are on the same level. And while we’re here
we’ll go ahead and look for the facial expression and test Cranial Nerve #7 which is your facial
nerve.
Q: So can you close your eyes tightly for me ma’am? Then open them up.
Q: Can you smile? Frown and puff your cheeks.
CRANIAL NERVE #7 IS INTACT.

 Next is we’re going to palpate the head, is that okay with you ma’am? In doing that I would like
to put on my gloves first. So what are we trying to look here is were trying to look or check for
any masses, indentions, skin breakdown and any infestations.
 Also, while we’re palpating for the head, we also need to make sure that there’s no abrupt like
round areas which could represent alopecia. So as I am assessing my client, everything is
normal. (take off the gloves & perform hand hygiene)
 Next we're gonna do is we're going to find the temporal artery and we're going to palpate them
bilaterally.And while we're right here we're gonna go ahead and test the cranial nerve #5 which
is the trigeminal nerve and this nerve is responsibke for many things like mastication.
 So ma'am, I want you to clench your teeth like bite down for me and I'm going to feel the
meseta muscle which is right here and it should be a nice dirm ball and then I'll also palpate
the temporal muscle.
 Now what I'm going to do is to also test that nervous. So ma'am, can you open your moutg
against resistance. Okay as we can see maam, she can do that.
 Next, we are going to inspect for the external part of your eyes which are your eyelids,
eyelashes and eyebrows. So as I observe ma’am, there’s no swelling of the eyelids, no signs
of jaundice and erythema, the sclera is white and shiny, and I can see that your conjunctiva
doesn't have any drainage and it is pinkish which is completely normal. Your eyelashesh are
evenly distributed as well as your eyebrows. Your eye socket are equal there's no sign of
anisocoria, strabismus and nystagmus.
 Next is were going to assess at cranial nerves #3,4,&6. Oculomotor, Trochlear, and Abducens.
We will do a several tests to check their function.
 So I will be using a penlight on each of your eyes to see how the pupil will react. I observe that
your pupil constrict and have the same size and shape which is good to know.
 In checking for your pupillary accomodation, can you stare off at a distant object that helps
dilate the pupils and using a penlight, I’ll move it slowly inward to your nose. Is that okay with
you? So as I observe ma’am that your pupils are equal, round, and reactive to light.
 OPTHALMOSCOPE

 SNELLEN CHART

 In order to look if there’s an involuntary shaking of the eye, we are going to perform the 6
cardinal field of gaze. I want you to keep your head not moving and just use your eyes to
watch where I move the penlight.
 So next, we’re going to move on the ears.
 We’ll inspect the outside or the external part of your ear ma’am. So what are we trying to look
here is that we’re trying to look for any abnormalities, any redness, and drainage. So as I’m
assessing your external ear there’s no abnormalities, redness and drainage.
Q: Are you having any pain in your ear ma’am?
 So I’ll palpate your ear and you’re going to tell me if you have any tenderness or pain
whenever I palpate. So as I’m assessing my client, there’s no feeling of tenderness nor pain
which concludes that everything is normal.
 Then we're also palpate the mastoid process (likod ng ear) which is the big behind the ear and
we're looking if it is swollen, if there's any redness.
 Next is othoscopic examination. Since we have no othoscope I’ll just explain what to do in
examining your ear. For adult, pull the pinna up and back. In child, pull the pinna down and
back. And take note any condition of the tympanic membrane. The cone of light should be
5o’clock on the right ear and 7o’clock in the left.
 Next we're gonna do one more thing, we're gonna test the Cranial Nerve #8 which is the
vestibulocochlear.
 So we'll perform the whisper test. So I’m going to whisper words on the other side of your ear
and all I want you to do is to cover your other ear and tell me what I’ve said.
SO THAT NERVE IS INTACT.
 Next is Webers Test and Rinne Test. Again since we don’t have tuning fork, I’ll just expalin it.
So the tuning fork will be activated by flicking it between your fingers or by tapping the tuning
fork on the knee. For Rinne Test, we can place the tuning fork on any bony area surrounding
the ear and then the patient will hear a buzzing and tell you which position is louder. For
Webers Test, the patient will hear the sound loudest in her left or right ear or in the middle.
 Next is we’re going to inspect and palpate for your nose, make sure that it is midline on the
face. And it is naman po. And we’re gonna look at the septum. So as I’m assessing my client, I
can see that her nose is in the midline of her face.
 So ma’am I’ll pull up your nose and use penlight is that okay with you? What are we trying to
look here is we’re trying to look for its color, moisture, masses, bleeding, drainage or if there’s
a presence of polyps. So as I can see that it is pinkish color inside, no masses, there’s a
presence of hair which is completely normal and there’s no bleeding, drainage or polyps.
 To check for the patency of the nose, can you cover one side of your nostril then breathe out of
the other and vice versa. Ok, so the airflow was nice. Sometimes, people can have Polyps that
can block it or the devirted septum.
 Next is we’re going to palpate your temporomandibular joint (by placing index finger over the
front of each ear). Ma’am can you open your moth and then close. I'm feeling for any grading
or clicking sensations and I feel none. Thank uuu. So as I observe maam that there’s no
cracking.
 Then we will also palpate the sinuses which are your maxillary and the frontal, so ma'am I'm
going to put pressure on these two sinuses right here and you tell me if you feel any pain.
 Now, we’ll be moving on assessing the lips. We'll have to make sure that it's pink and there's
no cracking, sores and I can see that your lips in in good condition and there’s no sign of
discoloration and dryness.
 Next is were going to inspect the inside of the mouth. But first, let's test for cranial nerve
number 12 which is your hypoglossal nerve.
 So ma'am can you stick out your tonque and move it side to side.
 So ma’am I’ll also inspect your oral mucosa, hard and soft palates, gingivae, teeth and salivary
gland opening using a tonque depressor and penlight is that ok with you? So can you open
your mouth maam. I'm gonna look in the inside of the cheeks, it's nice and pink and I don't see
any sores, lesions. So as I’m assessing my client, I can see that it’s nice and pink, there’s no
signs of abnormalities like swelling, sores, lesions and discoloration. The tonque should be
moist and pink also and it is. I can also observe that she doesn’t have any cavities or tooth
decay.
 Next is we'll assess your uvula. As I’m assessing my client, it is in the midline, there’s no
redness and sores, it is not dry, it is moist and pinkish and also there’s no signs of swelling.
 We will also going to test for the cranial nerve number 9 which is the glossopharyngeal. So
ma'am can you say AHHH and then were just gonna test the gag reflex, so ill just move the
tonque depressor a little bit back there is that okay with u? okay Cranial nerve number 10
which is the vagus is intact because he can talk to me and he's able to swallow. (remove
gloves)
 Next, I’m going to inspect the neck first. So ma’am can you extend your neck up a little bit.
What are we trying to look here is we’re trying to look for the trachea if it is midline, we also
look for any lesions and lumps. So as I’m assessing my client, I don’t see any lumps and
lesions and her trachea is in the midline which is good to know.
 Next is we're going t test the cranial nerve number 11 which is the accessory nerve. So ma'am
can you move your head side to side, up and down and then shrug against my resistance. So
she did that without difficulty so that means that the cranial nerve is intact.
 Then ma'am I'll turn your head to the side is that okay with you? So what are we trying to look
here is the jugular vein distension. As I am assessing my client i do not see any.
 Next im going to palpate for the lymph nodes, as I do this ma’am tell me if you feel any pain or
tenderness.
 We will start at the pre auricular which is right in front of your ears and then we're gonna go to
the back of the ears which is the post auricular and then we're gonna go to the occipital, tha
parotid, jugular digastric, then were gonna go to the submandibular and then the submental
then we're gonna go to the superficial cervical and then we're gonna make our way down to
the deep cervical chain. Any tenderness so far maam? Then we're gonna go to the posterior
cervical and then right above the clavicle and to the supraclavicular. So there's no any pain or
tenderness. That's good.
 And we will also inspect and palpate your right and left carotid arteries one at a time. So I
observe the pulse was nice and have the same strength. I'ts 2 plus.
 Next, what we want to do is we're going to auscultate the carotid artery. We'll do it on one side
at a time and after that we'll compare the findings. I'll listen with the bell of the steth and listen
 for a bruit which is a swooshing sound. So ma'am all i want you to do is to breathe in breathe
out and hold it for me okay? Okayy so I did not hear any bruit on both sides.
 Lastly, we'll check the ability of your neck. So ma'am can you touch your chest and your
shoulders using your chin. Okay thats good.
 So now we're now done with the assessment so let me just document all the findings.
 And then after that, I would like perform hand hygiene again to avoid cross contamination or
microorganisms. Thank You