HA Retdem

Gathers equipment
Good morning sir, I am Owen San Luis your student nurse sir, form Lorma colleges.
So for verification sir may I know your name po, how a about your birthday sir? And how old are you po?
Ok sir, so, I perform the assessment na po, but before that I just have a hand hygiene po
So for today sir, I just explain the procedure that I’ll be doing to you, I be assessing your head and neck
and for me to be able to assess that, I be able to touch parts of your body specifically in the head and
neck parts, so is it ok for you sir?
So lets assure that all the documents and findings are completely confidential with me and the attending
position that I’ll be referring you to, so sir, do you have any questions?
So before I start sir, we need to ware this gown sir.
So sir, the first part of our assessment is, I will going to inspect your face sir and I will also going to
palpate your head. Is it ok for you sir? ( inspect for the head )
Before I’ll going to palpate you sir, I will going to wear a clean gloves first
So ok po, I’ll be palpating your head po sir. ( touch head )
ok I’ll just observe your scalp po sir.
I’ll just check the back of your head po.
ok sir, I observed that your head is symmetrical, it is round, it is eric, it is in the midline and you are
normocephalic which means your head is appropriate in your body and don’t see any lesions, scars,
masses that is present in your head also there are no parasites present.
So next one sir, I’ll be checking your facial symmetry and your facial movement symmetry (just observe)
So next one sir, I’ll be checking your cranial nerve 7 which is the facial nerve, so please do the things that
I’ll tell you to do, so can you please rase your eyebrows po, ok, and then lower it and can you please
blink your eye for me po, so close your eyes po tightly, ok sir open na po, next one is smile and show
your teeth po, how about puff po your cheeks
Ok po that’s a very good po sir, I didn’t see any abnormalities po and there is no drooping of the face on
both side and your facial features po are symmetric po and there is no also involuntary movement of the
face po.
So next one I’ll be palpating your temporal artery, so allow me to touch you po again sir, can you please
bite your teeth po then release po then bite po again, next one sir I’ll be checking your
temporomandibular joint, can you please open your mouth po and again po ok very good, I haven’t seen
any swelling po and I haven’t observe any clicking.
When I do that po ba sir did you feel any pain or tenderness po? Ok so that’s good to know sir,
Did you feel any headaches po this past few days sir? Ok that’s good to hear sir
And the next part po of our assessment is the neck part po, so I’ll be checking your neck po, so I’ll be
observing this part po, I’ll just feel it.
So can take a small sip of water sir.. so I can see po that your trachea is in the middle line and when you
take sip of water po, the process is ok naman po, and the thyroid and cricoid cartilage and thyroid gland
move upwards symmetrically naman po and that’s normal po sir, I didn’t see any bulging or any swelling
po in our neck part po.
So next part of our assessment sir, I’ll be checking your cervical vertebrae po, so I’ll assess it posteriorly
po, so can you please flex your neck po, chin to chest po and then ear to shoulder po and then can you
twist your neck po from left to right and right to left po and backwards and forward po, I don’t see any
irregularities naman po when you do that po and the next one po is I will check your neck range or your
neck motion po so can you please turn your chin to right and left shoulder and then touch each ear to
the shoulder po, and touch chin to chest po and then lift your chin to ceiling po.
do you feel any tenderness or painful when you do that po?
And next one sir, I’ll be palpating your trachea po, so I’ll palpating it posteriorly po, I observed and I can
feel that na sa middle naman po siya. Ok po, can you swallow po sir, I can see that your tracheal rings
are working po and maganda naman po yung pag swallow nyo po
Now sir, can you please look up and turn your neck slightly po and the other side po, its ok sir, and your
trachea is in the middle line po
Next one po sir I’ll be auscultating your thyroid gland po to see if there are any present bruits po, can
you please inhale po and hold your breath po for a while po then exhale po then inhale po ulit, I can see
that there are no present bruits and your carotid artery are functioning well so for the last one po sir, I’ll
be palpating your lymph nodes, so allow me to touch your face again po.
 So right now I’m palpating your preauricular nodes which is front of the ears
 I’ll be palpating your postauricular nodes or behind the ears
 Then the occipital node
 And then the tonsillar nodes po
 The submandibular nodes
 And then submental nodes
 The superficial nodes
 Posterior cervical nodes
 Deep cervical chain nodes
 And the supraclavicular nodes
So that’s the last part of your assessment sir, for the head and neck, if you have any questions or
clarification or if you felt anything in your health po I refer your attending physician po and siya po yung
mag eexplain of all the things that you need to know po, so this assessment that we do po is to treat our
necessary needs.
So thank you sir, for you cooperation. Make sure sir, to drink your vitamins, and drink enough of water
po and eat balance diet po for everyday. So do have any questions pa po ba sir?

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Gathers equipment

So before I start sir, we need to ware this gown sir.

So ok po, I’ll be palpating your head po sir. ( touch head )

ok I’ll just observe your scalp po sir.

I’ll just check the back of your head po.

do you feel any tenderness or painful when you do that po?

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