NOSE

Nurse: Now we’re going to inspect the nose (inspect and palpate the nose) I can see
that your nose is fairly symmetrical.
Are you having trouble with your nose?
Are you having any drainage?
Patient: No
Nurse: I’m going to palpate your sinuses.
PALPATION QUESTIONS: Any pain with that? Tenderness?
1. Maxillary

2. Frontal
Nurse: To checks the patency of the nasal passages. Can you cover one nostril then
breathe through the other and vice versa.
Any trouble breathing? Okay, heard airflow, heard airflow. So, both nares are Payton
Okay, nice because some people have polyps that can block it or the deviated septum.
Nurse: Now, let’s inspect the internal nostrils to detect if there is any can
edema, inflammation, and excessive drainage.

Number 34 - CHECKLIST
Nurse: I’m going Palpate the
temporomandibular joint, to
check for any clicking or any
pain. Can you open and close
your mouth.
Nurse: Any pain with that?
Patient:
MOUTH
Nurse: Then moving on to the mouth.. (wear gloves)
I can see that your lip is moist and pinkish color, there is no lesions or
cracking.
So now, let’s inspect the inside of the mouth, can you open your mouth?
Your teeth are white; I do not see any missing teeth, there is no cavities
I see the gums are pink, they look tight around the teeth. There is no gum
disease or inflammation or redness.

Now, I’m looking at the inside of the cheeks. It’s the buccal mucosa and the
other side. It’s pink, shiny, and with no lesions.
Open your mouth for a bit more, I’m going to check your soft and hard
palate, and the uvula is nice in midline.

For the inspection of the tongue, can you stick your tongue out?
So there’s the ventral surface of the tongue, it’s pink and moist.
Can you lift your tongue up?
Okay, there is no lesion underneath the tongue.

CRANIAL NERVE 9 – GLOSSOPHARYNGEAL

Now, let’s check for the uvula, it is nice in midline. Can you say “ahh” while
sticking out the tongue. Okay so the uvula and soft palate rise.

CRANIAL NERVE 10 – VAGUS NERVE

Also, the vagus are intact because she’s able to talk to me without
hoarseness and she’s able to swallow.
REMOVE GLOVES AND PERFORM HAND HYGIENE

NECK
Nurse: Now moving on to the inspection of the neck (extend the neck up a
little bit – chin up ang peg)
Nurse: There is no swelling of the salivary glands and the base of the neck
for the thyroid gland.
Nurse: Now, we’re going to assess the lymph nodes of the neck by using
the pads of my fingers in a slow, circular motion.
- Preauricular
- Post auricular – behind the ears
- Occipital bone – 1 inch pa sa behind ears
- Submental – under the chin
- Submandibular – jaw bone
- Jugular digastric – corner sa panga
- Superficial Carvical –
- Deep cervical chain then all the way down the neck
- Posterior Cervical – batok
- Sub clavicular – collarbone (Can you shoot your shoulders up?okay
you can relax.)
Nurse: Okay, so I do not feel a lymph node.
Nurse: So next, I will palpate your carotid artery.
Nurse: It is nice and bounding two plus, and we’re going to feel on the other
side…okay, it’s same strength two plus.

Now we’re going to auscultate the carotid artery. We’re going to listen
a swooshing sound. Okay so breathe in, breathe out and hold it for
me.
Nurse: Okay, I did not hear on that side (right)
Then breather in, breathe out and hold it.
Nurse: Okay, I did not also hear on this side (left)
Nurse: Now, we’re going to assess for your range of motion of your neck.
So can you put your chin up, then put your chin down to your chest. Then
turn side to side. Then put your ear to shoulder and to the other side. tip the
head back as far as possible.
Nurse: Okay, good. So the range of motion of your neck is normal, it is
smooth and controlled.

Remove any additional PPE, if used. Perform hand hygiene

INTRODUCTION
Nurse: Good Day! My name is Ivie and I’m your student nurse for today. So
before we begin, can you please tell me you name? Birthday?
Nurse: Can I check your Identification bracelet to verify your identity?
Nurse: I am here to do an assessment for your head and neck
Nurse: So before we begin, may I ask some questions, do you smoke? Any
problems with your mouth or your face that you’re aware of? Any problems
with your thyroid? Okay, alright.

HEAD
Nurse: Okay, so I’m going to start by looking at your face. So I’m looking at
your shape and size of your head which is appropriate for your size of
person and that is normal cephalic. Your skin color is light brown. There are
no abnormal movements that are involuntary, also your face is
symmetrical. Your eyes and ears are at the same level.

TEST FOR CRANIAL NERVE 7 – FACIAL NERVE

CHECK
Nurse: To check for facial expression and test cranial nerve 7. Okay, so
can you close your eyes tightly for me and open the mouth?
Okay, now, smile for me? Frown? And puff out your cheeks. Okay, thank
you. (She did that with E) Your cranial nerve is intact.

(WHILE WEARING A GLOVES)

Nurse: Now, I’m going palpate for your head to check for any masses,
indentations, look for skin breakdown and any infestations.
EYES
Nurse: Now, we’re going to inspect the eyes. I’m looking at the eyelid,
sclera (WHITE OF THE EYES), pupil, iris, and I’m looking at the
conjunctiva (TINITIGNAN KAPAG ANEMIC SA MATA)
Nurse: There is no swelling of the eyelids, sclera is white and shiny, and
the conjunctive is nice in pink.
Nurse: Also, the eyes are normal. You eye color is dark brown. There’s no
strabismus and anisocoria.

Sclera:
YELLOWISH – JAUNDICE
REDDISH - ERYTHEMA

EYES:
STRABISMUS – CROSSED EYE
ANISOCORIA – 1 PUPIL IS SMALLER; NOT EQUAL IN SIZE
NYSTAGMUS – INVOLUNTARY SHAKING OF THE EYE

NORMAL PUPILS – 3-5 MILLIMETERS

Nurse: So let’s now do the visual acuity test to check your distance vision
by using Snellen chart. Okay so you are positioned 20 ft. from the Snellen
chart. Cover your left eye and I’d like you to read the smallest line that you
can read. Same procedure to the other eye.
20/25 means is that at 20 ft. you are reading what the normal eye can read
at 25ft.
TEST FOR CRANIAL NERVE 3 – OCULOMOTOR
TEST FOR CRANIAL NERVE 4 – TROCHLEAR
TEST FOR CRANIAL NERVE 6 – ABDUCENS

Nurse: I am now going to assess cranial nerve such as ..

Nurse: Now, I’m going to check for the involuntary shaking of the eye
((nystagmus) – 12 to 14 inches away from the patient’s nose) Okay, Don’t
move your head and just use your eyes to watch where I move the
penlight.
((PERFORM IT IN A 6 CARDINAL FIELDS OF GAZE))

Nurse: Now I’m going to see how reactive the pupils are to light and to do
that we’re going to dim the light a little bit. Stare off at the distant object that
helps to dilate the pupils
((3 MILLIMETERS TO 1 MM))
Nurse: I am going to dilate, constrict. And do the same thing to the other,
and they both constricted.

Nurse: Now, I’m going to check for accommodation and convergence, and
if the eyes cross while looking at the pen light. Stare off in the distance,
don’t move your head, and just follow this pen light

Nurse: Okay, so the pupils are round, equal, and reactive to light, and
accommodate.
DOCUMENTATION TO EYES: PERRLA – ACRONYM
EARS
Nurse: Now, I am going to inspect the ears to check if there are any
abnormalities, redness, and drainage. Are you having pain in your ear?
Okay, so I’m going to palpate your ear, is there any tenderness? I’m now
going to palpate the mastoid process which is the big hump behind the ear
to check if it is swollen, redness, and does it hurt?

Now, we will use an otoscope to inspect the tympanic membrane

Nurse: We are now going to test the cranial nerve 8 which is the
vestibulocochlear. In which I am going to whisper two words while I cover
your other ear, are you ready?
Okay, and that nerve is intact

Nurse: So the last assessment for the ear is to perform Weber’s test and
Rinne test using a tuning fork. I’m to place this tuning fork at the top of your
head. Do you hear the tone equally in both ears or is it louder on one ear?
Okay, so now I will put this tuning fork on the mastoid process and tell me if
the sound caused by the vibration is no longer heard.
TUNING FORK IS 1-2 CM FROM THE AUDITORY CANAL
Pearly gray translucent color and shiny – tympanic membrane
5:00 – RIGHT EAR
7:00 – LEFT EAR

TOPHI – LONG-TERM GOUT ON THE HELIX OF THE EAR

- WHITE/YELLOWISH NODULES

CRANIAL NERVE 8 – VESTIBULOCOCHLEAR

NORMAL WEBER TEST – HEARD EQUALLY IN BOTH EARS

SENSORY NEURAL HEARING LOSS – SOUND WILL LATERIZE TO THE
UNAFFECTED EAR. THE TONE WILL BE HEARD LOUDER IN THE
GOOD EAR
CONDUCTIVE HEARING LOSS – SOUND LATERIZE TO THE
AFFECTED EAR. THE TONE WILL BE HEARD BETTER IN THE POOR
EAR.

NORMAL OR POSITIVE RINNE TEST – THE SOUND HEARD OUTSIDE

THE EAR (AIR CONDUCTION OR AC) IS LOUDER THAN IN MASTOID
PROCESS.
AC > BC – POSITIVE
ABNORMAL HEARING = (BONE CONDUCTION) BC > AC – NEGATIVE
RINNE – CONDUCTIVE HEARING LOSS