Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

Name: Year & Section: BSN-1A

A. Nursing Interview Guide to Collect Subjective Data from the Client

Questions Findings
Current Symptoms
1. Lumps or lesions on head or neck that do not heal or
disappear.
2. Difficulty moving head or neck.
3. Facial or Neck pain or frequent headaches.
4. Dizziness, Lightheadedness, spinning sensation or loss
of consciousness
Past History
Previous head or neck problems, trauma, injury (surgery,
medication, physical or radiation therapy) results
Family History
1. Family history of head or neck cancer.
2. Family history of migraine headaches.
Lifestyle and Health Practices
1. Do you smoke or chew tobacco? Amount? Secondhand
smoke?
2. Do you wear a helmet or hard hat?
3. Typical posture when relaxing, during sleep, and when
working
4. Type of recreational activities.
5. Satisfaction with appearance.
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

Name: Year & Section: BSN-1A

B. Physical Assessment Guide to Collect Objective Client Data

Questions Findings
1. Gather equipment (gloves, penlight, or flashlight, small
glass of water, stethoscope)
2. Explain procedure to client.
Head and Face
1. Inspect head for size, shape, and configuration.
2. Palpate head for consistency while wearing gloves
3. Inspect face for symmetry, features, movement,
expression and skin condition.
4. Palpate temporal artery for tenderness and elasticity
5. Palpate temporomandibular join for range of motion,
swelling, tenderness, or crepitation by placing index finger
over the front of each and asking client to open mouth.
Ask if client has history of frequent headaches.
Neck
1. Inspect neck while it is in a slightly extended position
(and using a light) for position, symmetry, and presence of
lumps and masses.
2. Inspect movement of thyroid and cricoid cartilage and
thyroid gland by having client swallow small sip of water.
3. Inspect cervical vertebrae
4. Inspect neck range of motion by having client turn chin
to right and left shoulder, touch each ear to the shoulder,
touch chin to chess, and lift chin to ceiling.
5. Palpate trachea by playing your finger in sternal notch,
feeling to each side and palpating the tracheal rings.
6. Palpate the thyroid gland.
7. Auscultate thyroid glands for bruits if the gland is
enlarged (use bell of stethoscope)
8. Palpate lymph nodes for size/shape, delimitation,
mobility, consistency, and tenderness (refer to display on
characteristics of lymph nodes).
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

a. Preauricular nodes (front of ears)

b. Postauricular nodes (behind the ears)
c. Occipital nodes (posterior base of skull)
d. Tonsillar nodes (angle of the mandible, on the anterior
edge of the sternocleidomastoid muscle)
e. Submandibular nodes (medial border of the mandible);
do not confuse with the lobulated submandibular gland
f. Submental nodes (a few centimeters behind the tip of the
mandible); use one hand
g. Superficial cervical nodes (superficial to the
sternomastoid muscle)
h. Posterior cervical chain nodes (posterior to the
sternocleidomastoid and anterior to the trapezius in the
posterior triangle)
i. Deep cervical chain nodes (deep within and around the
sternomastoid muscle)
j. Supraclavicular nodes (hook fingers over clavicles and
feel deeply between the clavicles and the sternomastoid
muscles)
Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.