Professional Documents
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Retdem Physical Assessment
Retdem Physical Assessment
1ST CLIP: ASSESSMENT OF THE HEAD, NECK, EYES, EARS, NOSE, MOUTH AND THROAT
SHYLA JANNESSA M. LINGAD/ BSN1-Y2-1
2ND CLIP: HELLO EVERYONE THIS IS SHYLA JANNESSA M. LINGAD, A STUDENT NURSE FROM
OUR LADY OF FATIMA UNIVERSITY PAMPANGA. TODAY I’LL BE SHOWING YOU HOW TO
ADEQUATELY EVALUATE PATIENT’S PHYSICAL ASSESSMENT.
4TH CLIP: MAKE SURE TO GATHER ALL THE EQUIPMENTS NEEDED FOR THIS ASSSESSMENT.
1. ASK THE CLIENT TO SIT IN AN UPRIGHT POSITION WITH ARMS RELAXED AT THE SIDES
Nurse: Before we start ma’am, I will ask few questions about your health and past health
history.
Nurse: You may sit properly ma’am and relaxed your arms at the side.
1. THROUGHOUT THE EXAMINATION, ASSESS FOR THE SKIN COLOR, VARIATIONS,
TEXTURE, TEMPERATURE, TURGOR, EDEMA, LESIONS
QUESTIONS
Nurse: Our first question is do you have lumps or lesions to head or neck that do not heal or
disappear?
Patient: None
Nurse: Do you experience difficulty in moving your head or neck?
Patient: None
Nurse: Do you have facial or neck pain or frequent headaches?
Patient: None
Nurse: Do you experience dizziness, like headedness, spinning sensation or loss of
consciousness?
Patient: No
Nurse: On your past history, do you have previous head or neck trauma or injury?
Patient: None
Nurse: Your family history has/had an head or neck cancer?
Patient: None
Nurse: Your family history had migraine or headaches?
Patient: None
Nurse: Do you smoke or chew tobacco?
Patient: No
Nurse: Do you wear a helmet or a hat?
Patient: No
Nurse: What is your typical posture when working, during sleep and relaxing?
Patient: Naka side lang or straight
Nurse: What type of recreational activities do you do?
Patient: Riding a bike and playing badminton in my free time.
Nurse: And are you satisfied with your appearance?
Patient: Yes
Nurse: Thank you ma’am for answering that questions. Before we start the procedure, I will just
close the door and sanitize my hands for you to have privacy.
• Provide Privacy
* CLOSE CURTAIN*
* HAND HYGIENGE*
* INSERT CLIP WEARING OF GLOVES*
* HEAD AND FACE*
Nurse: The first part of our assessment is that I will inspect your face and palpate your head. Is
that okay with you ma’am?
Patient: Yes
Inspect and Palpate the head
1. Note hair for texture, brittleness and moisture, color, consistency and distribution
2. Observe face for symmetry, features
* PALPATE HEAD FOR CONSISTENCY WHILE WEARING GLOVES*
1. PALPATE THE FRONT HEAD
2. PALPATE THE BACK OF HEAD
3. SCALP
Result: Upon observing your head and scalp ma’am, I notice that your head is symmetrical, it
is round and it is in the mid-line. You are normocephalic, it means that it is appropriate in
your body.
Nurse: I also do not see any lesions, scars or bumps in your head. Parasites like lice are also
not present. And I do not see allocation.
Nurse: Our next procedure ma’am is that I will be checking your Facial Symmetry and Facial
movement. LOOK AT THE FACE
Nurse: Okay ma’am.
HAVE THE CLIENT SMILE, FROWN, SHOW TEETH, BLOW OUT CHEEKS, RAISE EYEBROWS, AND
TIGHTLY CLOSE EYES (CN VIII) Nurse: Next ma’am, I will be checking your cranial nerve #8 or
your facial nerves. Just do the actions that I will be telling you.
Nurse: Can you raise your eyebrows ma’am?
Nurse: You can lower them
Nurse: Can you blink?
Nurse: Okay. Can you close your eyes slightly?
Nurse: Okay ma’am. Can you smile?
Nurse: Uhm, can you frown?
Nurse: And can you puff your cheeks?
Result: Based on the assessment ma’am I didn't observe any abnormalities and irregularities
Nurse: Now ma’am, I’m going to assess each of your nostril for airflow, ability to smell and any
signs of abnormalities. Is that okay with you?
• Asked the patient to occlude the each of her nostril to check the patency of airflow.
Nurse: Ma’am, can you close your right nostril and try to breath
Nurse: The other one naman po’
Nurse: Did you have hard time breathing?
Both of my patient’s nostril are well-functioning. This indicate that there is no obstruction
Nurse: Next ma’am, I’m going to let you smell a familiar scent, and you need to tell me what you
perceived. But first I need you to close your eyes and occlude the left nostril. Is that okay?
• Paamoy yung
Nurse: Okay we’re going to do the same thing in your right nostril. Can you please close your
eyes and occlude your left nostril.
• Paamoy ulit
Nurse: You did great ma’am. So far you managed to name all scent correctly.
Accurate sense of smell means that the 1st cranial nerve or olfactory nerve is intact.
• Inspect the internal nose for any abnormalities, such as, swelling, discoloration, exudate,
discharge, nodules, or perforated septum
Nurse: Ma’am, can you look at the ceiling again? Okay thank you.
No signs of the mentioned abnormalities, which is good.
Nurse: Also, I have to check your Gag reflex so I need to insert this depressor in your mouth and
you’ll probably feel uncomfortable and that’s completely normal.
• Assessing the gag reflex is the stimulation of the posterior pharynx in each of its side.
My patient has normal gag reflex which indicates normal
Nurse: Then, Ma’am. I need to inspect and palpate your tongue for any abnormality, okay?
• (Inspect first then Palpate the tongue.)
Okay, the ventral and side surface of the tongue does not have leukoplakia, persistent lesions,
and nodules which is normal.
Nurse: Now, I’m going to assess your tongue strength and will use tongue depressor. I will exert
a force and I need you to resist against it, okay?
“Your tongue seems to be in a good condition.” This indicates that the Glossopharyngeal and
Vagus nerves are intact.
Nurse: Ma’am, I will assess your sense of taste. I’m going to swab your tongue with three
different flavors and I need you to tell me what are these, okay?
• I’m going to test the 2/3 anterior portion of the tongue controlled by facial nerve, and the
1/3 posterior portion of the tongue controlled by Glossopharyngeal nerves. And each side
of it should be tested. (Do the assessment)
Since my patient perfectly distinguish all of the flavors, it means that the mentioned cranial
nerves earlier are intact.
Nurse: May I ask maam when you swallow the water did you feel any pain or tenderness at the
neck part?
Patient: None
Nurse: Okay ma’am, did you have difficulty in swallowing the water?
Patient: None
Nurse: That’s very good to know.
Nurse: Next ma’am I will assess your cervical vertebrae and I will assess it posteriorly. Okay
maam
• Look on the side and tilt upper
• Opposite side ma’am
Based on the observation ma’am and procedure your trachial is in the middle line.
Nurse: Our next procedure ma’am is auscultate your thyroid glands to see if there is any
presence of bruits.
Nurse: Okay maam. That is the last part of the assessment. If you have anymore concerns and
questions I will refer you to our attending physician and he’ll tell you all about the things he
need to know.
Nurse: Thats all for the assessment. Thank you for cooperating, thank you and have good day!
Patient: Thank you!