Good afternoon ma’am!
I’m Glaiza Torres, your student nurse from Our Lady of Fatima
University.
So for verification ma’am,
1. May I know your name po?
2. How about your birthday ma’am?
3. How old are you po?
So for today ma’am, I'll just explaining the procedure that I'll be doing to you. I'll be assessing
your head and neck, and for me to be able to assess that I'll be able to touch that certain parts
of your body, specifically in the head and neck parts, so is it okay with you ma'am?
So rest assured that all of the documents and findings are completely confidential with me.
So ma’am do you have any questions?
Okay, so before i start ma’am I’ll just have a quick history about you so
1. Are there any lumps or lesions on the head or neck that do not heal or disappear?
2. How about difficulty po sa pag move ng head and neck niyo po?
3. How about sa facial and neck pain po? meron po ba kayong mga frequent headaches?
4. Nahihilo po ba kayo minsan or nawawalan po ng malay?
Okay, so move forward naman po tayo sa Past History ma’am.
1. Is there any previous head or neck problems/trauma/injury?
Sa Family History po
1. Meron po ba sa family niyo na nagkaroon ng head or neck cancer?
2. How about family history of migraine headaches?
Sa Lifestyle and Health Practices po
1. Nag s-smoke po ba kayo or nag chew ng tobacco?
2. Do you wear a helmet or hard hat?
3. How about sa pag tulog niyo, ano po yung typical na posture niyo?
4. How about sa type of recreational activities po?
5. Sa satisfaction of appearance naman po ma’am?
Okay ma’am so I’ll perform the assessment na po. But before that I’ll just have a hand hygiene
po. Ico-close ko lang po yung curtains para sa privacy niyo po.
Wear gloves
(HEAD AND FACE)
1,2. Okay ma’am so the first part of our assessment, i-inspect ko po yung face niyo and
1. ipa-palpate ko po yung head niyo, okay lang po ba yun? (Okay ma’am, I observe that
your head is symmetrical, it is round, it is in the midline and your head is appropriate in
your body. I don’t see any lesions, scars, masses that are present in your head. There
are no parasites present like lices and I haven't observed any alopecia.)
3. Next one ma’am, I'll be checking your facial symmetry and your facial movements,
expression and skin condition.
*observe
Next one ma’am i'll be observing your facial nerves. Please do the things that i’ll tell you to do.
1. Can you please raise your eyebrows po, okay lower it.
2. Can you please blink your eyes for me po
3. Close your eyes po tightly
4. Smile and show your teeth po
5. Frown po tayo
6. How about po Puff the cheeks
Okay po, that’s very good ma’am. (Hindi naman po ako naka-kita ng any abnormalities nung
ginawa niyo po yung mga procedures na pinagawa ko.
Also ma’am, hindi rin nag d-droop yung face niyo sa mag kabilang sides, pantay lang po and
okay lang po.)
So next one ma’am, i’ll be palpating your temporal artery, so allow me to touch you again
ma’am
-can you please bite your teeth like this po
Next one ma’am, i’ll be checking your temporomandibular joint
-can you please open your mouth po
Okay, very good. I haven’t seen any swelling and hindi naman po ako naka-observe ng any
creaky.
Nung ginawa ko po yung procedure nakaramdam po ba kayo ng any tenderness po?
So, nakaranas po ba kayo ng any headaches these past few days ma’am?
NECK
Yung next part naman po ng ating assessment is neck part po.
So, i’ll be checking your neck po
1. Inspect the neck in neutral position
2. Inspect the neck in extended position
3. Can please sip a small amount of water po, hold niyo lang po muna saglit yung water po
So i can see po that your trachea is in the midline naman po, no lumps, no bulges or any
masses which is normal po.
So nung nag sip po kayo nakaramdam po ba kayo ng any tenderness or pain po?
So next part of our assessment ma’am, i’ll be checking your cervical vertebrae. So posteriorly or
nakatalikod ko po siya i-assess.
-assess the cervical
-look sa side
I don’t see any irregularities naman po
So next part naman, ichecheck ko po yung neck range of motion.
1. Can you please look at the ceiling po
2. Look to the floor
3. Can you look to the right side
4. Can you look to the left side
Next one ma’am, i’ll be palpating your trachea po and posteriorly ko po ulit siya gagawin.
Na-observe ko naman po ma’am and i can feel na nasa middle naman po siya.
Palpate the thyroid gland
Okay so i can say na your tracheal rings are working and good naman po ang pag swallow
So next one ma’am i’ll be auscultating your thyroid gland let’s hear kung may sounds of bruits
po
1. Can you please inhale and hold your breath po muna for awhile
-I can see that there are no present bruits
So for the last one naman po ma’am. I’ll be palpating your lymph nodes, so allow me to touch
your face again.
So that is the last part po of your head and neck assessment. You have any questions or
clarification po ma’am?