Before I start, I will perform handwashing technique to deter the spread of microorganisms and

prevent healthcare associated infections.

Skin:

1. Hi po good afternoon, ma’am. How are you po? I am nurse cha and I will be your nurse po for today.

2. Can you please state your name and your birthday po.

3. I will be also closing the curtains to give you privacy

4. At this moment I will be assessing your Skin, Hair, Nails, Face, Eyes, Ears, Nose, Mouth, and Neck.
Would that be okay with you? (YES)

5. And now I will start with your skin. Would it be okay if I ask you several questions po? (OKAY)

6. Do you have any pain or itching? Presence of skin lesions, bruises, abrasions, or pigmented spots?
Previous skin problems? Or any family history? Related systemic condition? Do you use any medications,
lotions, or home remedies? Tendency to bruise easily? And lastly recent contact with allergens.

7. Can I have your hands po? (INSPECT)

8. I will be palpating your skin po for the temperature

9. Now I will be assessing your skin turgor.

10. Thank you. Hygiene. Document

Hair:

1. Now I will be assessing your hair. But before that would it be okay if I ask you several questions po?
(YES)

2. Do you use any chemical treatment? Chemotherapy? Or chronic or acute conditions?

3. So now I will be positioning myself at your back so that I can assess your hair properly

4. Can I look at your arms please

5. Thank you. Hygiene. Document

Nails:

1. So now I will be assessing your nails. Would it be okay if I ask you several questions?

2. Do you have diabetes mellitus? Peripheral circulatory disease? Previous injury or severe illness?

3. So now we will proceed with assessment of your nails. Can I have your hands po

4. Now I will be performing blanch test, I will be putting pressure on your nails

5. Now I will be performing schamroth’s test. Kindly put your finger against each other like this.

6. Thank you. Hygiene. Document

1. So now I will be assessing your skull and face. Would it be okay if I ask you several questions?

2. Do you have any past problems with skin/scalp? History of loss of consciousness, dizziness, seizure,
facial pain or injury? History of any lumps/bumps detected? Known causes of problems? Associated
symptoms, treatment, or recurrences?

3. So now I will be assessing your skull and face

4. I will be observing for symmetry of movement. Can you please smile? Can you please frown? Can you
please puff your cheeks

5. Thank you. Hygiene.

Eyes and vision:

1. Now I will be assessing your eyes and vision but before that would it be okay if I ask you several
questions?

2. Do you have any family history of diabetes, hypertension, blood dyscrasia, or eye disease? Last visit to
ophthalmology? Current use of eye medication? Use of contact lenses? And current symptoms of eye
problems?

3. Now I will be assessing your eyes and vision (lawen eyebrows and mata)

4. I will also be assessing your conjunctiva, I would retract the lower part of your eyelids would that be
okay?

5. Now I will be assessing your pupillary reaction but I would be needing to turn the lights off. Look
straight at me (sulwan yang penlight)

6. Next is your pupillary accommodation. Kindly look at this penlight and now look far away

7. Next is your peripheral vision. Please cover your right eye with ur hand then tell me once when you’re
already seeing the penlight

8. Thank you. Hygiene. Documentation

Visual acuity:

1. Now I will be assessing your visual acuity.

2. As you can see there is a chart right there I want you to read the letter that I point out

3. Okay can you please cover your left eye

4. Please read the letters left to right from line number 3

5. Thank you. Hygiene. Documentation

Ears and hearing ability:

1. Now I will be assessing your ears and hearing ability. Would it be okay if I ask you several questions?
2. Do you have any family history of hearing problems? Presence of ear problems? Medication history?
Hearing difficulty? Or use of correcting hearing device?

3. I will be positioning myself at your back so I can assess your ear properly

4. Now I will inspect the outer part of your ear. Please tilt your head to the left (talnan and lawen ing
ears na)

5. Now I will be inspecting the inner part of your ear. I will be using an otoscope and I will be pulling your
ears upward and backward

6. Now im going to test your hearing ability by using a tuning fork. (Palwan ya ing tuning fork saka ya
kabit keng babo ng buntuk) Can you hear the sound

7. Next is I will be putting the tuning fork at the back of your ear. Please raise your arm if you no longer
hear the vibration

8. Now were going to do the rombergs test to check ur balance. Please stand, feet together, raise your
hands, and kindly close your eyes

9. Thank you. Hygiene. Documentation

Nose and sinuses:

1. Now I will be assessing your nose and sinuses. Would it be okay if I ask you several questions?

2. Do you have any allergies? Difficulty breathing through the nose? Injuries to nose or face?
Nosebleeds? medications taken? Changes in sense of smell? Or sinus infections?

3. Now I will be assessing your nose

4. I will also be palpating your nose to assess if there are nodules or inflammation

5. Can you please close one of your nostrils and breathe through the other

6. Thank you. Hygiene. Documentation

Mouth and Oral cavity:

1. Now I will be assessing your mouth and oral cavity. Would it be okay if I ask you several questions?

2. Do you have a routine pattern of dental care? Last visit to dentist? Length of time ulcers? Denture
discomfort? Medications?

3. Now I will be assessing your outer lips (lawen yamu)

4. Next is I will be assessing the oral cavity. Please open your mouth put out your tongue (stick keng dila
chaka sulwan penlight)

5. Can you please say “ahh” while I take a look at your oral cavity

6. Thank you. Hygiene. Documentation

1. Now I will be assessing your neck. Would it be okay if I ask you several questions?

2. Do you have any problems with neck lumps? Neck pain? Previous diagnoses of thyroid problems? Or
other treatments provided to neck?

3. Now I will be inspecting your neck. Can you please turn your head to your right then left.

4. Kindly put your chin down. Tilt your head upwards. Next is to move your ear towards your shoulder.

5. Next is I will assess the muscular strength. I’m going to add some pressure you need to act against the
resistance.

6. Now I will put some pressure on your shoulder I would like you to shrug them

7. Next is I will palpate your neck would it be okay?

8. Thank you. Hygiene. Documentation