HEAD TO NECK ASSESSMENT SCRIPT ●​ INSPECT THE NECK

(tignan yung neck if there are lumps or masses etc.)

PREPARATION:
N: Good day Ma'am! I am, a student nurse from. Before we proceed I TCI: The neck of the client is symmetric with her head centered and no
will first verify your name. May I please have your hand mam? Alright, bulging masses are observed.
please state your full name mam. Your birthday? Your age?
●​ INSPECT MOVEMENT OF THE NECK STRUCTURES
N: And, how would you like me to call you?
N: Okay mam, this time I will be needing you to drink from the cup of
N: Alright mam, today I will be doing a head to neck assessment of you water to be able to help us in inspecting the movement of your neck
and I will be needing your full cooperation in order to help us in structures.
providing the best care possible for you. During the assessment, I will
be needing to touch some of your body parts, will that be alright with TCI: As the patient swallows, the thyroid and cricoid cartilage moves
you? symmetrically.

N: Alright, please wait for a while mam. ●​ INSPECT THE CERVICAL VERTEBRAE

PERFORM HAND HYGIENE (REMOVE WATCH PLS) THEN N: Now could you please put your chin towards your chest?
ASSEMBLE YOUR EQUIPMENTS
TCI: The cervical vertebrae/C7 of the patient is visible and palpable.
N: Now I will be drawing the curtains in order to provide you privacy.
●​ INSPECT THE RANGE OF MOTION
HEAD & FACE:
●​ INSPECT THE HEAD N: Okay mam, now please put your chin upwards to the ceiling, now
(check yung head like tignan siya and all) sidewards putting your chin to your right and left shoulder. This time,
you left ear to your left shoulder and your right ear to your right
TCI: The patient’s head is symmetric, round, in midline, proportional to shoulder.
its body size, no lesions.
TCI: In terms of the range of motion it is smooth and controlled with a
●​ INSPECT THE FACE 45 DEGREE FLEXION, 55 DEGREE EXTENSION, 40 DEGREE
N: Alright mam, can you please raise your eyebrows for me? Then LATERAL ABDUCTION, AND 70 DEGREE ROTATION.
frown, then close your eyes, smile while showing your teeth, then can
you pop your cheeks? ●​ PALPATE THE TRACHEA
(place finger sa may sternal notch; feel each side of the notch then
-​ RAISE EYEBROWS palpate tracheal rings; nasa harap daw si nurse when we do so)
-​ FROWN
-​ CLOSE YOUR EYES TCI: The client’s trachea is in midline.
-​ SMILE SHOWING TEETH
-​ POP YOUR CHEEKS ●​ PALPATE THE THYROID GLAND
(palpate while asa likod; ask client to swallow as you palpate the right
N: Thank you mam. side of the gland, then reverse the technique to palpate the left lobe of
the thyroid)
TIC: The patient's face is symmetric, round/oval, elongated
appearance and there are no abnormal movements. N: Alright mam, this time I will be palpating your thyroid gland and i will
be needing you to swallow later on.
●​ PALPATE THE HEAD
(check yung consistency ng head ng client, hawakan siya) TCI: The client’s thyroid gland is not enlarged and is positioned in
midline.
N: Upon palpation, the patient’s head is normally hard and smooth
without lesions ●​ AUSCULTATE THE THYROID

●​ PALPATE THE TEMPORAL ARTERY N: As I auscultate your thyroid mam, please hold your breath for a
(palpate the temporal artery; located between the top of the ear and while.
the eye; circular motions)
TCI: There are also no bruits auscultated.
TIC: The temporal artery of the patient is elastic and not tender.
●​ PALPATE LYMPH NODES
●​ PALPATE THE TMJ (palpate the tonsil nodes, submandibular nodes, and supraclavicular
(palpate TMJ; place index finger over the front of each ear and ask nodes)
client to open the mouth TWICE)
TCI: This time I will be palpating the lymph nodes of the patient.
N: Could you please open your mouth mam? One more.
-​ SUBMENTAL
TIC: The temporomandibular joint of the patient has no swelling, -​ SUBMANDIBULAR
tenderness or any crepitation. The mouth opens and closes fully. -​ TONSILLAR
-​ PREAURICULAR
-​ POSTERIOR AURICULAR
NECK: -​ OCCIPITAL
 -​ SUPERFICIAL CERVICAL
-​ DEEP CERVICAL CHAIN ●​ PERFORM COVER TEST
-​ POSTERIOR CERVICAL (ask patient to look straight then use yung cardboard cover then
-​ SUPRACLAVICULAR remove two times each eye)

TCI: There is no swelling, tenderness or enlargement observed. N: This time mam, please look straight again.

EYES: TCI: The uncovered and covered eye remained fixed straight ahead.
●​ TEST DISTANT VISUAL ACUITY
(position client 20 feet from the snellen chart; instruct client to cover the ●​ PERFORM POSITIONS TEST
eye that will not be used using an opaque card and read lines from top (pen approx. 12 inches away from the client’s face; move object
to bottom until the patient can no longer decipher the letters then through the six cardinal positions of gaze, clockwise)
repeat on the other eye) *until red line yung normal
N: Alright mam, could you please look at the pen without moving your
N: This time mam, could you please stand up over here and please head.
wear your glasses and read the letter that I will be pointing at.
TCI: The eye movement of the patient is smooth and symmetric
N: This time mam, please remove your glasses and cover your right throughout the six directions.
eye as you read the letter that I will be pointing at.
●​ INSPECT EYELIDS AND EYELASHES
N: Thank you mam, you may now take your seat again. (note with and position of palpebral fissures)

TCI: The client’s distant visual acuity is _______. with a corrective lens, TCI: There is no drooping, no white sclera above and below the iris,
the patient can read clearly. the upper lid margin is at the upper margin of the iris and pupil. The
lower lid margin rests on the lower border of the iris. The eyelashes are
●​ TEST NEAR VISUAL ACUITY evenly distributed.
(give the handheld vision chart to the client and let them hold it 14
inches away from the eyes; have the client cover one eye with an ●​ ASSESS ABILITY OF EYELID TO CLOSE
opaque card before reading from top to bottom; repeat test for the (assess if upper and lower lids close easily and meet completely when
other eye too) closed)

N: Now mam, I will be needing you to cover one eye and read this for N: Okay mam, please close your eyes.
me while wearing your glasses. Now can you please do the same
without your glasses and read it again. TCI: The upper and lower lids close easily and meet completely when
closed.
N: Thank you Mam Jalyka.
N: Thank you mam, you can now open your eyes.
TCI: The client shows difficulty in reading the chart. But again with a
corrective lens, the patient can read clearly. ●​ NOTE POSITION OF EYELIDS IN COMPARISON TO THE
EYEBALLS
●​ TEST FOR VISUAL FIELDS FOR GROSS PERIPHERAL
VISION TCI: The lower eyelid of the patient is upright and no inward or outward
(move yung pen while naka cover din yung opposite eye mo; down to turning is observed. Eyelashes are evenly distributed and curve along
up, right to left, up to down, and left to right) the lid margins normally.

N: Okay mam, now please cover your _____ eye and look straight. ●​ OBSERVE EYELIDS (REDNESS, SWELLING,
Once you see the pen, could you please raise your hand? DISCHARGE OR LESIONS)

N: Alright, thank you mam. TCI: There are no redness, swelling, or lesions on both skin of the
eyelids.
N: Then please cover the other eye this time.
●​ OBSERVE EYELIDS (POSITION, AND ALIGNMENT OF
TCI: The client has a normal peripheral vision since she sees the pen EYEBALL IN THE SOCKET)
at the same time I can at 70 DEGREES INFERIOR, 50 DEGREES (observe if eyes are symmetrically aligned in sockets without any
SUPERIOR, 90 DEGREES TEMPORAL AND 60 DEGREES NASAL. protruding or sinking)

●​ PERFORM CORNEAL LIGHT REFLEX TEST TCI: The eyeballs are symmetrically aligned in sockets without sinking
(hold penlight approx. 12 inches away from the clients face; shine light or protruding.
towards the bridge of the nose while client stares straight ahead; note
light reflected on the cornea) ●​ INSPECT BULBAR CONJUNCTIVA AND SCLERA

OS - LEFT WEAR THE GLOVES

OD - RIGHT
OU - BOTH N: This time mam, could you please look side to side, then downward
N: Please look straight mam (hawak yun eyelids pataas)

TCI: The reflection of light indicates parallel alignment since they are at TCI: The bulbar conjunctiva is clear, moist, and smooth. Underlying
the exact same spot on each eye of the client. structures are visible and the sclera is white.
 ●​ INSPECT PALPEBRAL CONJUNCTIVA TCI: The ears of the patient are equal in size bilaterally. The Auricle
aligns with the corner of each eye in a 10 degree angle. Earlobes are
N: Now could you please look upward (pull the lid downward) free, attached. The skin is smooth with no lesions and the color is
consistent with the facial color.
TCI: The lower and upper palpebral conjunctivae is clear and free of
swelling and lesions. ●​ INSPECT EXTERNAL AUDITORY CANAL
(use otoscope)
●​ EVERT UPPER EYELID
(gently grasp client’s upper eyelashes and pull lid downwards; place TCI: (small amount of odorless cerumen; cerumen may be color yelloe,
cotton tipped applicator 1 cm above eyelid margin and push down the orange, red, brown, gray, or black; consistency may be soft, moist, dry,
applicator while holding the eyelashes) flaky, or hard)

N: This time mam I will be everting your upper eyelids. TCI: Canal walls are pink and has no nodules

TCI: It is free of swelling, trauma and foreign bodies. ●​ PALPATE AURICLE AND MASTOID PROCESS

●​ INSPECT AND PALPATE LACRIMAL APPARATUS TCI: The auricle, tragus, and mastoid process are not tender.
(use gloves, use one finger to palpate just inside the lower orbital rim)
●​ PERFORM WHISPER TEST
TCI: There is no swelling or redness. Puncta is visible without swelling (2 feet behind the client (bawal makita ni client mouth mo); whisper two
or redness and turned slightly towards the eye. Also there is no syllable word like popcorn or football)
drainage noted.
N: Alright mam, this time I will be needing you to repeat the words that
●​ INSPECT CORNEA AND LENS I will say. While doing so, please cover your right ear.
(shine light from the side of the eye for an oblique view)
N: Ballpen, Baseball, Football, Popcorn, Flower, Basket
N: Please look straight again mam.
TCI: The patient is able to repeat the two syllable word which indicates
TCI: The cornea is transparent and has no opacities. Oblique view she passed the test and is normal.
shows a smooth and moist surface. The lens has no opacities.
●​ PERFORM WEBER TEST
●​ INSPECT IRIS AND PUPIL (asa top ng head) note number of seconds

TCI: The iris is round, flat and evenly colored. The pupil is round with a N: Please let me know if you no longer hear the sounds or vibrations in
regular border and is centered. both ears

●​ TEST PUPILLARY REACTION TO LIGHT N: Do you hear the vibrations equally in both ears?
(shine light obliquely into pupil and ask client to focus on an object in
distance; darkened room dapat) TCI: The vibrations are heard by the patient equally in both ears for
___________ seconds.
N: This time mam, could you please look at the _______.
●​ PERFORM RINNE’S TEST
TCI: The pupils constricted. The pupils are equal, round, reactive to (sa mastoid process & infront of external auditory canal) note number
light and accommodation. of seconds

●​ ASSESS CONSENSUAL RESPONSE N: Alright mam, this time I will be putting the tuning fork behind your
(put cardboard sa gitna ng nose then shine the light uli obliquely; do on ears and beside your ears, please raise your hand if you no longer
both sides) hear the sound.

TCI: The pupils reacted at direct and consensual pupillary testing. TCI: The air conduction was heard for ____ seconds while the bone
conduction was heard for _____ seconds. The air conduction sound is
●​ TEST ACCOMMODATION OF PUPILS heard longer than the bone conduction by the patient which indicates
(hold pen 12 to 15 inches away from the client) normal findings.

N: Okay mam, so now I will be needing you to focus on the pen as I ●​ PERFORM ROMBERG TEST
move it closer towards your eyes (do not forget magalalay baka matumba si patient)

TCI: The pupils constrict and the eyes converge. N: Now I will be needing you to stand with both your feet together and
your arms at the sides while your eyes are open for 20 seconds.
TCI: For sanitary purposes, this time I should be changing my gloves
to a new pair. N: Now could you please close your eyes again for 20 seconds.

EARS: N: Thank you mam, you may now take your seat.
pataas hila then backward for adult then baba then back pag
pedia TCI: The client maintains position for 20 seconds without swaying or
●​ INSPECT AURICLE, TRAGUS, AND LOBULE minimal swaying observed.
(look lang sa dalawang gilid at back ng ears)
NOSE:
CHANGE GLOVES N: Now please touch the roof of your mouth using your tongue

●​ INSPECT AND PALPATE THE EXTERNAL NOSE TCI: The ventral surface of the tongue is smooth, shiny, pink, with
(pat pat din yung nose; check then pull upwards yun nose) visible veins and has no lesions.

TCI: The client’s nose color is the same with the rest of the face, the ●​ INSPECT FOR WHARTON DUCTS
nasal structure is smooth and symmetric and there is no tenderness.
TCI: The frenulum is midline and wharton ducts are visible with
●​ CHECK PATENCY OF AIRFLOW THROUGH NOSTRILS moistness in the area. There is also no swelling, redness, or pain.

N: This time mam, could you please cover or occlude your right nostril ●​ OBSERVE THE SIDE OF THE TONGUE
then sniff (use square gauze pad to hold client’s tongue to each side)

N: Now please do the same on the other side, then sniff again TCI: There are no nodules, lesions, or ulcers apparent.

TCI: The client is able to sniff at each nostril while the other is ●​ CHECK THE STRENGTH OF THE TONGUE
occluded. (place finger outside the client’s cheek; repeat on opposite cheek)

●​ INSPECT INTERNAL NOSE (use otoscope) N: This time mam, I will be placing my fingers by your cheeks and I will
be needing you to press the tip of your tongue against it as you resist
N: Now I will be checking your nose and I will be needing you to lift the pressure from my fingers
your head up a little
N: Now please do the same thing on the other side.
TCI: the nasal mucosa is dark pink most anf free of exudate. Nasal
septum is intact without ulcers or perforations. Turbinates are dark N: Thank you mam.
pink, moist and free of lesions.
TCI: The tongue has a strong resistance
SINUSES:
●​ PALPATE AND PERCUSS THE SINUSES ●​ INSPECT HARD (ANTERIOR) AND SOFT (POSTERIOR)
(use thumb and press on the brow on each side of the nose; percuss: PALATES AND UVULA
tap over the frontal sinuses and maxillary sinuses for tenderness) (look at the roof of the mouth with a penlight)

TCI: The frontal and maxillary sinus are not tender and no crepitus is N: Now please open your mouth wide again mam.
evident.
TCI: The hard palate is pale or whitish wrinkle like folds (transverse
TCI: The sinuses are also not tender on percussion. rugae). Palatine tissues are intact and the soft palate is pinkish,
movable, spongy and smooth.
MOUTH AND THROAT:
●​ NOTE ODOR WHILE MOUTH IS WIDE OPEN
CHANGE GLOVES
TCI: No unusual or foul odor noted.
●​ INSPECT THE LIPS
●​ ASSESS THE UVULA
TCI: The client’s lips are smooth and moist without lesions (apply tongue depressor to tongue and shine a penlight to the mouth)

●​ INSPECT THE TEETH AND GUMS N: Could you please say “aaah”
(note number of teeth, color, and condition)
TCI: The uvula freely hangs in the midline, No redness or exudate from
N: Could you please open your mouth as wide as possible mam? uvula or soft palate.

TCI: The client has 31 teeth. It is noticeable that the client has 1 tooth ●​ INSPECT THE TONSILS
removed by her lower right. There are also signs of tooth decay and (use tongue depressor keep mouth wide open and inspect tonsils;
the client has an overbite. grade tonsils)

●​ INSPECT THE BUCCAL MUCOSA TCI: The tonsils are present or absent, pink and symmetric, no lessons
(penlight and tongue depressor to retract the lips and cheeks; note or swelling.
color and consistency)
1+ - tonsils are visible
TCI: The buccal mucosa is pink which is also normal. 2+ - tonsils are midway between tonsillar pillars and uvula
3+ - tonsils touch the uvula
●​ INSPECT AND PALPATE THE TONGUE 4+ - tonsils touch each other

N: Please stick out your tongue mam. ●​ INSPECT THE POSTERIOR PHARYNGEAL WALL
TCI: The tongue is pink and moist, a moderate size with papillae with (tongue depressor still in place, shine penlight at back of the throat)
no lesions.
TCI: The throat is pink without any lesions or exudate.
●​ ASSESS THE VENTRAL SURFACE OF THE TONGUE
 remove gloves then hand hygiene ulit

N: Alright, that will be all for our procedure. Thank you for your time
and cooperation. Have a nice day ahead.