SCRIPT FOR RETURN DEMONSTRATION: Physical Assessment Part 1 (HEENT)

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.

3RD CLIP: MATERIALS

-Stethoscope for auscultation.
-Gloves to avoid cross-contamination
- Tongue Depressor for testing Gag Reflex
- Penlight to visualize the body parts I’m going to assess
- Alcohol for disinfection
- Cotton ball with alcohol disinfection of the equipment
- Receptacle for the disposal of used articles

4TH CLIP: MAKE SURE TO GATHER ALL THE EQUIPMENTS NEEDED FOR THIS ASSSESSMENT.

1. PREPARE THE PATIENT

• Introduce self and verify client’s identity
Nurse: Good morning, ma’am. I’m Shyla Jannessa M. Lingad, the assigned student nurse today .
For verification ma’am, May I ask what is your name?
Patient: (name of patient) EX: Blake Rhyiezen Morales
Nurse: Okay
Nurse: And when is your birthday?
Patient: July 4, 2004
Nurse: and how old are you?
Patient: 17 years old
• Explain the procedure to the patient | Maintain comfort and safety of the patient
Nurse: Okay ma’am. Now I’m going to explain the procedure. I need to assess certain parts of
your body specifically your Head, Neck, Eyes, Ears, Nose, Mouth And Throat. Will that be okay
ma’am?
Patient: Yes po
Nurse: Rest assured that your personal information and findings will be confidential to me and
to the physician I will be attending you too. Do you have any questions and clarifications?
Patient: None

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

1. TEST SENSATION OF FOREHEAD, CHEEKS AND CHIN (CN V)

Nurse: Ma’am can you close your eyes and tell me if you feel the sensation, say yes and if not
say no.
Patient: ( Patient answer normal is yes and no is abnormal)
• With the sharp part repeat at the same areas.
• Last picture should be repeated on the other side of the chin
Nurse: Can you tell me if it is sharp or soft?
Patient:
1. PALPATE TEMPORAL ARTERIES OR ELASTICITY AND TENDERNESS
Nurse: Kakapain yung ulo, start in the side to the middle back, then check if there’s tenderness
around the head.
Nurse: Can you please bite your teeth?
Nurse: Okay ma’am, can you bite it again?
Upon observing your temporal arteries, I didn’t see any clicking or tenderness. May I ask you
ma’am when I did the procedure did you feel any pain or tenderness in temporal arteries?
Patient: None at all
Nurse: Did you have any headaches this last few days?
Patient: None at all
Nurse: Okay ma’am, that’s good to know

[Link] TEMPOROMANDIBULAR JOINT

Nurse: Can you please open your mouth?
Nurse: And again ma’am
Nurse: Okay, thank you ma’am
Nurse: Can you potract it, retract it. Can you move it side to side? Okay thank you.
Result: There are no signs of popping, clicking and tenderness which indicates normalcy.

1. ASSESS VISUAL FUNCTION

Now I’m going to inspect my patient’s eye. Upon examination, I need to perform hand hygiene
to facilitate a clean assessment.
Nurse: Ma’am, I’m going to assess your eye. And later, I’m going to expose your eyes to little
light to assess your pupils. Is that okay with you ma’am?
• Eyes are bilaterally symmetrical and in lined with ears, and the shape seems to be
normal.
Nurse: Ma’am I will just check your external eye. Can you look at the ceiling?
• There are no signs of inflammation to the sclera, no problems to the eyelids, no protusion
or sunken appearance. It’s all normal
The next test is test for pupillary reaction to light and accommodation. To do this, Dim the
lights to check for pupil constriction when I expose it to light.
Nurse: Ma’am I will just dim the lights so that I can assess your pupils.
 Nurse: Now I need you to focus on the object, and I will expose your eyes to light to see if it
constricts (Penlight)
Nurse: Ma’am, upon observing your both pupils are responsive to light, equal and round
which is normal. Now I’m going to turn on the lights and repeat the assessment.
Nurse: Now ma’am, I need you to look at this pen so that I can assess your corneal reflex.
(Move the pen)
Nurse: great!
My patient’s reaction to light is normal. I therefore conclude that her pupil is Equal, round
and also reactive to light and accommodation.

1. ASSESS HEARING FUNCTION

• The next procedure is I’m going to assess is the functionality of my patient’s ears, it seems
normal because they are symmetrical and there are no signs of dysmorphology.
• Perform Hand Hygiene
• Observe any external trauma, inflammation, redness or exudate, and obvious discharge
and cerumen.
Nurse: Ma’am, can I inspect your ears po?
• Inspect both sides
Nurse: Okay ma’am, There is no signs of the mentioned abnormalities which is good.
• Palpate the auricle and mastoid process to see if there’s any signs of nodules or
inflammation.
• Palpate both sides
There are no inflammation and nodules which indicates it is normal.
• Inspect the internal ear for any abnormalities. Use penlight ( Inspect both sides)
I have not seen any discharge, swelling and modules which indicates it is normal.

1. ASSESS THE SENSE OF SMELL

• Inspect and palpate the external nose.
Nurse: Ma’am, I’m going to touch your nose to know if there are any tenderness, okay?
• Palpate the Nose
Your external nose is normal. Can you turn your head upward?
The Patient’s nose is symmetrical, no septal deviation, no impacted foreign bodies, no
swelling, no discharge, no bleeding, moist and the color pale red which are all considered
normal.

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.

1. Assess the mouth

• Assess patient’s oral cavity. Put gloves
• Inspect the lips for shape, symmetry, color, dryness and fissure at the corners of the
mouth. Inspect also the teeth in terms of number of present, condition, color, alignment
and caries.
Nurse: Ma’am, I will inspect your oral cavity, so I need you to open your mouth. Is that okay with
you?
• Inspect the oral cavity
Lips shape is normal and no swelling, symmetrical no signs of cyanosis, paleness, moist and
no fissures which means it is normal. Teeth are 32 present, white-yellowish in color, have
proper alignment and all of his teeth are in good condition.

• Inspect my patient’s gums and buccal mucosa. Use tongue depressor

Nurse: Now ma’am, I will inspect your gums and cheeks and I’m going to insert this depressor to
properly assess them. Is that okay with you?
Upon checking, there are no signs of abnormalities. The gums are not receding, and color
pink. Also, the buccal area is moist and dark pink.

• Inspect patient’s hard and soft palates

Nurse: Ma’am can you open your mouth again? ( Use penlight)
Palates are nice, and pink and there are no signs of yellow tint which could indicate jaundice.

Nurse: Next ma’am, I will observe your uvula and tonsilitis

Your uvula is intact so is your tonsils and no signs of inflammation.

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.

1. Assess the Neck

Nurse: The last part of our assessment ma’am is I will Inspect your neck ma’am.
• Inspect the neck (using penlight)
Nurse: Can you please tilt your head?
Nurse: Okay ma’am, can you please sip a bit water and do not swallow it.
Nurse: Okay ma’am, you can now swallow it.
• Inspect the movement of thyroid and cricoid cartilage & thryoid gland
Based on the assessment ma’am, I can see that your trachea is in the middle lline, and when
you swallow the water the process was good. This part is moving upper which means its
normal. I also didn’t see any swelling.

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

Nurse: Okay ma’am.

Based on the action that you did ma’am, I did not see any irregularities when you did the action.
Nurse: I will now assess your neck range
Nurse: Can you look at the ceiling maam? And down on the floor, And on the side and in the
side.
Nurse: Okay maam, while doing the procedure, did you experience any pain or tenderness
Patient: None
Nurse: Next one ma’am, I will be palpating your trachea. Is it okay with you ma’am.
Patient: yes
Nurse: I will palpate it posteriorly ma’am.
Nurse: Okay ma’am, I can feel that your trachea is in the middle line. Now ma’am can you
swallow?
Nurse: Okay ma’am, next ma’am, swallow again ma’am, and for the last time ma’am can you
swallow?
Nurse: Okay po ma’am
Nurse: I can tell that your trachial nerves are working and functioning well. Now ma’am can you
look on this side maam? Okay, and in this 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.

• Auscultate thyroid glands for bruits if the gland is enlarged

Nurse: Okay ma’am, can you inhale ma’am and hold it. And now exhale , And inhale ma’am and
exhale
Nurse: Okay ma’am, based on the procedure I can see that there is no presence of bruits.
• Palpating lymph nodes
Nurse:The last procedure ma’am is I’m going to palpate your lymph nodes. Allow me to palpate
your face again ma’am.
Nurse: First palpation is your preauricular nodes infront of your ears. Post aeuricular nodes
which is behind your ears. And your occipital nodes, your tonsil nodes, your submandibular
nodes and next id your submental nodes.

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!