SKIN

: Good morning Ma’am/Sir, I am nurse Alex and I am going to be your nurse today. May I have your name
and date of birth? Can I have a look at your wristband please?

: How are you feeling today? So for today, I will be doing a physical assessment from your head up to the
neck, and this might take some time as we will be doing several procedures and tests in order to assess
properly and accurately. Would that be ok with you?

: So first, I am going to assess your skin. Before starting, Is it okay if I ask you some questions?

: Are you experiencing any pain, itching, tingling or numbness?

: Are you experiencing any current skin problems like lesions, bruises, swelling, abrasions, or pigmented
spots or changes in skin color? If so, can you tell me what causes these? Is it seasonal, is it because of
stress or does it happen when you travel?
: Do you have any previous skin problems?
: Do any of your family members have/had any skin problems?
: Have you had measles, chicken pox, rashes, or excessive acne?
: Are you taking any medications? Do you use any lotions, ointments or creams? Are you taking any
herbal or nutritional supplements or vitamins? If so, how long have you been taking them?
: Are you experiencing dryness or oiliness of skin?
: Are there instances where you bruise easily?
: Have you experienced any allergic reactions lately?
: Lastly, have you noticed any general changes in your skin?

*PERFORM HAND HYGIENE

: Ok, so we’re done. Thank you for answering the questions.

: So, I am going to assess your skin now, can I have your hands? (PALPATE)
- Inspect for skin color
- Inspect for uniformity of skin
- Assessed edema
- Inspect and palpate and described skin lesions
- Observe skin moisture
: Next, I am going to palpate your skin to assess your temperature.
: Ok, I am going to assess your skin turgor. I am going to pinch your skin, but I assure you that these
won’t hurt.

*DOCUMENT IF THERE IS ANY ABNORMALITIES*

*IF NONE STATE THAT “After assessing your skin, the findings are all normal”

HAIR
: Next, I will be assessing your hair but before that I am going to ask some questions. Is it ok with you?

: Do you use any chemical treatments like dyes, rinses, curling or straightening products?
: Have you had chemotherapy before?
: Have you been diagnosed before with acute or chronic conditions?
: So I will be positioning myself at your back so I can assess your hair properly, is that ok?

*WEAR GLOVES AND PERFORM HAND HYGIENE*

: Inspect while saying “have you had any hair loss, or unusual increase in hair growth?”
- Evenness of hair growth
- Inspect hair thickness, texture and oiliness
*checking behind the ears and along the hairline at the neck*

: Can I have your hand?

- Inspect amount of body hair

*REMOVE GLOVES AND PERFORM HAND HYGIENE*

*DOCUMENT IF THERE IS ANY ABNORMALITIES*

*IF NONE STATE THAT “After assessing your hair, the findings are all normal”

: Thank you ma’am.

NAILS

: So next, I am going to assess your nails. Before starting, is it ok if i would ask some questions?

: Have you’ve been diagnosed with diabetes or any peripheral circulatory diseases?
: Any previous injury?
: Do you have any severe illness?

: Thank you for answering the questions. So now can I have your hands so I can assess your nails
properly?

: Inspect for:
- Nail shape and curvature
- Nail texture and color of nail bed
- Surrounding tissues of the nail (border around the nail)

: Now, I will perform Blanch Test. In this procedure I am going to press your nails.

: Next, we will perform Schamroth's Test. KIndly put your fingers against each other. *LIKE THIS*

: Thank you ma’am for cooperating.

*DOCUMENT IF THERE IS ANY ABNORMALITIES*

*IF NONE STATE THAT “After assessing your nails, the findings are all normal”

SKULL AND FACE

: So next, I will be assessing your skull and face. Before starting, is it ok if i would ask some questions?

: Do you have past problems with your skin or your scalp?

: Any history of loss of consciousness, dizziness, seizures, headache, facial pain, or injury?
: Any history of any lumps or bumps detected?
(Known causes of problems)
(Associated symptoms, treatment, recurrences)

: I am done asking questions, now I will start assessing your skull.

: Inspect
- Skull size, shape and symmetry
- Facial features
- Eyes for edema and hollowness

: Now what we are going to do is that I am going to give you some instructions and you have to
follow them because it will help me assess if you have symmetrical facial movements. Would
that be okay?
- Smile
- Frown
- Puff your cheeks

*DOCUMENT IF THERE IS ANY ABNORMALITIES*

*IF NONE STATE THAT “After assessing your skull and face, the findings are all normal”

EYES AND VISION

: Alright, now I will be assessing your eyes and vision. Before starting, I would like to ask some questions.
Would that be okay?

: Is there anyone in your family diagnosed with diabetes, hypertension, eye disease or injury, or any
surgery related to the eye?
: When was the last time you visited your ophthalmologist?
: Do you use any eye medications?
: Do you use contact lenses or eyeglasses? Or Corrective lenses?
: Do you experience any symptoms of eye problems?

: Now, we’re done with the questions. I am going to proceed with assessing your eyes and vision.

Inspect eyebrows for hair distribution, alignment, skin quality and movement.

: I would like you to raise your eyebrows.

Inspected the eyelashes for evenness of distribution and direction of curl.

Inspected the eyelids for surface characteristics (e.g., skin quality and texture), position in relation to the
cornea, ability to blink, and frequency of blinking.
Inspected lower eyelids while the client’s eyes were closed.

: So next, I am going to assess your conjunctiva. Now what i am going to do is i am going to retract the
lower part of your eyelids. Would that be okay?

Inspected the bulbar conjunctiva for color, texture, and the presence of lesions.

: Thank you, so next I am going to inspect your eye to be specific, your cornea and your pupil.
*held the penlight in oblique angle*

: Next, I am going to inspect your pupillary reaction and I'll be needing to turn the lights off. Would that
be okay?

: Let me just turn the lights off.

: I will be needing you to look straight at me. *penlight tutok sa eyes*

: So, were done with that and I am going to turn the lights on

: Next I will assess your pupil's accommodation.

- Place the penlight 10 cm away tapos patient titingin sa malayo.

: So next, I will assess your peripheral vision. I will give you some instructions and you just have to
follow.

: First, I want to cover your right eye, using your right hand. Then, say YES if you are seeing the penlight.
● UP, LATERAL, DOWN

: So we’re done assessing your eye and vision.

VISUAL ACUITY

: So the next step is the assessment of your visual acuity for this moment

: So I'd like you to stand here, would that be okay?

: as you can see ma’am we have a chart right there

: i'm going to ask you to read each letter within the specific line that i point out, is that clear?

: Can you please cover your right eye, and read the letter from left to right within line number 3.

PAG MAY GLASSES

= we will be doing two sets since you are wearing your glasses. So for the first set, you will be reading the
letters with glasses and for the second is without glasses. So let us proceed with the assessment.
= Can you please cover your right eye, and read the letter from left to right within line number 3.
= Can you please remove your glasses this time, cover your right eye, and read the letter from left to right
within line number 3 again.

= Okay thank you ma’am.

EARS AND HEARING

: Next I'm going to assess your ears as well as your hearing ability, would that be okay?

: May i ask first, does your family have a history of hearing problems or loss>
: Do you experience ear problems such as ear pain?
: Are you having difficulty hearing?

EARS
: Okay so to continue with the assessment I’m going to place myself at your back so that i can assess
your ear properly.
: So ma’am, i will be inspecting the outer part of your ear, so could you tilt your head towards your neck,
thank you so much.

: i will be inspecting the inner part of your ear using an otoscope so i can see it clearly.
: Also I want to inform you that I'll be needing to pull your ears upwards and backwards, would that be
okay?

HEARING ABILITY
: Next, I will be testing your hearing ability. I'm going to use a metal tool or this tuning fork, would that be
okay?
: Now I'm going to place a vibrating tool on top of your head, and i'm going to ask some questions. Can I
proceed?

*lalagay sa ulo

: Can you hear the sound?

: Any particular side where you hear the sound more?

: next is i’m going to put the vibrating tool at the back of your ear
: once you no longer hear the sound I want you to raise your arm, is that clear ma’am?

*lalagay sa likod ng tenga

: now we are going to do the romberg’s test to check your balance

: Kindly stand, and put your feet together
: Put your hands up forward
: I will be staying here, and I want you to close your eyes for a few seconds.
 NOSE AND SINUSES

: Okay so the next thing is assessing your nose as well as your sinuses

: But let me ask first if do you allergies

: Do you often have difficulty breathing through your nose?
: Did you have a previous injury of nose or face?
: Have you ever had nosebleed
: Did you ever encounter a change of smell?

: okay thank you ma’am, let us proceed to the assessment.

*INSPECT NOSE
*WEAR GLOVES

: Okay ma’am so for this step I’m going to be palpating your nose, if you feel any tenderness or pain just
tell me. *PALPATE NOSE, cheeks, pati narin jaw ganon”

: Can you please close one of your naris with your finger and try to breathe in and out on the other one.

: Next I am going to take a look at your nasal cavity using this penlight. Would that be okay ma’am?

Thank you so much.

*REMOVE GLOVES.

MOUTH AND OROPHARYNX

: Next is I will be assessing your mouth and oral cavity

: but before that may i ask when was your last visit to dentist
: Do you have denture discomfort?
: Do you use any medication for your mouth and dental care?

: Okay so let us proceed to the assessment, I will start to the outside portion of mouth

*ASSESS OUTSIDE PORTION OF MOUTH

*WEAR GLOVES

: Next I'm going to assess your oral cavity, and I will be giving you some instructions.
: can you please open your mouth and put out your tongue and move it upward and move it from side to
side.
: KIndly place the tip of the tongue against the roof of the mouth.
: lastly, I will need you to say “ahh” for a few seconds and I will take a look at your oral cavity *use tongue
depressor and penlight*

: okay so thank you ma’am for your cooperation.

NECK
: Okay for the last part of our session today, I will be assessing your neck.

: Do you often feel neck pain or stiffness?

: Have you ever had problems with neck lumps?
: Have you ever had a diagnosis due to thyroid problems?

: Okay thank you ma’am, let us proceed to the assessment.

: I will be inspecting your neck, could you please turn your head to the right.
: Kindly turn it to the left

HEAD MOVEMENT
: alright, so now I will be giving you some instructions to check your head movement, if you feel any
discomfort or pain just tell me
: can you please move your head down or place your chin to your chest, do you feel any pain?
: Can you tilt your head upward, how’s that?
: You can now face forward, can you please place your right ear to your shoulder. Can you do it on the
other side? Do you feel any pain?

MUSCULAR STRENGTH
: Now we are going to assess your muscular strength
: I’m going to put some pressure and I need you to act against the resistance, i need you to face your
head to the side.
: As I put up a resistance , please move your head towards it.
: The next step is, I’m going to put pressure on your shoulders and I need you to shrug them off and see if
we can act against that resistance.

CHECK FOR INFLAMMATION OF LYMPH NODES

: Okay next is we are going to proceed on checking if you have any enlarged lymph nodes or nodules.

: i’m going to palpate your neck, if you have any discomfort just tell me

*put gloves
*palpate ung jaw mostly and chin
*neck, tapos likod ng neck

: can you please look down *palpate yung collar bone (supraclavicular nodes) (sternocleidomastoid)
: look at the other side, left *palpate ung likod side ng neck
: Look forward *palpate throat

: alright so thank you so much for your cooperation.

OUTRO

= I will be going back to the nursing station to record all of the findings from the assessment that we did
today. If you have any questions and concerns just press the nursing call button, thank you!