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PA Head To Neck

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13 views4 pages

PA Head To Neck

Uploaded by

Elizabeth Mataverde
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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St. Ferdinand College, Inc.

COLLEGE OF HEALTH SCIENCES www.sfc.edu.ph


Sta. Ana St., Ilagan, Isabela 3300  (078) 624-2125 email address:
sfc@sfc.edu.ph

NCM 101 – HEALTH ASSESSMENT


PHYSICAL ASSESSMENT
SUMMER 2023-2024

Name: ______________________________ Year level & Section: _________________ Rating: ________

Put a ( / ) mark on the specific scores to indicate the quality of achievement that describes as follows:

Score 1 2 3 4
Description Poor Fair Good Excellent
Interpretation The student was not The student was able The student was able The student was able
able to perform the to perform the to perform the to perform the
procedure correctly procedure with 2-4 procedure with procedure correctly
and unable to identify errors; able to minimal errors and and able to narrate
normal and abnormal identify few normal able to identify some normal and abnormal
findings and abnormal normal and abnormal findings
findings findings

I. SKIN, NAILS, HEAD, HAIR, EYES, EARS, NOSE, MOUTH, AND NECK

Procedure Quality of Achievement


1 2 3 4
1. Perform hand hygiene
2. Identify the patient and explain the procedure to the
patient.
3. Prepare all the necessary equipment’s needed.
4. Prepare the examination room and provide privacy to the
patients.
Assessing Appearance and Mental Status
1. Observe body build, height and weight in relation to
client’s age lifestyle and health.
2. Assess level of consciousness and signs of distress.
3. Observe the client’s posture and gait.
4. Observe the client’s overall hygiene and grooming.
5. Listen for relevance and organization of thoughts.
Assessment of the Skin
1. Inspect for the general skin color
2. Check for skin integrity
3. Inspect, palpate and describe skin lesion..
4. Palpate skin temperature, moisture and temperature
5. Note skin turgor by pinching the skin.
6. Assess edema , if present.
Assessment of the Nails
1. Inspect fingernails plate shape to determine the curvature
and angle.
2. Inspect fingernails and toenails bed color.
3. Inspect ad palpate nail texture.
4. Inspect the skin/tissues surrounding the nails
5. Perform blanch test of Capillary refill.
Assessment of the Head
1. Inspect the size, shape and symmetry of the head
2. Check for any abnormal or involuntary movement,
3. Palpate the head for presence of nodules, mass and
depression
4. Inspect face for symmetry, features, movement,
expression, and skin condition
Assessment of the Hair
1. Inspect the evenness and growth of hair over the scalp,
body, axillae, and pubic hair
2. Inspect hair texture and oiliness
3. Inspect thickness and thinness.
4. Note presence of infestations and infections.
Assessment of the Eyes
1. Inspect the eyebrows for hair distribution.
2. Inspect the eyelashes for evenness of distribution and
direction of curl.
3. Inspect the eyelids for surface characteristics
4. Inspect palpebral conjunctiva by everting the lids.
5. Inspect and palpate the lacrimal gland and sac for
presence of edema and swelling.
6. Inspect the cornea for clarity and texture and perform
corneal sensitivity test.
7. Inspect the pupils for color, shape, and symmetry of size.
8. Assess each pupil’s reaction to light.
9. Assess each pupils direct and consensual response to
light
10. Assess each pupil reaction to accommodation.
11. Assess peripheral visual fields
12. Assess eye muscle using the cardinal position gaze
13. Assess near vision by providing adequate lighting and
asking the client to read newspaper held at a distance of 14
inches.
14. Assess distance vision by asking client to wear corrective
lenses unless they are used for reading only.
Assessment of the Ears
1. Inspect the auricles for color, symmetry of size , and
position.
2. Palpate the auricles for texture, elasticity, and areas of
tenderness.
3. Using an otoscope inspect the external ear canal for
cerumen, pus, and blood.
4. Inspect the tympanic membrane for color and gloss
5. Perform Weber test and conduct Rinne test for hearing
acuity.
6. Perform the Romberg Test for equilibrium
Assessment of the Nose
1. Inspect the external nose for shape, size , color and
flaring or discharge from the nares.
2. Lightly palpate the external nose
3. Observe for the presence of discharge, redness, polyps
and bleeding.
4. Inspect the nasal cavities using penlight and nasal
speculum.
5. Palpate the sinuses
6. Transillumminate the frontal and maxillary sinuses
Assessment of the Mouth
1. Inspect the outer lips for color, symmetry of contour and
texture.
2. Inspect and palpate the inner lips and buccal mucosa for
color, moisture, texture and presence of lesions.
3. Inspect the teeth and gums.
4. Inspect and palate the tongue
5. Inspect the tongue movement
6. Inspect the ventral surface of the tongue and frenulum
7. Check the anterior tongue for its ability to taste
8. Inspect salivary glands for swelling and redness.
9. Note odor
10. Inspect the position of the uvula.
11. Inspect the tonsils for color, discharge and size.
12. Elicit the gag reflex by pressing the posterior tongue with
a tongue blade.
Assessment of the Neck
1. Inspect the neck muscles for symmetry, abnormal
swelling or masses.
2. Observe movement of the neck structures.
3. Inspect range of motion
4. Palpate for enlarged lymph nodes.
5. Palpate the trachea for lateral deviation.
6. Inspect and palpate the thyroid gland for enlargement,
masses and nodules.
Total Score

COMMENTS/SUGGESTIONS:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Name of the Student : _________________________________________


Signature of the Student : _________________________________________
Date performed : _________________________________________
Evaluated by : _________________________________________
Signature of the Evaluator : ________________________________________

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