Assessing the Skull and Face; Eye Structures and Visual Acuity; Ears and Hearing;

Nose and Sinuses; Mouth and Oropharynx; and Neck

Basic Concept:
Assessing the skull and face is an inspection and palpation of the skull and face; and
also measuring the skull circumference, in which the presence of deviation and changes of
facial shape may indicate a disorder or certain condition.

Assessing the eye structures and visual acuity is an examination of the eye that
includes the external eye structure, visual perception, ocular movement and visual fields.
Assessment of vision provides important information about client’s ability to interact with the
environment and perform activities of daily living (Weber, et.al. 2014).

Assessing the ears and hearing is an examination of the ear structure and
determination of the client’s hearing acuity which consists of direct inspection, palpation of
the ear and techniques to assess auditory acuity and sound conduction.

Assessing the nose and sinuses is an inspection and palpation of the external nose
structure and sinuses; and inspection of patency of the nasal cavities.

Assessing the mouth and oropharynx is an inspection of the structures associated with
eating and taste which is composed of the lips, oral mucosa, tongue, floor of the mouth, teeth,
gums, hard and soft palate, uvula, salivary glands, tonsillar pillars and tonsils (Berman, et.al.
2015).

Assessing the neck is an examination of the neck muscles, lymph nodes, trachea,
thyroid gland, carotid arteries and jugular veins (Berman, et.al. 2015).

Objective:
1. To check for any deviations of the skull and face; eye structures and visual acuity; ears and
hearing; nose and sinuses; mouth and oropharynx and neck.
2. To acquire information and accurate nursing history of the eyes and vision; ears and
hearing; nasal, oral and neck of the client.
3. To be able to formulate nursing diagnosis, collaborative problem and referral.

Preparation:
1. Introduce yourself, and verify the client’s identity. Explain to the client what you are going
to do, why it is necessary, and how the client can cooperate.
2. Perform hand hygiene, and observe appropriate infection control procedures.
3. Provide for client privacy.

PROCEDURE RATIONALE

1. Inquire if the client has any history

of the following:
- Lumps or bumps, itching, scaling,
or dandruff
- Loss of consciousness, dizziness,
seizures, headache, facial pain, or
 injury

2. If so, ascertain the following:

-When and how any lumps occurred
-Length of time any other problem
existed
-Any known cause of any problem
-Associated symptoms, treatment,
and recurrences

3. Inspect the skull for size, shape, and

symmetry.

4. Palpate the skull for nodules or

masses and depressions.
-Use a gentle rotating motion with
the fingertips.
-Begin at the front and palpate down
the midline, then palpate each side of
the head.

5. Inspect the facial features.

6. Inspect the eyes for edema and

hollowness.

7. Note symmetry of facial movements.

-Ask the client to elevate the
eyebrows, frown, or lower the
eyebrows, close the eyes tightly, puff
the cheeks, and smile and show
teeth.

8. Document findings in the client

record.

Assessing the Eye Structures and Visual Acuity

Preparation:

1. Assemble equipment and supplies:

Cotton-tipped applicator
Examination gloves
Millimeter ruler
Penlight
Snellen’s or E chart
Opaque card
 PROCEDURE RATIONALE

1. Inquire if the client has any history

of the following:
 Family history of diabetes,
hypertension, or blood dyscrasia
 Eye disease, injury, or surgery
 Last visit to an ophthalmologist
 Current use of eye medications
 Use of contact lenses or eyeglasses
 Hygienic practices for corrective
lenses
 Current symptoms of eye problems

Assessing external eye structures:

2. Inspect the eyebrows for hair
distribution and alignment, and for
Note: Italicize step/s is excluded in the
skin quality and movement.
return demonstration routine; however, the
student is required to state or mention the
3. Inspect the eyelashes for evenness of
step.
distribution and direction of curl.

4. Inspect the eyelids for surface

characteristics, position in relation to
the cornea, ability to blink, and
frequency of blinking. Inspect the
lower eyelids while the client’s eyes
are closed.

5. Inspect the bulbar conjunctiva for

color, texture, and the presence of
lesions.

6. Inspect the palpebral conjunctiva by

everting the lids.

7. Evert the upper lids if a problem is

suspected.
-Ask the client to look down while
keeping the eyelids slightly open.
-Gently grasp the client’s eyeglass
with thumb and forefinger.
-Pull lashes gently downward while
holding the eyelashes.
-Hold the margin of the everted lid
or eyelashes against the ridge of the
upper bony orbit with the applicator
stick or your thumb.
-Inspect the conjunctiva for color,
texture, lesions and foreign bodies.
8. Inspect and palpate the lacrimal
gland.
-Using the tip of your index finger,
palpate the lacrimal gland.
-Observe for edema between the
lower lid and the nose.

9. Inspect and palpate the lacrimal sac

and nasolacrimal duct.
-Observe for evidence of increased
tearing.
-Using the tip of your index finger,
palpate inside the lower orbital rim
near the inner canthus.

10. Inspect the cornea for clarity and

texture.
-Ask the client to look straight ahead.
---Hold a penlight at an oblique angle
to the eye, and move the light slowly
across the corneal surface.

11. Perform the corneal sensitivity

(reflex) test to determine the function
of the fifth (trigeminal) cranial nerve.
- Ask the client to keep both eyes
open and look straight ahead.
-Approach from behind and beside
the client, and lightly touch the
cornea with a corner of the gauze.

12. Inspect the anterior chamber for

transparency and depth.
-Use the same oblique lighting used
when testing the cornea.

13. Inspect the pupils for color, shape,

and symmetry of size.

14. Assess each pupil’s direct and

consensual reaction to light in a
partially darken room.
-Ask the client to look straight ahead.
-Using a penlight and approaching
from the side, shine a light on the
pupil.
-Observe the response.
-Shine the light on the pupil again,
and observe the response of the other
 pupil.

15. Assess each pupil’s reaction to

accommodation.
-Hold an object about 10cm from the
client’s nose.
-Ask the client to look first at the top
of the object and then at a distant
object behind the penlight.
-Alternate the gaze between the near
and far objects.
-Observe the pupil response.
-Next, move the penlight or pencil
toward the client’s nose. The pupils
should converge.
-To record normal assessment of the .
pupil’s use the abbreviation
PERRLA.

Assessing visual fields:

16. Assess peripheral visual fields.
-Have the client sit directly facing
you at a distance of 60-90cm.
-Ask the client to cover right eye
with the card and look directly at
your nose.
-Cover or close your eye directly
opposite the client’s covered eye, and
look directly at the client’s nose.
-Hold an object in your fingers,
extend your arm, and move the
object into the visual field from
various points in the periphery.
-Ask the client to tell you when the
moving object is first spotted.
-To test the temporal field of the left
eye, extend and move your right arm
in from the client’s right periphery.
-To test the upward field of the left
eye, extend and move the right arm
down from the upward periphery.
-To test the downward field of the
left eye, extend and move the right
arm up from the lower periphery.
-To test the nasal field of the left eye,
extend and move your left arm in
from the periphery.
-Repeat the above steps for the right
eye.
Extraocular muscle tests:
17. Assess six ocular movements to
determine eye alignment and
coordination.
-Stand directly in front of client, and
hold the penlight at a comfortable
distance such as 30 cm in front of the
client’s eyes.
-Ask the client to hold the head in a
fixed position facing you and follow
the movements of the penlight with
the eyes only.
-Move the penlight in a slow, orderly
manner through the six cardinal
fields of gaze.
-Stop the movement of the penlight
periodically so that nystagmus can be
detected.

18. Assess for location of light reflex by

shinning a penlight on the pupil in
corneal surface (Hirschberg Test).

19. Have the client fixate on a near or far

object. Cover one eye, and observe
for movement in the uncovered eye
(cover test).

Assessing visual acuity:

20. Assess near vision by providing
adequate lighting and asking the
client to read from a magazine or
newspaper.

21. Assess distance vision by asking the

client to wear corrective lenses
unless they are used for reading
only.
-Ask the client to sit or stand 6
meters (20ft) from Snellen’s chart,
cover the eye not being tested, and
identify the letters or characters.
-Take three readings: right eye, left
eye, and both eyes.

22. Perform functional vision tests if the

client is unable to see the top line
(20/200) of Snellen’s chart.

23. Document findings in the client

 record.

Assessing the Ears and Hearing

Preparation:

1. Assemble equipment:
 Otoscope with several sizes or ear specula

PROCEDURE RATIONALE

1. Inquire if the client has any history

of the following:
 Family history of hearing problems
or loss
 Presence of any ear problems or pain
 Medication history, especially if
there are complaints of ringing in
ears
 Any hearing difficulty: its onset,
factors contributing to it, and how it
interferes with activities of daily
living
 Use of a corrective hearing device:
when and from it was obtained

2. Position the client comfortably-

seated, if possible.

Auricles
3. Inspect the auricles for color,
symmetry of size, and position.
- To inspect position, note the level
at which the superior aspect of the
auricle attaches to the head with
relation to the eye.

4. Palpate the auricle for texture,

elasticity, and areas of tenderness.
- Gently pull the auricle upward,
downward, and backward.
- Fold the pinna forward. (It should
recoil)
- Push in on the tragus.
- Apply pressure to the mastoid
process.

External ear canal and tympanic membrane:

5. Using an otoscope, inspect the
 external ear canal for cerumen, skin
lesions, pus and blood.
- Attach a speculum to the otoscope.
- Tip the client’s head away from
you and straighten the ear canal.
- Hold the otoscope either right side
up, with your fingers between the
otoscope handle and the client’s
head, or upside down, with your
fingers and the ulnar surface of your
hand against the client’s head.
- Gently insert the tip of the otoscope
into the ear canal, avoiding pressure
by the speculum against either side
of the ear canal.

6. Inspect the tympanic membrane for

color and gloss.

Gross hearing acuity test:

7. Assess the client’s response to
normal voice tones.
- If the client has difficulty hearing
the normal voice, proceed with the
following tests.

a. Perform the watch tick test.

-Have the client occlude one ear.
-Out of the client’s sight, place a
ticking watch 2-3cm (1-2 inches)
from the unoccluded ear.
-Ask what the client can hear. Repeat
with the other ear.

b. Tuning fork test

b.1. Perform Weber test.

- Hold the tuning fork at its base.
- Activate it by tapping the fork gently
against the back of your hand near the
knuckles or by stroking the fork between
your thumb and index fingers.
- Place the base of the vibrating fork
on the top of the client’s head, and ask
whether the client hears the noise.
b.2. Conducting Rinne test.
- Ask the client to block the hearing in
one ear intermittently by moving a fingertip
in and out of the ear canal.
- Hold the handle of the activated
tuning fork on the mastoid process of one
ear until the client states that the vibration
can no longer be heard.
- Immediately hold still the vibrating
fork prongs in front of the client’s ear canal.
- If necessary, push aside the client’s
hair.
- Ask whether the client now hears the
sound.
8. Document findings in the client
record.
Assessing the Nose and Sinuses

Preparation:

1. Assemble equipment:
 Nasal speculum
 Flashlight/penlight

PROCEDURE RATIONALE

1. Inquire if client has any history of

the following:
 Allergies
 Difficulty breathing through the nose
 Sinus infections
 Injuries to nose or face
 Nosebleeds
 Any medications taken
 Any changes in sense of smell
2. Position the client comfortably-
seated, if possible.

Nose:
3. Inspect the external nose for any
deviations in shape, size or color and
flaring, or discharge from the nares.

4. Lightly palpate the external nose to

determine any areas of tenderness,
masses, or displacements of bone
and cartilage.

5. Determine patency of both nasal

cavities.
- Ask the client to close the mouth,
exert pressure on one naris, and
breathe through the opposite naris.
- Repeat the procedure to assess
 patency of the opposite naris.

6. Inspect the nasal cavities using a

flashlight or a nasal speculum.
-Hold the speculum in your right
hand and inspect the client’s left
nostril, and in your left hand to
inspect the client’s right nostril.
-Tip the client’s head back.
-Facing the client, insert the tip of
the closed speculum about 1cm or up
to the point at which the blade
widens.
-Care must be taken to avoid
pressure on the sensitive nasal
septum.
-Stabilize the speculum with your
index finger against the side of the
nose.
-Use the other hand to position the
head and then to hold the light.
-Open the speculum as much as
possible and inspect the floor of the
nose, the anterior portion of the
septum, the middle meatus, and the
middle turbinates.
-Inspect the lining of the nares and
the integrity and the position of the
nasal septum.

7. Observe for the presence of redness,

swelling, growths, and discharge.

8. Inspect the nasal septum between

the nasal chambers.

Facial Sinuses
9. Palpate the maxillary and frontal
sinuses for tenderness.

10. Document findings in the client

record.

Assessing the Mouth and Oropharynx

Preparation:

1. Assemble equipment and supplies:

Clean gloves
 Tongue depressor
2 x 2 gauze pads
Penlight

PROCEDURE RATIONALE
1. Inquire if client has any history of
the following:
 Routine pattern on dental care
 Last visit to the dentist
 Length of time ulcers or other
lesions have been present
 Any denture discomfort
 Any medications the client is
receiving
2. Position the client comfortably-
seated, if possible.
Lips and buccal mucosa:
3. Inspect the outer lips for symmetry
of contour, color and texture.
- Ask the client to purse lips as if to
whistle.
4. Inspect and palpate the inner lips and
buccal mucosa for color, moisture,
texture, and the presence of lesions.
Teeth and gums:
5. Inspect the teeth and gums while
examining the inner lips and buccal
mucosa.
6. Inspect the dentures.
- Ask the client to remove complete
or partial dentures. Inspect their
condition, nothing in particular
broken or worn areas.
Tongue/ floor of the mouth:
7. Inspect the surface of the tongue for
position, color, and texture.
- Ask the client to protrude the
tongue and to move it from side to
side.
8. Inspect tongue movement.
-Ask the client to roll the tongue
upward and to move it from side to
side.
9. Inspect the base of the tongue, the
mouth floor, and the frenulum.
-Ask the client to place the tip of
his/her tongue against the roof of the
mouth.
10. Palpate the tongue and floor of the
mouth for any nodules, lumps, or
 excoriated areas.
-Use a piece of gauze to grasp the tip
of the tongue and, with the index
finger of your other hand, palpate the
back of the tongue, its borders, and
its base.
Salivary glands:
11. Inspect salivary duct openings for
any swelling or redness.
Palates and Uvula:
12. Inspect the hard and soft palate for
color, shape, texture, and the
presence of bony prominences.
-Ask the client to open mouth wide
and tilt head backward.
-Then, depress tongue with a tongue
blade as necessary, and use a
penlight for appropriate
visualization.
13. Inspect the uvula for position and
mobility while examining the
palates.
-To observe the uvula, ask the client
to say “ah” so that the soft palate
rises.
Oropharynx and tonsils:
14. Inspect the oropharynx for color and
texture.
-Inspect one side at a time to avoid
eliciting the gag reflex.
-To expose one side of the
oropharynx, press a tongue blade
against the tongue on the same side
about halfway back while the client
tilts head back and opens mouth
wide.
-Use a penlight for illumination, if
needed.
15. Inspect the tonsils for color,
discharge, and size.
16. Elicit the gag reflex by pressing the
posterior tongue with a tongue blade.
17. Document findings in the client
record.

Assessing the Neck

PROCEDURE RATIONALE
1. Inquire if the client has any history of
the following:
  Any problems with neck lumps
 Neck pain or stiffness
 When and how any lumps occurred
 Any diagnoses of thyroid problems
 Any treatments such as surgery or
radiation .
Neck muscles:
2. Inspect the neck muscles
(sternocleidomastoid and trapezius)
for abnormal swellings or masses.
- Ask the client to hold head erect.
3. Observe head movement.
-Ask the client to:
Move chin to the chest.

Move head back so that the chin

points upward.
Move head so that the ear is moved
toward the shoulder on each side.
Turn head to the right and to the left.

4. Assess muscle strength.

Ask the client to:
- Turn head to one side against the
resistance of your hand. Repeat with
the other side.
- Shrug shoulders against the
resistance of your hands.
Lymph nodes:
5. Palpate the entire neck for enlarged
lymph nodes.
Trachea:
6. Palpate the trachea for lateral
deviation.
- Place your fingertip or thumb on the
trachea in the suprasternal notch, then
move your finger laterally to the left
and the right in spaces bordered by
the clavicle, the anterior aspect of the
sternocleidomastoid muscle, and the
trachea.
Thyroid gland:
7. Inspect the thyroid gland.
- Stand in front of the client.
- Observe the lower half of the neck
overlying the thyroid gland for
symmetry and visible masses.
- Ask the client to hyperextend head
and swallow.
- If necessary, offer a glass of water
 to make it easier for the client to
swallow.
8. Palpate the thyroid gland to
smoothness.
-Note any areas of enlargement,
masses, or nodules.
9. If enlargement of the gland is
suspected:
-Auscultate over the thyroid area for
a bruit.
-Use the bell-shaped diaphragm of
the stethoscope.
10. Document findings in the client
record.
Adopted from Kozier and Erb’s Fundamentals of Nursing (2015).
Berman, Audrey, et.al. (2015). Kozier and Erb’s Fundamentals of Nursing: Concept, Process and Practice, 10th
ed.
Weber, Janet R., et.al. (2014). Health Assessment in Nursing, 5th ed.
Lynn, P.(2008). Taylor’s Clinical Nursing Skills, 2nd ed.
 PERFORMANCE CHECKLIST

Name: __________________________________________ Date of Return Demo:

__________

Assessing the Skull and Face; Eye Structures and Visual Acuity; Ears and Hearing;
Nose and Sinuses; Mouth and Oropharynx; and Neck

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly and appropriately. Shows

excellent attitude and gives the correct rationale of the step/ procedure to be performed.
Answers the question/s correctly and analyzes the situation on or before performing the
procedure.
2 – Performs more independently with increasing dependability but occasionally needing
assistance. Shows very satisfactory attitude and gives the correct rationale of the step/
procedure to be performed but occasionally needing follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and
explanations. Has knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance
and direction to be able to perform the step/ procedure correctly and appropriately. There is a
need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/
procedure to be performed; cannot answer the question raised by the supervising clinical
instructor based on the step or procedure to be performed; unable to grasp understanding of
the topic or procedure; unable to perform the required step and state the rationale after being
instructed, guided or directed. Student’s behavior is inappropriate and potentially harmful to
the client.

1 2 3 4 5
ASSESSMENT
1. Verifies the client’s identity.
PLANNING
1. Reviews previously learned concepts and principles.
2. Explains the procedure to the client and how the client can
cooperate.
3. Prepares and assembles all equipment.
IMPLEMENTATION
1. Performs hand hygiene.
2. Introduces self.
3. Provides client privacy.
Assessing the skull and face:
4. Inquires if the client has any history of the following:
a. Lumps or bumps, itching, scaling, or dandruff
b. Loss of consciousness, dizziness, seizures, headache, facial pain, or
injury
5. If so, ascertains the following:
a. When and how any lumps occurred
b. Length of time any other problem existed
c. Any known cause of any problem
d. Associated symptoms, treatment, and recurrences
6. Inspects the skull for size, shape, and symmetry.
7. Palpates the skull for nodules or masses and depressions.
a. Uses a gentle rotating motion with the fingertips.
b. Begins at the front and palpate down the midline, then palpate each
side of the head.
8. Inspects the facial features.
9. Inspects the eyes for edema and hollowness.
10. Notes symmetry of facial movements.
a. Asks the client to elevate the eyebrows, frown, or lower the
eyebrows, close the eyes tightly, puff the cheeks, and smile and show
teeth.
Assessing the eye structures and visual acuity:
11. Inquires if the client has any history of the following:
a. Family history of diabetes, hypertension, or blood dyscrasia
b. Eye disease, injury, or surgery
c. Last visit to an ophthalmologist
d. Current use of eye medications
e. Use of contact lenses or eyeglasses
f. Hygienic practices for corrective lenses
g. Current symptoms of eye problems
Assessing external eye structures:
12. Inspects the eyebrows for hair distribution and alignment, and for
skin quality and movement.
13. Inspects the eyelashes for evenness of distribution and direction of
curl.
14. Inspects the eyelids for surface characteristics, position in relation
to the cornea, ability to blink, and frequency of blinking.
15. Inspects the lower eyelids while the client’s eyes are closed.
16. Inspects the bulbar conjunctiva for color, texture, and the
presence of lesions.
17. Inspects the palpebral conjunctiva by everting the lids.
18. Evert the upper lids if a problem is suspected.
a. Ask the client to look down while keeping the eyelids slightly open.
b. Gently grasp the client’s eyeglass with thumb and forefinger.
c. Pull lashes gently downward while holding the eyelashes.
d. Hold the margin of the everted lid or eyelashes against the ridge of
the upper bony orbit with the applicator stick or your thumb.
e. Inspect the conjunctiva for color, texture, lesions and foreign
bodies.
19. Inspects and palpate the lacrimal gland.
a. Uses the tip of index finger, palpates the lacrimal gland.
b. Observes for edema between the lower lid and the nose.
20. Inspects and palpate the lacrimal sac and nasolacrimal duct.
a. Observes for evidence of increased tearing.
b. Uses the tip of his/ her index finger, palpates inside the lower
orbital rim near the inner canthus.
21. Inspects the cornea for clarity and texture.
a. Asks the client to look straight ahead.
b. Holds a penlight at an oblique angle to the eye, and moves the light
slowly across the corneal surface.
22. Performs the corneal sensitivity (reflex) test to determine the
function of the fifth (trigeminal) cranial nerve.
a. Asks the client to keep both eyes open and look straight ahead.
b. Approaches from behind and beside the client, and lightly touches
the cornea with a corner of the gauze.
23. Inspects the anterior chamber for transparency and depth.
a. Uses the same oblique lighting used when testing the cornea.
24. Inspects the pupils for color, shape, and symmetry of size.
25. Assesses each pupil’s direct and consensual reaction to light in a
partially darken room.
a. Asks the client to look straight ahead.
b. Uses a penlight and approaching from the side, shines a light on the
pupil.
c. Observes the response.
d. Shines the light on the pupil again, and observes the response of the
other pupil.
26. Assesses each pupil’s reaction to accommodation.
a. Holds an object about 10cm from the client’s nose.
b. Asks the client to look first at the top of the object and then at a
distant object behind the penlight.
c. Alternates the gaze between the near and far objects.
d. Observes the pupil response.
e. Moves the penlight or pencil toward the client’s nose.
f. Records normal assessment of the pupil using the abbreviation
PERRLA.
Assessing visual fields:
27. Assesses peripheral visual fields.
a. Have the client sits directly facing you at a distance of 60-90cm.
b. Asks the client to cover right eye with the card and look directly at
your nose.
c. Covers or closes your eye directly opposite the client’s covered
eye, and look directly at the client’s nose.
d. Holds an object in your fingers, extend your arm, and moves the
object into the visual field from various points in the periphery.
e. Asks the client to tell you when the moving object is first spotted.
f. Extends and moves right arm in from the client’s right periphery.
g. Extends and moves the right arm down from the upward periphery.
h. Extends and moves the right arm up from the lower periphery.
i. Extends and moves left arm in from the periphery.
j. Repeats the above steps for the right eye.
Extraocular muscle tests:
28. Assesses six ocular movements to determine eye alignment and
coordination.
a. Stands directly in front of client, and holds the penlight at a
comfortable distance such as 30 cm in front of the client’s eyes.
b. Asks the client to hold the head in a fixed position and follows the
movements of the penlight with the eyes only.
c. Moves the penlight in a slow, orderly manner through the six
cardinal fields of gaze.
d. Stops the movement of the penlight periodically so that nystagmus
can be detected.
29. Assesses for location of light reflex by shinning a penlight on the
pupil in corneal surface (Hirschberg Test).
30. Have the client fixate on a near or far object. Covers one eye, and
observes for movement in the uncovered eye (cover test).
Assessing visual acuity:
31. Assesses near vision by providing adequate lighting and asks the
client to read from a magazine or newspaper.
32. Assesses distance vision by asking the client to wear corrective
lenses unless they are used for reading only.
a. Asks the client to sit or stand 6 meters (20ft) from Snellen’s chart,
cover the eye not being tested, and identify the letters or characters.
b. Takes three readings: right eye, left eye, and both eyes.
33. Performs functional vision tests if the client is unable to see the
top line (20/200) of Snellen’s chart.
34. Inquires if the client has any history of the following:
a. Family history of hearing problems or loss
b. Presence of any ear problems or pain
c. Medication history, especially if there are complaints of ringing in
ears
d. Any hearing difficulty: its onset, factors contributing to it, and how
it interferes with activities of daily living
e. Use of a corrective hearing device: when and from it was obtained
35. Positions the client comfortably-seated, if possible
Auricles
36. Inspects the auricles for color, symmetry of size, and position.
a. To inspect position, notes the level at which the superior aspect of
the auricle attaches to the head with relation to the eye.
37. Palpates the auricle for texture, elasticity, and areas of tenderness.
a. Gently pulls the auricle upward, downward, and backward.
b. Folds the pinna forward. (It should recoil)
c. Pushes in on the tragus.
d. Applies pressure to the mastoid process.
External ear canal and tympanic membrane:
38. Uses an otoscope, inspects the external ear canal for cerumen,
skin lesions, pus and blood.
a. Attaches a speculum to the otoscope.
b. Tips the client’s head away and straightens the ear canal.
c. Holds the otoscope either right side up, with fingers between the
otoscope handle and the client’s head, or upside down, with fingers
and the ulnar surface of hand against the client’s head.
d. Gently inserts the tip of the otoscope into the ear canal, avoiding
pressure by the speculum against either side of the ear canal.
39. Inspects the tympanic membrane for color and gloss.
Gross hearing acuity test:
40. Assesses the client’s response to normal voice tones.
a. If the client has difficulty hearing the normal voice, proceeds with
the following tests.
A. Performs the watch tick test:
a. Have the client occlude one ear.
b. Out of the client’s sight, places a ticking watch 2-3cm (1-2 inches)
from the unoccluded ear.
c. Asks what the client can hear. Repeat with the other ear.
B. The tuning fork tests:
Performs Weber test.
a. Holds the tuning fork at its base.
b. Activates it by tapping the fork gently against the back of hand
near the knuckles or by stroking the fork between your thumb and
index fingers.
c. Place the base of the vibrating fork on the top of the client’s head,
and ask whether the client hears the noise.
Conducting Rinne’s test:
a. Asks the client to block the hearing in one ear intermittently by
moving a fingertip in and out of the ear canal.
b. Holds the handle of the activated tuning fork on the mastoid
process of one ear until the client states that the vibration can no
longer be heard.
c. Immediately holds still the vibrating fork prongs in front of the
client’s ear canal.
d. If necessary, pushes aside the client’s hair.
e. Asks whether the client now hears the sound.
Assessing the nose and sinuses:
41. Inquires if client has any history of the following:
a. Allergies
b. Difficulty breathing through the nose
c. Sinus infections
d. Injuries to nose or face
e. Nosebleeds
f. Any medications taken
g. Any changes in sense of smell
42. Positions the client comfortably-seated, if possible.
Nose:
43. Inspects the external nose for any deviations in shape, size or
color and flaring, or discharge from the nares.
44. Lightly palpates the external nose to determine any areas of
tenderness, masses, or displacements of bone and cartilage.
45. Determines patency of both nasal cavities.
a. Asks the client to close the mouth, exert pressure on one naris, and
breathe through the opposite naris.
b. Repeats the procedure to assess patency of the opposite naris.
46. Inspects the nasal cavities using a flashlight or a nasal speculum.
a. Holds the speculum in your right hand, and inspect the client’s left
nostril, and in left hand to inspect the client’s right nostril.
b. Tips the client’s head back.
c. Facing the client, inserts the tip of the closed speculum about 1cm
or up to the point at which the blade widens.
d. Care is taken to avoid pressure on the sensitive nasal septum.
e. Stabilizes the speculum with index finger against the side of the
nose.
f. Uses the other hand to position the head and then to hold the light.
g. Opens the speculum as much as possible and inspect the floor of
the nose, the anterior portion of the septum, the middle meatus, and
the middle turbinates.
h. Inspects the lining of the nares and the integrity and the position of
the nasal septum.
47. Observes for the presence of redness, swelling, growths, and
discharge.
48. Inspects the nasal septum between the nasal chambers.
Facial sinuses:
49. Palpates the maxillary and frontal sinuses for tenderness.
Assessing the mouth and oropharynx:
50. Inquires if client has any history of the following:
a. Routine pattern on dental care
b. Last visit to the dentist
c. Length of time ulcers or other lesions have been present
d. Any denture discomfort
e. Any medications the client is receiving
51. Positions the client comfortably-seated, if possible.
Lips and buccal mucosa:
52. Inspects the outer lips for symmetry of contour, color and texture.
a. Asks the client to purse lips as if to whistle.
53. Inspects and palpates the inner lips and buccal mucosa for color,
moisture, texture, and the presence of lesions.
Teeth and gums:
54. Inspects the teeth and gums while examining the inner lips and
buccal mucosa.
55. Inspects the dentures.
a. Asks the client to remove complete or partial dentures. Inspects
their condition, noting in particular broken or worn areas.
Tongue/ floor of the mouth:
56. Inspects the surface of the tongue for position, color, and texture.
a. Asks the client to protrude the tongue and to move it from side to
side.
57. Inspects tongue movement.
a. Asks the client to roll the tongue upward and moves it from side to
side.
58. Inspects the base of the tongue, the mouth floor, and the frenulum.
a. Asks the client to place the tip of his/her tongue against the roof of
the mouth.
59. Palpates the tongue and floor of the mouth for any nodules,
lumps, or excoriated areas.
a. Uses a piece of gauze to grasp the tip of the tongue and, with the
index finger of other hand, palpates the back of the tongue, its
borders, and its base.
Salivary glands:
60. Inspects salivary duct openings for any swelling or redness.
Palates and Uvula:
61. Inspects the hard and soft palate for color, shape, texture, and the
presence of bony prominences.
a. Asks the client to open mouth wide and tilt head backward.
b. Then, depresses tongue with a tongue blade as necessary, and uses
a penlight for appropriate visualization.
62. Inspects the uvula for position and mobility while examining the
palates.
a. To observe the uvula, asks the client to say “ah” so that the soft
palate rises.
Oropharynx and tonsils
63. Inspects the oropharynx for color and texture.
a. Inspects one side at a time to avoid eliciting the gag reflex.
b. To expose one side of the oropharynx, presses a tongue blade
against the tongue on the same side about halfway back while the
client tilts head back and opens mouth wide.
c. Uses a penlight for illumination, if needed.
64. Inspects the tonsils for color, discharge, and size.
65. Elicits the gag reflex by pressing the posterior tongue with a
tongue blade.
Assessing the neck:
66. Inquires if the client has any history of the following:
a. Any problems with neck lumps
b. Neck pain or stiffness
c. When and how any lumps occurred
d. Any diagnoses of thyroid problems
e. Any treatments such as surgery or radiation
Neck muscles:
67. Inspects the neck muscles (sternocleidomastoid and trapezius) for
abnormal swellings or masses.
a. Asks the client to hold head erect.
68. Observes head movement.
a. Asks the client to:
Move chin to the chest.
b. Moves head back so that the chin points upward.
c. Moves head so that the ear is moved toward the shoulder on each
side.
d. Turns head to the right and to the left.
69. Assesses muscle strength.
Ask the client to:
a. Turns head to one side against the resistance of hand. Repeats with
the other side.
b. Shrugs shoulders against the resistance of hands.
Lymph nodes:
70. Palpates the entire neck for enlarged lymph nodes.
Trachea:
71. Palpates the trachea for lateral deviation.
a. Places fingertip or thumb on the trachea in the suprasternal notch,
then moves finger laterally to the left and the right in spaces bordered
by the clavicle, the anterior aspect of the sternocleidomastoid muscle,
and the trachea.
Thyroid gland:
72. Inspects the thyroid gland.
a. Stands in front of the client.
b. Observes the lower half of the neck overlying the thyroid gland for
symmetry and visible masses.
c. Asks the client to hyperextend head and swallow.
d. If necessary, offers a glass of water to make it easier for the client
to swallow.
73. Palpates the thyroid gland to smoothness.
a. Notes any areas of enlargement, masses, or nodules.
b. If enlargement of the gland is suspected:
Auscultates over the thyroid area for a bruit.
c. Uses the bell-shaped diaphragm of the stethoscope.
74. Performs hand hygiene.
75. Documents findings in the client record.
EVALUATION
1. Observes appropriate infection control measures throughout the
performance of the procedure.
2. Applies related and relevant principles / concepts.
3. Distinguishes what is normal findings and deviation to normal
findings,
4. Relates findings or assessment to client’s culture, socioeconomic
status and current circumstances, certain condition or disorder.
5. Shows understanding of the terms, description or findings stated.
6. Performs the procedure with mastery and confidence.
7. Shows a positive and caring attitude towards the client.

Comments and Suggestions:

Rating: ______
Signature of Supervising Clinical Instructor: _______________________