COLLEGE OF NURSING

STUDENT: _________________________________________________ DATE: _______________________

BLOCK: ________________________________________________ SCORE: ______________________
CLINICAL INSTRUCTOR: __________________________________________________________________

ASSESSMENT OF HEAD, EYES, EARS, NOSE, MOUTH, NECK, & THROAT

PROCEDURE CHECKLIST
I. OBJECTIVES
1. To establish baseline data for subsequent evaluation.
2. To make thorough assessment of the head, eyes, ears, nose, mouth, neck, and throat and to
differentiate between normal and abnormal findings.
3. To analyze collected assessment findings for formulation of care plan, referrals and laboratory
studies.
II. MATERIALS/EQUIPMENT
1. Tape Measure 11. Tongue depressor
2. Clean gloves 12. Gauze
3. Penlight 13. Glass with water
4. Ophthalmoscope 14. Kidney basin
5. Portable eye chart 15. Stethoscope
6. Cotton applicator 16. P.E. Form/notebook
7. Cotton wisp 17. Pen
8. Ruler
9. Otoscope
10. Nasal speculum
III. PROCEDURE STEPS. CHECK THE DONE NOT SCORE
APPROPRIATE BOX. 1 DONE
The student is expected to perform the following: 0
PREINTRODUCTORY PHASE
1. Review client’s medical records and related literature.
2. Prepare all necessary materials or equipment needed.
INTRODUCTORY PHASE
3. Introduce yourself by giving your name, title, and role.
4. Wear proper ID, neat uniform and RLE hair.
5. Perform handwashing and if needed, wear PPE.
6. Verify the client’s identity using institution protocol.
7. Provide privacy by closing the doors and windows and
drawing the curtain.
8. Maintain comfortable room temperature.
9. Explain to the client what you are going to do, why is it
necessary and how he/she can participate.
10. Instruct client to remove any wig, hat, hair pins, rubber
bands, jewelry and neck scarves.
11.Ask client to sit in an upright position with back and
shoulders held back and straight.
Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
Rhoda Grace Estioco-Ruelos, MAN, RN Page - 1 -
Health Assessment 2nd Semester January 2021 Faculty Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Dean
 COLLEGE OF NURSING

IMPLEMENTATION PHASE

A. INSPECTION and PALPATION of the Head

12.Inspect for size, shape, contour of the skull. Size
and shape of head varies, Usually round, symmetric,
erect and in midline. (Normal shape of the skull is
Normocephalic)
13. Inspect for involuntary movement.
14. Inspect scalp by separating the hair in several areas.
(Note presence of lice, nits, dandruff or lesions)
15. Palpate the head using finger pads. Note for
consistency and tenderness. (Head is normally hard
and smooth. No lesions and tenderness)
B. INSPECTION of the Face.
16. Inspect the face for shape, movement, expression
and skin condition.
17.Observe symmetry. Instruct client to smile. Note for
bilateral nasolabial folds which are indented lines from
the edges of the nose to the outer corners of the mouth
seen when smiling. (Slight asymmetry in folds is
normal). Inspect for palpebral fissures. (The opening
between the margins of the upper and lower eyelids. It
should be equal in both eyes.) Nasolabial folds and
palpebral fissures are ideal places to check facial
features for symmetry.
18. Palpate temporal artery. (Note pulsations and
tenderness)
19. Palpate the temporomandibular joint. Ask client to
open the mouth then place your index finger over the
front of each ear. (there should be no swelling,
tenderness or crepitation with movement. CREPITUS-
creaking, grating sound when moving a joint)

C. INSPECTION and PALPATION of the Eyebrows,

Eyes, and Eyelashes.
20. Inspect symmetry of eyebrows, eyelashes and
eyes. (Note that they are not perfectly symmetrical)
21. Palpate eyebrows for distribution of hair. Note for
tenderness and lesions.
22. Observe proportion and alignment of the eyeball in
The eye socket. (No protrusion or sinking. Should be
Symmetrically aligned.)
C. INSPECTION and PALPATION of the Eyelids and
Lacrimal Apparatus.
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Rhoda Grace Estioco-Ruelos, MAN, RN Page - 2 -
Health Assessment 2nd Semester January 2021 Faculty Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Dean
 COLLEGE OF NURSING

23. Inspect eyelids for symmetry and position. (Slight

asymmetry is normal)
24.Inspect areas over lacrimal glands (lateral aspect of
upper eyelids) and puncta (medial aspect of lower
eyelid)
25. Palpate eyelids for lacrimal glands. (Wear gloves
use the pad of your index finger and palpate lightly
inside the upper orbital rim. Ask client if there is pain
or tenderness)
26. Palpate nasolacrimal duct for blockage or
obstruction. (Wear gloves use the pad of your index
finger and palpate lightly inside the lower orbital rim
at the lacrimal sac)
D. INSPECTION of the Conjunctivae and Sclerae.
27. Examine bulbar conjunctiva and sclera by
separating the eyelids widely instructing client to hold
head straight while looking from side to side then
upward. (Bulbar conjunctiva is
moist, clear and smooth. Sclera is white in color.)
NOTE: Do not exert too much pressure to avoid discomfort to
the client
28. Examine palpebral conjunctivae. With gloves on,
Place your finger at the lower bony orbital rim and
gently pull down to expose the palpebral conjunctiva
while client is looking up. Do not put too much
pressure. (The palpebral conjunctivae should be clear
and no swelling)
29. To examine for swelling, presence of foreign
bodies and trauma. Evert upper eyelid and instruct
client to look down with eyes slightly open. (This
relaxes levator muscles and closing eyes contracts
orbicularis oculi muscle, preventing lid eversion.)
Gently grasp the client’s upper eyelashes and pull the
lid downward.
30. Place a cotton-tipped applicator approximately 1
cm above the eyelid margin ang gently push down with
the applicator while still holding the lashes. Hold
lashes against the upper ridge of the bony orbit beneath
the eyebrow. Examine for swelling, presence of foreign
bodies or trauma. Return the lid by moving lashes
forward and instruct client to look up and blink. The lid
should return to normal position.
NOTE: This procedure is done only if the client complains
pain or presence of foreign objects in the eye because this is
uncomfortable for the client.
Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
Rhoda Grace Estioco-Ruelos, MAN, RN Page - 3 -
Health Assessment 2nd Semester January 2021 Faculty Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Dean
 COLLEGE OF NURSING

D. INSPECTION of Cornea and Lens.

31. Shine a light from the side of the eye for an oblique
view and look through the pupil to inspect the lens.
(The cornea is transparent with no opacities. Oblique
view shows smooth and moist surface. Lens is free of
opacities.)
E. Inspection of Iris and Pupils.
32. Examine shape and color of iris and size and shape
of pupil. Measure pupil gauge. (Iris is round, flat with
even color. Pupils round and equal in size,3-5mm)
33. Test pupillary reaction to light.
Darken the room and instruct client to focus on a
distant object. Shine a light obliquely into one eye and
observe pupillary reaction. (Normal pupillary response
is constriction) Assess consensual response at the same
time by shining a light obliquely into one eye and
observing the pupillary reaction in the opposite eye.
(Normal consensual pupillary response is constriction)
34. Test accommodation of pupils.
Hold your finger or a pencil about 12 to 15 inches
from the client. Ask client to focus on your finger or
pencil and fix his/her gaze as you move your finger or
pencil toward the eyes. (Normal pupillary response is
constriction of the pupils and convergence of the eyes
when focusing on a near object and pupillary dilation
when focusing on distant object.) (PERRLA)
F. Testing Visual fields.
35. Assess peripheral vision. Have client sit directly
facing you at 2-3 ft. Then ask client to
cover the right eye with a card and look directly at your
nose.
36. Cover or close your opposite eye and look
directly at the client’s nose.
37. Hold an object in your fingers (pencil, penlight)
And extend your arm, and move the object in the
visual fields from different points in the periphery.
(Object should be at an equal distance from the
client and yourself.)
38. Ask client to tell you when the moving object is first
spotted.
39. Repeat steps on the left eye.
(Normally when client looks straight ahead, client
Can see objects in the periphery)
G. INSPECTION of the Ears
Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
Rhoda Grace Estioco-Ruelos, MAN, RN Page - 4 -
Health Assessment 2nd Semester January 2021 Faculty Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Dean
 COLLEGE OF NURSING

Auricles
40. Inspect the auricles for color, symmetry of size, and
Position. (Auricles should be aligned with outer
canthus of eye)
41. Palpate the auricles for texture, elasticity, and areas
of tenderness and the mastoid process for firmness.
Gently pull the auricle upward, downward, and
Backward then fold pinna forward. (It should recoil)
External Ear Canal and Tympanic Membrane
42. Inspect external ear canal for cerumen, discharges,
lesions and blood.
(For adult, pull pinna upward and backward to
straighten the ear canal.
For children, pull pinna downward and backward
to straighten the ear canal.)
43. Perform otoscopic examination of the tympanic
membrane. Gently insert the tip of the otoscope into
the ear canal, avoiding pressure by the speculum
against either side of the ear canal. (The inner two
thirds of the ear canal is bony and if speculum is
pressed, will cause discomfort to client.) Note
and gloss of tympanic membrane.

H. INSPECTION and PALPATION of the Nose

44. Inspect external nose for symmetry, any deviations
in shape, size, or color, or flaring from the nares.
45. Palpate external nostrils for displacement of bone and
cartilage, any tenderness and masses.
46. Check patency of nostrils by occluding one nostril at
a time and asking client to breathe through
opposite nostril. Repeat procedure to the opposite
nostril.
47. Inspect internal nostrils using a otoscope, penlight or
a nasal speculum. Gently tilt the head of the client or
hyperextend the neck. Using your thumb, push tip of
the nose upward while shining a light into the
nostrils. Observe for presence of redness, swelling,
masses and discharge. (Mucosa is pink in color,
clear, watery discharge and no masses or lesions)
48. Inspect nasal septum between the nasal chambers.
(Nasal septum is intact and in midline)
49. Palpate the frontal sinuses using thumbs to press up
on the brow on each side of the nose.
50. Palpate the maxillary sinuses by pressing with
thumbs up on the maxillary sinuses. (Frontal and
Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
Rhoda Grace Estioco-Ruelos, MAN, RN Page - 5 -
Health Assessment 2nd Semester January 2021 Faculty Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Dean
 COLLEGE OF NURSING

maxillary sinuses are nontender to palpation.)

51. Percuss the sinuses. Lightly tap over the frontal
sinuses and over the maxillary sinuse for tenderness.

I. INSPECTION and PALPATION of Mouth and

Oropharynx
52. Inspect the outer lips for symmetry of contour, color,
and texture. Ask client to purse the lips as if to
whistle.
53. Inspect and palpate inner lips and buccal mucosa for
color, moisture, texture, and lesion. With gloved
hands, ask client to relax mouth, pull the lip outward
and away from the teeth for better visualization.
54. Inspect teeth and gums.
Ask client to open mouth. Using tongue depressor,
retract the cheek and view buccal mucosa from top to
bottom, back to front and use penlight to illuminate
the surface. Repeat to other side.
55. Examine teeth for completeness, number, color,
dental carries, alignment, and malocclusions.
should also be assessed during this procedure.
56. Inspect and palpate the tongue. Ask client to stick out
the tongue. Inspect for color, moisture, size,
texture and lesions.
57. Inspect tongue movement by asking client to roll the
tongue upward and side to side. Inspect base of the
tongue, mouth floor and frenulum.
58. With gloved hands, palpate tongue for mass and
tenderness.
59. Inspect hard and soft palate for color, shape, texture
and presence of bony prominences.
60. Uvula. Inspect using a tongue depressor, shine a
penlight into the mouth and note for position, color,
and mobility. Ask client to say “aahh” and watch
uvula and soft palate to move.
61. Tonsils. Inspect tonsils for inflammation,
and size.

Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
Rhoda Grace Estioco-Ruelos, MAN, RN Page - 6 -
Health Assessment 2nd Semester January 2021 Faculty Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Dean
 COLLEGE OF NURSING

J. INSPECTION, PALPATION and AUSCULTATION

of Neck and Thyroid.
62. Inspect the neck muscles (sternocleidomastoid and
trapezoid) for abnormal swelling and masses. Ask
client to hold head erect.
63. Assess Range of movement of the neck. Ask client to
move chin to chest and move the head back, then letting
the head touch the shoulder in each side. Then turn head
to the right and to the left.
64. Assess head for muscle strength. Ask client to turn
Head to one side against the resistance of your hand
Repeat to the other side. (Determines the strength of
sternocleidomastoid muscle)
65. Ask client to shrug the shoulders against the resistance
of your hands. (Determines the strength of trapezius
muscles)
66. Palpate the entire neck for enlarged lymph nodes. Face
the client, bend the client’s head forward slightly or
toward the side being examined. (This relaxes the soft
tissues and muscles).
67. Using the pads of your fingers, palpate the lymph
Nodes and move fingertips in a gentle rotating
motion. Describe lymph nodes size, regularity,
consistency, tenderness and fixation to surrounding
tissues.
68. Submental and submandibular nodes- place
fingertips under the mandible on the side nearest the
palpating hand, and pull the skin and subcutaneous
tissue literally over the mandibular surface so that the
tissue rolls over the nodes.
69. Supraclavicular nodes- Bend the client’s head
forward to relax the tissues of the anterior neck and the
shoulder. Use your free hand to flex the client’s head
and hook your index and third fingers over the clavicle
to the sternocleidomastoid muscle.
70. Anterior and posterior cervical nodes- Move
slowly in forward circular motion against the
sternocleidomastoid muscle and trapezius
respectively.
71. Deep cervical nodes- Bend or hook your fingers
around the sternocleidomastoid muscle.
TRACHEA
72. Palpate the trachea for lateral deviation. Place fingertip
or thumb on the trachea in the suprasternal notch, move
finger laterally to the left and the right in spaces
Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
Rhoda Grace Estioco-Ruelos, MAN, RN Page - 7 -
Health Assessment 2nd Semester January 2021 Faculty Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Dean
 COLLEGE OF NURSING

bordered of the sternocleidomastoid muscle, and the

trachea.
THYROID GLAND
73. Inspect the thyroid gland. Let the client sit on a chair.
Stand in front of the client and observe the lower half
of the neck overlying the thyroid gland for symmetry
and visible masses.
74. Ask client to extend the head and swallow. If
necessary, offer a glass of water to make it easier for
client to swallow. Palpate the thyroid while the
client is swallowing.
75. Auscultation of the thyroid is necessary when there
is thyroid enlargement. (The examiner may hear
bruits, as a result of increased and turbulence in
blood flow in an enlarged thyroid)
POST IMPLEMENTATION PHASE
76.Validate the information gathered for accuracy,
reliability, and completeness.
77. Discard PPE used appropriately.
78. Perform Hand hygiene.
79. Report significant findings and needs that requires
immediate intervention to nurse supervisor or the
physician.
80.Document and record data and findings gathered in
the client’s chart in a factual manner using
appropriate terminologies.

TOTAL SCORE /80

PRECEPTOR’S NAME AND SIGNATURE

REFERENCE:
Weber J. & Kelley, J. (2014). Health Assessment in Nursing Fifth Edition
Weber J. & Kelley, J. (2018). Health Assessment in Nursing Sixth Edition
Berman, A., Snyder, S., and Frandsen, G. (2016). Kozier and Erb’s Fundamentals of Nursing, Concepts,
Process, and Practice Tenth Edition,

REVISED FOR SCHOOL YEAR 2021-2022

Checklist for: Date Effective Date Revised Prepared and Revised By: Approved by:
Rhoda Grace Estioco-Ruelos, MAN, RN Page - 8 -
Health Assessment 2nd Semester January 2021 Faculty Dr. Almira A. Tenorio, RN, MAN, MAEd of 1
SY 2021-2022 Dean