Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 2-4

Assessing the Head and Neck

Goal: The assessment is completed without the patient

experiencing anxiety or discomfort, the findings are documented,

and the appropriate referral is made to the other healthcare

professionals, as needed, for further evaluation. Comments

1. Perform hand hygiene and put on PPE, if indicated.


2. Identify the patient.


3. Close curtains around bed and close the door to the room,
   if possible. Explain the purpose of the head and neck
   examination and what you are going to do. Answer any
   questions.


4. Inspect the head and then the face for color, symmetry,
   lesions, and distribution of facial hair. Note facial expres-
   sion. Palpate the skull.


5. Inspect the external eye structures (eyelids, eyelashes, eye-
   ball, and eyebrows), cornea, conjunctiva, and sclera. Note
   color, edema, symmetry, and alignment.


6. Examine the pupils for equality of size, shape, and reaction
   to light by darkening the room and using a penlight to shine
   the light on each pupil.


7. To test for pupillary accommodation and convergence, ask
   the patient to focus on an object as you bring it closer to
   the nose.


8. Using an ophthalmoscope, check the red reflex.


9. Test the patient’s visual acuity with a Snellen chart. Ask
   the patient to read the smallest possible line of letters, first
   with both eyes and then with one eye at a time.


10. With the patient about 2 feet away, ask the patient to focus
    on your finger and move the patient’s eyes through the six
    cardinal positions of gaze.


11. Inspect the external ear bilaterally for shape, size, and
    lesions. Palpate the ear and mastoid process.


12. Perform an otoscopic examination. For an adult, pull the
    auricle up and back; for a child, pull the auricle down and
    back. Note cerumen (wax), edema, discharge, or foreign
    bodies and condition of the tympanic membrane.


13. Use a whispered voice to test hearing. Stand about 1 to
    2 feet away from the patient out of the patient’s line of
    vision. Ask the patient to cover the ear not being tested.
    Perform test on each ear.

ExcellentSatisfactoryNeeds Practice