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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:SKILL 2-4Assessing the Head and Neck (Continued)
Comments- Use a tuning fork to perform Weber’s test and Rinne test
if the patient reports diminished hearing in either ear. - Put on gloves. Inspect and palpate the external nose.
- Palpate and lightly percuss over the frontal and maxillary
sinuses. - Occlude one nostril externally with a finger while patient
breathes through the other; repeat for the other side. - Inspect the internal nostrils using an otoscope with a nasal
speculum attachment. - Palpate the temporomandibular joint by placing your index
finger over the front of each ear as you ask the patient to
open and close the mouth. - Inspect the lips, oral mucosa, hard and soft palates, gingi-
vae, teeth, and salivary gland openings by asking the
patient to open the mouth wide using a tongue blade
and penlight. - Inspect the tongue. Ask the patient to stick out the tongue.
Place a tongue blade at the side of the tongue while patient
pushes it to the left and right with the tongue. Inspect the
uvula by asking the patient to say “ahh” while sticking out
the tongue. Palpate the tongue for muscle tone and tender-
ness. Remove gloves. - Palpate from the forehead to the posterior triangle of the
neck for the posterior cervical lymph nodes using the finger
pads in a slow, circular motion. - Inspect and palpate in front of and behind the ears, under
the chin, and in the anterior triangle for the anterior cervi-
cal lymph nodes. - Inspect and palpate the left and then the right carotid
arteries. Only palpate one carotid artery at a time.
Use the bell of the stethoscope to auscultate the
arteries. - Inspect and palpate for the trachea.
- Palpate the thyroid gland (illustrate the two techniques).
Then, if enlarged, auscultate the thyroid gland using the
bell of the stethoscope. - Inspect and palpate the supraclavicular area.
ExcellentSatisfactoryNeeds Practice