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Notre Dame of Tacurong College College of Nursing

This document is a checklist for assessing the head, eyes, ears, nose, and neck during a physical examination of a student nurse. It includes instructions for using a 5-point rating scale to evaluate the student's performance of each assessment step. The checklist then lists 16 specific assessment procedures for the head, eyes, ears, nose, mouth, and neck, including inspecting the skin, palpating glands, and checking hearing and vision. Students are rated on their ability to correctly perform each assessment, state the appropriate rationale, and answer any questions.

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Jona Phie Montero Ndtcnursing
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148 views4 pages

Notre Dame of Tacurong College College of Nursing

This document is a checklist for assessing the head, eyes, ears, nose, and neck during a physical examination of a student nurse. It includes instructions for using a 5-point rating scale to evaluate the student's performance of each assessment step. The checklist then lists 16 specific assessment procedures for the head, eyes, ears, nose, mouth, and neck, including inspecting the skin, palpating glands, and checking hearing and vision. Students are rated on their ability to correctly perform each assessment, state the appropriate rationale, and answer any questions.

Uploaded by

Jona Phie Montero Ndtcnursing
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

CHECKLIST ON HEALTH ASSESSMENT AND PHYSICAL EXAMINATION

ASSESSING THE HEAD, EYES, EARS, NOSE, AND NECK

Student Name: _____________________________________ Year Level: _________________


Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the
performance of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
4 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
3 Satisfactory
Student performs the procedure correctly but failed to states the
rationale.
Student is able to answer questions when cued.
2 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
1 Poor
Student fails to perform the procedure correctly even when cued.
Student does not know the rationale.
NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

HEALTH ASSESSMENT AND PHYSCIAL EXAMINATION

DEFINITION
● Health assessment is the collection of data about an individual’s health.
Physical examination is a head to toe review of each body system that offers
objective information about the client and allows the health care provider to
make clinical judgment.

PURPOSE
● Health Assessment.
1. To make a clinical judgment or diagnosis about the individual’s health
state or condition.
2. To obtain baseline data about the client’s functional abilities

● Physical Examination
1. For routine screening to determine the client’s eligibility for health
insurance.
2. For acquiring a new job
3. For client’s admission to the hospital.

EQUIPMENT:
● BP apparatus
● Thermometer
● Penlight
● Drape
● Tongue depressor
● Stethoscope
● Percussion hammer
● Vaginal speculum
● Gloves

PROCEDURE 1 2 3 4 5
1. Identify the client and explain the procedure
1 2 3 4 5
2. Properly position the client. 1 2 3 4 5

3. Take the health history of the client. 1 2 3 4 5

4. Conduct physical examination using the four skills in physical assessment 1 2 3 4 5


(Inspection, Palpation, Percussion, Auscultation)

A. Assessing the head


5. Hair

a. Evenness 1 2 3 4 5

b. Texture and oiliness 1 2 3 4 5

c. Thickness/thinness 1 2 3 4 5

d. Infection and infestation (lice) 1 2 3 4 5

6. Assessing the skull and face. 1 2 3 4 5


a. Skull for size, shape and symmetry 1 2 3 4 5
b. Skull of nodules or masses and depressions 1 2 3 4 5
c. Symmetry of facial movement. 1 2 3 4 5
7. Assessing the eye,
structure and visual acuity
a. Inspect the eyebrows for hair distribution. 1 2 3 4 5
b. Eyelids – ability of blinking. 1 2 3 4 5
c. Conjunction (lining the eyelids by reversing the lids). 1 2 3 4 5
d. Cornea – clarity and texture 1 2 3 4 5
e. Pupil for color and symmetry of size 1 2 3 4 5
f. Pupil reaction to light. 1 2 3 4 5
g. Reaction to accommodation. 1 2 3 4 5
8. Assessing the ears.
a. Auricles – color symmetry 1 2 3 4 5
b. Auricles for elasticity and areas for tenderness 1 2 3 4 5
c. Hearing acuity: 1 2 3 4 5
- Client’s response to normal voice tones.
- Client’s response to whispered voice-nonconsecutive numbers. 1 2 3 4 5
9. Assessing the nose
a. External nose for any deviation in shape, size or in color and flaring 1 2 3 4 5
or discharge from the nares
b. External nose to determine any areas of tenderness, masses and 1 2 3 4 5
displacement of bone and cartilage.
c. Patency of both nasal cavities 1 2 3 4 5
10. Assessing the mouth and
oropharynx
a. Lip and buccal mucosa 1 2 3 4 5
b. Teeth and gums 1 2 3 4 5
c. Tongue/floor of the mouth 1 2 3 4 5
d. Tongue movement 1 2 3 4 5
e. Oropharynx and tonsils – inspect the oropharynx for color and 1 2 3 4 5
texture using a tongue depressor.
B. Assessing the neck.
11. Inspect the neck muscles. 1 2 3 4 5
12. Observe head movement 1 2 3 4 5
13. Palpate the thyroid glands 1 2 3 4 5
for smoothness
14. Reposition the client 1 2 3 4 5

Evaluation
15. Make findings of health assessment and physical examination done on the
client. 1 2 3 4 5

Documentation
16. Record/document and report any pertinent findings found during
assessment to appropriate personnel. 1 2 3 4 5

Total Points: _______________


Average: _______________
RD Grade: _______________

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

________________________________
Signature over Printed Name
(FACULTY)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

________________________________
Signature over Printed Name
(Student)

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