ASSESSING THE HEAD (HAIR, SCALP, SKULL AND FACE)

ASSESSMENT NORMAL FINDINGS PATIENT’S

FINDINGS
Inspected the Evenly distributed, thick No deviation from the
distribution, thickness, hair, silky, and resilient normal findings.
color, elasticity, and hair.
texture of hair.

Inspected the scalp for No infection or infestation. No deviation from

cleanliness and noted normal findings.
for presence of lesions.

Palpated the scalp for Smooth; uniform No deviation from the

unusual masses or consistency; absence of normal findings.
prominences. nodules or masses

Inspected the skull for Rounded (normocephalic No deviation from the

size, shape and and symmetric, with normal findings.
symmetry. frontal, parietal, and
occipital prominences);
smooth skull contour
Palpated the skull for No body odor or minor No deviation from the
nodules or masses or body odor; no breath odor normal findings.
depressions.

Inspected the facial Symmetric or slightly No deviation from the

features and symmetry asymmetric facial normal findings.
of facial movement. features; palpebral
fissures equal in size;
symmetric nasolabial
folds

ASSESSING THE EYES

Inspected the eyebrow, Hair evenly distributed; No deviations from

eyelashes and eyelids. skin intact. normal findings.
Eyelash is curled
 slightly outward.
Eyelid skin is intact; no
discharge; no
discoloration
Lids close
symmetrically
Approx. 15 to 20
involuntary blinks per
minute; bilateral
blinking
Inspected the anterior When lids open, no No deviations from
eyeballs and sclera. visible sclera above the normal findings.
corneas, and upper
and lower borders of
cornea are slightly
covered.
Sclera appears white.
Inspected the bulbar Transparent; capillaries No deviations from
and palpebral sometimes evident. the normal findings.
conjunctiva for the Shiny, smooth,and pink
color, texture and or red
presence of lesions.

Inspected for lacrimal No edema or No deviation from

gland, lacrimal sac and tenderness over the
nasolacrimal duct. lacrimal gland normal findings.

Palpated the lacrimal No edema or tearing No deviation from

gland, lacrimal sac and the normal findings.
nasolacrimal duct.

Inspected the cornea Transparent, shiny and No deviation from

for clarity and texture. smooth; details of iris the normal findings.
are visible
Palpated the iris and No deviation from
pupils for color, shape the normal findings.
 and symmetry of size.

Inspected each pupil’s Illuminated pupil contricts No deviation from

direct and consensual (direct response) the normal findings.
reaction to light and Non illuminated pupil
reaction to constricts (consensual
accommodation. response)

Pupil constrict when

looking at near object;
pupils dilate when looking
at far object; pupils
converge when near
object is moved toward
nose
Inspected the peripheral When looking straight No deviation from the
visual fields ahead, client can see normal findings.
(Confrontation test). object in the periphery.

Inspected the six ocular Both eyes coordinated, No deviation from the
movements (Extraocular move in unison, with normal findings.
muscle function). parallel alignment.

Inspected the near vision Uncovered eyes don’t No deviation from the
and distance vision of move. normal findings.
the client.