Republic of the Philippines

TARLACSTATEUNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines
Tel.no.: 4931865 Fax: (045) 982-0110 website: www.tsu.edu.ph
Accredited Level 2 status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines, Inc,
(AACCUP)

NCM 101 SKILLS LAB

PERFORMANCE CHECKLIST
ASSESSMENT OF EYES, EARS AND NOSE

Name:___________________________ Date:_______________
Year & Group: ____________________ Score:______________
Instructor/Evaluator: _______________

A. EYES
ASSESSMENT PROCEDURE 2 1 0 Comment
PREPARATION
1. Introduce yourself and verify the client’s identity. Explain to
the client what you are going to do, why it is necessary, and
how the client can cooperate.
2. Perform hand hygiene and observe other appropriate infection
control
3. Assemble equipment and supplies:
Clean gloves Cover card
Snellen Chart Object
Newspaper/magazine Penlight
4. Provide for client privacy and dignity.
ASSESSMENT
1.Determine client’s history of the following:
 Vision difficulty
 Eye pain
 Childhood strabismus
 Redness or swelling
 Excessive or lack of tearing
 Use of glasses or contact lenses
2. Inspect eyelids and eyelashes.
 Position and appearance
 Blinking
3. Inspect conjunctiva and sclera for clarity and appearance by
separating lids with thumb and index finger and asking client to move
up, down and to other side.
4. Inspect cornea (using oblique lighting) for appearance.
5. Inspect iris and pupil for the following:
 Shape
 Equality
 Color
6. Inspect lens for clarity.
7. Inspect and palpate lacrimal apparatus
 Appearance
 Response to pressure applied at nasal side of lower orbital
rim
8. Check visual acuity.
 Check distance vision with Snellen chart 20 feet from client.
 Check near vision with newspaper approximately 14 inches
from client’s head.
9. Check for peripheral vision.

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  Face client at a distance of 2-3 feet, client and examiner look
directly ahead and cover eye directly opposite each other.
10. Check accommodation.
 Ask client to stare at an object 3-4 feet away, and move
object in towards client’s nose.
11. Check for extraocular movements.
 Ask client to follow object as it is moved in six cardinal
fields.
12.Check response to light.
 Check corneal light reflex by asking client to look straight
ahead and then shining light toward facial midline.
 Check direct pupil response by asking client to look straight
ahead and approaching each eye from the client’s side with a
penlight.
 Check consensual pupil response by asking client to look
straight ahead and approaching each eye from the client’s
side with a penlight.
13.Check for abnormal eye movement using cover or non-cover test.
 Ask client to look straight ahead, covering one eye with a
cover card, and observe uncovered eye for movement.
14. Document findings in the client record.
EVALUATION
1.Perform a detailed follow-up examination of other individual
system based on findings that deviated from expected or normal for
the client.
2. Relate findings to previous assessment data if available.

Score: /40 Grade:_________

B. EARS
ASSESSMENT PROCEDURE 2 1 0 Comment
PREPARATION
1. Introduce yourself and verify the client’s identity. Explain to the
client what you are going to do, why it is necessary, and how the
client can cooperate.
2. Perform hand hygiene and observe other appropriate infection
control.
3. Assemble equipment and supplies:
Clean gloves Tuning fork
Ruler Otoscope
Watch with second hand
4. Provide for client privacy and dignity.
ASSESSMENT
1.Determine the client’s history of the following:
 Classic symptoms of ear disease: deafness, tinnitus,
discharge (otorrhoea), pain (otalgia) and vertigo.
 Previous ear surgery, or head injury.
 Family history of deafness.
 Systemic disease (eg, stroke, multiple sclerosis,
cardiovascular disease).
 Ototoxic drugs (antibiotics (eg, gentamicin), diuretics,
cytotoxics).
 Exposure to noise (eg, pneumatic drill or shooting).
 History of atopy and allergy in children.
2.Inspect external ear for the following:
 Size and shape
 Position
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  Lesions and discolorations
3.Palpate for external ear.
4.Palpate mastoid process for the following;
 Tenderness
 Temperature
 Edema
5.Inspect auditory canal using otoscope for the following:
 Cerumen
 Appearance
 Tenderness
6.Inspect tympanic membrane using otoscope for the following:
 Color
 Consistency
 Landmarks
7.Assess auditory function for the following:
 Gross hearing ability: Whisper words 1-2 feet behind
client; hold watch 1-2 inches from client’s ear.
 Laterization of sound
Weber Test: Place activated tuning fork on center top of
client’s head.
 Comparison of air conduction (AC) to bone conduction
(BC) – Rinne Test: Place tuning fork on mastoid process
until no longer heard, and then move it to front of ear.
8.Perform Romberg test for equilibrium by waving client stand with
feet together first with eyes open, then with eyes closed (put your
arms around client to prevent fall).
9. Document. findings in the client record.
EVALUATION
1.Perform a detailed follow-up examination of other individual
system based on findings that deviated from expected or normal for
the client.
2. Relate findings to previous assessment data if available.

Score: __ Grade:_________

C. NOSE

ASSESSMENT PROCEDURE 2 1 0 Comment

PREPARATION
1. Introduce yourself and verify the client’s identity. Explain to the
client what you are going to do, why it is necessary, and how the
client can cooperate.
2. Perform hand hygiene and observe other appropriate infection
control.
3. Assemble equipment and supplies:
Clean gloves Penlight
4. Provide for client privacy and dignity
ASSESSMENT
1.Determine client’s history:
 Allergies/atopic disease.
 Smoking.
 Pets at home.
 Occupation.
 History of previous surgery.
 Previous trauma.
 General medical history.
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  Seasonal or daily variation in symptoms.
2.Observe external nose for the following:
 Skin appearance
 Shape
 Nares
3. Palpate external nose for firmness.
4. Inspect for internal nose for the following:
 Appearance
 Landmarks: Turbinates, septum
4. Assess function of nose for patency (with client’s mouth closed
and one nares occluded, feel for air).
5.Palpate and percuss sinuses, both frontal and maxillary.
6. If palpation and percussion suggest sinusitis, transillumination
should be performed.
6. Document findings in the client record.
EVALUATION
1.Perform a detailed follow-up examination of other individual
system based on findings that deviated from expected or normal for
the client.
2. Relate findings to previous assessment data if available.

Score: Grade:________

Shown To Me: ________________________________

Student’s Signature over Printed Name

Shown by:
_____________________________________________
JERELYN S. VICTORIANO, RN-EMT, MAN, LPT
Clinical Instructor

Noted by:
____________________________
REGIE S. JIMENEZ, RN, MSN
Program Chairperson

_____________________________________
PROF. MARY JANE N. RIGOR, RN, MSN
Dean

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