Central Mindanao University

University Town, Musuan, Maramag Bukidnon

College of Nursing

PERFORMANCE CHECKLIST

NOSE, MOUTH AND NECK

NAME: ___________________________________________ RATING: _____________

SEC/GRP: ________________ DATE: ______________

Directions: Every student will be rated according to the rating scale below. Keeping the guidelines in
mind, please complete the Assessment Tool.
Scale Description Interpretation Assistance Needed
5 Outstanding Demonstrates exceptional performance and mastery of the procedure. Proficient, Without Direction
coordinated and confident
Very Able to state and demonstrate the step-by-step procedure but failed to mention the With occasional physical or
4
Satisfactory rationale. Efficient, coordinated, confident. Expedient use of time. verbal direction
Meets the standards or basic requirements of the procedure. Misses some steps
With frequent verbal and/or
3 Satisfactory and rationale with partial demonstration of skills, inefficient, uncoordinated. Delayed
direction
time Expenditure
Barely meets the requirements of the Performance of the procedure. Unskilled and With continuous verbal and/or
2 Fair
inefficient. Considerable and prolonged time expenditure. physical direction
Needs Fails to meet the requirements of the performance of the procedure. Misses most of With continuous verbal and
1
Improvement the steps, without rationale. Lacks confidence, coordination and efficiency. physical direction

STEPS 5 4 3 2 1
Preparatory Phase
1 Reassess client's previous medical records if available.
2 Determine the scope of assessment needed. Prepare necessary equipment.
3 Perform hand washing and donned gloves (if deemed necessary).
Assemble equipment & supplies needed
4 Introduce self and verify the client's identity.
5 Explain the procedure to the client.
6 Position patient comfortably and provides privacy.
Assessment Phase
SINUSES
8 Inspect frontal sinuses above the eyes and maxillary sinuses below the eyes
9 Palpate frontal sinuses by pressing upward just below eyebrows and note for tenderness.
10 Palpate maxillary sinuses by pressing below eyes and note for tenderness
11 Percuss frontal sinuses with direct or immediate percussion above eyebrows
12 Percuss maxillary sinuses with direct or immediate percussion below eyes.
NOSE
13 Inspect the nose for alignment and symmetry, size and shape.
14 Tilt head back and use penlight to inspect nasal mucosa.
Test for the Olfactory nerve.
15 Have the patient occlude one nostril as he inhales and exhales and check for patency. Or offer
anything and instruct to inhale while closing both eyes.
MOUTH (external structure, tongue, throat)
16 Inspect the mouth for color, condition, lesions and odor
17 Have patient open and close mouth. Note for occlusion, number, color, condition of teeth
Inspect color, condition, lesions of mucosa and note for condition of gingiva, bleeding, retraction, or
18 hypertrophy
19 Inspect for color and condition of hard and soft palate by using a penlight.
ASSESSING FOR SALIVARY DUCTS
Stensen’s duct:
20 Inspect the inner aspect of cheek (buccal mucosa) opposite the second upper molar
Wharton’s duct:
21 Have patient lift tongue and inspect the floor of mouth
ASSESSING FOR THE TONGUE AND THROAT
22 Inspect for color, texture, moisture, and mobility of the tongue
Inspect oropharynx for color, lesions, and drainage. Instruct patient to open mouth and pull out
23 his/her tongue
 STEPS 5 4 3 2 1
Locate tonsils posterior to arches on sides of throat and note for color, size, and presence of
24 exudates (if any)
Test for the Glossopharengeal nerve and Vagus nerve.
25 Have patient say “AH!” and note symmetrical rise of the uvula.
26 Lightly palpate lips for consistency and tenderness
27 Lightly palpate tongue for consistency and tenderness
ASSESS FOR GLANDS ((Parotid, Submandibular, and Sublingual)
28 Palpate in front of ears the parotid glands
29 Palpate under the mandible submandibular and sublingual glands and check for tenderness
NECK AND THYROID
30 Inspect the alignment of the neck in neutral position.
31 Instruct patient to hyperextend neck and note for bulges, lumps or masses
Offer a glass of water to patient and inspect the neck when patient swallows water if there is
32 obstruction
33 Palpate neck lightly and check for masses or areas of tenderness.
PALPATE FOR CERVICAL NODES
34 Occipital node: Lightly palpate at the back of the head at the base of the skull
35 Postauricular node: Lightly palpate behind the ears
Pre-auricular node: Lightly palpate in front of the ears. Roll your finger in front of the ear, against
36 the maxilla.
37 Tonsillar node: Lightly palpate at the angle of the jaw
38 Sub-mandibular: Lightly palpate under the mandible
Sub-mental: Lightly palpate under the tip of the chin. Roll your fingers against inner surface of
39 mandible with patient's head gently tilted towards one side.
40 Superficial cervical node: Lightly palpate the upper portion of the sternocleidomastoid muscle
Posterior cervical node: Lightly palpate in the posterior triangle behind the sternocleidomastoid
41 muscle.
42 Deep cervical node: Palpate the sternocleidomastoid muscle.
43 Supraclavicular node: Lightly palpate above the clavicle.
44 Infra-clavicular node: Lightly palpate below the clavicle
ASSESSING FOR THYROID
45 Locate the thyroid isthmus below the cricoid cartilage.
Palpate thyroid in two ways:
46 a. Anterior approach: palpate the right lobe, slide fingers to the right, gently displace trachea to
right, and palpate gland as patient swallows.
b. Posterior approach: Have patient tilt head to right, and then gently displace trachea to right,
47 slide fingers to right, and palpate right thyroid lobe as patient swallows
Have patient hold breath and then listen over the thyroid gland with the bell portion of the
48 stethoscope for bruits if thyroid is palpable.
Termination Phase
Review the information obtained during the assessment phase and discussed findings to the client.
49 Present to the client possible plans to resolve health concern, if present.
Measure client's understanding of the plan and the need for further teaching. Provide the client the
50 opportunity to clarify, ask or raise any concern
51 End the interview politely.
52 Do after care. Fix the equipment used and arrange it properly.
53 Perform hand washing.
54 Document the findings in the client’s record.
TOTAL
References:
Dillon, P. (2006). Nursing Health Assessment: A Critical Thinking, Case Studies Approach, 2nd Ed. Philadelphia: F A Davis.
Potter AP, Perry GA. 2007. Basic nursing essentials for practice. 6th edition. India: Mosby Elsevier
Weber, Janet R. (2018). Health Assessment in Nursing. Philadelphia: Lippincott Williams & Wilkins.