Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

PERFORMANCE EVALUATION CHECKLIST

ASSESSMENT OF THE EYES

Name of Student:

Year and Clinical Group:

School Year: Term: 1st Sem 2nd Sem Summer

Inclusive dates of Clinical Rotation:

Instructor:

Preparation SCORE
Assessment of the Eyes 2 1 0 REMARKS
1. Assemble equipment and supplies:
 Cotton-tipped applicator
 Examination gloves
 Millimeter ruler
 Penlight
 Opaque card
Procedure
2. 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.
3. Perform hand hygiene and observe other appropriate infection
control procedures.
4. Provide for client privacy.
5. Inquire if the client has any history of the following:
 Family history of diabetes, hypertension, or blood
dyscrasia
 Eye disease, injury or surgery
 Last visit to an ophthalmologist
 Current use of eye medications
 Use of contact lenses or eyeglasses
 Hygienic practices for corrective lenses
 Current symptoms of eye problems
External Eye Structures
6. Inspect the eyebrows for hair distribution and alignment, and for
skin quality and movement.
7. Inspect the eyelashes for evenness of distribution and direction
of curl.
8. Inspect the eyelids for surface characteristics, position in
relation to the cornea, ability to blink, and frequency of blinking.
Inspect the lower eyelids while the client’s eyes are closed.
9. Inspect the bulbar conjunctiva for color, texture, and the
presence of lesions.
10 Inspect the palpebral conjunctiva by everting the lids.
.
11 Evert the upper lids if a problem is suspected.
 Ask the client to look down while keeping the eyelids slightly
open.
Gently grasp the client’s eyelashes with thumb and forefinger.
Pull lashes gently downwards.
Place a cotton-tipped applicator stick about 1cm above the lid
.
margin, and push it gently downward while holding eyelashes.
Hold the margin of the everted lid or eyelashes against the ridge
of the upper bony orbit with the applicator stick or your thumb.
Inspect the conjunctiva for color, texture lesions, and foreign
bodies.
Inspect and palpate the lacrimal gland.
12
Using the tip of your index finger, palpate the lacrimal gland.
.
Observe for edema between the lower lid and the nose.
Inspect and palpate the lacrimal sac and nasolacrimal duct.
13 Observe for evidence of increased tearing.
. Using the tip of your index finger, palpate inside the lower orbital
rim near the inner canthus.
14 Inspect the cornea for clarity and texture. Ask the client to look
. straight ahead. Hold a penlight at an oblique angle to the eye,
and move the light slowly across the corneal surface.
15 Perform the corneal sensitivity (reflex) test to determine the
. function of the fifth (trigeminal) cranial nerve. Ask the client to
keep both eyes open and look straight ahead. Approach from
behind and beside the client, and lightly touch the cornea with a
corner of the gauze.
16 Inspect the pupils for color, shape, and symmetry of size.
.
Asses each pupil’s direct and consensual reaction to light.
Partially darken a room.
Ask the client to look straight ahead.
Using a penlight and approaching from the side, shine a light on
17
the pupil.
.
Observe the response. The pupil should constrict (direct
response).
Shine the light on the pupil again, and observe the response of
the other pupil. It should also constrict (consensual response).
Assess each pupil’s reaction to accommodation.
Hold an object about 10cm from the client’s nose.
Ask the client to look first at the top of the object and then at a
distant object behind the object. Alternate the gaze between the
18 near and far objects.
. Observe the pupil response. Pupil should constrict when looking
at the near object and dilate when looking at the far object.
Next, move the penlight or pencil toward the client’s nose. The
pupil should converge. To record normal assessment of the
pupils, use the abbreviation PERRLA.
Visual Fields
19 Assess peripheral visual fields.
. Have the client sit directly facing you at a distance of 60-90cm.
Ask the client to cover right eye with the card and look directly at
your nose.
Cover or close your eye directly opposite the client’s covered
eye, and look directly at the client’s nose.
Hold an object in your fingers, extend your arm, and move the
object into the visual field from various points in the periphery.
The object should be at an equal distance from the client and
yourself. Ask the client to tell you when the moving object is first
spotted.
 To test the temporal field of the left eye, extend and
move your right arm in from the client’s right periphery.
Temporally, peripheral objects can be seen at right
 angles to the central point of vision.
 To test the upward field of the left eye, extend and move
the right arm down from the upward periphery. The
upward field of vision is normally 50degrees because the
orbital edge is in the way.
 To test the downward field of the left eye, extend and
move the right arm up from the lower periphery. The
downward field of vision is normally 70 degrees because
the cheekbone is in the way.
 To test the nasal field of the left eye, extend and move
your left arm in from the periphery. The nasal field of
vision is normally 50 degrees away from the central point
because the nose is in the way.
Repeat the above steps for the right eye.
Extraocular Muscle Test
20 Assess six ocular movements to determine eye alignment and
. coordination.
 Stand directly in front of the client and hold the penlight
at a comfortable distance, such as 30 cm in front of the
client’s eyes.
 Ask the client to hold head in a fixed position facing you
and follow the movements of the penlight with the eyes
only.
 Move the penlight in a slow, orderly manner through the
six cardinal fields of gaze.
 Stop the movement of the penlight periodically so that
the nystagmus can be detected.
21 Assess for location of light reflex by shinning a penlight on pupil
. in corneal surface (Hirschberg Test).
22 Have the client fixate on a near or far object. Cover one eye and
. observe for movement in the uncovered eye (Cover test).
Visual Acuity
23 Assess near vision by providing adequate lighting and asking
. the client to read from a magazine or newspaper.
Assess distance vision by asking the client to wear corrective
lenses unless they are used for reading only.
24 Ask the client to sit or stand 6 meters (20ft) from Snellen’s
. Chart, cover the eye not being tested, and identify the letters or
characters.
Take three readings: right eye, left eye, and both eyes.
25 Document findings in the client’s record.
.
Total Score:
Transmuted Grade:

Shown to me:

_________________________________
Signature over Printed Name
Student

Shown to me by:

EMMANUEL DOMINIC RAYMOND M. BUGAYONG, RN

Clinical Instructor
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

PERFORMANCE EVALUATION CHECKLIST

ASSESSMENT OF THE EARS

Name of Student:

Year and Clinical Group:

School Year: Term: 1st Sem 2nd Sem Summer

Inclusive dates of Clinical Rotation:

Instructor:

Preparation SCORE
Assessment of the Ears 2 1 0 REMARKS
1. Assemble equipment and supplies:
 Otoscope with several sizes or ear specula
Procedure
2. 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.
3. Perform hand hygiene and observe other appropriate infection
control procedures.
4. Provide for client privacy.
5. Inquire if the client has any history of the following:
 Family history of hearing problems or loss
 Presence of any ear problems or pain
 Medication history, especially if there are complaints of
ringing in ears
 Any hearing difficulty: its onset, factors contributing to it,
and how it interferes with activities of daily living
 Use of a corrective hearing device: when and from
whom it was obtained
Auricles
6. Inspect the auricles for color, symmetry of size, and position. To
inspect position, note the level at which the superior aspect of
the auricle attaches to the head with relation to the eye.
Palpate the auricles for texture, elasticity, and areas of
7. tenderness.
Gently pull the auricle upward, downward, and backward.
External Ear Canal and Tympanic Membrane
8. Using an otoscope, inspect the external ear canal for cerumen,
skin lesions, pus, and blood.
Attach a speculum to the otoscope.
 For adults: pull helix up and back.
For preschool child: pull helix down and back.
Hold the otoscope either right side up, with your fingers between
the otoscope handle and the client’s head, or upside down, with
your fingers and the ulnar surface of your hand against the
client’s head.
Gently insert the tip of the otoscope into the 1/3 of the ear canal,
avoiding pressure by the speculum against either side of the ear
canal.
9. Inspect the tympanic membrane for color and gloss.
Gross Hearing Acuity Tests
Assess the client’s response to normal voice tones. If the client
has difficulty hearing the normal voice, proceed with the
following tests.
Perform the watch tick test.
Have the client occlude one ear. Out of the client’s sight, place a
ticking watch 2-3 cm (1-2 inches) from the unoccluded ear.
Asking what the client can hear. Repeat with the other ear.
Tuning fork test.
Perform Webber Test
 Hold the tuning fork at its base. Activate it by tapping the
fork gently against the back of your hand near the
knuckles or by stroking the fork between your thumb and
10
index finger.
.
 Place the base of the vibrating fork on top of the client’s
head and ask whenever the client hears the noise.
Conduct Rinne Test
 Ask the client to block the hearing in one ear
intermittently by moving a fingertip in and out of the ear
canal.
 Hold the handle of the activated tuning fork on the
mastoid process of one ear until the client states that the
vibration no longer can be heard.
 Immediately hold still the vibrating fork prongs in front of
the client’s ear canal. If necessary, push aside the
client’s hair. Ask whether the client now hears the sound.
11 Perform Romberg Test
.  Have the client stand with feet together, hands at side
with eyes opened and then with eyes closed. Note ability
to maintain balance. Identifies swaying as positive
Romberg.
12 Document findings in the client’s record.
.
Total Score:
Transmuted Grade:

Shown to me:

_________________________________
Signature over Printed Name
Student

Shown to me by:
EMMANUEL DOMINIC RAYMOND M. BUGAYONG, RN
Clinical Instructor

Republic of the Philippines

TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

PERFORMANCE EVALUATION CHECKLIST

ASSESSMENT OF THE NOSE AND SINUSES

Name of Student:

Year and Clinical Group:

School Year: Term: 1st Sem 2nd Sem Summer

Inclusive dates of Clinical Rotation:

Instructor:

Preparation SCORE
Assessment of the Nose and Sinuses 2 1 0 REMARKS
1. Assemble equipment and supplies:
 Nasal speculum
 Penlight
Procedure
2. 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.
3. Perform hand hygiene and observe other appropriate infection
control procedures.
4. Provide for client privacy.
5. Inquire if the client has any history of the following:
 Allergies
 Difficulty breathing through the nose
 Sinus infection
 Injuries to nose or face
 Nosebleeds
 Any medications taken
 Any changes in sense of smell
Nose
6. Inspect the external nose for any deviations in shape, size, or
color and flaring, or discharge from the nares.
7. Lightly palpate the external nose to determine any areas of
tenderness, masses, or displacements of bone and cartilage.
8. Determine patency of both nasal cavities.
 Ask the client to close the mouth, exert pressure on one naris,
and breath through the opposite naris. Repeat the procedure to
assess patency of the opposite naris.
Inspect the nasal cavities using a penlight or nasal speculum.
Tip the client’s head back.
Push the tip of the nose upward with thumb of the non-dominant
9.
hand and direct a penlight into the nares.
Use the other hand to position the head and then to hold the
light.
10 Observe for the presence of redness, swelling, growths, and
. discharge.
11 Inspect the nasal septum between the nasal chambers.
.
Facial Sinuses
Palpate and percuss the maxillary and frontal sinuses for
12 tenderness.
. If palpation and percussion suggest sinusitis, transillumination
should be performed.
13 Document findings in the client’s record.
.
Total Score:
Transmuted Grade:

Shown to me:

_________________________________
Signature over Printed Name
Student

Shown to me by:

EMMANUEL DOMINIC RAYMOND M. BUGAYONG, RN

Clinical Instructor
 Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
NURSING DEPARTMENT
Villa Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph

PERFORMANCE EVALUATION CHECKLIST

ASSESSMENT OF THE MOUTH AND OROPHARYNX

Name of Student:

Year and Clinical Group:

School Year: Term: 1st Sem 2nd Sem Summer

Inclusive dates of Clinical Rotation:

Instructor:

Preparation SCORE
Assessment of the Mouth and Oropharynx 2 1 0 REMARKS
1. Assemble equipment and supplies:
 Clean gloves
 Tongue depressor
 2x2 gauze pads
 Penlight
Procedure
2. 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.
3. Perform hand hygiene and observe other appropriate infection
control procedures.
4. Provide for client privacy.
5. Inquire if the client has any history of the following:
 Routine pattern of dental care
 Last visit to dentist
 Length of time ulcers or other lesions have been present
 Any dental discomfort
  Any medications the client is receiving
Lips and Buccal Mucosa
6. Inspect the outer lips for symmetry of contour, color, and
texture.
Inspect and palpate the inner lips and buccal mucosa for color,
moisture, texture, and the presence of lesions.
7.
Use tongue depressor and penlight to inspect buccal mucosa,
and Stensen’s ducts.
Teeth and Gums
8. Inspect the teeth and gums while examining the inner lips and
buccal mucosa. Inspect gums for color, bleeding, edema,
retraction, and lesions.
Inspect the dentures.
9. Ask the client to remove complete or partial dentures. Inspect
their condition, noting in particular broken or worn areas.
Tongue/Floor of the Mouth
Inspect the surface of the tongue for position, color, and texture.
10 Ask the client to produce the tongue and move it from side to
. side. Examine upper surface for color, texture, position, and
mobility.
Inspect tongue movement
11
Ask the client to roll the tongue upward and move it from side to
.
side.
Inspect the base of the tongue, the mouth floor, and the
12 frenulum.
. Ask the client to place tip of his tongue against the roof of the
mouth.
Palpate the tongue and floor of the mouth for any nodules,
lumps, or excoriated areas.
13
Use a piece of gauze to grasp the tip of the tongue and, with the
.
index finger of your other hand, palpate the back of the tongue,
its borders, and its base.
Palates and the Uvula
Inspect the hard and soft palate for color, shape, texture, and
the presence of bony prominences.
14
Ask the client to open mouth wide and tilt head backward. Then,
.
depress tongue with a tongue blade as necessary, and use a
penlight for appropriate visualization.
Inspect the uvula for position and mobility while examining the
15 palates.
. To observe the uvula, ask the client to say “ah” so that the soft
palate rises.
Oropharynx and Tonsils
Inspect the oropharynx for color and texture.
Inspect one side at a time to avoid eliciting the gag reflex. To
16 expose one side of the oropharynx, press a tongue blade
. against the tongue on the same side about halfway back while
the client tilts head back and opens mouth wide. Use a penlight
for illumination, if needed.
17 Inspect the tonsils for color, discharge, and size.
.
18 Elicit gag reflex by pressing the posterior tongue with a tongue
. blade.
19 Document findings in the client’s record.
.
Total Score:
Transmuted Grade:

Shown to me:
_________________________________
Signature over Printed Name
Student

Shown to me by:

EMMANUEL DOMINIC RAYMOND M. BUGAYONG, RN

Clinical Instructor