Remedios Trinidad Romualdez Medical Foundation

College of Nursing
Tacloban City

ASSESSMENT CHECKLIST FOR NOSE AND SINUSES

Client’s Name: _______________________ Date Performed: _________________

Examiner’s Name: _______________________

Instruction: Indicate a check mark ( / ) based on client’s response to queries and assessment findings.

Inquire if client has any history of the following: YES NONE NOTES/ REMARKS
1. Allergies
2. Difficulty breathing through the nose
3. Sinus infections
4. Injuries to nose or face
5. Nose bleeds
6. Medications taken
7. Changes in sense of smell

ASSESSMENT NORMAL FINDINGS DEVIATION FROM NORMAL

NOSE
1.Inspect the external nose for any
deviations in shape, or color and
flaring or discharge from the nares.
2. Lightly palpate the external nose
to determine any tenderness,
masses, and displacements of bone
and cartilage.
3. Determine patency of both nasal
cavities.
4. Inspect the nasal cavities using a
flashlight or a nasal speculum.
5. Observe for the presence of
redness, swelling, growths, and
discharge.
6. Inspect the nasal septum
between the nasal chambers.
FACIAL SINUSES
7. Palpate the maxillary and frontal
sinuses for tenderness.
( ) Symmetrical and ( ) Asymmetric
straight ( ) Discharge from nares
( ) No discharge of flaring ( ) Localized areas of redness or
( ) Uniform color presence of skin lesions
( ) Not tender ( ) Tenderness on palpation
( ) No lesions ( ) Presence of lesions
( ) Air moves freely as the ( ) Air movement is restricted
client breathes through the to one or both nares.
nares
( ) Mucosa pink ( ) Mucosa red
( ) Clear watery discharge ( ) Abnormal discharge (pus)
( ) No lesions ( ) Presence of lesions (polyps)
( ) Nasal septum intact and ( ) Septum deviated to the right
in midline or to the left
( ) Not tender ( ) Tenderness in one or more
sinuses.

Prepared by: Clinical Group B

 Remedios Trinidad Romualdez Medical Foundation
College of Nursing
Tacloban City

ASSESSMENT CHECKLIST FOR EARS

Client’s Name: _______________________ Date Performed: _________________

Examiner’s Name: _______________________

Instruction: Indicate a check mark ( ∕ ) based on client’s response/s to queries and assessment findings.
Inquire if client has any history of the following: YES NONE NOTES/REMARKS
1. Family history of hearing problem/loss
2. Presence of any ear problem or pain
3. Medication history, especially if there are
complaints of ringing in ears
4. Any hearing difficulty; its onset, factors
contributing to it, and how it interferes with ADL
5. Use of corrective hearing device: when and from
whom it was obtained

ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL

AURICLES
1. 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 eye.
2. Palpate the auricles for texture,
elasticity and areas of tenderness.
- Gently pull auricles upward,
downward & backward
- Fold the pinna forward
- Push in on the tragus
- Apply pressure on the mastoid
process
EXTERNAL EAR CANAL &
TYMPANIC MEMBRANE
1. Use an otoscope, inspect the
external ear canal for cerumen,
skin lesions, pus and blood
- Attach a speculum to the
otoscope
- Tip the client’s head away from
the nurse and straighten ear canal
( ) Color same as facial skin
( ) Symmetrical
( ) Auricle aligned with outer
canthus of the eye, about 10,
from vertical
( ) Mobile, firm, and not
tender; pinna recoils after it is
folded
( ) Distal third contains hair
follicles and glands
( ) Dry cerumen, grayish-tan
color; or sticky, wet cerumen in
various shades of brown
( ) Bluish color of earlobes
( ) Pallor
( ) Excessive redness
( ) Asymmetrical
( ) Low-set ears (associated
with a congenital syndrome)
( ) Lesions
( ) Flaky, scaly skin
( ) Tenderness
( ) Redness and discharge
( ) Scaling
( ) Excessive cerumen
obstructing canal

Prepared by: Clinical Group B

- Hold otoscope either right side
up or upside down.
- Gently insert the tip of the
otsocope into the air canal, avoid
the pressure of the speculum
against either side of the ear canal ( ) Pearly gray color, ( ) Pink to red , some opacity
2. Inspects the tympanic semitransparent ( ) Yellow-amber ( ) White
membrane for color and gloss ( ) Blue/Deep Red ( ) Dull
GROSS HEARING ACUITY TESTS
1. Assesses client’s response to ( ) Normal voice tones audible ( ) Normal voice tones not
normal voice tones. If the client audible
has difficulty hearing the normal
voice, proceeds with the following
tests.
- Perform watch stick test
- Asks the client to occlude one ( ) Able to repeat phrases
ear. Out of the client’s sight, correctly in both ears ( ) Unable to repeat phrases
places a ticking clock 2-3 cm (1-2 in one or both ears
inches) from the unoccluded ear
- Asks what the client can hear.
Repeat with other ear.
TUNING FORK TEST
Perform Weber Test
1. Hold the tuning fork at its base. ( ) Sound is heard in both ears ( ) Sound is heard better in
Activate it by tapping the fork or is localized at the center of impaired ear, indicating a
gently against the back of the the head (Weber negative) bone-conductive hearing loss;
nurse’s hand near the knuckles or or sound is heard better in ear
by stroking the fork between the without a problem, indicating
thumb and index fingers a sensorineural disturbance
2. Place the base of the vibrating (Weber positive)
fork on top of the client’s head
and ask whether the client hears
the noise

Perform Rinne Test

1. Ask the client to block hearing ( ) Air-conducted (AC) hearing ( ) Bone conduction time is
in one ear intermittently by is greater than bone-conducted equal to or longer than the air
moving a fingertip in and out of (BC) hearing, i.e., AC > BC conduction time, i.e., BC > AC
the ear canal (positive Rinne) or BS = AC (negative Rinne;
2. Hold the handle of the activated indicates a conductive hearing
tuning on the mastoid process of loss)
one ear until the client states the
vibration can no longer be heard.
3. Immediately hold still the
vibrating fork prongs in front of
the client’s ear canal. Push aside
the client’s hair. Ask whether the
client now hears the sound.

Prepared by: Clinical Group B

 Remedios Trinidad Romualdez Medical Foundation
College of Nursing
Tacloban City

ASSESSMENT CHECKLIST FOR MOUTH & OROPHARYNX

Client’s Name: _______________________ Date Performed: _________________

Examiner’s Name: _______________________

Instruction: Indicate a check mark ( ∕ ) based on client’s response/s to queries and assessment findings.
Inquire if client has any history of the following: YES NONE NOTES/REMARKS
1. Routine pattern of dental care ---- ----
2. Last visit to dentist ---- ----
3. Length of time ulcers/ other lesions have been ---- ----
present
4. Denture discomfort
5. Any medication client is receiving

ASSESSMENT NORMAL FINDINGS DEVIATION FROM NORMAL

LIPS & BUCCAL MUCOSA
1.Inspect the outer lips for
symmetry of contour, color, and
texture. Ask the client to purse the
lips as if to whistle
2. Inspect and palpate the inner lips
and buccal mucosa for color,
moisture, texture, and the
presence of lesions.
TEETH & GUMS
1. Inspect the teeth and gums while
examining the inner lips and buccal
mucosa.
( ) Uniform pink color
(darker, e.g., bluish hue, in
Mediterranean groups and
dark skinned clients)
( ) Soft, moist, smooth
texture
( ) Symmetry of contour
( ) Ability to purse lips
( ) Uniform pink color
(freckled brown
pigmentation in dark-
skinned clients)
( ) Moist, smooth, soft,
glistening, and elastic
texture (drier oral mucosa
in older clients due to
decreased salivation)
( ) 32 adult teeth
( ) Smooth, white, shiny
tooth enamel
( ) Pink gums (bluish or
brown patches in dark-
skinned clients)
( ) Moist, firm texture to
gums
( ) Pallor
( ) cyanosis
( ) Blisters;
( ) Generalized or localized
swelling
( ) Fissures, crusts, or scales
( ) Inability to purse lips (may
indicate facial nerve damage)
( ) Pallor
( ) Leukoplakia (white patches),
red, bleeding
( ) Excessive dryness
( ) Mucosal cysts; irritations
from dentures; abrasions,
ulcerations; nodules
( ) Missing teeth
( ) Brown or black discoloration
of the enamel (may indicate
staining/ presence of caries)
( ) Excessively red gums
( ) Spongy texture
( ) bleeding; tenderness (may
indicate periodontal disease)

Prepared by: Clinical Group B


2. Inspect the dentures. Ask the
client to remove complete or
partial dentures. Inspect their
condition, noting in particular
broken or worn areas.
TONGUE/ FLOOR OF THE MOUTH
1. Inspect the surface of the tongue
for position, color, and texture. Ask
the client to protrude the tongue.
2. Inspect tongue movement.
3. Inspect the base of the tongue,
the mouth floor, and the frenulum.
SALIVARY GLANDS
1. Inspect salivary duct openings
for any swelling or redness
PALATES & UVULA
1. Inspect the hard and soft palate
for color, shape, texture, and the
presence of bony prominences.
2. Inspect the uvula for position
and mobility while examining the
palates.
OROPHARYNX & TONSILS
1. Inspect the oropharynx for color
and texture
2. Inspect the tonsils for color,
discharge, and size
3. Press posterior tongue with a
tongue blade
( ) No retraction of gums
(pulling away from the
teeth)
( ) Smooth, intact dentures
( ) Central position
( ) Pink color (some brown
pigmentation on tongue
borders in dark-skinned
clients)
( ) Moist; slightly rough;
thin whitish coating
( ) Smooth, lateral margins;
no lesions
( ) Raised papillae (taste
buds
( ) Moves freely; no
tenderness
( ) Smooth tongue base
with prominent veins
( ) No swelling/redness
( ) Light pink, smooth, soft
palate
( ) Lighter pink hard palate,
more irregular texture
( ) Positioned in midline of
soft palate, rises during
vocalization
( ) Pink and smooth
posterior wall
( ) Pink and smooth
( ) No discharge
( ) Normal size/ not visible
( ) Elicits gag reflex
( ) Receding, atrophied gums;
( ) Swelling that partially covers
the teeth
( ) Ill-fitting dentures; irritated
and excoriated area under
dentures
( ) Deviated from center
( ) Excessive trembling
( ) Smooth red tongue (may
indicate iron, vitamin B12, or
vitamin B3 deficiency)
( ) Dry, furry tongue
( ) White coating (may be oral
yeast infection)
( ) Nodes, ulcerations,
discolorations
( ) Areas of tenderness
( ) Restricted mobility
( ) Swelling, ulceration
( ) Presence of
swelling/redness
( ) Discoloration (e.g., jaundice
or pallor)
( ) Palates the same color
Irritations
( ) Exostoses (bony growths)
growing from the hard palate
( ) Deviation to one side from
tumor or trauma
( ) Immobility
( ) Reddened or edematous
( ) Presence of lesions, plaques,
or drainage
( ) Inflamed
( ) Presence of discharge
( ) Swollen
( ) No elicited gag reflex
Prepared by: Clinical Group B
Prepared by: Clinical Group B