College of Nursing

Assessment of the Eyes, Ears, Nose & Throat

UC-VPAA-CON-FORM-24 Page 3 of 3
JUNE 2012 REV:00
 College of Nursing

Instruction: Check on the column as to what level is the performance of the student in the following procedure. Be guided in the
scoring with the legend below.
4 Very satisfactory (Performed all the procedures correctly)
3 Satisfactory (Needs minimal assistance in performing the procedure)
2 Good (Needs more practice in performing the procedure)
1 Fair (inappropriate in the performance of the procedure)

STEP PROCEDURE 4 3 2 1
1 Assemble equipment:
- Clean gloves
- Examination gown and drape
- Penlight
- Cotton-tipped applicator
- Ophthalmoscope
- Visual acuity charts
- Eye occlude
- Tongue depressors
- Nasal speculum
- Otoscope
- Tuning fork
2 Consider the following:
- Adequate lighting.
- Comfortable room temperature
Introduce self and verify client’s identity. Explain the procedure, its purpose and how the client can
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cooperate.
Provide privacy and ask if they prefer to have a family or significant other with them during the
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procedure.
5 Perform hand hygiene. Don gloves and observe other appropriate infection control procedures.
6 Let the client sit in an upright position.
EYES
7 Inspect the upper and lower eyelids.
8 Inspect the sclera and conjunctiva and note for exudates, lesions and foreign bodies.
9 Inspect the pupil size, shape and reaction.
10 Inspect the cornea and the anterior chamber with the use of the penlight.
Assess ocular muscle movements by asking the client to follow an object with eyes as the object is
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moved through the 6 fields of gaze.
12 Inspect the lacrimal apparatus and note for any swelling and discharge.
13 Inspect the retinal structures by the use of an ophthalmoscope.
14 Check for visual acuity:
a. Position the client in sitting or standing position 20 ft. from the Snellen’s chart.
b. Instruct to remove glasses if any, and to cover the left eye with the occluder.
c. Instruct to read as many lines on the chart as possible and record the visual acuity of the last
line where more than half of the letters were read correctly.
d. Move the client closer to the chart if the client is unable to read and note the distance where
the client is able to read to the top line
e. Repeat the test on the right eye.
15 Palpate the lacrimal sac for obstruction by pressing the index finger near the inner canthus and note v
any discharges from the punctum.

EARS
16 Inspect the external ear and note their position, color, size and shape. v
17 Note any deformities, nodules, inflammation and lesions. v
18 Note the color, consistency and the amount of cerumen. v
Palpate the auricle between the thumb and the index finger, noting any tenderness or lesions and v
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presence of pain.
20 Palpate the mastoid tips using the index and middle fingers and note for any tenderness. v
21 Auditory
UC-VPAA-CON-FORM-24 screening test: Voice whisper test Page 3 ofv3
JUNE 2012 a. Instruct the client to occlude one ear with a finger.
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b. Stand 2 ft. behind the client’s other ear and whisper a two-syllable word or phrase that is
evenly accented.
c. Repeat with the other ear.
 College of Nursing

UC-VPAA-CON-FORM-24 Page 3 of 3
JUNE 2012 REV:00