FAR EASTERN UNIVERSITY

Institute of Health Sciences and Nursing (IHSN)

PERFORMANCE EVALUATION TOOL

HEALTH ASSESSMENT OF HEAD TO NECK

Name : __________________________________________ Score: ___________________

Sec/Grp: ___________________________ Date: ___________________

DIRECTION: Rate the Learner based on the competencies listed below.

KEY:
3 – Acceptable Demonstrates expected procedure/behavior correctly.
2 – Moderately Acceptable Demonstrates expected procedure/behavior with minimal error.
1 – Slightly Acceptable Demonstrates expected procedure/behavior with many errors.
0 – Unacceptable Missed procedure or procedure done but entirely incorrect.

ASSESSMENT PROCEDURES RATING REMARKS

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 0 1 2 3
how the client can cooperate.
2. Perform hand hygiene and observe other appropriate
0 1 2 3
infection control procedures.
3. Assemble equipment 0 1 2 3
4. Provide for client privacy 0 1 2 3
HEAD & FACE
5. Inspect the head 0 1 2 3
6. Inspect the face 0 2 2 3
7. Palpate the head 0 1 2 3
8. Palpate the temporal artery 0 1 2 3
9. Palpate the temporomandibular joint (TMJ). 0 1 2 3
NECK
10. Inspect the neck 0 1 2 3
11. Inspect movement of the neck structures 0 1 2 3
12. Inspect the cervical vertebrae 0 1 2 3
13. Inspect range of motion 0 1 2 3
14. Palpate the trachea 0 1 2 3
15. Palpate the thyroid gland. 0 1 2 3
16. Auscultate the thyroid only if you find an enlarged thyroid
0 1 2 3
gland during inspection or palpation.
17. Palpate the lymph nodes. 0 1 2 3
1
 ASSESSMENT PROCEDURES RATING REMARKS
EYES
18. Test distant visual acuity. 0 1 2 3
19. Test near visual acuity. 0 1 2 3
20. Test visual fields for gross peripheral vision. 0 1 2 3
21. Perform Corneal Light reflex test. 0 1 2 3
22. Perform cover test. 0 1 2 3
23. Perform Positions Test. 0 1 2 3
24. Inspect the eyelids and eyelashes. 0 1 2 3
25. Assess ability of eyelids to close. 0 1 2 3
26. Note the position of the eyelids in comparison with the 0 1 2 3
eyeballs
27. Observe eyelids for redness, swelling, discharge or lesions. 0 1 2 3
28. Observe eyelids for the position and alignment of the eyeball
0 1 2 3
in the eye socket.
29. Inspect the bulbar conjunctiva and sclera. 0 1 2 3
30. Inspect the palpebral conjunctiva. 0 1 2 3
31. Evert the upper eyelid. 0 1 2 3
32. Inspect the lacrimal apparatus. 0 1 2 3
33. Palpate the lacrimal apparatus. 0 1 2 3
34. Inspect the cornea and lens. 0 1 2 3
35. Inspect the iris and pupil. 0 1 2 3
36. Test pupillary reaction to light (Pupillary Light Reflex). 0 1 2 3
37. Assess Consensual Response 0 1 2 3
38. Test accommodation of pupils. 0 1 2 3
EARS
39. Inspect the auricle, tragus and lobule. 0 1 2 3
40. Inspect the external auditory canal 0 1 2 3
41. Palpate the auricle and mastoid process 0 1 2 3
42. Perform whisper test 0 1 2 3
43. Perform Weber’s Test 0 1 2 3
44. Perform the Rinne’s Test 0 1 2 3
45. Perform the Romberg Test 0 1 2 3
NOSE
46. Inspect and palpate the external nose 0 1 2 3
47. Check the patency of airflow through the nostrils 0 1 2 3
48. Inspect the internal nose 0 1 2 3

2
 ASSESSMENT PROCEDURES RATING REMARKS
SINUSES
49. Palpate the sinuses 0 1 2 3
50. Percuss the sinuses 0 1 2 2
MOUTH & THROAT
51. Inspect the lips. 0 1 2 3
52. Inspect the teeth and gums 0 1 2 3
53. Inspect the buccal mucosa. 0 1 2 3
54. Inspect and palpate the tongue. 0 1 2 3
55. Assess the ventral surface of the tongue 0 1 2 3
56. Inspect for Wharton’s ducts 0 1 2 3
57. Observe the sides of the tongue. 0 1 2 3
58. Check the strength of the tongue. 0 1 2 3
59. Inspect the hard (anterior) and soft (posterior) palates and
0 1 2 3
uvula.
60. Note the odor while the mouth is wide open 0 1 2 3
61. Assess the uvula 0 1 2 3
62. Inspect the tonsils 0 1 2 3
63. Inspect the posterior pharyngeal wall 0 1 2 3

TOTAL

_________________________________ ____________________________________
Signature of Student Name & Signature of Faculty