Schools of Health and Allied Health Sciences

College of Nursing

LEVEL 1
NUR 098
2nd Semester
SY: 2023 – 2024

Name:________________________________ Group: ________ Date: ____________ Rating:_________

PERFORMANCE CHECKLIST IN ASSESSING THE HEAD AND NECK

CRITERIA PROFICIENT APPROACHING DEVELOPING BEGINNING

PROFICIENCY
(4) (3) (2) (1)
INITIAL STEPS Independently Performs skills with Perform skills with Perform skills with
Performs all skills assistance of faculty assistance of assistance of faculty
frequently and 1-2 times during faculty 3-4 times greater than 4 times
without simulation during simulation during simulation.
difficulty
1. Identify the patient
2. Explain the purpose of the Head and neck
examination and answer any question.
3. Perform hand hygiene
ASSESSING THE HEAD AND NECK (HEAD-
EYES)
1. Inspect the head and then the face for
color, symmetry, lesions, and
distribution of facial hair. Note
facial expression. Palpate the skull.
2. Inspect the external eye structures
(eyelids, eyelashes, eyeball and
eyebrows) cornea, conjunctiva and
sclera. Note color, edema, symmetry
and
alignment.
3. Examine the pupils for equality of size,
reaction to light by darkening the room
and using a penlight to shine the light
on each pupil.
4. To test for pupillary accommodation and
convergence, ask the patient to focus
on an object as you bring it closer to the
nose.
5. Using an ophthalmoscope, check the red
reflex.
6. Test the patient’s visual acuity with a
Snellen Chart. Ask the patient to read
the smallest possible line of letters, first
with both eyes and then with one eye at
a time.
7. With the patient about 2 feet away, ask
the patient to focus on your finger and
move the patient’s eyes through the six
cardinal positions of gaze.
ASSESSING THE EARS
1. Inspect the external ear bilaterally for
shape, size and lesions. Palpate the
ear and mastoid process.
2. Perform an otoscopic examination. For
an adult, pull the auricle up and back;
for a child pull the auricle down and
back. Note Cerumen, edema,
discharges or foreign bodies and
condition of the tympanic membrane.
3. Use a whispered voice to test hearing.
Stand about 1 to 2 feet away from the
patient, out of her line of
vision. Ask the patient to cover the ear
not being tested. Perform tests on
each other.
 4. Use the tuning fork to perform Weber’s
test and Rinne’s Test if the patient
reports diminished hearing in either
ear.
ASSESSING THE NOSE

1. Inspect and palpate the external nose.

2. Palpate lightly percuss over the frontal
and maxillary sinuses.
3. Occlude one nostril externally with a
finger while
patient breathes through the other;
repeat for the other side.
4. Inspect the internal nostrils using an
otoscope with a nasal speculum
attachment.
ASSESSING THE MOUTH
1. Palpate the temporomandibular joint by
placing your index finger over the front
of each ear as you ask the patient to
open and close the mouth
2. Perform hand hygiene and gloves.
Inspect the lips, oral mucosa, hard and
soft palate, gingivae, teeth, and salivary
gland opening by asking the patient to
open the mouth wide using a tongue
blade and penlight.
3. Inspect the tongue. Ask the patient to
stick out the tongue. Place the tongue
blade at the side of the tongue while the
patient pushes it to the left and right
with the tongue. Inspect the uvula by
asking the patient to say “ahhh” while
sticking out the tongue. Palpate the
tongue for muscle tone and tenderness.
Remove gloves.
ASSESSING THE POSTERIOR- NECK
1. Palpate the forehead to the posterior
triangle of the neck and the posterior
cervical lymph nodes using the finger
pads in a slow circular motion.
2. Inspect and palpate in front of and behind
the ears, under the chin, and in the
anterior triangle for the anterior cervical
lymph node.
3. Inspect and palpate the left and then the
right carotid arteries. Only palpate one
carotid artery at a time, Use the bell of
the stethoscope to auscultate the
arteries.
ASSESSING THE ANTERIOR-NECK
1. Inspect and palpate the trachea.
2. Palpate the thyroid gland. Then, if
enlarged, auscultate the thyroid gland
using the bell of the stethoscope to
auscultate the arteries.
3. Inspect and palpate the supraclavicular
area.
4. Inspect the ability of the patient to move
his neck. Ask the patient to touch his
chin to chest and to each shoulder,
each ear to the corresponding
shoulder, and then tip head back as far
as possible.
AFTER PROCEDURE
1. Perform hand hygiene.
2. Document the findings of the
assessment
RATING RATING RATING RATING
TOTAL POINTS: 120
Instructor’s Comments:
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____________________________________
Signature over Printed name of the Student

____________________________________
Signature over Printed name of the Clinical
Instructor

Prepared:

Cherry Joy H. Datan, RN, MAN, Ed.D

Level I – Coordinator

Noted:

Jill Marie C. Hermogenes, RN, MAN, Ed.D

Assistant Dean

Approved:

Michelle B. Yu, RN, MAN, DM

Dean