HEALTH

ASSESSMENT
PREPARED BY: RHANILYN R. BRUL,RN
Clinical Instructor
 ASSESSING THE SKULL
AND FACE
LEARNING OBJECTIVES:
• Perform a skull and face assessment.
• Modify assessment techniques.
• Recognize and report significant deviations from normal.
• Document actions and observations.
Assessing the skull and
face is an inspection and palpation of
the skull and face; and also measuring
the skull circumference, in which the
presence of deviation and changes of
facial shape may indicate a disorder or
certain condition.
Before to proceed with the assessment:

Don’t forget!

Always ask first the client history

Inspection:
- For size, contour, shape and
evidence of trauma.

Palpation:
- For lumps or bumps, lesions and
any evidence of trauma.
 Size, shape and symmetry
of skull
NORMAL: DEVIATION FROM NORMAL:
• Rounded (normocephalic and • Lack of symmetry;
symmetric, with frontal, • increased skull size with
parietal, and occipital more prominent nose and
prominences); forehead;
• smooth skull contour • longer mandible (may
indicate excessive growth
hormone or increased bone
thickness)
 ASSESSING FOR NODULES,
MASSESS AND DEPRESSION
NORMAL: DEVIATIONS FROM
• normally hard and NORMAL:
smooth uniform. • Presence of nodule or
• consistency masses and depressions
• Absence of nodule or
masses and
depressions
LUMPS LESION

BUMPS
How to palpate the skull for any
nodules, masses and depression?

> Use gentle rotating motion with

fingertips. Begin at the front and
palpate down the midline, then palpate
each side of the head.
 INSPECTION OF THE FACIAL FEATURES,
EYES, AND FACIAL MOVEMENTS
 Facial features:
> Inspect the symmetry of structures and of the distribution
of hair.
 Eyes:

> Inspect for edema or hollowness.

 Facial movements:
> Note symmetry of facial movements.
How to inspect:
Ask the client to elevate the eyebrows, frown, or lower the eyebrows,
close the eyes tightly, puff the cheeks, and smile and show the teeth.
 ASSESSING OF THE FACIAL FEATURES,
EYES, AND FACIAL MOVEMENTS
NORMAL:
• Symmetric or slightly
asymmetric facial features;
palpebral fissures equal in
size; symmetric nasolabial
folds.
• No edema.
• Symmetric facial movement.
DEVIATIONS FROM NORMAL
• Increased facial hair; low hair line;
thinning of eyebrows; asymmetric
features; exophthalmos; myxedema
face; moon face.
• Periorbital edema; sunken eyes
• Asymmetric facial movements (e.g.,
eye cannot close completely);
drooping of lower eyelid and mouth;
involuntary facial movements (i.e.,
tics or tremors)
IDEAL PROPORTION OF THE FACE
DROOPING OF MOUTH
DROOPING OF EYELID MOON FACE

Example of
images related
to Skull and
face
conditions
 ASSESSING THE SKULL AND FACE
PROCEDURES
1.Introduced self and verified client's identity.
2. Explained procedure to client and discussed how results will To gain rapport for compliance and
be used
3. Observed appropriate infection prevention procedures.
4. Provided for client privacy.
5. Inquired about the client's history related to the skull and
face.
6. Inspected the skull for size, shape, and symmetry.
8. Inspected the eyes for edema and hollowness.
9. Noted symmetry of facial movements.
10. Used effective body mechanics throughout procedure.
11. Communicated appropriately with the client.
12. Documented all relevant information.
RATIONALE
To gain rapport for compliance and cooperation of the client
cooperation of the client
To prevent the spread and growth of infectious microorganisms.
In order for the client to cooperate comfortably thus having a
successful assessment.
Current problems may be a recurrence of previous ones. And to
ensure that there aren’t any medical risks that would predispose
the patient to a medical emergency during the actual procedure .
Lack of symmetry may suggest excessive growth hormone or
increased bone thickness.
Periorbital edema or sunken eyes may indicate dehydration,
starvation, and illness.
Asymmetric facial movements may be a sign of serious health
condition.
To serve as a record/evidence of what we did and
assessed.
 ASSESSING THE
EYE STRUCTURES
AND VISUAL
ACUITY
 ASSESSING THE EYES AND
VISION
LEARNING OBJECTIVES:
• Perform an eye assessment, including visual
acuity and extraocular motion.
• Modify assessment techniques.
• Document actions and observations.
• Recognize and report significant deviations
from normal.
ASSESSING THE EYES AND VISION
- Is a series of tests performed to assess vision and ability
to focus on and discern objects. It also includes other
tests and examinations pertaining to the eyes.
- Inspection of the eyes for abnormalities
- Testing the cranial nerves responsible for eye function: III,
IV, VI.
- Assessing for nystagmus, accommodation, pupil size and
reactivity to light etc.
- Inspect of the eyes, eye lids, pupils, sclera, and
conjunctiva.
- To help diagnose common conditions.
 Before to proceed with the assessment:

Don’t forget!
Inquire if the client has any history of the following:
 family history of diabetes, hypertension, blood dyscrasia, or eye
disease, injury, or surgery;
 client’s last visit to a provider who specifically assessed the eyes
(e.g., ophthalmologist or optometrist);
 current use of eye medications; use of contact lenses or
eyeglasses;
 hygienic practices for corrective lenses;
 current symptoms of eye problems (e.g., changes in visual acuity,
blurring of vision, tearing, spots, photophobia, itching, or pain).
 EQUIPMENT TO USE

SNELLEN CHART PENLIGHT MILLIMETER RULER

COTTON WISP
 ASSESSMENT OF THE EYE EXTERNAL
STRUCTURES
NORMAL RATIONALE

EYEBROWS Hair is evenly To assess the 7th

(HOW TO INSPECT: distributed, and cranial nerve (Facial
Ask the client to eyebrows are Nerve)
raise and lower the symmetric; equal
eyebrows) movement.
EYELASHES Equally distributed To assess if there
along the lids are underlying
margins; curled diseases or
slightly outward conditions (ex.
Trichiasis)
EYELIDS Skin intact, no To check if equally,
(HOW TO INSPECT: discharge and symmetrically, if with
Inspect the lower eyelids discoloration; lids close Puffiness around one's
while the client’s eyes symmetrically. eyes and checking the
are closed) Frequent blinking and eyelid muscles or
bilateral blinking. nerves.

BULBAR Should be china

CONJUNCTIVA white and no
(HOW TO INSPECT:
• Retract the eyelids presence lesions.
with your thumb
and index finger.
• Ask the client to look
up, down and side to
side).
PALPEBRAL
CONJUNCTIVA
(HOW TO INSPECT:
• Evert both eyelids
• Ask the client to look
up
• Gently retract the
lower lids with the
index finger
• Evert upper lids if
problem is
suspected).
 Other causes:

Drooping of eyelid • Stroke

• Bell’s palsy
• Trichiasis
Introversion of eyelashes • Allergies
• Infections
• Kidney
problem
• Eyelid
dermatitis

Puffiness of eyelids Discoloration of eyelids

Icteric sclera –
yellowish
discoloration of the
sclera.

Example disorder:
• Liver disorder
• Problem in
pancreas and
gallbladder
 NORMAL RATIONALE

CORNEA • Transparent,
(HOW TO INSPECT for shiny, smooth;
clarity and texture: details of the iris
• Ask the client to look are visible.
straight ahead.
• No scratches
• Hold a penlight at an
oblique angle to the • No ulceration
eye.
• Move the light slowly
across the corneal
surface.)
CORNEAL SENSITIVITY
TEST – Asking the - This determines the
patient to keep both function of the fifth
eyes open and look cranial nerve
straight ahead. (Trigeminal Nerve).
CORNEAL EYE REFLEX
PUPILS • round, regular, and
- For color, shape and size equal in size( 2-4mm To determine the
- Consensual reaction to light function of the third
- Reaction to accommodation to bright light and 4-8
in the dark) and (oculomotor) and fourth
(HOW TO INSPECT: shape. (trochlear) cranial
• Partially darken the room. • If direct to light, pupil nerves.
• Ask the client to look
straight ahead.
constrict; then dilate
• Using a penlight and in the dark.
approaching from the side, • Pupils constrict when
shine a light on the pupil. looking at near
• Shine the light on the object;
pupil again and observe
the response of the other
• pupils dilate when
looking at far object PERRLA—Pupils Equal,
pupil. It should also
constrict.) Round, and Reactive to
• Focus on near object, Light and
pupil constrict Accommodation.
(accommodation)
OTHER CAUSES:

• ANEURISM-
DILATED

• CLUSTER
HEADACHE-
CONSTRICTED

• GLAUCOMA-MID
DILATED

• HEAD TRAUMA-
UNEQUAL(ANISOC
ORIA)

• SYPHILIS-
CONSTRICTED
REACTION TO LIGHT DIRECT ACCOMMODATION
ASSESSING PERIPHERAL VISUAL FIELDS AND
EXTRA OCULAR MOVEMENTS
 COVER TEST
-Determines the balance mechanism that keeps the
eye parallel.
• explain that the patient will look at a fixed point while
covering each eye.
• Remove the card from covered eye and observe the
newly uncovered eye for movement. it should focus
straight ahead.
• Cover one eye with a card and observe the uncovered
eye which should remain focused on the designation
point.
 Distance Vision

Snellen eye chart

- A distance vision test is a way to measure how clearly a
person can see from a certain distance.
- The most common method is to use a Snellen eye chart,
which has letters and shapes of different sizes.
- The person will cover one eye and read the chart from 20 feet
away, then repeat with the other eye.
- The lower the number on the chart, the better the visual
acuity. Alternatively, the test can be done at home with a
printed chart and a 10 feet distance.
 Near visual acuity

Jaeger eye chart is used to test and document near visual acuity at a normal reading
distance. Here’s how it works:
1. Purpose: The Jaeger chart assesses your ability to read small print up close. It helps detect refractive
errors and conditions that cause blurry reading vision, such
as astigmatism, hyperopia (farsightedness), and presbyopia (loss of near focusing ability after age
40).
2. Procedure:
1. Distance: Hold the Jaeger chart 14 inches from your eyes (use a tape measure to verify this
distance).
2. Lighting: Illuminate the chart with lighting typical of comfortable reading conditions.
3. Both Eyes Open: Testing is usually performed with both eyes open. However, if there’s a
significant difference between your eyes, cover one eye and test each eye separately.
4. Reading: Start with the largest block of text you can see clearly without squinting. Read that
passage aloud. Then try reading the next smaller block of text. Continue reading successively
smaller blocks until you reach a size that is not legible.
5. Recording: Record the “J” value of the smallest block of text you can read
 PROCEDURES
1 Introduced self and verified client's identity
2. Explained procedure to client and discussed how results will be
used
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
prevention procedures.
5. Provided for client privacy.
6. Inquired about the client's history related to the eyes.
7. Inspected the eyebrows for hair distribution, alignment, skin quality,
and movement.
8. Inspected the eyelashes for evenness of distribution and direction of
curl.
9. Inspected the eyelids for surface characteristics, position in relation to the cornea, ability
to blink, and frequency of blinking. Inspected lower eyelids while the client's eyes were
closed.
10. Inspected the bulbar conjunctiva for color, texture, and the presence of lesions

11. Inspected the cornea for clarity and texture.

12. Inspected the pupils for color, shape, and symmetry of size.
13. Assessed each pupil's direct and consensual reaction to light.
 PROCEDURES
14. Assessed each pupil's reaction to accommodation.
15. Assessed peripheral visual fields.
16. Assessed six ocular movements to determine eye alignment and coordination.

17. Assessed for location of corneal light reflex.

18. Performed cover test.
19. Assessed near vision by asking client to read from a magazine or newspaper
held at a distance of 36 cm.

20. Assessed distance vision.

21. If client was unable to see top line of the Snellen-type chart, performed one or
more of the following vision tests: Light perception,

22. Used effective bod mechanics throughout procedure.

23. Communicated appropriately with the client.
24. Documented all relevant information.
 Assessing of
Ears and
Hearing Acuity
Learning Objectives:
• Perform an ear and hearing assessment, including
hearing acuity.
• Distinguish the three main division of the ear.
• Modify assessment techniques to reflect variations
across the life span.
• Document actions and observations.
• Recognize and report significant deviations from
normal.
 Assessing of Ears and Hearing
 Is an important skill for nurses in any care environment.
 Screens for various ear problems, such as:
• Hearing loss
• Ear pain
• Discharge
• Lumps
• Objects in the ear
 It helps identify issues in the ear canal, eardrum, and middle
ear.
Three division of Ear
 EQUIPMENT TO USE

OTOSCOPE TUNING FORK

 Before to proceed with the assessment:
Don’t forget!
Inquire the client history.

• Have you had any trouble hearing? If so, do you wear hearing
aids?
• Have you had any symptoms like ringing in the ears, drainage
from the ears, or ear pain?
• Do you ever feel dizzy, off-balance, or like the room is spinning?
• Have you ever been diagnosed with an ear condition such as an
infection, tinnitus, or vertigo?
• Are you currently using any medications, ear drops, or
supplements for your ears?
TWO WAYS OF ASSESSING THE EARS:
INSPECTION
PALPATION

INSPECTION
- Color, symmetry of size, and position
of auricle or pinna and checking for
cerumen, skin lesions, pus, and blood.
PALPATION
- texture, elasticity, and areas of
tenderness.

Normal:
no tenderness, no pain upon
palpation, no swollen lymph nodes
 Assessing for color, symmetry of size,
position of ears
Pinnae
•Asymmetry: by comparing the pinnae you may identify subtle unilateral
pathology.
•Deformity of the pinnae: this may be acquired (e.g. cauliflower ear) or
congenital (e.g. anotia, microtia, low-set ears).
•Ear piercings: can be a potential source of infection, an allergen and a cause of
trauma.
•Erythema and edema: typically associated with otitis externa.
•Scars: indicative of previous surgery.
•Skin lesions: look for evidence of pre-malignant (actinic keratoses) and
malignant (e.g. basal cell carcinoma, squamous cell carcinoma) skin changes.
Mastoid

•Erythema and swelling: typically associated with mastoiditis.

•Scars: indicative of previous surgery (e.g. mastoidectomy).
Pre-auricular region (in front of the ear)
•Pre-auricular sinus/pit: a common congenital deformity that appears
as a dimple in the pre-auricular region. These sinuses can sometimes
become infected and require surgical drainage.
•Lymphadenopathy: typically associated with an ear infection (e.g.
otitis media, otitis externa).
PALPATION
Palpate the tragus for tenderness which is
typically associated with otitis externa.

Palpate the regional lymph nodes:

•Pre-auricular lymph nodes
•Post-auricular lymph nodes
Cauliflower ear
is an irreversible condition that develops as a result
of repeated blunt ear trauma.

congenital ear deformity including:

• Anotia: a complete absence of the pinna.
• Microtia: underdevelopment of the pinna.
• Low-set ears: the ears are positioned lower on the head
than usual. Low-set ears are a feature of several genetic
syndromes including Down’s syndrome and Turner’s
syndrome.
How to inspect using Otoscope?
To help decide which ear to examine first:
•Check if the patient has any ear
discomfort and if so examine the non-painful
side first.
•Ask the patient which is their “better”
ear and examine this one first (this can be
useful for comparison).
INSERTING OTOSCOPE:
1. Ensure the light is working on the otoscope and
apply a sterile speculum (the largest that will
comfortably fit in the external auditory meatus).
2. Pull the pinna upwards and backwards with your
other hand to straighten the external auditory canal.
3. Position the otoscope at the external auditory
meatus:
• The otoscope should be held in your right hand for
the patient’s right ear and vice versa for the left
ear.
• Hold the otoscope like a pencil and rest
your hand against the patient’s cheek for
stability. This will prevent damage to the
ear if there is sudden movement.

4. Advance the otoscope under direct

vision. Be gentle with the otoscope and
ensure movements are slow and considered
otherwise you will cause discomfort.
EXTERNAL AUDITORY CANAL

5. Inspect the external auditory canal for:

• Excessive ear wax: the most common cause of conductive
hearing loss.
• Erythema and edema: typically associated with otitis
externa.
• Discharge: may suggest otitis externa or otitis media with
associated tympanic membrane perforation.
• Foreign bodies: these may include cotton buds, insects and
other small objects.
 TYMPANIC MEMBRANE
6. Systematically inspect the four quadrants of the tympanic membrane (TM) to avoid missing
pathology.
Colour
 A healthy TM should appear pearly grey and translucent.
 Erythema suggests inflammation of the TM which can occur in conditions such as acute
otitis media.
Shape
 A healthy TM should appear relatively flat.
 Bulging of the TM suggests increased middle ear pressure, which is commonly caused by
acute otitis media with effusion
 Retraction of the TM suggests reduced middle ear pressure, which is commonly caused
by pharyngotympanic tube dysfunction secondary to upper respiratory tract infections and
allergies.
Perforation
 Note the size and the position of any perforations.
 Causes of TM perforation include infection, trauma,
cholesteatoma and insertion of tympanostomy tubes (also known as
grommets).
 Cholesteatoma typically causes perforation in the superior part of
the TM and there may be visible granulation tissue and discharge in
this region.
Scarring
 Scarring of the TM is known as tympanosclerosis and can result in
significant conductive hearing loss if it is extensive.
 Tympanosclerosis often develops secondary to otitis media or after
the insertion of a tympanostomy tube.
7. Withdraw the otoscope carefully.
8. Repeat your assessment on the other ear, comparing your
findings. If the patient has an infection in one ear, you
should change the speculum on the otoscope before
examining the other ear.
9. Discard the otoscope speculum into a clinical waste bin.
Adult-
pull upward and backward the pinna
using thumb and index finger (3yo and
up)
Child-
pull downward and backward the
pinna.
Rationale:
>This allows you to stabilize the otoscope and
decreases risk of scraping the external auditory
canal with the speculum.
> Inspection may reveal any abnormalities.
To check if there are any infection related to ear
problem upon assessment.
The early treatment that may provide to the
patient.
Ear problems:

 Otitis Media – is common, especially in children. It often starts with a

cold, and will usually go away by itself without antibiotics. It can
cause ear pain, reduced hearing and fever. You may see fluid leaking
if the ear drum bursts.
 Blocked eustachian tube - which is itself often caused by a cold.
 Ear cellulitis - skin infection
 Eardrum infection (myringitis) - is a form of acute otitis media and
is caused by a variety of viruses and bacteria.
 Otitis externa - often called swimmer’s ear, It is caused by bacteria or
fungi.
 Mastoiditis - infection of the bone behind the ear that is often
caused by spread of a middle ear infection.
Hearing Acuity
 ability to perceive sounds of low intensity,
to detect differences between two sounds, or
to recognize the direction from which a
sound proceeds.

How to assess?
WHISPERED VOICE TEST
WATCH TICK TEST
(Note: the ticking of a watch has a higher pitch than
human voice)
Have the client COVER one ear. Out of the client’s sight, place a
ticking watch 2-3cm (1-2inches) from the UNCOVERED ear.
Ask what the client can hear. Repeat with the other ear.

TUNING FORK TEST:

>WEBER TEST
>RINNE TEST
How to do Weber’s Test
 Explain to the patient that you are going to test their hearing using a tuning fork.
 1. Tap a 512Hz tuning fork and place in the midline of the forehead. The tuning
fork should be set in motion by striking it on your knee (not the patient’s knee or a
table).
 2. Ask the patient “Where do you hear the sound?”
 These results should be assessed in context with the results of Rinne’s test before
any diagnostic assumptions are made:
• Normal: sound is heard equally in both ears.
• Sensorineural deafness: sound is heard louder on the side of the intact ear.
• Conductive deafness: sound is heard louder on the side of the affected ear.
 A 512Hz tuning fork is used as it gives the best balance between time of decay and
tactile vibration. Ideally, you want a tuning fork that has a long period of decay
and cannot be detected by vibration sensation.
 How to do Rinne’s Test

 By stroking the fork between your thumb and index fingers.

 1. Place a vibrating 512 Hz tuning fork firmly on the mastoid
process (apply pressure to the opposite side of the head to make
sure the contact is firm). This tests bone conduction.
 2. Confirm the patient can hear the sound of the tuning fork and
then ask them to tell you when they can no longer hear it.
 3. When the patient can no longer hear the sound, move the tuning
fork in front of the external auditory meatus to test air conduction.
 4. Ask the patient if they can now hear the sound again. If they can
hear the sound, it suggests air conduction is better than bone
conduction, which is what would be expected in a healthy individual
(this is often confusingly referred to as a “Rinne’s positive” result).
 • Allow it to stay there for 2-3 seconds to allow them to
appreciate the intensity of the sound.
• Then promptly lift the fork off the mastoid process and
place the vibrating tips about 1cm from their external
auditory meatus
• Leave it there again for a few seconds before taking
the tuning fork away from their ear.
• Ask the patient in which of the positions they were able
to hear the note the loudest.
Interpretations of Rinne’s Test

• 1) If a patient can hear best when the tuning fork is in

the air (positive Rinne’s) then air conduction is better
than bone conduction so there is no significant
conductive hearing loss.

• 2) If the patient can hear best when the tuning fork is

on the mastoid (negative Rinne’s) bone conduction is
better than air conduction, demonstrating a
conductive hearing loss.
Two categories of hearing loss:
• Conductive hearing loss
- problems in delivering sound to the inner
ear(external auditory canal, tympanic membrane and
middle ear). Causes of conductive hearing loss include
excessive ear wax, otitis externa, otitis media,
perforated tympanic membrane and otosclerosis.
• Sensorineural hearing loss
- problems of the inner ear, or cochlea, and/or the
auditory nerve that connects the inner ear to the brain).
Causes include increasing age (presbycusis), excessive
noise exposure, genetic mutations, viral infections
 PROCEDURES
1. Introduced self and verified client's identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed appropriate infection prevention procedures.
5. Provided for client privacy.
6. Inquired about the client's history related to the ears and hearing
7. Positioned the client comfortably, seated if possible
8. Inspected the auricles for color, symmetry of size, and position.
9. Palpated auricles for texture, elasticity, and areas of tenderness.
10. Inspected the external ear canal for cerumen, skin lesions, pus, and blood.
11. Visualized the tympanic membrane using an otoscope.
12. Assessed client's response to normal voice tones. If client had difficulty hearing the normal
voice, proceeded with the
following tests:
a. Watch tick test.
b. Tuning fork tests: Weber and Rinne.
13. Used effective body mechanics throughout procedure.
14. Communicated appropriately with the client.
15. Documented all relevant information.
 THANK YOU FOR
LISTENING FUTURE
RNs!
KNOWLEDGE IS
POWER BUT
ATTITUDE IS
EVERYTHING