WASH HANDS
INTRODUCE & STATE PURPOSE
INSPECTION: HEAD & FACE
1. HEAD (Size, Shape, Symmetry) – NO abnormal movements, drooping of one side of the face
– Look at the facial expressions! (1) Close eyes tightly & open
mouth, Smile, (3) Frown, (4) Pop out cheeks
PALPATION
2. G Light Palpation (HEAD size, shape, symmetry, areas of tenderness) – NO loss of hair, tenderness
3. NG TMJ
ASSESSING VISUAL ACUITY
4. Client stand 20ft from chart, separately test eye OS, OD, OU – NO more than 2 mistakes, smallest
line of print
5. ‘’ stand 14in from newsprint OS, OD, OU
6. Color perception, write defected color
7. Visual Fields; Fix gaze straight ahead cover one eye vv, bring pen from 4 dif fields (superior, inferior, temporal,
nasal), have say ‘now’ once seen
ASSESSING EXTRAOCCULAR MUSCLES OF THE EYE
8. Corneal light reflex test – light midline, look for eye alignment
9. Cover one eye, focus object afar & notice for drifting
10. Cardinal fix of gaze – straight ahead, follow pen box (up, side, down, down, side, up)
INSPECTION: EYE EXTERNAL STRUCTURES
11. Clarity & parallel alignment
12. Eyelashes hair
13. Eyelids – NO edema & lesions
14. Eyeball – NO protrusion
15. Lacrimal glands & Nasolacrimal ducts – NO swelling, redness, drainage
16. EXAMINE Conjunctiva (color, blood vessel, thickening)
17. Sclera (color)
18. Rolled cotton touch cornea, note blinking & tearing
19. Iris (color &shape)
20. Pupillary Reaction light side to side (size, shape)
21. Straight ahead, shine light from side across eye (clarity &shadowing of iris)
PALPATION
22. Eyeball (firmness)
23. Lacrimal glands & Nasolacrimal ducts (tender, tearing, nonpalpable gland)
INSPECTION: SINUSES
24. Frontal sinuses & Maxillary sinuses (presence of periorbital edema, dark undereye, circles)
25. Shine light upward under eyebrow
26. Shine light below eyes while looking for red glow on the palate of mouth
PALPATION
27. Frontal sinuses (tenderness)
28. Maxillary sinuses (tenderness)
PERCUSSION
29. Frontal sinuses (tenderness) – Feel pressure?
30. Maxillary sinuses (tenderness)
INSPECTION: NOSE
31. (size, shape, symmetry) – Midline placement
32. Internal mucosa, penlight (septum located midline, color)
33. Turbinates’
PALPATION
34. Nostril
INSPECTION: EAR
35. Angle attachment of ears (shape, color, position)
PALPATION
36. Tragus, Helix, Mastoid process (soft/pliable/nontender)
37. Otoscope examination
38. External Auditory Canal – Speculum
39. Tympanic Membrane (color)
ASSESSING HEARING PERCEPTION
a) WHISPER TEST, cover opposite ear tested (in/ability to repeat words/phrase)
b) WATCH TICK TEST, hold ticking watch 5in (un/hears ticking at 5in distance)
c) WEBER TEST, tap prongs, place middle of top head (equal/lateralization hearing)
d) RINNE TEST, vibrating tuning fork on mastoid process then in front of ear, count ‘til no longer hear sound say
‘no’, compare (length air conduction & bone conduction)
e) ROMBERG TEST, stand feet together, eyes closed (balance)
INSPECTION: LIPS
40. (color, lesion, odor)
INSPECTION: MOUTH & THROAT
41. Open & close mouth (color of teeth, pair of teeth, location, status)
42. Oral mucosa & Gums (color)
43. Hard palate & Soft palate (color)
44. Salivary gland, Buccal mucosa (color, texture)
45. Tongue (color, texture)
46. Oropharynx
47. Tonsils (color)
48. Uvula, say ‘ah’ (color, location, texture)
PALPATION
49. Lips (soft/tender/nontender/thickening)
50. Tongue (“”)
51. Parotid gland (palpable/nonpalpable/tender/nontender)
52. Submandibular & Sublingual (palpable/nonpalpable/tender/nontender/soft)
INSPECTION: NECK
53. Neutral position, hyperextended position, swallows water
54. Palpate cervical nodes: (size, shape, consistency, delimination, mobility, tenderness)
a) Occipital node
b) Post auricular
c) Pre auricular
d) Tonsilar
e) Submandibular
f) Submental
g) Superficial
h) Posterior
i) Deep
j) Supraclavicular
k) Infraclavicular
55. Palpate thyroid gland
AUSCULTATION: THYROID GLAND
Hold breath, listed thyroid gland using bell
PROVIDE COMFORT & DO AFTER CAREDOCUMENT ASSESSMENT FINDINGS
