Head and Neck

Head

Head inspection / Done
perfectly / poor / Not
done / mark
  1. Hair distribution, quantity

  1. Skull size, contour

  1. Face expressions, and symmetry of structure

  1. Skin color. Lesions

  1. Hair distribution, lesions, hair loss

  1. facial asymmetry, involuntary movements, or edema

Palpate the head / Done
perfectly / poor / Not
done / mark
  1. Hair texture

  1. Skull for lumps and lesions

  1. Skin temperature, Texture

Neck

Inspection and Palpation of the neck / Done
perfectly / poor / Not
done / mark
  1. Skin color, integrity, shape

  1. Symmetry

  1. Masses, scars

  1. Enlarged glands or lymph nodes

  1. Trachea – position (should be midline)

  1. Thyroid gland enlargement,consistency, masses, tenderness

Eyes

Inspection of the eyes / Done
perfectly / poor / Not
done / mark
  1. Symmetry

  1. Position and alignment of eyes

  1. Eyebrows-Quantity, distribution

  1. Eyelids-Edema, color, lesions

  1. Conjunctiva and sclera-color, vascular pattern

  1. Cornea and lens

  1. Iris

  1. Pupils

Pupils examination / Done
perfectly / poor / Not
done / mark
  1. Size

  1. Shape

  1. Reaction to light

  1. Symmetry

Examination of the eyes / Done
perfectly / poor / Not
done / mark
  1. Visual acuity (Snellen eye chart)

  1. Visual field by confrontation

  1. Extraocular movements

  1. Accommodation

  1. Using the Ophthalmoscope

1-Visual acuity (Snellen eye chart)
Position patient 20 feet (6 meters) from the chart /
Patients should wear glasses if needed
Test one eye at a time
2-Visual field by confrontation
The client should be sitting 60-90 cm from you and at eye level
Test one eye at a time
The client’s peripheral visual fields are compared to that of the examiner.
This test assumes the examiner has normal peripheral vision
3- Extraocular movements
The client must keep the head still while following a pen that you will move in several directions to form a star in front of the client’s eyes.
Always return the pen to the center before changing direction
3- Accommodation
An object held about 10 cm from the client’s nose

Ears

Inspect and palpate the ears / Done
perfectly / poor / Not
done / mark
  1. Auricle for redness, lesions, symmetry

  1. Ear canal for discharge, foreign bodies, redness, swelling

  1. Use otoscope to see the tympanic membrane

  1. Palpation Auricle for lumps, tenderness

  1. Palpate the mastoid process for tenderness or deformity

Examine the hearing acuity / Done
perfectly / poor / Not
done / mark
  1. Whisper test

  1. Rinne test

  1. Weber test

  1. Romberg test

1- Whisper test
Ask the client to occlude the other ear or the ear may be occluded by the nurse.
Cover your mouth so the client cannot see your lips
Standing 30-60cm behind patient, softly say “nine-four,” “baseball”
Ask the client to repeat the phrase.
2- Rinne test
Compare time of air vs. bone conduction
Place the base of the tuning fork on the client’s mastoid process- and note the number of seconds.
Then move the fork in front the external auditory meatus (1-2 cm)
If bone conduction is equal or greater than air conduction, then suspect conductive hearing loss
3- Weber test
Lateralization of sound to impaired ear; suspect unilateral conductive hearing loss /
4- Romberg test
Ask the patient to remain still and close their eyes (for about 20 seconds). /
If the patient loses their balance, the test is positive.

Nose

Inspect and palpate the nose / Done
perfectly / poor / Not
done / mark
  1. Size, shape

  1. Symmetry

  1. Lesions/signs of infection

  1. Patency test

  1. Septum (by use nasal speculum)-deviation, inflammation or perforation

  1. Palpate for tenderness, swelling

Mouth and Pharynx

Examining the Mouth and Pharynx / Done
perfectly / poor / Not
done / mark
  1. Lips-Note color, moisture, lumps, ulcers, cracking

  1. Gums and teeth-Note color, presence and position of teeth

  1. Roof of mouth-Note color

  1. Tongue and floor of mouth -Note color and texture, ulcers

  1. uvula, tonsils, pharynx-Note color, symmetry, presence of exudate, swelling, ulceration or tonsillar enlargement

Thyroid gland

Examine the thyroid gland / Done
perfectly / poor / Not
done / mark
  1. Flex neck slightly forward

  1. Locate thyroid gland

  1. Ask patient to swallow

  1. Note the size, shape, and consistency

  1. Identify any nodules or tenderness

  1. If enlarged, auscultate-to detect a bruit