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Name __________________________________________________________ Date ____________________________________
Course _________________________________________________________ Year ____________________________________
Instructor/examiner _ ____________________________________________ Position _ _______________________________
Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
1. Identify the patient.
2. Check the medical order or clinical pathway/care plan.
3. Introduce yourself, explain the rationale for the
procedure to the patient and family, and obtain consent.
4. Gather the necessary equipment.
Equipment:
penlight, ophthalmoscope, otoscope, tuning
fork, watch with a second hand, Snellen eye chart, tongue
blade, stethoscope.
5. Undertake a risk assessment, if indicated.
6. Perform hand hygiene.
7. Put on personal protective equipment (PPE), including
gloves.
8. Ensure that patient privacy is maintained and the patient
is comfortable. Ensure that interruptions are minimal.
9. Undertake a health history, as per Skill 2-1.
10. Inspect the head and then the face for colour, symmetry,
lesions and distribution of facial hair. Note facial
expression. Palpate the skull.
11. Inspect the external eye structures (eyelids, eyelashes,
eyeball, lacrimal glands and eyebrows), cornea, iris,
conjunctiva and sclera. Note colour, oedema, symmetry
and alignment.
12. Examine the pupils for equality of size, shape and
reaction to light by darkening the room and using a
penlight to shine the light on each pupil.
13. To test for pupillary accommodation and convergence,
ask the patient to focus on your finger as you bring
it closer to their nose: ask the patient to look directly
forwards at your forefinger held 10–15 cm from their
nose, then at a distant object and back to your finger.
Following this, move your forefinger towards their nose.
14. Using an ophthalmoscope, check the red reflex.
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Goal:
The assessment is completed without the patient
experiencing anxiety or discomfort, the findings are
documented and the appropriate referral is made to other
healthcare professionals, as needed, for further evaluation.
Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery:
A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment
skill 2-4
Assessing the head and neck
