20
skill 2-4
Assessing the head and neck
(continued)
Comments
Excellent
Satisfactory
Needs practice
Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
15. 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. Note
whether corrective lenses are worn.
16. With the patient about 60 cm away, ask them to focus on
your finger and follow it with their eyes through the six
cardinal positions of gaze.
17. Test peripheral vision. With the patient 60 cm away,
ask them to cover one eye with a hand or card and look
directly at your nose. Cover your own eye opposite the
patient’s closed eye. Holding one arm outstretched, at
equal distance from you and the patient, move your
fingers into the visual fields from various peripheral
points. Ask the patient to tell you when they first see your
fingers. Repeat for the other eye.
18. Inspect the external ear bilaterally for shape, size and
lesions. Palpate the ear and mastoid process.
19. Perform an otoscopic examination. For an adult, pull the
auricle up and back; for a young child, pull the auricle
down and back. Note any cerumen (wax), oedema,
discharge or foreign bodies and the condition of the
tympanic membrane.
20. Test hearing. Stand about 30–60 cm away from the
patient out of the patient’s line of vision. Ask the patient
to cover the ear not being tested while you talk into the
other ear using a whisper. Ask the patient to repeat what
was said. Perform the test on each ear.
21. Use a tuning fork to performWeber’s test and the Rinne test
(if the patient reports diminished hearing in either ear).
(a)
Weber’s test:
hold the tuning fork at its base and strike
it against your palm so that the fork vibrates. Place
the base of the fork on the centre of the top of the
patient’s head. Ask the patient where the sound is
heard best.
(b)
Rinne test:
strike the tuning fork as for Weber’s test.
Hold the base of the fork against the mastoid process
and ask the patient to tell you when the sound can no
longer be heard. Immediately place the still-vibrating
fork close to the external ear canal for one ear and
ask whether the patient can still hear the sound; the
normal ear will do so. Repeat with the other ear.
22. Inspect and palpate the external nose, nares and
turbinates.
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