Checklists for Clinical Nursing Skills

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Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

skill 2-4 Assessing the head and neck

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

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. 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.

Comments

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Needs practice

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