Checklists for Clinical Nursing Skills

First page Previous page 17 Next page Last page

skill 2-4 Assessing the head and neck (continued)

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____

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.

____ ____ ____

Made with FlippingBook