Peformance Checklist Sensory System

CC2433

Basic Health Assessment and Clinical Skills Sensory System PERFORMANCE CHECKLIST

EYES Yes Identify client Obtain relevant history Wash hands Gather instrument Provide privacy Position the patient Test central visual acuity Snellen eye chart  20 feet from the chart, cover one eye  numerator/ denominator, normal 20/20 Near vision (Jaeger card)  14 inches (35 cm), normal 14/14 Vs presbyopia Test visual fields  2 ft away, cover one eye, look straight to me Confrontation test Inspect extraocular muscle function Corneal light reflex (Hirschberg test) Cover test Diagnostic positions test (6 cardinal positions of gaze Inspect external eye structures General Eyebrows Eyelids and lashes Eyeballs Conjunctiva and sclera Eversion of upper lid Lacrimal apparatus Inspect anterior eyeball structures Cornea and lens Iris and pupil (pupillary light reflex, accommodation) Inspect the ocular fundus Optic disc Retinal vessels General background Macula Special considerations Transcultural Developmental Document findings

OS: oculus sinister (left eye) OD: oculus dexter (right eye) OU: oculus uterque (each eye)

No

Comments

CC2433

Basic Health Assessment and Clinical Skills Sensory System

Ears Yes Identify client Obtain relevant history Wash hands Gather equipment Provide privacy Position the client External ear Inspect Size and shape Skin condition External auditory meatus Palpate Pinna Tragus Mastoid process Otoscopic examination External canal Tympanic membrane Color Characteristics Position Integrity Hearing acuity Voice test Rinne test Weber test Special considerations Developmental Transcultural Document findings

No

Comments

CC2433

Basic Health Assessment and Clinical Skills Sensory System

PERFORMANCE CHECKLIST NOSE, MOUTH, AND THROAT Yes No Obtain relevant history Gather equipment Provide privacy Wash hands Inspect nose for symmetry, deformity, lesions, and patency External nose Nasal cavity (use speculum) Color Integrity Septum Deviation Perforation Bleeding Turbinates Color Exudate Swelling Polyps Palpate the external nose The sinus area Palpate Perform transillumination The mouth Inspect Lips Teeth Gums Inspect and palpate (using clean gloves) Tongue Buccal mucosa Palate Observe uvula The throat Inspect and grade tonsils Test cranial nerve XII (have patient stick out tongue) Special considerations Transcultural Developmental Document findings

Comments

CC2433

Basic Health Assessment and Clinical Skills Sensory System

Tonsils are graded in size as follows: 1+ Visible 2+ halfway between tonsillar pillars and Uvula 3+ touching the uvula 4+ touching each other