CC2433 Basic Health Assessment and Clinical Skills

Sensory System
PERFORMANCE CHECKLIST
EYES
Yes No Comments
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)
CC2433 Basic Health Assessment and Clinical Skills
Sensory System
Ears
Yes No Comments
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
CC2433 Basic Health Assessment and Clinical Skills
Sensory System
PERFORMANCE CHECKLIST
NOSE, MOUTH, AND THROAT
Yes No Comments
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
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