NURS 6512 Physical Examination Check Off Rubric Part 1: Head and Face, Ears, Eyes, Nose, Throat and Mouth Grades are awarded as follows: 2/4 = Demonstrated thoroughly with correct technique 1/2 = Demonstrated Partially with mostly correct technique 0 = Did not demonstrate or demonstrated with incorrect technique *A head to toe (cephalo – caudal), and anterior – posterior approach should be used when conducting the exam. No deductions given for exam steps out of order. Students should verbalize each exam step and must identify all cranial nerves by name and number. Appropriate documentation noted in blue Have patient sit up HEAD AND FACE Palpates lymph nodes of the head and neck: Preauricular (in front ears) , postauricular (behind ears) , occipital (back of head), tonsillar (edge of jaw) , submandibular (under jaw) , submental (chin) , anterior cervical (front neck) , posterior cervical (back neck), supraclavicular (above clavicle) (verbalize locations) No enlargements and they are equal bilaterally 4 2 0 CN 5 (Trigeminal) Motor – palpate over the masseter muscle as patient clenches jaw – CN 5 intact Sensory – light touch sensation to forehead, cheeks, chin, nose (patient closes eyes and identifies where they are being touched) – CN 5 intact 2 1 0 CN 7 (Facial) Inspect for facial symmetry with smile, frown, raise eyebrows, puff cheeks, pucker lips CN 7 intact 2 1 0 EAR Inspect auditory canal and TM (using otoscope) To both ears (Pull up and back). External auditory canal is clear. No swelling, redness, drainage, or cerumen. Tympanic membrane is pearly gray and there is no effusion. 4 2 0 CN 8 (Acoustic) (Hearing) Whisper Test (whisper 3 words out of patient’s sight, and patient repeats words back) Test one ear at a time. Hearing is intact bilaterally. 2 1 0 EYE CN 2 (Optic) Assess peripheral/central vision Peripheral vision – stand at same eye level and bring hands from beside patient until they see them. Let me know when you see my hands. Do directly beside, above, and below. Peripheral vision is normal. 2 1 0 CN 2 (Optic) Check pupillary response to light [PERRL] Using ophthalmoscope with light have patient stare at my nose and come from side with light source. Pupils are about 2 – 3mm and they respond to light. 2 1 0 CN 3 (Oculomotor), 4 (Trochlear), 6 (Abducens) Extraoccular Movement Test for conjugate gaze with EOM. Using an H pattern have patient follow with only eyes. All EOM’s are intact equally. 2 1 0 Assess blood vessels in the eye – Fundoscope exam (using ophthalmoscope) To both eyes . Disc margins are round and sharp No AV nicking No exudate or hemorrhages 2 1 0 NOSE Assess nasal turbinates and septum (using light source) Lift tip of nose All turbinates are pink and moist. Septum is midline. Angling anteriorly, I see the septum is straight with no deviation. 2 1 0 Palpates frontal and maxillary sinuses No tenderness noted. 2 1 0 THROAT AND MOUTH
Inspect lips, teeth, gums, buccal mucosa, palate, tongue, the floor of the mouth (under the tongue), posterior pharynx, and tonsils ( grade tonsils, if present ) Lips – pink and moist. Open mouth. Teeth – no signs of decay or cracks. Gums – no redness or swelling and moist and pink. Buccal Mucosa – moist and pink bilaterally Upper Soft and Hard Palates – pink and moist Tongue – smooth and pink Lift tongue Floor of mouth is pink with no nodules or drainage and is moist. Posterior pharynx – no drainage and is moist and pink. Grade Tonsils if present 4 2 0 CN 9 (glossopharyngeal) and 10 (Vagus). Say “Ahh” and soft palate and uvula rise symmetrically with phonation (CN 10) * Gag reflex not tested for this exam (CN 9). Must only state name and number Uvula rises symmetrically with phonation, so CN 10 is intact. 2 1 0 CN 12 (Hypoglossal) Stick out tongue and move it left to right. Intact 2 1 0
