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
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