Rasmussen College Documentation of Head Eyes & Ears Assessment

You will perform a history of a head, ear, or eye problem that your instructor has provided you or one that you have experienced and perform an assessment including head, ears, and eyes. You will document your findings, identify actual or potential risks,

Documentation of Head, Eyes, Ears Assessment
Examiner:
Date:
Patient:
Age:
Reason for Visit:
Health History – Head
1. Any unusually severe or frequent headaches?
2. Any head injury?
3. Experienced any dizziness?
4. Any neck pain?
5. Any lumps or swelling in the head or neck?
6. Any surgery on the head or neck?
Health History – Eyes
1. Any difficulty seeing or blurring vision?
2. Any eye pain?
3. Any history of crossed eyes?
4. Any redness, swelling, or discharge?
5. Any watering or tearing?
6. Any injury or surgery?
7. Ever tested for glaucoma?
8. Wear glasses or contact lenses?
9. Ever had vision tested?
10. Taking any medications?
Health History – Ears
1. Any earache or pain?
2. Trauma?
3. History of ear infections?
4. Any discharge?
5. Any hearing loss?
6. Exposure to loud noises at home or at work?
7. Any ringing or buzzing noticed?
8. Any history of vertigo (spinning)?
9. How do you clean your ears?
10. Do you use ear protection from loud noise or while swimming?
Physical Assessment
1. Inspect and palpate the head.
a. Note any lesions, parasites, deformities.
b. Is hair distributed evenly?
c. Any tenderness noted on palpation?
d. Any masses noted?
2. Inspect and test eyes
a. Inspect external eyes for symmetry (eyes, eyelashes, eyebrows)
b. Any redness, discharge, watering noted from eyes?
c. Inspect conjunctival sac for redness or discharge.
d. Test for PERRLA (Pupils equal, round, reactive to light and accommodation)
e. Test six cardinal directions of gaze and note any nystagmus.
f. Perform confrontation test to assess peripheral vision.
g. Test visual acuity with Snellen Eye Chart.
3. Inspect and test ears
a. Inspect external ear for symmetry, redness, and discharge.
b. Inspect ear for excess cerumen or redness inside with penlight
c. Palpate tragus and pinna for tenderness.
d. Perform whisper test or finger rub test to assess hearing ability.
e. Perform Rinne and Weber test to assess conductive or sensorineural hearing loss.
Regional Write-Up
1. Subjective (health history)
2. Objective (Physical Assessment)
3. Assessment of Risks and Plan (two risks and care plan to improve outcomes)