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Head, Face, and Eyes

Nursing 315

QuestionAnswer
Step 1: Inspect and palpate hair Distribution, color, and texture. Hair is brown, fine, and evenly distributed.
Step 2: Inspect and palpate scalp Color and lesions. Scalp color consistent with ethnicity, dry, smooth, moveable and without lesions.
Step 3: Inspect and palpate skull Size, contour, and symmetry. Normocephalic.
Step 4: Inspect face (CN V & VII) Symmetry, movement, expression, and sensation. Bilateral symmetry of face with symmetrical facial movements, no involuntary movements, facial expression appropriate to situation.
Step 6: Inspect eyebrows, eyelids, and eyelashes. Position, color, symmetry, lesions. Eyelids symmetrical in alignment and position. Color consistent with complexion. No lesions, edema.
Step 7: Inspect lacrimal apparatus and conjunctiva. Patent, color, texture. Ducts patent, no redness or discharge. Conjunctiva pink, smooth, without inflammation.
Step 8: Inspect sclera, cornea, lens, iris. Color, clarity, surface. Sclera white and intact. Corneas clear, shiny, smooth, no opacities. Iris blue, clear, round bilaterally.
Step 9: Inspect pupils. Size, shape, equality, reaction to light, accomodation. Pupils equal, round, reactive to light and accomodation. (PERRLA)
Step 10: Corneal light reflex. Symmetry. Symmetical corneal light reflex.
Step 11: Inspect extraocular eye movements (CN III,IV,VI) Parallel alignment, symmetrical ROM. Eyes in parallel alignment wit EOMs intact bilaterally. No nystagmus.
Step 12: Assess fields of peripheral vision. Confrontation. Peripheral vision intact.
Step 13: Visual acuity (CN II) Snellen eye chart. Snellen test 20/20 right eye.Snellen test 20/30 left eye.
Step 5: Inspect globes (CN II,III,IV,VI) Position and alignment. Eyes symmetrical in alignment and position. No protrusion noted.
Created by: bethanne89
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