Cranial Nerve Assessment Normal Response Clients Response

Technique
I. Olfactory Ask the client to smell Client is able to Client was able to
and identify the smell identify different smell describe the odor of
of cologne with each with each nostril the materials used.
nostril separately and separately and with
with the eyes closed. eyes closed unless
such condition like
colds is present.
II. Optic Provide adequate The client should be Client was able to
lighting and ask client able to read with each read with both eyes.
to read from a reading eye and both eyes.
material held at a
distance of 36 cm. (14
in.).
III. Oculomotor Reaction to light: Illuminated and non-
Using a penlight and illuminated pupil PERLA (pupils
approaching from the should constrict. equally round and
side, shine a light on reactive to light and
the pupil. Observe the but reactive on
response of the accommodation)on
illuminated pupil. both eyes
Shine the light on the
pupil again, and
observe the response
of the other pupil.
Reaction to Pupils constrict when
accommodation: As looking at a near
k client to look at a object, dilate when
near object and then looking at a distant
at a distant object. object, converge when
Alternate the gaze near object is moved
from the near to the towards the nose.
far object. Next, move
an object towards the
clients nose.
IV. Trochlear Hold a penlight 1 ft. in Clients eyes should Both eyes are able
front of the clients be able to follow the to move as
eyes. Ask the client to penlight as it moves. necessary.
follow the movements
of the penlight with
the eyes only. Move
the penlight upward,
downward, sideward
and diagonally.
V. Trigeminal While client looks Client should have a Client was able to
upward, lightly touch (+) corneal reflex, elicit corneal reflex,
lateral sclera of eye to able to respond to sensitive to pain
elicit blink reflex. light and deep stimuli and
To test light sensation, sensation and able to distinguish hot from
have client close eyes, differentiate hot from cold.
wipe a wisp of cotton cold.
over clients forehead.
To test deep
sensation, use
alternating blunt and
sharp ends of an
object. Determine
sensation to warm
and cold object by
asking client to
identify warmth and
 coldness.
VI. Abducens Hold a penlight 1 ft. in Both eyes Both eyes move in
front of the clients coordinated, move in coordination.
eyes. Ask the client to unison with parallel
follow the movements alignment.
of the penlight with
the eyes only. Move
the penlight through
the six cardinal fields
of gaze.
VII. Facial Ask client to smile, Client should be able Client performed
raise the eyebrows, to smile, raise various facial
frown, and puff out eyebrows, and puff expressions without
cheeks, close eyes out cheeks and close any difficulty and
tightly. Ask client to eyes without any able to distinguish
identify various tastes difficulty. The client varied tastes.
placed on tip and should also be able to
sides of tongue. distinguish different
tastes.
VIII. Have the client Client should be able Client was able to
Vestibulocochlear occlude one ear. Out to hear the tickling of hear tickling in both
of the clients sight, the watch in both ears. Responds to
place a tickling watch ears. voice or sound
2 to 3 cm. ask what
the client can hear
and repeat with the
other ear.
Ask the client to walk The client should have The client was able
across the room and upright posture and to stand and walk in
back and assess the steady gait and able a stooped position
clients gait. to maintain balance. but able to maintain
balance.
IX. Ask the client to say Client should be able Client was able to
Glossopharyngeal ah and have the to elicit gag reflex and elicit gag reflex and
patient yawn to swallow without any able to swallow
observe upward difficulty. without difficulty.
movement of the soft
palate.
Elicit gag response.
Note ability to
swallow.
X. Vagus Ask the patient to The client should be Client was able to
swallow and speak able to swallow swallow without
(note hoarseness) without difficulty and difficulty and speak
speak audibly. audibly.
XI. Accessory Ask client to shrug Client should be able Good shoulder
shoulders against to shrug shoulders shrug.
resistance from your and turn head from
hands and turn head side to side.
to side against
resistance from your
hand (repeat for other
side).
XII. Hypoglossal Ask client to protrude The client should be The client was able
tongue at midline and able to move tongue to move tongue in
then move it side to without any difficulty. different directions.
side. Ability to move
tongue side to side.
DEEP TENDON REFLEXES and MUSCLE STRENGTH
DEEP TENDON REFLEX SCALE
RATE THE REFLEX WITH THE
FOLLOWING SCALE:
5+ Sustained clonus
4+ Very brisk, hyper reflexive,
with clonus
3+ Brisker or more reflexive than
normally.
2+ Normal
1+ Low normal, diminished
0.5 A reflex that is only elicited
+ with reinforcement
0 No response

MOTOR SENSORY

5/5 5/5
 2+ 2+
5/5
5/5

2+ 2+

REVIEW OF SYSTEMS
SYSTEM PHYSICAL EXAM REVIEW OF SYSTEMS
General survey UPON ADMISSION ():
BP:
Temp:
RR:
HR:
Height:
Weight:
PRESENT PHYSICAL ASSESSMENT
():
BP:
Temp:
RR:
HR:
Previous weight:
Previous BMI:
Current Weight:
Current BMI:
Skin, Skull and Inspection
Hair, Nails, Skin Observe the skins color, temperature
and turgor Skin is fair in color, warm to
touch with normal skin turgor.
Palpation
perform palpation by running the pads
of the fingers over the skin
Skull and Hair Inspection and Palpation: Skin is moist. Skins temperature
Observe the size, shape and contour of is within normal limit.
the skull.

Observe scalp in several areas by

separating the hair at various Generally round, with
locations. Note for tenderness prominence in the frontal and
Nails Inspect and feel the hair condition occipital area.

No presence of lice, nits,

Inspection dandruff or lesions and
Observe the color and shape of the tenderness
nails.
Long hair, black in color, evenly
distributed covers the whole
scalp.
No evidence of Alopecia, neither
brittle nor dry.
 The client has a light pink nails
and has the shape of convex
curve. It is smooth and is
intact with the epidermis.
When nails pressed between
the fingers (Blanch Test), the
nails return to usual color in
less than 3 seconds.

Face and Neck Inspection

Observe for shape and symmetry
Palpation
Palpate for swelling and tenderness.
Ask to open mouth full and to smile
NECK
Inspection
Observe for size and coordination
Palpation
Palpate for lymph nodes and the
trachea.
The face of the client appeared
smooth and has uniform
consistency and with no
presence of nodules or
masses.
There is no swelling tenderness
with movement. Mouth opens
fully and face is symmetrical
when smiling

The neck muscles are equal in

size. The client showed
coordinated, smooth head
Eyes, Eyelids movement with no discomfort.
and Eyelashes Inspection and Palpation
The lymph nodes of the client
are not palpable.
The trachea is placed in the
midline of the neck.
The thyroid gland is not visible
on inspection and the glands
ascend during swallowing but
are not visible.

Eyebrows: Hair is evenly

distributed. The clients
eyebrows are symmetrically
aligned and showed equal
movement when asked to raise
and lower eyebrows.
Eyelashes: Eyelashes appeared
to be equally distributed and
curled slightly outward.
Eyelids: There were no
presence of discharges, no
discoloration and lids close
symmetrically with involuntary
blinks approximately 15-20
times per minute.
Eyes

o The Bulbar
conjunctiva appeared
transparent with few

Ears Inspection and Palpation.
Inspect the auricles of the ears for
parallelism, size and position,
appearance and color.
Palpate the auricles and mastoid
process for firmness of the cartilage of
the auricles, tenderness when
manipulating the auricles and mastoid
process
Inspect the auditory meatus or the ear
canal for color, presence of cerumen,
discharges and foreign bodies.
capillaries evident.
o The sclera
appeared white.
o The palpebral
conjunctiva appeared
shiny, smooth and pale.
o There is no edema
or tearing of the lacrimal
gland.
o Cornea is
transparent, smooth and
shiny and the details of the
iris are visible. The client
blinks when the cornea
was touched.
o The pupils of the
eyes are black and equal in
size. The iris is flat and
round. PERRLA (pupils
equally round respond to
light accommodation),
illuminated and non-
illuminated pupils
constricts. Pupils constrict
when looking at near
object and dilate at far
object. Pupils converge
when object is moved
towards the nose.
o When testing for
the Extraocular Muscle,
both eyes of the client
coordinately moved in
unison with parallel
alignment.
o The client was able
to read the newsprint held
at a distance of 14 inches.
The ear lobes are bean shaped,
parallel, and symmetrical
The upper connection of the ear
lobe is parallel with the outer
canthus of the eye
Skin is same color as in the
complexion
No lesions noted on inspection
The auricles are has a firm
cartilage on palpation
There is no pain or tenderness
on the palpation of the
auricles and mastoid process
The ear canal has normally has
some cerumen of inspection
No discharges or lesions noted
at ear canal
Mouth, Throat, NOSE
Nose, Sinuses
External portion of the nose should be The nose appeared symmetrical,
inspected for: straight and uniform in color.
There was no presence of
Symmetry and placement
discharge of flaring. When
Patency of the nares
lightly palpated there were no
Discharges
tenderness and lesions.
External nares are palpated for:
Nasal septum in the midline and
Displaced of bone and cartilage
not perforated
For tenderness and masses
Nasal mucosa is pinkish to red in
Inspect for the following:
color
Position of the septum
Noted to have a dental caries on
Check septum for perforation
upper left wisdom tooth
The nasal mucosa (turbinates)
for swelling, exudates and
change in color.

MOUTH AND GUMS

Inspection and Palpation
The lips are symmetric and have
Inspect for: smooth texture.
Symmetry and surface The uvula is positioned in the
abnormalities midline of the soft palate.
Color There are no discolorations of
Uvula the enamels and the gums.
Inspect the gum for:
Color
Bleeding
Inspect for:
Color
Bleeding
Retraction of gums.
Breasts Inspection
Inspect and palpate the breast along
imaginary concentric circles. Areola is dark brown. No
swelling or lumps present.
The overlying breast is even,
nipples are round everted,
Hands same size, and equal in color.
No obvious mass noted.
No retractions or dimpling

Inspect the skin for color, do the

blanch test, inspect for any lesions. When nails pressed between
the fingers (Blanch Test), the
nails return to usual color in
less than 3 seconds.
Thorax and GENERAL The chest wall is intact with no
Lungs tenderness and masses. There
is a full and symmetrical
expansion. The client
Palpation manifested quiet, rhythmic
and effortless respiration.

Percussion Client reports no tenderness,

pain or unusual sensations.
Skin and subcutaneous tissue
 are free of lesions and
masses.

Resonance over the normal lung

tissue. Flatness over the
scapulae.
Auscultation: RR=22 cpm,
Heart HEART
Auscultation
Timing refers to whether the With normal hearth rhythm, but
murmur is with heart rate of 112 bpm
a systolic or diastolic murmur. (tachycardic)
Shape refers to the intensity No murmurs noted
over time; murmurs can
be crescendo, decrescendo or
crescendo-decrescendo.
Crescendo murmurs
progressively increase in
intensity. Decrescendo murmurs
progressively decrease in
intensity. With crescendo
decrescendo murmurs (diamond
or kite-shaped murmurs), a
progressive increase in intensity
is followed by a progressive
decrease in intensity.
Location refers to where the
heart murmur is usually heard
best. There are four places on
the anterior chest wall to listen
for heart murmurs; each of the
locations roughly corresponds to
a specific part of the heart and
should be listened to (through
the stethoscope) with the
patient lying down, face up. The
four locations are:
Aortic region - the 2nd
right intercostal space.
Pulmonic region - the 2nd
left intercostal spaces.
Tricuspid region - the 4th
left intercostal space.
Mitral region - the 5th left
mid-clavicular intercostal
space.
Additional maneuvers can be
performed for additional auscultation:
Left lateral decubitus.
With the patient sitting upright.
With the patient leaning forward
and exhaling.
Radiation refers to where the
sound of the murmur radiates.
The rule of thumb is that the
sound radiates in the direction
of the blood flow.
Intensity refers to the loudness
of the murmur, and is graded
according to the Levine scale,
from 1 to 6:[4][5]
 1. The murmur is only
audible on listening
carefully for some time.
2. The murmur is faint but
immediately audible on
placing the stethoscope
on the chest.
3. A loud murmur readily
audible but with no
palpable thrill.[6]
4. A loud murmur with a
palpable thrill.
5. A loud murmur with a
palpable thrill. The
murmur is so loud that it
is audible with only the
rim of the stethoscope
touching the chest.
6. A loud murmur with a
palpable thrill. The
murmur is audible with
the stethoscope not
touching the chest but
lifted just off it.
Pitch may be low, medium or
high and is determined by
whether it can be auscultated
best with the bell or diaphragm
of a stethoscope.
Quality refers to unusual
characteristics of a murmur,
such
as blowing, harsh, rumbling or
musical.
Abdomen Inspection Abdomen is unblemished skin
with uniform in color. Has a
Inspect for skin integrity like
symmetrical contour.
pigmentation, lesions, striae, scars,
Symmetrical movements
veins and umbilicus.
cause associated with clients
Contour
respirations
Distention With a scar of 4 inches long in
Respiratory movement length along the umbilicus
Visible peristalsis down to the symphysis pubis
Pulsations

Percussion
Percuss lightly for tympany and Percussion note is tympanic over
dullness. the umbilicus and dull over
the lateral abdomen and flank
areas. No tenderness elicited.
Genitourinary No complaints of dysuria, Nocturia, Client urinates at least more or
hematuria less 5 times a day
Musculoskeletal Inspection Client moves the muscle group
and overcomes the resistance
Observe for size, contour, symmetry
of the examiner
and movement.
No involuntary movement
Look for gross deformities, edema,
No edema
presence of trauma such as
Color is even
ecchymosis or other discoloration
Temperature is warm and even
Compare both extremities
Equal contraction and even
Neurologic Conscious and coherent and
conversant. Oriented to time,
place and person. No
problems in recalling past
memories of events.
Anus Has no difficulty in defecating.