Head-To-Toe Assessment N. Cranial Nerve I (olfactory Nerve)

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To test the adequacy of function of the olfactory nerve:

1. The client is asked to close his eyes and occlude.
2. The examiner places aromatic and easily distinguish nose. (e.g. coffee).
3. Ask the client to identify the odor.
4. Each side is tested separately, ideally with two different substances.

Mouth and OropharynxLips are inspected for:

1. Symmetry and surface abnormalities.
2. Color
3. Edema

Normal Findings:

1. With visible margin
2. Symmetrical in appearance and movement
3. Pinkish in color
4. No edema

Palpate the temporomandibular while the mouth is opened wide and then closed for:

1. Crepitous
2. Deviations
3. Tenderness

Normal Findings:

1. Moves smoothly no crepitous.
2. No deviations noted
3. No pain or tenderness on palpation and jaw movement.

Gums are inspected for:

1. Color
2. Bleeding
3. Retraction of gums.

Normal Findings:

1. Pinkish in color
2. No gum bleeding
3. No receding gums

Teeth are inspected for:

1. Number
2. Color
3. Dental carries
4. Dental fillings
5. Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth).
6. Tooth loss
7. Breath should also be assessed during the process.

Normal Findings:

1. 28 for children and 32 for adults.
2. White to yellowish in color
3. With or without dental carries and/or dental fillings.
4. With or without malocclusions.
5. No halitosis.

Tongue is palpated for:

1. Texture

Normal Findings:

1. Pinkish with white taste buds on the surface.
2. No lesions noted.
3. No varicosities on ventral surface.
4. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue.
5. Gag reflex is present.
6. Able to move the tongue freely and with strength.
7. Surface of the tongue is rough.

Uvula is inspected for:

1. Position
2. Color
3. Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note that the uvula will move upward and forward.

Normal Findings:

1. Positioned in the mid line.
2. Pinkish to red in color.
3. No swelling or lesion noted.
4. Moves upward and backwards when asked to say “ah”

Tonsils are inspected for:

1. Inflammation
2. Size

A Grading system used to describe the size of the tonsils can be used.

• Grade 1 – Tonsils behind the pillar.
• Grade 2 – Between pillar and uvula.
• Grade 3 – Touching the uvula
• Grade 4 – In the midline.

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• Head-To-Toe Assessment (M. Nose and Paranasal Sinuses) The external portion of the nose is inspected for the following: 1.     Placement and symmetry. 2.    Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in breathing) 3.    Flaring of alaenasi 4.    Discharge The external nares are palpated for: 1.    Displacement of bone and cartilage. 2.    For tenderness and masses The internal nares are inspected by heperextending
• Head-To-Toe Assessment A. Head (Skull, Scalp, Hair) 1. Observe the size, shape and contour of the skull. 2. Observe scalp in several areas by separating the hair at various locations; inquire about any injuries. Note presence of lice, nits, dandruff or lesions. 3. Palpate the head by running the pads of the fingers over the
• Head-To-Toe Assessment (Q. Breast) Inspection of the Breast There are 4 major sitting position of the client used for clinical breast examination. Every client should be examined in each position. The client is seated with her arms on her side. The client is seated with her arms abducted over the head. The
• Head-To-Toe Assessment (L. Ears) 1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color. 2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles, tenderness when manipulating the auricles and the mastoid process. 3. Inspect the auditory meatus or the
• Head-To-Toe Assessment (B. Face) 1.    Observe the face for shape. 2.    Inspect for Symmetry. a.    Inspect for the palpebral fissure (distance between the eye lids); should be equal in both eyes. b.    Ask the patient to smile, There should be bilateral Nasolabial fold (creases extending from the angle of the corner of the mouth). Slight asymmetry in the fold is normal. c.   If