Head-To-Toe Assessment N. Cranial Nerve I (olfactory Nerve)
To test the adequacy of function of the olfactory nerve:
- The client is asked to close his eyes and occlude.
- The examiner places aromatic and easily distinguish nose. (e.g. coffee).
- Ask the client to identify the odor.
- Each side is tested separately, ideally with two different substances.
Mouth and OropharynxLips are inspected for:
- Symmetry and surface abnormalities.
- With visible margin
- Symmetrical in appearance and movement
- Pinkish in color
- No edema
Palpate the temporomandibular while the mouth is opened wide and then closed for:
- Moves smoothly no crepitous.
- No deviations noted
- No pain or tenderness on palpation and jaw movement.
Gums are inspected for:
- Retraction of gums.
- Pinkish in color
- No gum bleeding
- No receding gums
Teeth are inspected for:
- Dental carries
- Dental fillings
- Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth).
- Tooth loss
- Breath should also be assessed during the process.
- 28 for children and 32 for adults.
- White to yellowish in color
- With or without dental carries and/or dental fillings.
- With or without malocclusions.
- No halitosis.
Tongue is palpated for:
- Pinkish with white taste buds on the surface.
- No lesions noted.
- No varicosities on ventral surface.
- Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue.
- Gag reflex is present.
- Able to move the tongue freely and with strength.
- Surface of the tongue is rough.
Uvula is inspected for:
- Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note that the uvula will move upward and forward.
- Positioned in the mid line.
- Pinkish to red in color.
- No swelling or lesion noted.
- Moves upward and backwards when asked to say “ah”
Tonsils are inspected for:
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.