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

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.

Complete Head to Toe Assessment with Videos

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