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NR509 Head to Toe Assessment
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NR509 Head to Toe Assessment
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NR509 Head to Toe AssessmentIntroduce yourself & patient - ANS-Hi, my name is ________ and I will be performing a
physical examination for NR509 Advanced Physical Assessment at Chamberlain
University
My name is _____ and I give permission for this video assessment to be uploaded to
Chamberlain college of nursing
Facial skin - ANS-No discoloration or lesions
Head - ANS-Midline, symmetrical, normal in size
Lymph node palpation (9 locations) - ANS-*Preauricular* - in front of ear
*Post auricular* - behind ear
*Occipital* - back of head
Move forward - *tonsillar*
Under jawline - *submandibular*,
*Submental*
*Anterior cervical*
*Posterior cervical*
*Supraclavicular* - above clavicles
---Do not feel any enlargement, equal bilaterally
CN 5 - ANS-*Trigeminal nerve*
Motor component - palpate over the master muscle as patient clenches jaw
--No distortions, great strength
Sensory component -- close eyes, let me know where you feel my touch -- forehead,
cheeks, chin, nose
CN 7 - ANS-*Facial nerve*
Inspect for facial symmetry with...
-Smile
-Frown
-Raise eyebrows
, -Puff cheeks
-Pucker lips
----symmetrical bilaterally
Outer Ear: Inspection - ANS-Inspect outer ear for nodules, skin lesions & symmetry
Ear: Inspection (Otoscope) - ANS-Pull ear up & back
*Auditory canal* -- clear, no redness, swelling, drainage, or cerumen
*Tympanic membrane* -- pearly gray, no effusion in middle ear
Do same for other ear -- no redness, swelling, drainage, or cerumen, tympanic
membrane is pearly gray, no fluid in external auditory canal
Ear: Palpation - ANS-Palpate pinnae and tragus for nodules & tenderness
CN 8 - ANS-*Acoustic nerve* (hearing)
Whisper test - whisper words out of patient's sight & patient repeats words back.
Test one ear at a time.
"one, two, three" and "four, five, six"
--Hearing intact bilaterally
Eyes: Inspection - ANS-*Conjunctiva* -- pink, clear, no drainage or lesions
*Sclera* - white & clear
CN 2 - ANS-*Optic nerve*
*Central vision*
*Snellen pocket eye chart
6 ft away, cover one eye...read lowest line possible...repeat other eye --- 20/20 left eye,
right eye, both eyes
*Peripheral vision*
Stand up at eye level, look straight ahead, do not move head.
--Hands forward from back
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