GUIDELINES FOR RNCM 101 HEALTH ASSESSMENT

RETURN DEMONSTRATIONS

Inclusive Dates: May 3-14, 2021

A. UNIFORM:
a. Female: Pants and White T-shirt (Small print in front of the shirt is acceptable)
b. Male: Pants and White T-shirt (Small print in front of the shirt is acceptable).
-Not following: 5 hours deficiency.
c. Wrist watch with second hand is part of the checking of your uniform.
- No watch: 5 hours deficiency.

B. HAIR: FEMALE (FIXED WITH HAIR NET; NO DYE); MALE (BARBER CUT; NO
DYE)
- Not following: 5 hours deficiency.

C. Important Reminders:
* Students are expected to report to the clinical area PREPARED. This entails
punctuality, complete paraphernalia as prescribed by the clinical instructors and following
of standards for clinical exposures. Those who fail these guidelines will incur deficiencies
with corresponding payment per hour (100.00/hour).
RLE Attendance
1. Students are expected to be at the Related Learning Experience area 15 minutes
before the start of the shift.
2. A student is considered late if he/she comes 15 minutes in any later than the supposed
start of the shift.
3. The following guidelines regarding tardiness are to be followed:
a. 1-5 minutes tardy: 2 hours extension; 6-10 minutes tardy: 4 hours extension;
11-14 minutes tardy: 6 hours extension,
b. An excused absence: 1:1 ratio meaning, 1 (one day) excused absence requires
one day (1) day or 8 hours make-up;
c. An unexcused absence: 1:3 ratio meaning 1 (one day) unexcused absence
requires three (3) days or 24 hours make-up;
d. 15-20 minutes tardy: 8 hours; 21-25 minutes tardy: 14 hours; 26-29 minutes
tardy: 16 hours; 30 minutes:
e. Beyond 30 minutes tardy is equivalent of 1 day unexcused absence – 3 days
extension (24hours).
f. Tardiness during break time (time of return to duty is specified by the
supervising clinical instructor): 1-5 minutes tardy: 2 hours extension; 6-10
minutes tardy: 4 hours extension; 11-15 minutes tardy 6hours extension; over
15 minutes: 8 hours extension; over 30 minutes: 24 hours extension
4. The following guidelines regarding deficiencies in paraphernalia and others:
a. incomplete paraphernalia: 2 hours extension per item;
b. hair code: 5 hours extension (male: proper haircut; female: fixed and tied with
hairnet; no dye colored hair);
c. Uniform code: 5 hours extension for non-compliance of the following prescribed
uniform (complete uniform, proper duty shoes, nursing pin, required wrist
watch, nursing cap for female).
d. Wearing of jewelries (earing/necklace) during RLE: 2 hours extension
e. Use of CELLPHONES during duty: 5 hours extension
f. Insubordination to the clinical instructor (24 hours extension)
Schedule:

Groupings:
Room Assignments:
Skills Skills Skills Lab JBB 21 JBB JBB23 JBB 24 JBB25 Funda Control
Lab 1 Lab 2 2 22 Room Room
(Ward (Delivery
Room) Room)
Clinical Sir Sir Ngo Sir Sir Sir Ma’am Sir Sir Ma’am Ma’am
Instructors Lazaro Riogelon Castillo Gono Antecristo Nuenay Almarez Pauya Baslot
May 3, 2021 LECTURE DISCUSSIONS
(Monday)
May 4, S1 S2 S3 S4 S5 S6 S7 S8 S9, S11 S10,
2021)Tuesday S12
May 5, 2021 S1 S2 S3 S4 S5 S6 S7 S8 S9, S11 S10,
Wednesday S12
May 6, 2021 S1 S2 S3 S4 S5 S6 S7, S11 S8, S12 S9 S10
(Thursday)
May 7, 2021 HOME RECORDINGS
(Friday)
May 8, 2021 SUBMISSION OF HOME RECORDINGS
(Saturday)
May10, 2021 S1 S2 S3 S4 S5 S6 S7, S11 S8, S12 S9 S10
(Monday)
May 11, S1 S2 S3 S4 S5 S6, S11 S7, S12 S8 S9 S10
2021)Tuesday
May 12, 2021 S1 S2 S3 S4 S5 S6, S11 S7, S12 S8 S9 S10
Wednesday
May 13, 2021 HOLIDAY
(Thursday)
May 14, 2021 S1 S2 S3 S4 S5 S6 S7 S8 S9, S11 S10,
(Friday) S12
 Legend – S1 (Student and their corresponding number in the groupings list)

Summary of Procedures (Return Demonstrations)

1. ASSESSMENT OF SKIN, HAIR, NAILS
2. ASSESSMENT OF HEAD AND NECK
3. ASSESSMENT EYES AND EARS
4. ASSESSMENT MOUTH, NOSE AND THROAT
5. ASSESSING ABDOMEN
6. ASSESSING THORAX (RESPIRATORY, CARDIOVASCULAR, BREAST)
7. ASSESSING MUSCULOSKELETAL SYSTEM
8. CRANIAL NERVE ASSESSMENT
HEALTH ASSESSMENT
PROCEDURES
 Hair, Skin, and Nails Assessment
Video Link: https://www.youtube.com/watch?v=_YG2MdSa8f8
Equipment/Materials:
- Clean gloves
- Measuring tape or ruler
Procedures Rationale
1. Identifies and explain the procedures to the An explanation facilitates cooperation.
patient.
2. Wash hands and if preferred put on gloves. Hand washing and gloving deters the
spread of microorganism.
3. Prepare the equipment needed. Place patient in Organization facilitates the performance of
comfortable sitting position. Face the patient. task.
4. Ask patient skin history: (skin cancer, moles, This is to determine possible risk for
use of sunscreen) developing cancer.
5. Position patient on comfortable position, lying Proper positioning promotes comfort and
on bed or sitting on bed to start the skin allows the nurse to assess appropriately.
assessment.
6. Inspect patient overall skin color in face, chest, This would help in identifying
upper and lower extremities, and inspect for the abnormalities in color which could indicate
presence of any skin abnormalities such as pallor, certain abnormalities.
cyanosis, jaundice, erythema, -Cyanosis (Hypoxia)
-Jaundice (Liver Problems)
-Pallor (Anemia)
- Erythema (Inflammation)
7. Inspect and palpate skin for temperature, The back of the hand is more sensitive to
moisture, and texture. temperature. Increase in skin temperature
may indicate elevated body temperature;

In a dehydrated patient, skin is dry, loose,

and wrinkled. Elevated body temperature
may result in increased perspiration.
8. Inspect for skin turgor, and mobility (mobility - This technique provides information about
pinch up move easily, and turgor - move back into the patient’s hydration status as well as
place) mobility and elasticity of the skin.
Decreased elasticity may be present in
dehydrated patients.
9. Inspect for lesions, bruising, rashes, and moles. Lesions can be normal variations, such
(anterior and posterior part of the body) as a macule or freckle, or an abnormal
lesion, such as a melanoma.
10. Inspect for pressure areas. This would help in identifying presence of
pressure sores.
11. Inspect skin for edema. Edema may be the result of over
hydration, heart failure, kidney
dysfunction, or peripheral vascular
disease.
12. Inspect for hair color, distribution and Hair condition provides information about
baldness. nutritional and oxygenation status. Hair
should be evenly distributed over the
scalp. There are variations in hair color.
Scalp should feel mobile and non-tender.
13. Inspect for hair smoothness, shiny and
firmness.
14. If lesions are present, wear gloves. Inspect
scalp for lesions and hair and scalp for presence
of lice and/or nits.
15. Inspect nails for consistency, color, and Normally, nails are firm and smooth and
capillary refill. capillary refill should be brisk, less than 3
seconds.
16. Document for any changes during assessment This would help identify possible
in skin using ABCD - (Asymmetry , Borders, Color malignancy like with melanoma.
-variable color, Diameter)
 Assessing the Face, Head and Neck
Video Link: https://www.youtube.com/watch?v=9MyUsJ-Ly7M
Equipment/Materials:
-Clean Gloves
-Otoscope
-Jot down notebook
- Patient’s Chart
Procedures Rationale
1. Identifies and explain the An explanation facilitates cooperation.
procedures to the patient.
2. Wash hands and if preferred put Hand washing and gloving deters the
on gloves. spread of microorganism.
3. Prepare the equipment needed. Organization facilitates the performance of
Place patient in comfortable task.
sitting position. Face the patient.
4. Bring the preparation to the Accessibility of the equipment/materials
patient’s bedside. Provide allows the nurse to perform procedures with
privacy for patient. ease and convenience. Demonstrates
respect for the patient’s feelings.
5. Begin the head and neck Check for the level of consciousness.
assessment by asking questions
to determine if there is previous
medical history.
6. Ask patient if there is difficulty To check for cervical instability in the neck.
swallowing or chewing.
7. Inspect the head, which includes
the face and hair.
8. Palpate the cranium and inspect
hair for infestation, loss of hair
and skin breakdown.
9. Palpate the temporal artery and To check the transmission of sensory
test cranial nerve V ( trigeminal ) information to the skin, sinuses and mucous
along with palpate membrane.
temporomandibular and
frontal/maxillary sinuses.
10. Inspect the eyes, which includes
sclera, conjunctiva, pupils, and
eyelids.
11. Inspect the ears and assess
tympanic membrane with
otoscope.
12. Assess the neck. Palpate the To check if it is in normal central position.
trachea and thyroid gland.
13. Palpate the lymph nodes of the
neck and carotid artery. Note for
any noticeable hard masses and
enlargement of thyroid glands
and lymph nodes.
14. Document the necessary This will help identify any abnormalities that
findings. would help in the diagnosis and
management of the patient.
15. Maintains body mechanics
throughout the performance of the
procedures.
 16. Manifest neatness in the performed
procedure.
17. Receptive to criticism.
18. Observes courtesy.
19. Shows calmness while performing
the procedure.
20. Uses correct English.
21. Shows mastery of the procedure.

ASSESSMENT OF THE EYES

Video Link: https://www.youtube.com/watch?v=PAor9WG7XF4&t=27s
Equipment/Materials:
- Examination gloves; Snellen’s Chart
- Penlight
- Opaque Cover
- Opthalmoscope
PROCEDURE RATIONALE
1. Perform hand hygiene and put on Hand hygiene and PPE prevent the spread of
PPE, if indicated. microorganisms.
PPE is required based on transmission
precautions.
2. Identify the patient. Explain the Patient identification validates the correct
procedure to the patient. patient and correct procedure.
Discussion and explanation help allay anxiety
and prepare the patient for what to expect.
3. Close curtains around bed and close Closing the door or curtain provides privacy.
the door to the room, if possible.
Adjust the head of the bed to a flat Proper bed height and lowering side rails
position or as low as the patient can make transfer easier and decrease the risk
tolerate. Raise the bed to a height for injury.
that is even with the transport
stretcher (VISN 8 Patient Safety
Center, 2009). Lower the side rails, if
in place.
4. Place the bath blanket over the Bath blanket provides privacy and warmth.
patient and remove the top covers
from underneath.
5. Test the patient’s visual acuity with a Numerator is the patient’s distance from the
Snellen eye chart. If he normally chart. Denominator is a distance at which a
wears corrective lenses, he may wear patient with normal vision can read the line.
them during this part of the eye exam. The larger the denominator, the poorer the
With the patient standing 20 feet from patient’s vision. Normal vision is 20/20.
the eye chart, instruct him to keep
both eyes open, cover one with a card
and read aloud the smallest line of
type on which he can read more than
half the letters. Note the line’s
numerator and also it’s denominator.
Record the patient’s vision for each
eye and note whether he was wearing
corrective lenses.
6. Inspect the patient’s eyes and The eyes should appear symmetrical and the
externalized structures. eyebrows should be free of scaling. The
upper eyelids should partially cover the iris
and the eyelashes should turn outward.
7. Test the oculomotor nerve by asking The eyelids should move symmetrically
the patient to close his eyes. Gently without tremors.
 palpate the eyelids for nodules or
tenderness.
8. Ask the patient to open his eyes and The conjunctiva should be pink and free of
look up as you evert the lower lid to exudate. The sclera should be white.
inspect the lower conjunctiva. Then
have the patient look down as you
pull up on his upper eyelid to inspect
the upper conjunctiva and sclera.
9. Palpate the lacrimal apparatus by Pressure here should not produce exudate or
gently pressing below the orbit. excessive tearing.
10. Check the patient’s extra-ocular To assess the extra-ocular muscles and
movements. innervation of the oculomotor, trochlear, and
abducens nerves
11. Place your finger 12 inches from the The eyes should move together equally and
patient’s eyes. Instruct him to watch smoothly through these six cardinal positions
your finger as it moves to the upper- of gaze. In the lateral position of gaze, they
right, far right, lower right, lower left, should show one or two beats of nystagmus,
far left, and upper left. a fine oscillating movement that’s abnormal in
other positions.
12. To test accommodation, hold your His pupils should constrict when they focus
finger four inches from the patient’s on your finger.
nose then ask him to look at your
finger at the wall behind you, and
back at your finger.
13. Performing Cover Uncover Test: The uncovered eye should not wander or
While the patient stares at the wall move.
behind you, have him cover one eye
with a card then observe his
uncovered eye.
14. When he removes the card, watch It should not wander or move.
the eye he’s just uncovered.
15. Inspect the patient’s cornea and lens If both corneas reflect the light in the same
for opacities then test his corneal spot, the eyes are properly aligned.
light reflex. To do this, instruct the
patient to stare straight ahead while
you shine a light on the bridge of his
nose from 12 inches away.
16. Inspect the pupils. Normally, they’re three to five centimeters
wide and equally round.
17. Check the patient’s pupillary light To assess the optic and oculomotor nerve.
reflex. To do this, darken the room Normally this causes both pupils to constrict
and shine your light on one pupil or become smaller.
from the side.
18. Assess the internal eye structure. You should see the red reflex, a reddish glow
First, prepare the ophthalmoscope by that fills the pupil.
selecting the lens size turning on the
ophthalmoscope and adjusting the
aperture to find the largest beam of
light. To examine the patient’s left
eye, use your left eye and hold the
ophthalmoscope in your left hand
with the index finger on the lens
selector. Instruct the patient to look
at a fixed point straight ahead and to
keep his eyes still. Approach him
from about 15 inches away and add
an oblique angle. Then focus a small
circle of light on his pupil.
19. Keep looking at the red reflex as you The disc should be a yellowish-orange to
move toward the patient. As the creamy pink oval or round structure.
retinal details become sharper, follow
the blood vessels until they converge
 at the optic disc on the nasal side of
the retina.
20. Use one disc diameter (1DD) as the
basis for measuring any retinal
background lesions and use a clock
face to indicate the lesions locations.
21. Observe the physiological cup which The retinal vessels, which should appear as
should be about half the size of the a pair, a vein plus a lighter thinner arteriole.
disc. The fundus, which should appear light red to
brown red and free of lesions. And the
macula, which should be about one disk
diameter temporal to the optic disc and
should contain no blood vessels.
22. REMEMBER: always inspect the Shining your light on it may cause tearing
macula last. and pupillary constriction which could make
it difficult to continue the exam.
23. After the procedure, raise the side Side rails promote safety; blanket promotes
rails and make patient comfortable. comfort and warmth.
To ensure the patient’s comfort,
cover the patient with blanket and
remove the bath blanket from
underneath.
24. Remove additional PPE, if used. Removing PPE properly reduces the risk for
Perform hand hygiene. infection transmission and contamination of
other items. Hand hygiene deters the spread
of microorganisms.
25. Document the necessary findings. This will help identify any abnormalities that
would help in the diagnosis and
management of the patient.
26. Maintains body mechanics
throughout the performance of the
procedures.
27. Manifest neatness in the performed
procedure.
28. Receptive to criticism.
29. Observes courtesy.
30. Shows calmness while performing the
procedure.
31. Uses correct English.
32. Shows mastery of the procedure.

ASSESSMENT OF THE EARS

Video Link: https://www.youtube.com/watch?v=LObJyhEdbZI&t=2s
Equipment/Materials:
Clean gloves; Otoscope
Procedures
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient. Explain the procedure to the patient.
3. Close curtains around bed and close the door to the room, if possible. Adjust the
head of the bed to a flat position or as low as the patient can tolerate. Raise the bed
to a height that is even with the transport stretcher (VISN 8 Patient Safety Center,
2009). Lower the side rails, if in place.
4. Inspect and palpate the ears. They should be symmetrical with no swelling, lesions,
thickening, or pain.
5. Palpate the mastoid process behind the ears. They should not cause tenderness.
6. Prepare to perform the otoscopic exam.
 7. To examine the patient’s ear, hold the otoscope in your dominant hand. Between your
thumb and finger, pull the pinna of the ear UP and BACK to straighten the ear canal.
(Remember you need to look in all directions to view the entire tympanic membrane
or ear drum).
8. Inspect the external ear canal. You should not see any redness, lesions, swelling, or
exudates.
9. Examine the tympanic membrane or ear drum. It should reflect the otosope’s light and
should appear shiny and gray with a white periphery. Its center should be concave with
no perforations.
10. Note the malleus and the light reflex. Occasionally you may see the incus.
11. Finally, withdraw the speculum. If you see exudate on it, change the tip to prevent
cross contamination.
12. Assess the patient’s hearing by performing the voice, Weber, and Rinne’s test.
13. For the voice test, gently occlude one of the patient’s ears with your finger, then test
the other ear as you stand one to two feet away from him.
14. Ask him to close his eyes. Gently wiggle your finger in his ear while you whisper a
two-syllable word. He should be able to repeat the word you whispered.
15. Performing Weber’s test to assess sound transmission through the skull bones. For this
test, use a tuning fork of 512 to 1,024 hertz (hz).
16. Hold the tuning fork by the stem and then strike the tines on your palm. Place the stem
of the vibrating fork midline on the patient’s skull. He should hear the sound equally
on both ears- meaning his conductive hearing is normal.
17. Performing Rinne’s test to detect if the patient has conductive hearing loss.
18. Strike the tuning fork and place the stem on the mastoid process.
19. Count the seconds until the patient says he can no longer hear the sound. This indicates
bone conduction or BC.
20. Immediately place the still vibrating fork close to the patient’s auricle near the ear
canal.
21. Count the seconds again until the patient’s says he can no longer hear the sound. This
indicates air conduction or AC.
22. Normally, air conduction is about twice as long as bone conduction.
23. Inform the patient about the results of the assessment.
24. Do after care.
25. Perform hand hygiene and record the findings to patient’s chart.
26. Maintains body mechanics throughout the performance of the procedures.
27. Manifest neatness in the performed procedure.
28. Receptive to criticism.
29. Observes courtesy.
30. Shows calmness while performing the procedure.
31. Uses correct English.
32. Shows mastery of the procedure.

ASSESSING NOSE AND MOUTH

Video Link: https://www.youtube.com/watch?v=MoNFz8okCR0&t=42s
Equipment/Materials:
- Clean gloves
- Tongue Depressor
- Penlight
- Otoscope
1. Washes hands thoroughly before the To deter the spread of microorganisms.
procedure.
2. Prepares the equipment needed for the To save time and effort
procedure.
3. Introduces oneself to the patient and To establish rapport.
validates the patient’s identity. To perform the right procedure for the right
patient.
4. Explains the procedure and ask for the To evaluate the client’s health practices.
patient’s Health History.
5. Provides privacy to the patient. To preserve the patient’s dignity.
6. Positions the patient in a comfortable To provide comfort
sitting position.
7. Inspect and palpate the external nose. To check for the color, structure and
symmetry of the nose.
8. Check patency of air flow through the Client is able to sniff through each nostril
nostrils by occluding each one of the while other is occluded. Problems may be
nostrils. a sign of swelling, rhinitis, or a foreign
object obstructing the nostrils. A line across
the tip of the nose just above the fleshy tip
is common in clients with chronic allergies.
9. If the patient reported an impaired sense Impaired sense of smell may indicate the
of smell during the health history test the following: damage to the olfactory nerves,
olfactory nerve by having the patient anosmia, hyposmia, dysosmia, phantosmia
identify specific smells with his/her eyes and parosmia.
closed one nostril at a time.
10. Inspect the nasal cavity with a short wide- To view the nasal structures easily.
tip nasal speculum.
11. Uses the nondominant hand to stabilize Use dominant hands to improve dexterity.
and gently tilt the client’s head back. The nasal mucosa should be dark pink,
Inserts the short wide tip of the otoscope moist, and free of exudates. The nasal
into the client’s nostril without touching the septum is intact and free of ulcers or
sensitive nasal septum. Slowly direct the perforations. Turbinates are dark pink
otoscope back and up to view the nasal (redder than
mucosa, nasal septum, the inferior and oral mucosa), moist, and free of lesions.
middle turbinates, and the nasal passage deviated septum may appear to be an
(the narrow space between the septum overgrowth of tissue. This
and the turbinates). is a normal finding as long as breathing is
not obstructed.
12. Ask the patient to remove dentures if Denture may hinder the inspection of the
present. Ask the patient to bite down and mouth
bare his/her teeth and assess jaw
alignment. The upper teeth should
override the lower teeth slightly.
13. Inspect the lips. Observe lip consistency Lips are smooth and moist without lesions
and color. or swelling. Pink lips are normal in light-
skinned clients as are bluish or freckled lips
in some dark-skinned clients.
14. Put on gloves and inspect the buccal Penlight and tongue depressors will help in
mucosa. Use a penlight and tongue viewing and illuminating the oral cavity.
depressor to retract the lips and cheeks to Putting on gloves helps in prevention of
check color and consistency. microbial contamination.
15. Retract the client’s lips and cheeks to Thirty-two pearly whitish teeth with smooth
check gums and teeth for color and surfaces and edges. Upper molars should
consistency. rest directly on the lower molars and the
front upper incisors should slightly override
the lower incisors. Some clients normally
have only 28 teeth if the four wisdom teeth
do not erupt.

16. Inspect the rest of the oral cavity. Check for decayed teeth, missing teeths.
Check for lesions, swelling and pain in the
oral cavity.
17. Inspect and palpate the tongue. Ask client Tongue should be pink, moist, a moderate
to stick out the tongue. Inspect for color, size with papillae (little protuberances)
moisture, size, and texture. present. A common variation is a fissured,
 topographic-map–like tongue, which is not
unusual in older clients.
18. Assess the ventral surface of the tongue. The tongue’s ventral surface is smooth,
Ask the client to touch the tongue to the shiny, pink or slightly pale with visible veins
roof of mouth. Using a gauze pad hold the and no lesions.
patient’s tongue to one side and inspect
ventral surface of tongue, frenulum, and
the area under the tongue.
19. Check the strength of the tongue. Place The tongue should offer strong resistance.
the tongue depressor at the side of the
tongue and ask the patient to push it Decreased tongue strength may occur with
away. Tongue pressure should be equal a defect of the twelfth cranial nerve—
on both sides. hypoglossal—or with a shortened frenulum
that limits motion.
20. Inspect the hard (anterior) and soft The hard palate is pale or whitish with firm,
(posterior) palates and uvula. Ask the transverse rugae.
client to open the mouth wide while you
use a penlight to look at the roof. Observe Check for unusual or foul odor. Fruity or
color and integrity. Slightly touch the back acetone breath is associated with diabetic
of the patient’s tongue with a tongue ketoacidosis. Foul odors may indicate an
depressor to check for the gag reflex. oral or respiratory infection, or tooth decay.
21. Check the anterior tongue’s ability to taste The client should distinguish between
by placing drops of sugar and salty water sweet and salty. Loss of taste
on the tip and sides of tongue with a discrimination occurs with zinc deficiency,
tongue depressor. a seventh cranial nerve (facial) defect, and
certain medication use.
22. Performs after care.
23. Washes hands.
24. Documents the procedure and other
pertinent observation.
25. Maintains body mechanics throughout the
performance of the procedures.
26. Manifest neatness in the performed
procedure.
27. Receptive to criticism.
28. Observes courtesy.
29. Shows calmness while performing the
procedure.
30. Uses correct English.
31. Shows mastery of the procedure.
 ASSESSING THE ABDOMEN
Video Link: https://www.youtube.com/watch?v=Si0PHV991t0&t=26s
The abdominal examination is performed for a variety of reasons: as part of a comprehensive
health examination; to explore GI complaints; to assess abdominal pain; tenderness of
masses: or to monitor a client postoperatively. Assessing the abdomen can be challenging,
considering the number of organs of the digestive system and the need to distinguish the
source of clinical signs and symptoms.
The sequence for assessment of the abdomen differs from the typical order of assessment.
Auscultate after you inspect so as not to alter a client's pattern of bowel sounds. Percussion
the palpation follows auscultation. Adjust the bed level as necessary throughout the
examination and approach the client from the right side. Use tangential lighting if available for
optional visualization of the abdomen.
Before assessing the abdomen, consider the patient’s history, if he reported an
abdominal pain, plan to examine the painful area last. If he has full bladder, have him
void and encourage relaxation.
PHYSICAL ASSESSMENT
When examining the structures in the abdominal quadrants, remember to perform the
examination in the following rules, inspection, auscultation, percussion and palpation.
Common abnormal findings include:
 Abdominal edema, or swelling, signifying ascites
 Abdominal masses, signifying abnormal growths or constipation
 Unusual pulsations such as those seen with aneurysm of the abdominal aorta
 Pain associated with appendicitis
EQUIPMENT
 Centimeter ruler
 Stethoscope (warm the diaphragm and belly)
 Marking pen
 Pen light
ASSESSMENT PROCEDURE RATIONALE
1. Perform hand hygiene and put on Always do safe work practices to protect
PPE if indicated. yourself and limit the spread of contamination.
2. Identify the patient and explain the This will ensure the right procedure to the right
procedure. patient and explaining the procedure promotes
understanding, foster patient’s cooperation
and ease anxiety.
3. Close curtains around bed and close This ensures patient’s privacy.
the door of the room, if possible.
4. Help the patient undress, if needed, Promotes visualization of area being assessed
and provide a patient gown. Assist and protect patient dignity.
the patient to a supine position and
expose the abdomen.
5. Observe patients face regularly for Guarding reflex may indicate the area of pain
sign of pain or guarding
6. Start by inspecting the abdomen from Abdomen should be symmetric evenly
the ribs to the symphysis pubis, its rounded or flat.
contour should be symmetrical.
7. Highlight any bulges by shining a Bulges can easily be detected through the use
light across the abdomen towards of light. No bulges should be visible.
you
8. Assess for the umbilicus , which
should be midline and inverted
9. Auscultate the abdomen. Always auscultate the abdomen before
percussing and palpating it, because these
actions can make bowel sounds more active
than normal.
10. Begin by placing the stethoscope’s Ileocecal valve is in this quadrant, vowel
diaphragm lightly on the right lower sounds are usually audible here. Decreased
quadrant, make sure that it is warm or absent bowel sounds signify the absence of
before you place it on the client’s bowel motility.
abdomen. Listen for at least 2
minutes
11. Assess bowel sound in all four Bowel sounds normally occur every 5 to 10
quadrants. seconds.
Determine if the sounds are normal,
hyperactive, hypoactive, or absent.
Be sure to listen for 5 minutes before
concluding that it is absent
12. Auscultate for vascular sounds by Vascular sounds are especially important if
switching to the bell of the the client has hypertension or if you suspect
stethoscope and listening over the arterial insufficiency to the legs.
Aorta, Renal Arteries, Iliac arteries
and Femoral arteries.
13. Listen for Bruits which may be heard Bruits are not normally heard over abdominal
during systole. aorta or renal, iliac, or femoral arteries.
14. Percuss in a systematic fashion. You Generalized tympany predominates over the
should hear dullness over the solid abdomen because of air in the stomach and
organs and tympany over the air- intestines. Dullness is heard over distended
filled organs. bladder, adipose tissue, fluid collection and
mass. Hyperresonance over gas-distended
organ.
15. Percuss each organ beginning with Indicates the upper border of the liver, it’s
the liver. To assess the liver percuss usually located at the 5th intercostal space.
from the right lung down the
midclavicular line until you hear
dullness, mark this point.
16. Then percuss up the midclavicular Indicates the liver’s lower border. It should be
line from the umbilical level until you at the right costal margin.
hear dullness, mark this point too.
17. Measure the distance between the It should measure 6-12 centimeters.
two marks to estimate the size of the
liver.
18. Assess the stomach by percussing Percussion here should produce tympani.
over the left upper quadrant.
19. Roll the patient onto his right side. Expect to hear dullness between the 9th and
Assess his spleen by percussing 11th intercostal spaces. Splenic percussion
from the sixth rib down the mid- may be obscured by air in the stomach or
axillary line. bowel.
20. Percuss at the lowest intercostal in On inspiration, dullness at the left intercostal
the anterior axillary line where you space at the anterior axillary line (AAL)
hear tympani. Then ask the patient suggests an enlarged spleen.
to take a deep breath and percuss
again. You should still hear tympani.
21. If you suspect the patient has urinary You should hear tympani over an empty
problem, percuss the bladder. Start bladder or dullness over a full one.
at a point 5 centimeters above the
symphysis pubis and continue to
percuss downwards.
22. Lightly palpate the abdomen avoiding Light palpation is used to identify areas of
only the tender areas. Using your tenderness and muscular resistance.
fingertips, palpate the right lower
quadrant and then move clockwise to
all four quadrants.
23. Now, switch to deep palpation You should detect no tenderness,
following the same palpation enlargements or masses. However, mild
sequence you used for light tenderness over the sigmoid colon is normal.
palpation, push in 5-8 centimeters. Severe tenderness or pain may be related to
Note the size, location, consistency, trauma, peritonitis, infection, tumors or
and mobility of abdominal organs. enlarged diseased organs.
24. If deep palpation proves difficult such
as in an obese patient bi- manual
palpation. To palpate the liver, slide
your left hand under the patient along
the 11th or 12th rib and push up.
25. Place your right hand on the right
upper quadrant and push your
fingers down and under the right
costal margin ask the patient to take
a deep breath and feel for the firm
liver to move down with inspiration.
26. Now, try to palpate the gallbladder Normally the gall bladder isn’t palpable if it’s
using the regular technique you used enlarged you’ll feel it below the liver.
for the liver.
27. Palpate the spleen next, reach over Normally the spleen is not palpable. If the
the patient, place your left hand edge of the spleen can be palpated, it should
behind his back at the 10th-12th rib be soft and non-tender.
and push up. Place your right hand
just below the left costal margin as
you push your right hand in and up
toward the axilla. Have the patient to
take a deep breath.
28. If a bladder problem is suspected
you’ll need to assess the bladder.
29. Place both hands in the midline two A normal bladder may not be palpable. A
and a half centimeters above the distended bladder is palpated as smooth,
symphysis pubis. Palpate in an round, and somewhat firm mass extending as
upward direction until you feel the far as the umbilicus.
edge of the bladder
30. Palpate the right kidney by placing If the kidney is palpable you should feel a
your left hand under the patient’s small round mass slide between your fingers.
waist below the 12th rib and your right An enlarged kidney may be due to a cyst,
hand directly above it. Tell the patient tumor, or hydronephrosis.
to take a deep breath and bring your
hands together as he does this.
31. Palpate the aortic pulsations by A wide, bounding pulse may be felt with an
placing your thumb and index finger abdominal aortic aneurysm. Do not palpate a
left of the midline. Estimate the pulsating midline mass; it may be a dissecting
pulsations width which should be two aneurysm that can rupture from the pressure
and a half to four centimeters. of palpation.
32. Test the patient’s abdominal Normally, muscles on the stroked side
superficial reflex to . To do this, contract and the umbilicus deviates toward the
stroke the handle of the reflex stroked area.
hammer or the wooden end of the
cotton-tipped across his abdomen
from the side to the midline.
33. Maintains body mechanics
throughout the performance of the
procedures.
34. Manifest neatness in the performed
procedure.
35. Receptive to criticism.
36. Observes courtesy.
37. Shows calmness while performing the
procedure.
38. Uses correct English.
39. Shows mastery of the procedure.
 ASSESSMENT OF THE THORAX, CARDIOVASCULAR AND BREAST
Video Links:
https://www.youtube.com/watch?v=IidNl4xO6Mg&t=110s
https://www.youtube.com/watch?v=FkM6muqmve0&t=20s
https://www.youtube.com/watch?v=1NQ8GqSOhp8&t=8s
Equipment/Materials:
PROCEDURES RATIONALE
1. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent the spread of
indicated. microorganisms.
PPE is required based on transmission
precautions.
2. Identify the patient. Explain the procedure Patient identification validates the correct
to the patient. patient and correct procedure.

Discussion and explanation help allay anxiety

and prepare the patient for what to expect.
3. Close curtains around bed and close the Closing the door or curtain provides privacy.
door to the room, if possible. Adjust the Proper bed height and lowering side rails make
head of the bed to a flat position or as low transfer easier and decrease the risk for injury.
as the patient can tolerate. Raise the bed to
a height that is even with the transport
stretcher (VISN 8 Patient Safety Center,
2009). Lower the side rails, if in place.
4. Place the bath blanket over the patient and Bath blanket provides privacy and warmth.
remove the top covers from underneath.
Assessing the Thorax
5. To assess the thorax, ask the patient to The patient should breathe comfortably while
breathe normally as you observe his sitting with his arms at rest
respirations.
6. Move around slowly at the patient’s back. Normally the lateral diameter is up to twice the
As you do this assess the anteroposterior anteroposterior diameter for a ratio of about
and lateral diameters of the thorax. two to one
7. Still standing behind the patient, use your They should be evenly spaced and non-tender.
finger pads to palpate the spinous
processes.
8. Assess the respiratory expansion. To do Their movement should be symmetrical.
this, place your thumbs at the level of T10
or the 10th thoracic vertebra. Spread your
fingers allowing for small folds of skins
between your thumbs. Ask the patient to
take deep slow breaths. As he does, watch
your thumbs move with respiration.
9. Assess for tactile fremitus or voice sounds In each location, you should feel equal
palpated on the chest wall surface using the vibrations.
ball of your hand. Feel for vibrations as the
patient repeats the phrase “Ninety-nine”.
Move from the apices inside the scapula
down to the lower and lateral thorax.
10. Perform mediate percussion using a Resonance should be equal over the lungs. You
systematic pattern so you can compare the should feel dullness over the diaphragm.
two sides. Hyperresonance means you found an area of
increased air in the lung or plural space as with
the pneumothorax or acute asthma. Abnomal
dullness indicates decreased air in the lungs as
with atelectasis or a buildup of pleural fluid.
11. Assess the diaphragmatic excursion. To do Normally, this distance which represents
this, ask the patient to exhale and then hold diaphragmatic excursion measures three to five
his breath. As he holds his breath, percuss centimeters and is equal on both sides.
from the scapula down to where the sound
changes from resonance to dullness. Mark
this spot with a pen. Ask the patient to
inhale deeply and hold his breath as you
percuss further down to the new area of
dullness. Mark this spot too. Repeat this
process on the other side. Measure the
distance between the set of marks on each
side.
12. Assess the kidneys using blunt or fist Percussion in this area should not cause
percussion over the costovertebral angle. tenderness.
13. Finally, auscultate breath sounds with the Normal breath sounds vary with the area
diaphragm of your stethoscope. To do this, you’re assessing. You should hear
instruct the patient to breathe deeply Bronchovesicular sounds between the scapula.
through his mouth. Starting at the lung These sounds are moderate in pitch and
apices, auscultate the lungs. Move amplitude with an inspiratory phase equal to
systematically from side to side down the the expiratory phase. You should hear
patient’s back, and laterally toward the vesicular sounds at the apices down to the
axilla. Be sure to listen for at least one bases and laterally. These sounds are low-
complete respiration at each location. pitched and soft with a longer inspiratory than
expiratory phase.
14. Listen for abnormal sounds such as crackles Crackles which can be heard on inspiration and
and wheezes and for coughing and sometimes on expiration result from collapsed
abnormal respiratory effort. If you hear or fluid0filled alveoli popping open. They have
crackles, ask your patient to cough then a fine crackling or sometimes a bubbling
listen again if the abnormal breath sounds sound. Wheezes which can be heard on both
have cleared. inspiration and expiration are high or low
pitched. They indicate airway obstruction.
15. If you suspect an abnormality, have the Normally the word sound muffled and
patient say “Ninety-nine” as you auscultate indistinct.
these areas.
16. To assess the anterior thorax, begin with the Normally, they appear symmetrical and you
bones and muscles. should not see accessory muscle use,
retractions, or bulges. The patient should not
have signs of respiratory difficulty such as
cyanosis or nostril flaring.
17. Palpate the thorax with your finger pads You should find no nodules or tenderness.
moving from the lung apices to the bases.
18. To assess respiratory expansion, place your They should move simultaneously and
hands on the patient’s chest along the symmetrically
coastal margins with your thumbs pointing
the xiphoid process. Have the patient take a
few deep breaths. As he does this, watch
your thumbs.
19. Assess for tactile fremitus as the patient Vibrations should feel equal but stronger in the
repeats the phrase “Ninety-nine”. Move upper chest than the lower chest.
from the long apices down to a point below
the nipples comparing sides.
20. Perform percussion over the lungs using a Percussion should produce low resonant
systematic approach. Start just above the sounds.
clavicle and percuss in the intercostal spaces
down the chest from side-to-side.
21. Auscultate over the patient’s lungs with the Normal breath sounds vary with the area
diaphragm of the stethoscope in the same you’re assessing. You should hear Tracheal
patter you used for percussion. At each sounds over the trachea. These are high-
location, listen for one complete respiration. pitched, loud, and tubular. You should hear
Bronchovesicular sounds laterally and over the
bronchi at the angle of Louis. Expect to hear
Vesicular sounds over most of the anterior
thorax and the periphery.
22. If you suspect an abnormality, have the Normally the word sound muffled and
patient say “Ninety-nine” several times as indistinct.
you auscultate the areas involved.
Assessing Cardiovascular aspect of the Thorax
23. Help the patient into Semi-Fowler’s In about half of patients, the apical pulse isn’t
position and move to the right side of the visible.
table. Check his apical pulse. Inspect the
fourth and fifth intercostal spaces at the
midclavicular line. To help visualize the
pulse better, you can repeat the process with
the patient on his left side.
24. Palpate the apical pulse even if it’s not It should feel like a short gentle tap and should
visible. be palpable in a area about one centimeter by
two centimeters.
25. Using the ball of your hand, systematically To note any lifts, heaves of vibrations.
palpate the heart’s borders in the
sternoclavicular area, aortic area, pulmonic
area, and left ventricular area.
26. Auscultate the heart at the right second S2 is best heard at the base of the heart and
intercostal space close to the sternum, along corresponds to pulmonic and aortic valve
the left sternal border in each intercostal closure at the end of ventricular systole. S1 is
space from the second through the fifth best heard at the apex. It corresponds to mitral
intercostal spaces, and at the apex. As you and tricuspid valve closure at the start of
auscultate using both the diaphragm and the ventricular systole. It should coincide with the
bell of the stethoscope, determine the carotid pulse. Especially note the timing of the
patient’s heart rate and rhythm and listen for heart sounds in relation to the cardiac cycle and
the normal heart sounds S1 and S2. stay alert for abnormal heart sounds such as S3
or ventricular gallop which may be a cardinal
sign of heart failure, and S4 or summation
gallop. S4 results from vibrations caused by
forceful ejection of blood from the atria into
ventricles that expand less than they should.
Assessing the Breast
27. MALE PATIENT: continue by assessing It should be smooth with no nodules or
the breast. swelling. Gynecomastia or breast enlargement
is normal in males only during puberty.
28. Palpate the nipples and breast tissue You should not find a nodule.
checking for nodules.
29. Check the axilla. It should have no enlarged lymph nodes.
30. FEMALE PATIENT: inspect the breast. In most women, one breast is slightly larger
than the other. The breast should be smooth
with no redness, lesions, dimpling, extreme
vascularity, or retractions. Lymph nodes in the
breast area should not be visible or bulging.
31. Assess the nipples. They should be symmetrical and show no
scaling, discharge, lesions, or bleeding.
32. Watch the patient as she raises her arms, In each position, you should see no puckering,
presses her hands on her hips, and leans dimpling, or retraction. As the patient leans
forward. forward, her breasts should swing freely.
33. Using the pads of your middle fingers, Small, freely movable lymph nodes are
palpate the axilla to assess the lymph nodes. normal.
Be sure to reach the pectoral muscle and
move your fingers toward the clavicle and
down against the ribs.
34. Instruct the patient to lie down and place a
pillow under her shoulder on the side you’ll
be examining then ask her to raise her arm
on that side. With the pads of your middle
fingers, use a circular motion to palpate
each section of the breast starting at the
nipple and moving out in concentric circles.
As you do this, teach the patient the proper
palpation technique and encourage her to do
a breast exam monthly. If you prefer, you
can use an in-and-out pattern when you
palpate or you can sweep your finger pads
across the breast. No matter which pattern
you use, be consistent and remember to
palpate the Tail of Spence.
35. Palpate the nipple compressing it gently. You should not detect any induration or
masses. If you see nipple discharge, obtain a
culture. If you suspect a mass, try to elicit
dimpling by moving or compressing the tissue
and check the opposite side for symmetry. If
you find a mass, document it’s size, shape,
consistency, mobility, and degree of
tenderness.
36. When documenting your findings, mentally
divide the breast into four quadrants or
imagine the breast as a clock face.
37. Check the epitrochlear lymph nodes by The nodes should not feel enlarged or tender.
palpating the groove between the biceps and
triceps muscles.
38. After the procedure, raise the side rails and Side rails promote safety; blanket promotes
make patient comfortable. To ensure the comfort and warmth.
patient’s comfort, cover the patient with
blanket and remove the bath blanket from
underneath.
39. Remove additional PPE, if used. Perform Removing PPE properly reduces the risk for
hand hygiene. infection transmission and contamination of
other items. Hand hygiene deters the spread of
microorganisms.
40. Maintains body mechanics throughout the
performance of the procedures.
41. Manifest neatness in the performed
procedure.
42. Receptive to criticism.
43. Observes courtesy.
44. Shows calmness while performing the
procedure.
45. Uses correct English.
46. Shows mastery of the procedure.
 Assessing Musculoskeletal System (Upper and Lower Extremities)
Video Links:
- https://www.youtube.com/watch?v=3zUm0uWn6cE&t=92s
- https://www.youtube.com/watch?v=ON4TdTFlQk8&t=75s
Equipment/Materials:
Procedures:
1. Note the ROM, muscle mass and strength.
2. To assess the vascular system in the arms, inspect the patient’s arms, they should feel warm,
no edema or lesions.
3. Check capillary refill time by depressing the nail bed until it blanches, then quickly release
the pressure. The nailbed should regain its color in one to two seconds.
4. Palpate the radial and brachial pulses which should be equal, regular in rate and rhythm and
strong but not bounding in amplitude.
SENSORY TESTING
5. Have the eyes close, scatter the stimuli, vary the pace, and compare distal and proximal
areas. Compare both sides of the body and map any areas of sensory loss.
6. Assess for a light touch sensation- randomly touch a cotton to the patient’s arm and have
him tell you when he feels the touch.
7. Assess the pain sensation, use a broken swab to test sharp and dull sensation. Tell the
patient to identify the sensation if it is dull or sharp as you lightly touch the skin with a swab.
Alternate the blunt and sharp edge of the swab. If the patient has trouble identifying the stimuli,
8. Assess for temperature sensation- in a similar way, using a test tube of warm and cold water.
9. Test for vibration sensation, activate a tuning fork and then quickly place its stem over a bony
prominence such as a finger. Instruct the patient to say no when the fork starts vibrating and
again when it stops vibrating. Perform this test in both arms. Normally the patient can tell when
the fork can start and stops vibrating. If he cant, test his vibrating sensation more proximally.
Perform same assessment on both legs.
10. Assess the patient’s position sensation. Tell the patient to close his eyes. As you move one
of his fingers up and down, instruct him to tell you which direction it is moving in. He should be
able to tell you correctly. If he can’t, test the sensation more proximally in both arms and both
legs.
TOUCH DISCRIMINATION TEST
11. Stereognosis Test - Ask the patient to close his eyes then place a coin or any object in his
hand and tell him to identify it.
12. Graphesthesia Test - perform this test if the patient has difficulty in moving his hands. Trace
a number on the palm of his hand and ask him to identify it.
13. Two- point Discrimination Test- Randomly touch two sharp objects to the patient’s
fingertips. Gradually decrease the distance between 2 objects. Note the distance in which he
can no longer perceive 2 separate points. Normally it is less than 5 mm.
14. Extinction Test- Touch two corresponding parts of the patient’s body at the same time and
ask him to show you where he was touched.
MOTOR FUNCTION TEST
15. Assess Deep Tendon Reflexes - have the patient relax his arms and remember to grade
the reflex on a scale of zero if it is absent to four if its hyperactive. Start by testing the biceps
reflex. Place your thumb on the patient’s biceps tendon and strike it with a reflex hammer.
Normally this causes the forearm to flex.
16. Test the triceps reflow as you support the patient’s upper arm. Strike the triceps tendon
above the elbow. This should elicit forearm extension.
17. Brachioradialis reflex - strike the forearm two to three cm above the radial above the styloid
process. This normally causes forearms flexion and supination.
18. Cerebellar function of the arm- to assess rapid alternating movements, have the patient pat
his knees with his palms facing upward first and then downward. Have him gradually increase
the speed of his movements. His movements should be coordinated and equal.
19. Ask the patient to touch his thumb to each finger on the same hand and then to reverse the
direction. He should be able to do this rapid skilled movements quickly and accurately.
20. Point -to -point localization using the finger to finger test- instruct the patient to touch your
finger with his finger and then touch his nose. His movements should be smooth and accurate.
21. Finger to nose test- instruct the patient to close his eyes then have him stretch out his arms
and touch his nose with one index finger then the other. Gradually increasing the speed. Again
his movements should be smooth and accurate.
LEG ASSESSMENT- NOTE THE LEGS ACTIVE ROM, MUSCLE MASS AND STRENGTH.
1. To assess the vascular system, inspect the patient’s legs, observe the skin color and
condition, hair distribution and toenail integrity. Observe for abnormalities such as asymmetry,
venous patterns, lesions and edema.
2. Using the back of your hand, check the temperature of the legs from the feet up, it should be
warm and symmetrical.
3. Flex the patient’s knee and compress the calf muscle against the tibia. Release the pressure
and then dorsiflex the patient’s foot. Neither action should cause pain.
4. Palpate the peripheral pulses in the legs. To palpate the femoral pulse, find the artery halfway
between the symphysis pubis and the anterior superior iliac spine.
5. Compress it and release slowly. The pulse should gently tap against your fingertips.
6. To locate the popliteal pulse, bend the patient’s knee and feel for the pulse in the popliteal
fossa.
7. Palpate the posterior tibialis pulse in the groove between the medial malleolus and the
Achilles tendon. Assess the dorsalis pedis pulse by palpating lightly lateral to the extensor
tendon of the great toe.
8. Check for edema by pressing over the tibia or medial malleolus for 5 seconds and then
releasing the pressure. Normally finger pressure does not leave an indentation or pit. If it does,
grade the pitting on a scale from plus one for mild pitting to plus four to severe pitting.
9. Assess the legs for LIGHT TOUCH SENSATION, PAIN SENSATION, VIBRATION
SENSATION, and TEMPERATURE SENSATION AND POSITION SENSATION.
10. SENSORY FUNCTION TEST( SAME PROCEDURE WITH THE UPPER EXTRMETIES)
MOTOR FUNCTION TEST-ASSESSING DEEP TENDON REFLEX
11. Test for quadriceps reflex-have the patient sit up with legs relaxed and dangling over the
edge of the table. Place one hand above the knee then tap his patellar tendon with a reflex
hammer. The lower leg should extend and the quadriceps should contract
12. Test for Achilles reflex- have the patient bend his knee rotate his hip upward and dorsiflex
his foot lightly the tap the Achilles tendon with a reflex hammer. The normal response is plantar
flexion.
13. Test for plantar or Babinski reflex- stroke the lateral aspect of the sole of the foot from the
heel upward. The normal response is plantar flexion with no toe fanning or great toe
dorsiflexion.
14. If any of the patient’s reflexes are hyperactive, check for clonus - an abnormal pattern of
rapidly alternating involuntary muscle contraction and relaxation. Lightly support the lower leg
in one hand and dorsiflex the foot with the other hand. Normally no extra movement or
contraction can be seen in the legs.
CEREBELLAR FUNCTION TEST
15. Heel to shin test - ask the patient to place one heel on the opposite knee and slide it down
to the ankle. He should be able to do this in a straight line on the shin
GAIT AND GROSS MOTOR FUNCTION TEST
16. Instruct the patient to walk 10-15 feet, turn, and walk back towards you. His movement
should be smooth and coordinated. His arms should swing freely and he should turn without
losing his balance.
ROMBERG TEST
17. Have the patient stand with feet together, his arms at his sides, and his eyes closed.
Standing close to the patient, observe him for 20 seconds, he may sway slightly but should not
lose his balance. This test assesses the acoustic nerve position sense, cerebellar function, and
muscle strength.
TANDEM WALKING
18. Have the patient walk heel to toe in a straight line. He should be able to walk in a straight
line without losing his balance.
19. Maintains body mechanics throughout the performance of the procedures.
20. Manifest neatness in the performed procedure.
21. Receptive to criticism.
22. Observes courtesy.
23. Shows calmness while performing the procedure.
24. Uses correct English.
25. Shows mastery of the procedure.
 CRANIAL NERVE ASSESSMENT
Video Link: https://www.youtube.com/watch?v=oZGFrwogx14&t=74s
Equipment/Materials:
1. Soap, or coffee, or vanilla
2. Snellen Chart
3. Pen light
4. Ball pen
5. Tongue depressor
PROCEDURES NORMAL FINDINGS
Nerve: Olfactory ( I )
Type: Sensory
Function: Sense of smell

Test: Client correctly identifies scent presented to

each nostril.
For all assessments of the cranial nerves,
have client sit in a comfortable position at
your eye level. Ask the client to clear the
nose to remove any mucus then to close
eyes, occlude one nostril, and identify a
scented object that you are holding such as
soap, coffee, or vanilla
Nerve: Optic ( II )
Type: Sensory
Function: Vision
Test:
1. Peripheral vision test by doing 1. The patient will acknowledge the
confrontational visual field. number of fingers you presented.
- have the patient stand in front of you
about the arm’s length away. Let your
patient cover his/her right eye. Also,
cover your left eye (same side).

Look at my eye not in my fingers, tell

me how many fingers in upper and
lower visual fields and about the middle
of the visual field.

Repeat the test on the other side of the

eye.

2. Visual Acuity using Snellen Chart. 2. The patient can read from line eight
- Let the patient stand in front of the so that means the patient has a 20/20
Snellen chart 20 feet away. vision, Means that he can see 20 feet
- ask if the patient is using glasses and that a person with normal vision can
ask patient does wear glasses, you’ll see at 20 feet.
wan to them to were those for this test.
- Let the patient read the lowest line.
Cover the left eye then cover the right
eye and let the both eyes read in the
Snellen chart. And ask the patient till
what line can you read for me.

Nerve/s: - Oculomotor ( III )

- Trochlear ( IV )
- Abducens ( VI )
Type: Motor
Function: Oculomotor: Innervates extrinsic
eyemuscles and ciliary muscle
Trochlear : Innervates superior oblique
muscle
Abducens : Innervates external rectus muscle
Important: These three (3) nerves operate as
a unit and
should be tested and evaluated together.

1. Test: Assess extraocular movements 1. Eyes move in a smooth,

coordinated motion in all
- take a pen light/ballpen and hold 12 to 14 directions (the six cardinal
inches away from the patient’s nose and fields).
instruct patient head still and don’t move your
head and watch were I move the pin
line/ballpen and as you doing this you’re
going to do you’re going to perform it in the
six cardinal field of gays and you’re just going
to move it you’re looking for any involuntary
shaking of the eyes.

2.Test: Assess pupillary response 2. Bilateral illuminated pupils

constrict simultaneously. Pupil
Dim the lights a little bit and were opposite the one illuminated
gonna have the patient stare off at constricts simultaneously.
a distant object that helps dilate
those pupils and then were going
to shine using our pen light at the
side and we’re gonna see how
that pupil response is she constrict
and then on the other side it
should constrict as well. Baseline
pupil size was like three
millimeters it should go down to
one milliliter and should happen
on both sides 3. Pupils are equal round reactive to
light accommodation (PERRLA)
3. Assess accommodation

1. Turn the lights back on, make the

light again we’re gonna have him
stare off at a distant object that
help dilate the pupils and we’re
going to take a pen light (use a
pen light finger) and you’re just
gonna slowly move it inward to
the nose. Pupils constrict they
accommodate and the eyes cross
while looking at the pen light.

Nerve: Trigeminal ( V )
Type: Motor; Sensory
Function: Chewing movements by innervation
of masseter, temporal, and
pterygoid muscles; corneal and sneezing Temporal and masseter muscles contract
reflexes; and sensations bilaterally.
of face, scalp, and teeth.

Test:
Test motor function. Ask the client to clench
the teeth while you palpate the temporal and
masseter muscles for contraction and let
client open his/her mouth against the
resistance.
Nerve: Facial ( VII )
Type: Motor
Function: Facial expression, taste ( anterior
2/3 of the tongue ), and salivary and lacrimal
gland innervation.
Test:
Let the client close his/her eyes tightly and Symmetrical facial contours, lines, wrinkles;
open them up. Let the client smile, frown, and symmetrical facial movement.
puff out your cheeks
Nerve: Acoustic/ vestibulocochlear ( VIII )
Type: Sensory
Function: Hearing and sense of balance
Test:
Occlude one of his/her ears and then whisper Client hears whispered words from 1 to
two words on the other side, he/she needs to 2 feet
tell me what I said.

Nerve/s: - Glossopharyngeal ( IX )
- Vagus ( X )
Types: Motor ; Sensory
Function: Swallowing movements and saliva
secretion. Gag and swallow reflexes.
Sensation in the pharynx and larynx, as well
as taste on posterior 1/3 of tongue. Also,
autonomic innervation of heart, lungs,
esophagus, and stomach.
Important: these two nerves operate as a
unit and should be tested and evaluated
together.

Test motor function. Ask the client to

open mouth wide and say “ah” while you
use a tongue depressor on the client’s Uvula and soft palate rise bilaterally and
tongue. symmetrically on phonation.

Test the gag reflex by touching the posterior

pharynx with the tongue depressor.
Warn the client that you are going to do Gag reflex intact. Some normal clients
this and that the test may feel a little may have a reduced or absent gag reflex.
uncomfortable.

Check the client’s ability to swallow by giving

the client a drink of water. Also note the
client’s voice quality. Client swallows without difficulty. No
hoarseness noted.

Nerve: Spinal Accessory ( XI )

Type: Motor
Function: Innervates sternocliedomastoid and The client does it with ease.
trapezius muscles.
Test: There is symmetric, strong contraction of
Let the client move the head side to side, up the trapezius muscles
and down. Ask the
client to shrug the shoulders against
resistance to assess the trapezius muscle
Nerve: Hypoglossal ( XII )
Type: Motor
Function: Innervates tongue muscle. The client does it with ease.
Test: To assess mobility of the tongue, ask
the client to protrude tongue, move it to each
side then put it back in the mouth.