Cranial Nerve Name Sensory and/or Motor Major Function

1 Olfactory Nerve Sensory Sense of Smell

2 Optic Nerve Sensory Vision
Eye movements; pupillary
3 Oculomotor Nerve Motor constriction and
accommodation; muscle of
upper eyelid
4 Trochlear Nerve Motor Eye movements (intorsion,
downward gaze)
Somatic sensation from
5 Trigeminal Nerve Sensory and Motor face, mouth, cornea;
muscles of mastication
Eye movements
6 Abducens Nerve Motor (abduction or lateral
movements)
Controls the muscles of
facial expression; taste
7 Facial Nerve Sensory and Motor from anterior tongue;
lacrimal and salivary
glands
8 Vestibulocochlear Nerve Sensory Hearing: sense of balance
Sensation from posterior
tongue and pharynx; taste
9 Glossopharyngeal Nerve Sensory and Motor from posterior tongue;
carotid baroreceptors and
chemoreceptors; salivary
gland.
Autonomic functions of
gut; cardiac inhibitions;
10 Vagus Nerve Sensory and Motor sensation from larynx and
pharynx; muscles of vocal
cords; swallowing
11 Spinal Accessory Nerve Motor Shoulder and neck
muscles
12 Hypoglossal Nerve Motor Movement of tongue

Material needed to assess the Head and Neck Assessment:

 Stethoscope
 Otoscope
 Tongue blade
 Penlight
 Gloves

EYE CONDITIONS;
PERRLA - Pupils are equal, round and reactive to light and accommodation.

 Eyelid Swelling - The skin of your eyelid is less than 1 millimeter thick. But, since the tissue is loose and
stretchy, your eyelid is capable of swelling considerably.
 Jaundice - causing a yellowish appearance of the skin and the whites of the eyes.
 Erythema - can be caused by environmental factors, infection, or overexposure to the sun
 Anisocoria – characterized by a difference in pupil sizes.
 Strabismus - misalignment of the eyes
 3 to 4 mm
Ears;

 Tophi – larges masses of urate crystals that presents as white/yellowish nodules that can be found under the
skin on the helix of the ears, elbows, fingers, toes, etc.
MOUTH;

 Thrush – a fungal (yeast) infection that can grow in your mouth, throat and other parts of your body.
 Tonsil Exudate – fluid secreted by the tonsils in response to infection or inflammation.
 Dental Caries - Severe dental caries affects general health and often causes pain and infection, which may
result in tooth extraction.
NECK;

 Goiter - a condition where your thyroid gland grows larger.

THORAX AND LUNGS ASSESSMENT

 Examination of the thorax and lungs begins when the nurse first meets the client and observes any obvious
breathing difficulties. Complete examination of the thorax and lungs consists of inspection, palpation,
percussion, and auscultation of the posterior and anterior thorax to evaluate functioning of the lungs.
Inspection and palpation are fairly simple skills to acquire. However, practice and experience are the best
ways to become proficient with percussion and auscultation.
Equipment’s;

 Examination Gown and drape

 Gloves
 Stethoscope
 Light source
 Mask
 Skin Marker
 Metric Ruler
GENERAL ROUTINE SCREENING
 Observe color of face, lips, and chest.
 Inspect color and shape of nails
 Inspect configuration of anterior and posterior thorax
 Observe use of accessory muscles and intercostal spaces
 Inspect the client’s positioning
 Palpate anterior and posterior thorax for tenderness, sensation, and surface masses
 Palpate anterior and posterior thorax for fremitus, crepitus, and surface characteristics
 Assess anterior and posterior thorax expansion
 Percuss for tone
 Auscultate normal lung sounds and adventitious breath sounds. Focused specialty assessment
 Percuss for diaphragmatic excursion
 Auscultate voice sounds
TRIPOD POSITION

 A person sits or stands leaning forward and supports the upper body with hands on knees or other surface.
Egophony – Ask the client to repeat the letter “E” while you listen over the chest wall
One-two-three – while you auscultate the chest wall

Thoracic Deformities and Configurations

 Normal chest configuration - Symmetrical posterior thorax with symmetrical chest expansion, no thorax
deformities or masses, spinous process in a straight line, no skin discoloration, anteroposterior to transverse
diameter
 Barrel chest - a deformity in which the chest becomes expanded in size.
 Pectus excavatum - when the ribs and sternum (breastbone) grow inward and form a dent in the chest.
 Pectus carinatum - a deformity of the chest wall in which the breastbone and ribs are pushed outward
 Scoliosis - when the vertebrae form a curved line instead of being straight.
 Kyphosis - an exaggerated increased rounding of the thoracic spine, often seen with osteoporosis in older
women.