Assessment Mouth: Observe for any body and breath odor in relation to activity level
Normal Findings
Actual Findings
Analysis
No body odor or minor body odor relative to work or exercise; no breath odor
Smells foul
Body odor or breath other indicates of lack of hygiene or com!lication in some body !arts or !resence of bacteria Fundamentals of nursing by "o#ier !! $%&
Skin: Inspect skin for any lesions and redness in any part of the clients body . Skin intact; no bruises; no cuts or any sign of skin lesions "rimary a#e midline and $ith Cranial III, IV, VI No lesions except a lump on ri ht flank. !edness can be seen on the sacral area
'ye movement de!endent (N & 0Abducens1 on (ranial Nerves ) $ and & * muscles they innervate+ , Allows smooth coordinated movement in all directions of both eyes muscle 5 moves eye simultaneously , -here.s some overla! between actions of muscles/nerves (N ) 0Oculomotor1 All other muscles eye movement 3 also raises lid * mediates down 0de!ression1 when looking towards nose; also rotates internally+ 2ateral rectus muscle
)he left eye has percei%ed less li ht stimulus *a defect in the then the opposite eye so the pupil dilates $ith the same li ht stimulus that caused constriction $hen the normal eye $as stimulated.
3 moves eye laterally test ob'ect (N $ 0-rochlear1 Su!erior obli4ue "rimary a#e midline and $ith left extra ocular mo%ement $eakness. &ixed constricted pupil approximately (mm bilaterally. Slu to li ht. ishly reacti%e
temporalis muscles.
Cranial V Sensory6 Ask !t to close eyes -ouch of ) areas 0o!hthalmic maxillary * mandibular1 lightly noting whether !atient detects stimulus+ 7otor6 Pal!ate tem!oralis * mandibular areas as !atient clenches * grinds teeth Cranial VII Observe facial symmetry 8rinkle Forehead Motor component,face of be
,"ee! eyes closed against resistance ,Smile !uff out cheeks 9vula midline 5 (N : Stick out tongue say ;Ahh< 3 use tongue de!ressor if can.t see 5 !alate/uvula rise (N : => ?ag @eflex !rovoked with tongue blade or 4 ti! 5 (N : => I-., -. .eak a reflex,
unable to s$allo$, moans $hen i%en pain stimulation. -II. )on ue in midline but de%iates to the left side of the mouth symmetrical.
,-ongue midline when !atient sticks it out (N =% check strengthby directing !atient !ush ti! into inside of either cheek while you !ush from outside -I. /nable to fully test
because patient is incoherent, ho$e%er no mo%ement can be seen from the left shoulder
(ranial AB -urn head to 2 into @ hand function of @ Sternocleidomastoid , -urn head to @ into 2 hand 02 S(71Shrug shoulders into your hands