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Western Mindanao State University

College of Nursing
Zamboanga City



Name : Jennylyn C. Guadalupe, RN
Subject : MSN-202
Professor : Rommel N. Rosaldo, RN ( RP/USA);MN;DPA
Topic : Complete Health History & Physical Examination
(Physical Assessment Ears,Eyes, Nose, Throat & Cranial Nerves)
Date : September 2, 2014

Introduction

Health History provides the examiner with complete health profile that guides all aspects of
the physical examination. It begins with questions that focus on problems a symptom of concern
to the patient.
Chief Complaint - reason for seeking care
Physical examination usually performed after the health history is taken.






Purposes of Physical Examination

The nurse uses physical assessment for the following reasons:
To gather baseline data about the clients health
To supplement, confirm or refute data obtained in the nursing history
To confirm and identify nursing diagnoses
To make clinical judgments about a clients changing health status and management
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Preparation of Examination
1. Environment A physical examination requires privacy. An examination room
that is well equipped for all necessary procedures is preferable
- To facilitate data collection process, the examination is carried out in a
well-lighted, warm area.
Gloves are worn by the examiner when there is possibility of coming in contact with
blood or other body secretions during the physical examination.
The persons physical and psychologic comfort is considered at all times; procedures and
their rationale are fully explained
The persons physical and psychologic comfort is considered at all times; procedures and
their rationale are fully explained.

4. Physical Preparation the clients physical comfort is vital to the success of the
examination. Before starting, the nurse asks if the client needs to use the toilet.

5. Positioning during the examination, the nurse asks the clients to assume proper
positions so that body parts are accessible and clients stay comfortable. Clients
abilities to assume positions will depend on their physical strength and degree of
wellness.
The patient is undressed and draped appropriately so that only the area to be examined
is exposed.

2. Equipment Hand washing is done before equipment preparation and the
examination. Hand washing reduces the transmission of microorganisms
- The examiners hands are washed prior to and immediately following
the examination.
Finger nails are kept short to avoid injuring the patient.
Client
3. Psychological Preparation clients are easily embarrassed when forced to
answer sensitive questions about bodily functions or when body parts are exposed
and examined. The possibility that the examination will find something abnormal
also creates anxiety so reduction of this anxiety may be the nurses highest
priority before the examination
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ORGANIZED & SYSTEMATIC EXAMINATION key to appropriate Data in a least
possible amount of time.
Order of Examination
1 General Survey includes observation of general appearance and
behavior, vital signs, height and weight measurement
2 Review of systems
3 Head to toe examination


INSTRUMENTS

Basic tools of the physical examination are the human senses of vision, hearing, touch,
and smell. Those human senses may be augmented by special instruments or tools e.g.
Stethoscope, OPTHALMOSCOPE) TO PERMIT A BETTER DEFINITION OF WHAT IS SEEN OR
HEARD, BUT THESE TOOLS SHOULD BE RECOGNIZED ONLY AS EXTENSIONS OF THE
HUMAN SENSES.



EXAMINATION TECHNIQUE
Patients Positioning and Prepping
- Most physical examination is conducted with the patient in the
seated and supine positions. Other positions are used for specific
aspects of the examination.
a. SEATED: when seated, the drape should cover the
patients lap and legs. It can be moved to uncover parts of
the body as they examined.



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b. SUPINE: the patient lies on his or her back, with arms at the
sides and legs extended. The drape should cover the patient from
chest and knees or toes. Again, you can move or reposition the
drape to give appropriate exposure.

c. PRONE: the patient lies on his or her stomach. This position may
be used for special maneuvers as part of the musculoskeletal
examination. Drape the patient to cover the torso.
d. DORSAL RECUMBENT: use for genital or rectal areas. The
patient lies supine with knees bent and feet on the table. Place the
drape in a diamond position from chest to toes. Wrap each leg
with the corresponding lateral corner of the diamond. Turn back
the distal corner of the drape to perform the examination.
e. LATERAL RECUMBENT: This is a side lying position, with
legs extended or flexed. The left lateral recumbent position
(patients left side is down) may be used in listening to heart
sounds.



f. LITHOTOMY: generally used for pelvic examination.





g. SIMS: of the rectum or obtaining rectal temperature.











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Skills in Physical Examination & The Process of Physical examination

1. Inspection to detect normal characteristics or significant physical signs. To inspect
body parts accurately the nurse observes the following principles:
o Make sure good lighting is available
o Position and expose body parts so that all surface can be viewed
o Inspect each areas from size, shape, color, symmetry, position and abnormalities
o If possible, compare each area inspected with the same area of the opposite side
of the body
o Use additional light (for example, a penlight) to inspect body cavities
Inspection- the first fundamental process is inspection or observation. General inspection
begins at the first moment of contact with the patient. Should be noted in the initial
examination of the patient are:

Slurred coz of CNS disease or damage to cranial nerves, laryngeal nerve will produce
hoarseness.


a. Posture and stature
Ex. Person who have breathing difficulties ( Dyspnea) secondary to cardiac disease
prefer to sit and may complain of feeling Smothered, if forced to lie flat for even
brief periods of time.
b. Body Movements
Generalized disruption of voluntary or involuntary movement and asymmetry of
movement.
Ex. Convulsive movements of epilepsy or tetanus or movements of patients with
rheumatic fever.
c. Nutrition
Ex. Obesity maybe generalized as a function of excessive intake of calories or may be
specifically localized to the trunk in those with endocrine disorders ( Cushing disease).
d. Speech pattern
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2. Palpation the hands can make delicate and sensitive measurements of specific physical
signs, so palpation is used to examine all accessible parts of the body. The nurse uses
different parts of the hand to detect characteristics such as texture, temperature and the
perception of movement.
Palpation assessed through touch.
Ex. Superficial blood vessels, lympnodes, the thyroid, the organs of the abdomen and
pelvis, and the rectum. It should be noted that when the abdomen is examined, auscultation is
performed before palpation and percussion to avoid altering bowel sounds.



Flatness- percussion of the thigh.

4. Auscultation is listening to sound created in body organs to detect variations from
normal. Some sounds can be heard with the unassisted ear, although most sounds can be
heard only through a stethoscope.
Auscultation- sound is produced within the body either by the movement of air through
hollow structures or by the forces set up by the movement of columns of fluid that set solid
structures in motion.
Ex. Breath sound- movement of air through the trachea and bronchi, Vesicular,
Brochovesicular, Bronchial
Spoken voice- movement of air past functioning vocal cords
Bowel sounds- movement of air through the intestine.
Murmur- movement of blood through vascular structures that provide critical resistance
to flow
Heart sounds- impendence of flowing blood provided by closed valves and the heart
wall

3. Percussion examination by striking the bodys surface with a finger, vibration and
sound are produced. This vibration is transmitted through the body tissues and the
character of the sound depends on the density of the underlying tissue
Percussion- application of physical force into sound. The principle is to set the chest wall or
abdominal wall into vibration by striking it with a firm object.
Sounds: Tympany is the drumlike sound produced by percussing the air-filled stomach.
Resonance- is the sound elicited over air-filled lungs.
Hyperresonance- is audible when one percusses over inflated lung tissue in someone
with emphysema.
Dull sound- percussion of liver.
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Head- to- Toe Assessment
Preview
Head (Skull, Scalp, Hair)
Face
Eyebrows, Eyes and Eyelashes
Eye lids and Lacrimal Apparatus
Conjunctivae
Sclerae
Cornea
Anterior Chamber and Iris
Pupils
Cranial Nerve II (optic nerve)
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
Ears
Nose and Paranasal Sinuses
Cranial Nerve I (olfactory Nerve)
Neck
______________________________________________________________________________
______________________
Skull, Scalp & Hair
Observe the size, shape and contour of the skull.
Observe scalp in several areas by separating the hair at various locations; inquire about
any injuries. Note presence of lice, nits, dandruff or lesions.
Palpate the head by running the pads of the fingers over the entire surface of skull;
inquire about tenderness upon doing so. (wear gloves if necessary)
Observe and feel the hair condition.
Normal Findings:

Skull
Generally round, with prominences in the frontal and occipital area. (Normocephalic).
No tenderness noted upon palpation.

Examples of Adventitious Breath Sounds
1.Crackles (previously called rales)
2.Rhonchi
3.Wheeze
4. Friction rub
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Scalp
Lighter in color than the complexion.
Can be moist or oily.
No scars noted.
Free from lice, nits and dandruff.
No lesions should be noted.
No tenderness or masses on palpation.
Hair
Can be black, brown or burgundy depending on the race.
Evenly distributed covers the whole scalp (No evidences of Alopecia)
Maybe thick or thin, coarse or smooth.
Neither brittle nor dry.
_____________________________________________________________________________
______________________
Face
1. Observe the face for shape.
2. Inspect for Symmetry.
o Inspect for the palpebral fissure (distance between the eye lids); should be equal
in both eyes.
o Ask the patient to smile, There should be bilateral Nasolabial fold (creases
extending from the angle of the corner of the mouth). Slight asymmetry in the
fold is normal.
o If both are met, then the Face is symmetrical
3. Test the functioning of Cranial Nerves that innervates the facial structures
CN V (Trigeminal)

1. Sensory Function
Ask the client to close the eyes.
Run cotton wisp over the fore head, check and jaw on both sides of the face.
Ask the client if he/she feel it, and where she feels it.
Check for corneal reflex using cotton wisp.
The normal response in blinking.
2. Motor function
Ask the client to chew or clench the jaw.
The client should be able to clench or chew with strength and force.
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CN VII (Facial)

1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
Place a sweet, sour, salty, or bitter substance near the tip of the tongue.
Normally, the client can identify the taste.
2. Motor function
Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or puff the cheeks.
Normal Findings
Shape maybe oval or rounded.
Face is symmetrical.
No involuntary muscle movements.
Can move facial muscles at will.
Intact cranial nerve V and VII.
______________________________________________________________________________
_________
Eyebrows, Eyes and Eyelashes
All three structures are assessed using the modality of inspection.
Normal findings

Eyebrows
Symmetrical and in line with each other.
Maybe black, brown or blond depending on race.
Evenly distributed.
Eyes
Evenly placed and inline with each other.
None protruding.
Equal palpebral fissure.
Eyelashes
Color dependent on race.
Evenly distributed.
Turned outward.
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______________________________________________________________________________
_______________________
Eyelids and Lacrimal Apparatus

1. Inspect the eyelids for position and symmetry.

2. Palpate the eyelids for the lacrimal glands.
a. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger
against the clients upper orbital rim.
b.Inquire for any pain or tenderness.

3. Palpate for the nasolacrimal duct to check for obstruction.
a.To assess the nasolacrimal duct, the examiner presses with the index finger against the
clients lower inner orbital rim, at the lacrimal sac, NOT AGAINST THE NOSE.
b. In the presence of blockage, this will cause regurgitation of fluid in the puncta

Normal Findings

Eyelids
Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open.
No PTOSIS noted. (Drooping of upper eyelids).
Meets completely when eyes are closed.
Symmetrical.
Lacrimal Apparatus
Lacrimal gland is normally non palpable.
No tenderness on palpation.
No regurgitation from the nasolacrimal duct.
______________________________________________________________________________
_______________________

Conjunctivae
The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and
having the client look up, down and to each side. When separating the lids, the examiner
should exert NO PRESSURE against the eyeball; rather, the examiner should hold the
lids against the ridges of the bony orbit surrounding the eye.
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In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done
as follow:
1. Ask the client to look down but keep his eyes slightly open. This relaxes the levator
muscles, whereas closing the eyes contracts the orbicularis muscle, preventing lid
eversion.
2. Gently grasp the upper eyelashes and pull gently downward. Do not pull the lashes
outward or upward; this, too, causes muscles contraction.
3. Place a cotton tip application about I can above the lid margin and push gently downward
with the applicator while still holding the lashes. This everts the lid.
4. Hold the lashes of the everted lid against the upper ridge of the bony orbit, just beneath
the eyebrow, never pushing against the eyebrow.
5. Examine the lid for swelling, infection, and presence of foreign objects.
6. To return the lid to its normal position, move the lid slightly forward and ask the client to
look up and to blink. The lid returns easily to its normal position.
Normal Findings:
Both conjunctivae are pinkish or red in color.
With presence of many minutes capillaries.
Moist
No ulcers
No foreign objects
______________________________________________________________________________
______________________
Sclerae
The sclerae is easily inspected during the assessment of the conjunctivae.


Normal Findings
Sclerae is white in color (anicteric sclera)
No yellowish discoloration (icteric sclera).
Some capillaries maybe visible.
Some people may have pigmented positions.
______________________________________________________________________________
_______________________


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Cornea
The cornea is best inspected by directing penlight obliquely from several positions.
Normal findings
There should be no irregularities on the surface.
Looks smooth.
The cornea is clear or transparent. The features of the iris should be fully visible through
the cornea.
There is a positive corneal reflex.
______________________________________________________________________________
_______________________
Anterior Chamber and Iris
The anterior chamber and the iris are easily inspected in conjunction with the cornea. The
technique of oblique illumination is also useful in assessing the anterior chamber.
Normal Findings:
The anterior chamber is transparent.
No noted any visible materials.
Color of the iris depends on the persons race (black, blue, brown or green).
From the side view, the iris should appear flat and should not be bulging forward. There
should be NO crescent shadow casted on the other side when illuminated from one side.
______________________________________________________________________________
_______________________

Pupils
Examination of the pupils involves several inspections, including assessment of the size,
shape reaction to light is directed is observed for direct response of constriction.
Simultaneously, the other eye is observed for consensual response of constriction.
The test for papillary accommodation is the examination for the change in papillary size as it is
switched from a distant to a near object.
Ask the client to stare at the objects across room.
Then ask the client to fix his gaze on the examiners index fingers, which is placed 5 5
inches from the clients nose.
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Visualization of distant objects normally causes papillary dilation and visualization of
nearer objects causes papillary constriction and convergence of the eye.
Normal Findings
Pupillary size ranges from 3 7 mm, and are equal in size.
Equally round.
Constrict briskly/sluggishly when light is directed to the eye, both directly and
consensual.
Pupils dilate when looking at distant objects, and constrict when looking at nearer
objects.
If all of which are met, we document the findings using the notation PERRLA, pupils equally
round, reactive to light, and accommodate
______________________________________________________________________________
_______________________
Cranial Nerve II (optic nerve)
The optic nerve is assessed by testing for visual acuity and peripheral vision.
Visual acuity is tested using a snellen chart, for those who are illiterate and unfamiliar
with the western alphabet, the illiterate E chart, in which the letter E faces in different
directions, maybe used.
The chart has a standardized number at the end of each line of letters; these numbers
indicates the degree of visual acuity when measured at a distance of 20 feet.
The numerator 20 is the distance in feet between the chart and the client, or the standard
testing distance. The denominator 20 is the distance from which the normal eye can read
the lettering, which correspond to the number at the end of each letter line; therefore the
larger the denominator the poorer the version.
Measurement of 20/20 vision is an indication of either refractive error or some other optic
disorder.
In testing for visual acuity you may refer to the following:
The room used for this test should be well lighted.
A person who wears corrective lenses should be tested with and without them to check
fro the adequacy of correction.
Only one eye should be tested at a time; the other eye should be covered by an opaque
card or eye cover, not with clients finger.
Make the client read the chart by pointing at a letter randomly at each line; maybe started
from largest to smallest or vice versa.
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A person who can read the largest letter on the chart (20/200) should be checked if they
can perceive hand movement about 12 inches from their eyes, or if they can perceive the
light of the penlight directed to their yes.
Peripheral Vision or visual fields
The assessment of visual acuity is indicative of the functioning of the macular area, the
area of central vision. However, it does not test the sensitivity of the other areas of the
retina which perceive the more peripheral stimuli. The Visual field confrontation test,
provide a rather gross measurement of peripheral vision.
The performance of this test assumes that the examiner has normal visual fields, since
that clients visual fields are to be compared with the examiners.
Follow the steps on conducting the test:
1. The examiner and the client sit or stand opposite each other, with the eyes at the same,
horizontal level with the distance of 1.5 2 feet apart.
2. The client covers the eye with opaque card, and the examiner covers the eye that is
opposite to the client covered eye.
3. Instruct the client to stare directly at the examiners eye, while the examiner stares at the
clients open eye. Neither looks out at the object approaching from the periphery.
4. The examiner hold an object such as pencil or penlight, in his hand and gradually moves
it in from the periphery of both directions horizontally and from above and below.
5. Normally the client should see the same time the examiners sees it. The normal visual
field is 180 degrees.
______________________________________________________________________________
_______________________
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular
Movement (EOM) or the six cardinal position of gaze.
Follow the given steps:
1. Stand directly in front of the client and hold a finger or a penlight about 1 ft from the
clients eyes.
2. Instruct the client to follow the direction the object hold by the examiner by eye
movements only; that is with out moving the neck.
3. The nurse moves the object in a clockwise direction hexagonally.
4. Instruct the client to fix his gaze momentarily on the extreme position in each of the six
cardinal gazes.
5. The examiner should watch for any jerky movements of the eye (nystagmus).
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6. Normally the client can hold the position and there should be no nystagmus.
______________________________________________________________________________
_______________________

Ears
1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color.
2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles,
tenderness when manipulating the auricles and the mastoid process.
3. Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges,
and foreign bodies.
o For adult pull the pinna upward and backward to straiten the canal.
o For children pull the pinna downward and backward to straiten the canal
4. Perform otoscopic examination of the tympanic membrane, noting the color and
landmarks.
Normal Findings
The ear lobes are bean shaped, parallel, and symmetrical.
The upper connection of the ear lobe is parallel with the outer canthus of the eye.
Skin is same in color as in the complexion.
No lesions noted on inspection.
The auricles are has a firm cartilage on palpation.
The pinna recoils when folded.
There is no pain or tenderness on the palpation of the auricles and mastoid process.
The ear canal has normally some cerumen of inspection.
No discharges or lesions noted at the ear canal.
On otoscopic examination the tympanic membrane appears flat, translucent and pearly
gray in color.
______________________________________________________________________________
_______________________

Nose and Paranasal Sinuses

The external portion of the nose is inspected for the following:
1. Placement and symmetry.
2. Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in
breathing)
3. Flaring of alae nasi
4. Discharge
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The external nares are palpated for:
1. Displacement of bone and cartilage.
2. For tenderness and masses
The internal nares are inspected by hyper extending the neck of the client, the ulnar aspect of the
examiners hard over the fore head of the client, and using the thumb to push the tip of the nose
upward while shining a light into the nares.

Inspect for the following:
1. Position of the septum.
2. Check septum for perforation. (Can also be checked by directing the lighted penlight on
the side of the nose, illumination at the other side suggests perforation).
3. The nasal mucosa (turbinates) for swelling, exudates and change in color.
Paranasal Sinuses
Examination of the paranasal sinuses is indirectly. Information about their condition is
gained by inspection and palpation of the overlying tissues. Only frontal and maxillary
sinuses are accessible for examination.
By palpating both cheeks simultaneously, one can determine tenderness of the maxillary
sinusitis, and pressing the thumb just below the eyebrows, we can determine tenderness
of the frontal sinuses.
Normal Findings
Nose in the midline
No Discharges.
No flaring alae nasi.
Both nares are patent.
No bone and cartilage deviation noted on palpation.
No tenderness noted on palpation.
Nasal septum in the mid line and not perforated.
The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of
allergy).
No tenderness noted on palpation of the paranasal sinuses.
______________________________________________________________________________
_______________________
Cranial Nerve I (Olfactory Nerve)
To test the adequacy of function of the olfactory nerve:
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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 Oropharynx Lips
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
Temporomandibular

Palpate 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

Inspected for:
1. Color
2. Bleeding
3. Retraction of gums.
Normal Findings:
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1. Pinkish in color
2. No gum bleeding
3. No receding gums
Teeth

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
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

Inspected for:
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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
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.
______________________________________________________________________________
_______________________
Neck
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid
gland and Jugular Venous Distension
Normal Findings:
1. The neck is straight.
2. No visible mass or lumps.
3. Symmetrical
4. No jugular venous distension (suggestive of cardiac congestion).
The neck is palpated just above the suprasternal note using the thumb and the index finger.

Normal Findings:
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1. The trachea is palpable.
2. It is positioned in the line and straight.
Lymph nodes are palpated using palmar tips of the fingers via systemic circular
movements. Describe lymph nodes in terms of size, regularity, consistency, tenderness
and fixation to surrounding tissues.
Normal Findings:
May not be palpable. Maybe normally palpable in thin clients.
Non tender if palpable.
Firm with smooth rounded surface.
Slightly movable.
About less than 1 cm in size.
The thyroid is initially observed by standing in front of the client and asking the client to
swallow. Palpation of the thyroid can be done either by posterior or anterior approach.
Posterior Approach:
1. Let the client sit on a chair while the examiner stands behind him.
2. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below
that is the isthmus.
3. Ask the client to swallow while feeling for any enlargement of the thyroid isthmus.
4. To facilitate examination of each lobe, the client is asked to turn his head slightly toward
the side to be examined to displace the sternocleidomastoid, while the other hand of the
examiner pushes the thyroid cartilage towards the side of the thyroid lobe to be
examined.
5. Ask the patient to swallow as the procedure is being done.
6. The examiner may also palate for thyroid enlargement by placing the thumb deep to and
behind the sternocleidomastoid muscle, while the index and middle fingers are placed
deep to and in front of the muscle.
7. Then the procedure is repeated on the other side.
Anterior approach:
1. The examiner stands in front of the client and with the palmar surface of the middle and
index fingers palpates below the cricoid cartilage.
2. Ask the client to swallow while palpation is being done.
3. In palpating the lobes of the thyroid, similar procedure is done as in posterior approach.
The client is asked to turn his head slightly to one side and then the other of the lobe to be
examined.
4. Again the examiner displaces the thyroid cartilage towards the side of the lobe to be
examined.
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5. Again, the examiner palpates the area and hooks thumb and fingers around the
sternocleidomastoid muscle.
Normal Findings:
1. Normally the thyroid is non palpable.
2. Isthmus maybe visible in a thin neck.
3. No nodules are palpable.
Auscultation of the Thyroid is necessary when there is thyroid enlargement. The examiner may
hear bruits, as a result of increased and turbulence in blood flow in an enlarged thyroid.
Check the Range of Movement of the neck.
______________________________________________________________________________
_______________________




























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Assessing Neurologic Function
A. Health assessment: Subjective data
a. Questions about present health status include
b. Tremors, problems with coordination or balance
c. Loss of movement of any part of the body
d. Difficulty with speaking or senses
e. Information about memory
f. Feeling state, e.g. anxius, depressed
g. Ability to perform self- care and ADL
h. Sexual activity
i. Weight changes
j. Prescribed and over the counter medications, frequency of use and duration
k. Prescribed and over the counter medications, frequency of use and duration
l. Seizures, fainting, dizziness, headaches
B. Physical assessment to collect objective data
1. Mental status assessment with abnormal findings
a. Unilateral neglect: strokes involving middle cerebral artery
b. Poor hygiene and grooming: dementing disorders
c. Abnormal gait and posture: transient ischemic attacks (TIAs), strokes,
Parkinsons disease
d. Emotional swings, personality changes: strokes of anterior cerebral artery
e. Masklike appearance on face: Parkinsons disease
f. Apathy: dementing disease
g. Aphasia ( demeting disease
h. Dysphonia ( change in tone of voice) : strokes of posterior inferior cerebral artery,
paralysis of vocal cords, cranial nerve X
i. Dysathria ( difficulty in speaking): strokes involving anterior inferior and superior
cerebral arteries, lesions involving UMN,LMN, cerebellum, extrapyramidal tract
j. Decreased level of consciousness: brain trauma, infections, TIAs, stroke, brain
tumors
k. Confusion, coma: strokes affecting bvertebralbasilar arteries
2. Cognitive function assessment with abnormal findings
a. Disorientation to time and place: stroke of right cerebral hemisphere
b. Memory deficits: anterior cerebral artery and vertebralbasilar artery
c. Perceptual deficits: strokes of middle cerebral artery, brain trauma, dementing
conditions
d. Impaired cognition: strokes of middle cerebral artery, vertebral trauma, brain
tumors

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3. Cranial nerve assessment with abnormal findings
a. CN 1 (Olfactory) Anosmia ( inability to smell)
1. Lesions of frontal lobe
2. Impaired blood flow to middle cerebral artery
b. CN II ( optic)
1. Blindness in one eye: strokes of internal carotid artery,TIAs
2. Homonymous hemianopia (impaired vision/blindness in one side of both eyes):
blockage of posterior cerebral artery
3. Impaired vision: strokes of anterior cerebral artery, brain tumors
4. Blindness,double vision: involvement of vertebralbasilar arteries;double or blurred
vision may occur with TIAs
5. Papilledema ( swelling of optic nerve): increased intracranial pressure
c. CN III, IV, VI ( oculomotor, trochlear, abducens)
1. Nystagmus ( involuntary eye movement): strokes of anterior, inferior, superior
cerebellar arteries
2. Constricted pupils: may signify impaired blood flow to vertebralbasilar arteries
3. Ptosis: strokes posterior inferior cerebellar artery, myasthenia gravis, palsy of CN III
d. CN V ( trigeminal) : Changes in facial sensations; impaired blood flow to carotid artery
1. Decreased sensation to face and cornea on same side of body: strokes of posterior
inferior cerebral artery
2. Lip and mouth numbness: strokes of vertebralbailar artery
3. Loss of facial sensation, contraction of masseter and temporal muscles; lesions of
CNV
4. Severe facial pain: trigeminal neuralgia (tic douloureux)
e. CN VII ( Facial)
1. Loss of ability to taste: brain tumors, nerve impairement
2. Decreased movement of facial muscles: lesions of UMN,LMN
3. Inability to close eyes, flat nasolabial fold, paralysis of lower face, inability to
wrinkle forehead: paralysis of LMN
4. Eyelid weakness, paralysis of lower face: paralysis of upper motor neuron
5. Pain, paralysis, sagging of facial muscles: affected side in Bells palsy
f. CN VIII ( acoustic): decreased hearing or deafness: strokes of vertebralbasilar arteries or
tumors of CN VII
g. CN IX and X ( glossopharyngeal, vagus)
1. Dysphagia ( difficulty in swallowing): impaired blood flow to vertebralbasilar
arteries, posterior or anterior inferior or superior cerebellar arteries
2. Unilateral loss of gag reflex: lesions of CN IX and X
h. CN XI ( Spinal accessory)
1. Muscle weakness: LMN
2. Contraleteral hemiparesis: strokes affecting middle cerebral artery and internal
carotid artery
i. CN XII ( hypoglossal)
1. Atrophy, fasciculations ( twitches): LMN disease
2. Tongue deviation toward involved side of body
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25

Assessment of Eye
a. Health assessment : subjective data
1. During interview, note nonverbal behaviors such as squinting or abnormal eye
movements
2. Explore watery, irritated yes, or changes in vision
3. Use of eyewear, care of eyeglasses or contact lenses
b. Physical assessment: objective data
1. Vision assessment with abnormal findings
a. Vision acuity is assessed with Snelen chart or E chart for testing distance vision;
Rosenbaum chart for testing near vision
b. Myopia or nearsightedness
1. Reading of 20/100 using Snellen or E chart
2. Impaired ability with near vision
3. Presbyopia in clients age > 45;loss of elasticity of lens
4. Hyperopia in clients younger than 45
2. Eye movement and alignment with abnormal findings
a. Failure of eyes to converge equally on an approaching object may indicate
neuromuscular disoreder or improper eye alignment
b. Failure of one or both eyes to follow an object in any given direction may indicate
extraocular muscles weakness or cranial nerve dysfunction
c. Involuntary rhythmic movement of eyes ( nystagmus): associated with use of
medications
d. Unequal corneal light reflex reveals improper alignment
3. Papillary assessment with abnormal finding
a. Pupils with unequal size may indicate severe neurologic problems including
increased intracranial pressure
b. Failure of pupils to respond to light may indicate retinal degeneration or
destruction to optic nerve
c. Client who has one dilated and one unresponsive pupil may have paralysis of one
oculomotor nerve.
d. Unequal dilation, constriction or inequality of pupil size may be caused by some
eye medications
1. Morphine and narcotics: small, unresponsive pupils
2. Anticholinergic drugs: dilated unresponsive pupils
e. Failure of eyes to accommodate with lack of papillary response to light may
indicate neurologic problem
f. Pupils that do not respond to light but accommodate properly is seen in clients
with diabetes

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4 External eye assessment with abnormal finding
a. Unusual redness or discharge indicates inflammatory state due to trauma, allergies, or
infection
b. Drooping of one eyelid, ptosis, may result from stroke, neuromuscular disorder, or
congenital
c. Unusual widening of lids may be due to exopthalmus ( protrusion of eyeball due to
increase in intraocular volume) is often associated with hypethyroid conditions
d. Yellow plaques noted on lid margins ( xanthelasma) may indicate high lipid levels
e. Acute localized inflammation of hair follicle known as hordeolum (sty) often caused by
staphylococcal organisms
f. Chalazion is infection or retention cyst of meibomian glands
g. Conjunctiva
1. Increased erythema, presence of exudates indicates acute conjunctivitis
2. Cobblestone appearance associated with allergies
3. Fold in conjunctiva (pterygium) is clouded area that is seen as clouded area over
cornea ( may interfere with vision if covering pupil)
h. Sclera
1. Unusual redness indicates inflammatory state resulting from trauma, allergies, or
infection
2. Yellow discoloration occurs with jaundice involving liver conditions
3. Bright red areas are subconjunctival hemorrhages and may indicate trauma or
bleeding disorders; may occur spontaneously
i. Cornea
1. Dullness, opacities, irregularities
2. Absence of blink reflex may indicate neurologic disorder
j. Iris
1. Lack of clarity may indicate cloudiness in cornea
2. Constriction of pupil accompanied by pain and circorneal redness indicates acute
iritis.

5 Internal eye assessment with abnormal findings: Opthalmoscopic examination
a. Absence of red reflex may indicate total opacity of pupil by cataract or hemorrhage
into vitreous humor
b. Dark shadow visualized is cataract ( opacity of lens) due to aging, trauma, diabetes,
or congenital defect
c. On retinal exam, areas of hemorrhage, exudates, white patches are found with
diabetes or long- standing HPT
d. Loss of optic disc as well as increase in size of physiologic cup results from
papilledema that occurs with increased intracranial pressure
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e. Blood vessels of retina
1. Displacement of blood vessels from center of optic disc occurs with increased
intraocular pressure as with glaucoma
2. Apparent narrowing of vein where an arteriole crosses over occurs with HPT
3. Engorged veins occur with diabetes, atherosclerosis, blood disorders
f. Variations in color of pale color in retinal background indicates disease
g. Upon inspection of macula, absence of fovea centralis may indicate macular
degeneration
h. Tenderness over lacrimal glands, puncta, masolacrimal duct or drainage may indicate
infection
i. Excessive tearing may indicate blockage of nasolacrimal duct.

Assessment of Ear
a. Health assessment: subjective data
1. Be aware of nonverbal behaviors ( inappropriate answers, asking for statements to be
repeated suggest altered hearing function)
2. Explore with client
a. Changes in hearing
b. Ringing in ears ( tinnitus)
c. Ear pain
d. Drainage from ears
e. Use of hearing aids
b. Physical assessment of ears and hearing

1. Hearing test with abnormal findings
a. Weber test
1. Tunning fork placed on midline vertex of head
2. If sound is heard in or lateralized to one ear, indicative of conductive hearing
loss I that ear or sensorineural loss in other.
b. Rinne test
1. Vibrating tuning fork placed on clients mastoid bone and client identifies
when sound no longer heard
2. Fork moved in front of clients ear close to ear canal, and client identifies
when sound no longer heard
3. Sound should be heard twice as long by air conduction than by bone
conduction
4. Bone conduction is greater than air conduction with a conductive hearing loss
c. Whisper test: rough estimate that hearing loss exists
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2 External ear assessment with abnormal findings
a. Unusual redness or drainage around auricle indicates inflammatory response to infection
or trauma
b. Scales or skin lesions around the rim may indicate skin cancer
c. Small, raised lesions around rim of ear are tophi and indicate gout
d. Unusual redness, lesion, or purulent drainage of external auditory canal indicates
infection
e. Hardened, dry, or foul-smelling cerumen in ear canal indicates infection or impaction of
cerumen
f. Inspection of tympanic membrane
1. Inconsistent texture and colr occur with scarring from previous perforation caused by
infection, allergies, or trauma
2. Bulging membranes ( loss of bony landmarks, distorted light reflex) indicate otitis
media or malfunctioning of auditory tubes
3. Retracted membranes with accentuated bony landmarks and distorted light reflex
occurs with obstructed auditory tube
g. Tenderness, swelling or nodules over auricles and mastoid process indicate inflammation
of external auditory canal or mastoiditis.

References:
Brunner & Suddarths, Medical-Surgical Nursing, 8
th
edition
Henry M. Seidel, Mosbys Guide to Physical Examination, 7
th
edition
Barbara Kozier, Fundamental of Nursing, 4
th
edition