Skin Assessment

Subjective:
Present:
Do you have any current skin problems? What aggravates or alleviates?
Describe any birthmarks or moles. Have they changed color, shape or size?
Any change in your skin sensory? (Change in sensation may indicate vascular or
neurologic problems and may put at risk for pressure ulcers)
Do you have trouble controlling body odor? (May indicate abnormality with sweat glands
or endocrine problem)
Do you have body piercing or tattoos? (More at risk for infection)
Have you had hair loss or change in hair condition? (May accompany infections, stress,
hairstyles, or chemo)
Have your nails changed condition or appearance? (Infections of:
bacteria=green/black/brown, fungal=yellow/thick/crumbling, yeast=white)
History:
Previous problems with skin, hair or nails?
Allergic reactions?
Fever, nausea, vomiting, GI or respiratory problems? (Skin issues may be related to
viruses or bacteria)
Pregnant? Periods regular? (Skin problems may relate to hormonal imbalances)
History of smoking or alcohol use? (Association between alcohol/cigarette smoking and
psoriatic males)
History of anxiety, depression, or any psychiatric problems?
Family:
Has anyone in your family had a recent illness, rash or other skin problem or allergy?
Has anyone in your family had skin cancer?
Do you have a family history of keloids?
Lifestyle:
Do you sunbathe? How much? Protection?
Harmful chemical exposure for skin?
Long periods sitting or lying in one position?
Have you had any exposure to extreme temperatures?
Daily routine for skin, hair, and nails? Products? How do you cut your nails?
What kind of foods do you eat? How much fluid?
Do skin problems limit any of your ADLs?
Stress?
Self skin examination once a month?

Objective:
• Inspect general skin coloration. Note any odors. [Pallor=arterial insufficiency;
decreased blood supply, and anemia; Central Cyanosis=cardiopulmonary
problem; Peripheral cyanosis=local problem from vasoconstriction;
Jaundice=hepatic dysfunction; Acanthosis nigricans=diabetes mellitus]
• Inspect for color variations. [Vitiligo=normal loss of pigmintation; Butterfly rash
across nose=Discoid lupus erythematosus (DLE); Albinism;
 Erythema=inflammation, trauma, or allergic reaction]
• Check skin integrity. Braden Scale. PUSH tool.
• Inspect for lesions. Note color, shape, and size. Note location, distribution, and
configuration. [Indicate local or systemic problems; Primary lesions vs.
Secondary vs. Vascular; squamous cell carcinoma, basal cell carcinoma,
malignant melanoma] [Normal elderly lesions: seborrheic or senile keratoses,
senile lentigines, cherry angiomas, purpura, and cutaneous tags and horns]
[Annular=circular; arciform=arcing; zosteriform=linear along a nerve route]
• If suspect fungus, shine a wood’s light. [Blue-green fluorescence=fungal
infection]

• Palpate skin to assess texture. [Rough, flaky, dry skin=hypothyroidism; obese

clients report dry, itchy skin]
• Palpate to assess thickness. Palpate lesions and note drainage. [Thin skin=arterial
insufficiency or steroid therapy]
• Palpate to assess moisture. [Diaphoresis=fever, hyperthyroidism; decreased
moisture=dehydration, hypothyroidism]
• Palpate to assess temperature. [Cool skin=shock or hypotension, arterial disease;
very warm skin=febrile state or hyperthyroidism]
• Palpate mobility (ability to pinch skin) and turgor (skin’s elasticity). [Decreased
mobility=edema; decreased turgor=dehydration]
• Palpate to assess edema.

• Inspect scalp and hair for color and condition. [Nutritional deficiencies=patchy
grey hair in some; Severe malnutrition=copper red hair in some African American
children]
• 1 inch intervals, inspect and palpate scalp for cleanliness, dryness or oiliness,
parasites and lesions. [Excessive scaliness=dermatitis; raised lesions; infections or
tumor growth; Dry, dull hair=hypothyroidism and malnutrition; pustules with hair
loss in patches=tinea capitis (contagious fungal disease=ringworm);
folliculitis=pustules surrounded by erythema]
• Inspect amount and distribution of scalp, body, axillae, and pubic hair. [General
hair loss=infection, nutrition deficiencies, hormonal disorders, thyroid or liver
disease, drug intoxicity, hepatic or renal failure, chemotherapy or radiation
therapy; patchy hair loss=infections of scalp, discoid or systemic lupus
erythematosus, and some chemotherapy; hirsutism (facial hair on
females)=cushing’s disease (imbalance of adrenal hormones) or side effect of
steroids]

• Inspect nail grooming and cleanliness.

• Inspect nail color and markings. [Pale and cyanotic nails=hypoxia or anemia;
splinter hemorrhages=trauma; Beau’s lines=after acute illness; yellow
discoloration=fungal infections or psoriasis; nail pitting=psoriasis]
• Inspect shape of nails. [Early and late clubbing=hypoxia; spoon nails=iron
deficiency anemia]
 • Palpate nail to assess texture. [Thickened nails=decreased circulation]
• Palpate texture and consistency, noting whether nail plate is attached to nail bed.
[Paronychia (inflammation)=local infection; detachment of nail plate
(onycholsis)=infections or trauma]
• Test capillary refill. [Slow capillary refill=respiratory or cardiovascular disease
that cause hypoxia]

Head and Neck Assessment

Subjective:
Present
• Neck pain? [Muscular problems; cervical spinal cord problems; stress and
tension; sudden head and neck pain plus elevated temp and neck
stiffness=meningeal inflammation]
• Do you have headaches? Describe. [Temporomandibular joint syndrome is a
cause; Migraine vs. Cluster vs. Tension vs. Tumor related]
• Do you have any facial pain? [Trigeminal neuralgia (tic douloureux)=sharp
shooting facial pains]
• Difficulty moving neck?
• Have you had any lumps or lesions that do not heal or disappear? Describe.
[Cancer]
• Have you experienced dizziness, lightheadedness, spinning sensation or loss of
consciousness? [Problems with neck vessels, neurologic system (inner ear
disease), cardiovascular system (heart block)]
• Change in texture of skin, hair, or nails? Have you experienced palpitations,
blurred vision or changes in bowel habits? [Hyperthyroidism=insomnia, thinning
hair, palpitations, weight loss; hypothyroidism=insomnia, thickening of skin and
nails, decreased energy levels, and constipation]
Past
• Describe previous head or neck problems (trauma, injury, falls). How were they
treated? What were the results? [Chronic pain]
• Have you ever gone through radiation therapy? [Development of thyroid cancer;
esophageal strictures leading to difficulty swallowing]
Family
• Family history of head or neck cancer?
• Family history of migraine headaches?
Lifestyle
• Smoke or chew tobacco? How much? [Risk for head and neck cancer]
• Wear a helmet when should? Use hard hat?
• What is your typical posture when relaxing, during sleep, and when working?
[Poor alignment can lead to or exacerbate neck discomfort]
• What kinds of recreation do you participate in?
• Have any problems with your head or neck interfered with your relationships with
others
Objective:
• Inspect the head. Inspect for involuntary movements. [Acromegaly; Acorn
shaped, enlarged skull bones=Paget’s disease] [Tremors associate with neurologic
disorder=horizontal jerking; involuntary nodding=aortic insufficiency; head tilted
to one side=unilateral vision or heading deficiency or shortening of sternomastoid
muscle] [Moon-shaped face with reddened cheeks and increased facial
hair=Cushing’s syndrome; tightened hard face with thinning facial
skin=scleroderma; exophthalmos=hyperthyroidism]
• Palpate head. [Lumps or lesions]
• Inspect face. [Asymmetry in front of earlobes=parotid gland enlargement; unusual
or asymmetric orofacial movements=organic disease or neurologic problem;
drooping of one side=stroke or cerebrovascular accident (CVA) or a neurologic
condition known as Bell’s palsy; masklike face=Parkinson’s disease; sunken face
with depressed eyes and hollow cheeks=cachexia (emaciation or wasting); pale,
swollen face=nephrotic syndrome]
• Palpate temporal artery. [Hard, thick temporal artery=temporal arteritis]
• Palpate temporomandibular joint. Explore headache history. [Limited range of
motion, swelling, tenderness or crepitation=TMJ syndrome]

• Inspect neck. [Swelling, enlarged masses, or nodules=enlarged thyroid gland,

inflammation of lymph nodes, or a tumor]
• Inspect movement of neck structures. Ask patient to swallow water. [Asymmetric
movement or generalized enlargement of thyroid gland is abnormal]
• Inspect cervical vertebrae. Chin to chest. [Cervical curvature increased=kyphosis;
fat accumulation around cervical vertebrae=”dowager’s hump”; prominence or
swellings other than C7 may be abnormal]
• Inspect ROM. [Muscle spasms, inflammation or cervical arthritis=stiffness,
rigidity and limited ROM]
• Palpate trachea. [Deviated trachea=tumor, thyroid gland enlargement, aortic
aneyrysm, pneumothorax, atelectasis, or fibrosis]
• Palpate thyroid gland, hyoid bone, thyroid cartilage, cricoid cartilage. Stand
behind, push to one side, patient swallow. [Landmarks deviated=masses or
abnormal growths; diffuse enlargement=hyperthyroidism, Graves disease,
endemic goiter; Enlarged tender gland=throiditis; multiple nodules of
thyroid=metabolic processes; rapid enlargement of single nodule=malignancy]
• Auscultate thyroid if find enlarged. Ask client to hold breath. [Soft blowing,
swishing=hyperthyroidism (increased blood flow through the thyroid arteries)]
• Palpate preauricular, postauricular, occipital nodes. Palpate tonsillar,
submandibular, submental nodes. Palpate superficial cervical, posterior cervical,
deep cervical chain, supraclavicular nodes. [Enlarged and tenderness are
abnormal; an enlarged, hard, nontender supraclavicular node on left
side=metastasis from malignancy in abdomen or thorax]
Eye Assessment

Subjective:
Present:
• Recent changes in eye? Sudden or gradual? [Sudden=head trauma or increased
intracranial pressure; gradual=aging, diabetes, hypertension, or neurologic
disorder]
• Do you see spots or floaters in front of your eyes? [Common among clients with
myopia or over 40 years (aging)]
• Do you experience blind spots? Constant or intermittent? [Scotoma=blind spot
surrounded by either normal or slightly diminished peripheral vision; glaucoma;
intermittent blind spots=vascular spasms (ophthalmic migraines) or pressure;
consistent blind spots=retinal detachment]
• Do you see halos or rings around lights? [Narrow angle glaucoma]
• Do you have trouble seeing at night? [Night blindness=optic atrophy, glaucoma,
vitamin A deficiency]
• Do you experience double vision? [Diplopia (double vision)=increased
intracranial pressure due to injury or tumor]
• Do you have any eye pain or itching? [Burning or itching=allergies; throbbing,
stabbing, or deep, aching pain=foreign body or changes with eye]
• Do you have any redness or swelling in eyes? [Related to inflammatory response
caused by allergy, foreign body, or bacterial or viral infection]
• Do you experience excessive watering or tearing of eye? One eye or both?
[Bilateral excessive tearing (epiphora)=exposure to irritants or systemic response;
unilateral epiphora=foreign body or obstruction]
• Have you had eye discharge? [Bacterial or viral infection]
Past
• Have you ever had problems with your eyes or vision?
• Have you ever had eye surgery? [May alter appearance of eye]
• Describe any past treatments you have received for eye problems (medications,
surgery, laser treatments, corrective lenses). Successful? Satisfied?
Family
• Family history of eye problems or vision loss? [Glaucoma, refraction errors, and
allergies]
Lifestyle
• Are you exposed to conditions or substances in workplace or home that may harm
your eyes or vision? Do you wear safety glasses?
• Do you wear sunglasses? [UV exposure can lead to cataracts]
• What types of medications do you take? [Ocular side effects with corticosteroids,
lovastatin, pyridostigmine, quinidine, risperidone, and rifampin]
• Has your vision loss affected your ADL’s?
• When was your last eye examination? [Recommended every 2 years]
• Do you have a prescription for corrective lenses? Wear them regularly? If have
contacts, how long do you wear them? How do you clean them? [Clients who do
not wear the prescribed corrective lenses are susceptible to eye strain]
Objective:
• Test distant visual acuity. 20 feet from Snellen or E chart. [Myopia; Client is
considered legally blind when vision is at best 20/200 or less]
• Test near visual acuity. Cover one eye and use snellen card 14 inches from eyes.
[Presbyopia=client moves card away from eyes]
• Test visual fields for gross peripheral vision. Confrontation test. [Delayed or
absent perception of the examiner’s finger indicates reduced peripheral vision]
• Perform corneal light reflex test. [Asymmetric position of the light
reflex=deviated alignment of the eyes due to muscle weakness or paralysis]
[Pseudostrabismus=pupils will appear at inner canthus; strabismus=constant
malalignment of eye (esotropia=inward turn; exotropia=outward turn)]
• Perform cover test. [Covered eye is uncovered, eye movement to reestablish focus
occurs=deviated alignment of the eyes and muscle weakness;
phoria=misalignment that only occurs when fusion reflex is blocked
(esophoria=inward drift; exophoria=outward drift)]
• Perform the positions test to assess eye muscle (six cardinal fields of gaze).
[failure of eyes to follow movement symmetrically=weakness in one or more
extraocular muscles or dysfunction of the cranial nerve; Nystagmus (shaking
movement of eyes)=inner ear disorder, multiple sclerosis, brain lesions, or
narcotics use]
• Inspect eyelids and eyelashes. [Drooping upper lid (ptosis)=oculomotor nerve
damage, myasthenia gravis, weakened muscle or tissue, or a congenital disorder;
retracted lid margins=hyperthyroidism]
• Assess ability of eyelids to close. Note turnings, color, swelling, lesions,
discharge. [Xanthelasma (raised yellow plaques near inner canthus)=normal with
age and high lipid levels] [Inverted lower lid (entropion) may cause pain and
injure the cornea; ectropion (everted lower eyelid) results in exposure and drying
of conjunctiva]
• Observe for redness, swelling, discharge, or lesions. [Redness, crusting=seborrhea
or blepharitis (staphylococcus aureus); Hordeolum (stye, a hair follicle
infection)=local redness, swelling, and pain; Chalazion (infection of the
meibomian gland, on eyelid)=extreme swelling of lid, moderate redness, but
minimal pain]
• Observe position and alignment of eyeball in eye socket. [Protrusion of the
eyeballs accompanied by retracted eyelid margins (exophthalmos)=Graves
disease-hyperthyroidism; Sunken appearance of the eyes=severe dehydration or
chronic wasting illness]
• Inspect bulbar conjunctiva and sclera. Patient look side to side and up. [Yellowish
nodules on the bulbar conjunctiva=pinguecula] [Generalized
redness=conjunctivitis (pink eye); dryness=allergies or trauma; episcleritis (local,
noninfectious inflammation of the sclera)=nodular appearance or by redness with
dilated vessels]
• Inspect palpebral conjunctiva (only if necessary). Pull down lower lid. Evert
upper lid. [Cyanosis in lower lid=heart or lung disorder; foreign body or lesion in
 upper eyelid=irritation, burning, pain, and/or swelling]
• Inspect and palpate lacrimal apparatus. [Sweling=blockage, infection, or an
inflammatory condition; redness or swelling around puncta=infectious or
inflammatory condition; excessive tearing=nasolacrimal sac obstruction]
[Expressed drainage from puncta on palpation=duct blockage]
• Inspect cornea and lens. [Arcus senilis (white arc around limbus)=normal with
aging and no effect on vision] [Roughness or dryness on cornea=injury or allergic
response; opacities of lens=cataracts]
• Inspect iris and pupil. Measure pupils. [Anisocoria (inequality in pupil size of less
than 0.5 mm)=normal] [Irregularly shaped irises=increased risk for narrow-angle
glaucoma; miosis (constricted and fixed pupils)=narcotic drugs or brain damage;
mydriasis (dilate and fixed pupils)=CNS injury, circulatory collapse, or deep
anesthesia; anisocoria (pupils of unequal size) in bright light=trauma, tonic pupil,
oculomotor nerve paralysis; anisocoria in dim light=Horner’s syndrome (paralysis
of cervical sympathetic nerves and characterized by ptosis, sunken eyeball,
flushing of affected side of face, and narrowing of palpebral fissure]
• Test pupillary reaction to light. Assess consensual response (shine light in one eye
and watch reaction in other). [Monocular blindness=no response in either pupil]
• Test accommodation of pupils. [No constriction or convergence=abnormal]
• Using ophthalmalscope, inspect internal eye. [Cataracts=black spots against the
background of the red light reflex; nuclear and peripheral cataracts]
• Inspect optic disc. Not shape, color, size, and physiologic cup. [Papilledema
(swelling of optic disc)=hyperemic (blood filled) appearance, more visible and
more numerous disc vessels=hypertension or increased intracranial pressure;
intraocular pressure associated with glaucoma=enlarged physiologic cup, pale
base of enlarged physiologic cup, and obscured or displaced retinal vessels; optic
atrophy (death of optic nerve fibers)=disc being white and lack of disc vessels]
• Inspect retinal vessels. Observe arteriovenous (AV) ratio and AV crossings.
[Changes in blood supply=constricted arterioles, dilated veins, or absence of
major vessels; hypertension=widening of arterioles light reflex and arterioles take
on a copper color; long standing hypertension=arteriole walls thicken and appear
opaque or silver] [Arterial nicking, tapering, and backing are abnormal AV
crossings=hypertension or arteriosclerosis]
• Inspect retinal background. [Cotton-wool patches (soft exudates) and hard
exudates=diabetes and hypertension; hemorrhages and microaneurysms=red spots
and streaks on retinal background]
• Inspect fovea (sharpest area of vision) and macula. [Excessive clumped
pigment=detached retinas or retinal injuries; macular degeneration may be due to
hemorrhages, exudates, or cysts]
• Inspect anterior chamber. [Hyphemia=injury causes red blood cells to collect in
lower half of anterior chamber; Hypopyon=inflammatory response in which white
blood cells accumulate in anterior chamber and produce cloudiness in front of
iris]
Ears Assessment

Subjective:
Present:
• Describe any recent changes in your hearing. [Otitis media=sudden decrease in
ability to hear in one ear]
• Are all sounds affected with this change? [Presbycusis often begins with loss of
high frequency sounds]
• Do you have any ear drainage? Amount and odor? [Drainage
(otorrhea)=infection; purulent, bloody drainage=infection of external ear (external
otitis); purulent drainage associated with pain and a popping sensation=otitis
media with perforation of the tympanic membrane]
• Do you have ear pain? Do you have accompanying sore throat, sinus infection, or
problem with your teeth or gums? [Earache (otalgia) can occur with ear
infections, cerumen blockage, sinus infections, or teeth and gum problems]
• Do you have ringing or crackling in your ears? [Ear ringing (tinnitus)=excessive
wax buildup, high blood pressure, or certain ototoxic medications (streptomycin,
gentamicin, kanamycin, neomycin, ethacrynic acid, furosemide, indomethacin, or
aspirin)]
• Do you ever feel like you are spinning or that the room is spinning? Do you feel
dizzy or unbalanced? [Vertigo=inner ear problem; Subjective vertigo=client feels
spinning; objective vertigo=client feels room is spinning]
Past
• Have you ever had problems with your ears such as infections, trauma, or
earaches? [History of repeated infections=affected tympanic membrane and
hearing]
• Describe any past treatments you have received for ear problems (medications,
surgery, hearing aids). Successful? Satisfied?
Family
• Family history of hearing loss?
Lifestyle
• Do you work or live around frequent or continuous noise? How do you protect
your ears? [Continuous loud noises can cause hearing loss]
• Do you spend a lot of time swimming or in water? How do you protect your ears?
[Swimmers ear (infection of the ear canal)]
• Has your hearing loss affected your ADL’s?
• Has your hearing loss affected your socializing with others?
• When was your last hearing examination? [Yearly]
• How do you care for your ears? [Qtips can cause impacted cerumen or ear
damage]

Objective:
• Inspect auricle, tragus, and lobule. [Ears smaller than 4cm or larger than
10cm=abnormal; Malaligned or low set ears=genitourinary disorders or
 chromosomal defects]
• Observe for lesions, discolorations, and discharge. [Darwin’s turbuncle=normal;
enlarged preauricular and postauricular lymph nodes=infection; tophi (nontender,
hard, cream colored nodules on helix or antihelix)=gout; blocked sebaceous
glands=postauricular cysts; ulcerated, crusted nodules that bleed=skin cancer;
redness, swelling, scaling, or itching=otitis externa; pale blue ear=frostbite]
• Palpate the auricle and mastoid process. [Painful auricle or tragus=otitis externa
or a postauricular cyst; tenderness over the mastoid process=mastoiditis;
tenderness behind the ear=otitis media]
• Inspect the external auditory canal. Observe color and consistency of ear canal
walls. Note discharge and consistency of cerumen. [Foul smelling, sticky yellow
discharge=otitis externa or impacted foreign body; bloody, purulent
discharge=otitis media with ruptured tympanic membrane; blood or watery
drainage (cerebrospinal fluid)=skull trauma; impacted cerumen blocking view of
external ear canal=conductive hearing loss] [Reddened swollen canals=otitis
externa; exostoses=nonmalignant nodular swellings; polyps may block eardrum]
• Inspect the tympanic membrane (eardrum). [Red, bulging eardrum and distored
diminished or absent light reflex=acute otitis media; yellowish, bulging
membrane with bubbles behind=serous otitis media; bluish or dark red
color=blood behind eardrum from skull trauma; white spots=scarring from
infections; prominent landmarks (eardrum retraction from negative ear
pressure)=obstructed Eustachian tube; obscured or absent landmarks (eardrum
thickening)=chronic otitis media]

• Perform Weber’s Test. [Conductive hearing loss=lateralization of sound to poor

ear; Sensorineural hearing loss=lateralization of sound to good ear]
• Perform Rinne Test. [Normal= 2AC=BC] [Conductive hearing loss=BC>AC;
Sensorineural hearing loss=AC>BC]
• Perform Romberg Test (client stands with eyes closed). [Client moves feet to
prevent falls or starts to fall from loss of balance=vestibular disorder]

Mouth, Nose, Throat and Sinuses Assessment

Subjective:
Present:
• Do you experience tongue or mouth sores or lesions? Are they painful? How long
have you had them? Do they recur? Is it single or do you have many? [Painful,
recurrent ulcers in mouth=aphthous stomatitis (canker sores) and herpes simplex
(cold sores); mouth or tongue sores that do not heal, red or white patches that
persist, lump or thickening, or rough crusty, eroded areas=warning signs of
cancer]
• Do you experience redness, swelling, bleeding, or pain in gums or mouth? How
long has this been happening? Do you have any toothache? Have you lost any
permanent teeth? [Red, swollen gums that bleed easily=gingivitis; destruction of
gums with tooth loss=periodontits (more advanced gum disease)]
• Do you have pain over your sinuses? [Sinusitis=pressure and pain over sinuses]
 • Do you experience nosebleeds? How much bleeding? What color is the blood?
[Overuse of nasal sprays, excessively dry nasal mucosa, hypertension, leukemia,
thrombocytopenia, and other blood disorders]
• Do you experience frequent clear or mucous drainage from your nose? [Thin,
watery, clear nasal drainage (rhinorrhea)=chronic allergy or cerebrospinal fluid
leak (in a person with past head injury); Mucous drainage especially yellow=cold,
rhinitis, or a sinus infection]
• Can you breath through both of your nostrils? Do you have stuffy nose at times
during the day or night? [Sinus congestion, obstruction, or a deviated septum]
• Do you have seasonal allergies (hay fever)? Describe timing of allergies and
symptoms. [Pollens cause seasonal rhinitis; dust may cause rhinitis year round]
• Have you experienced a change in your ability to smell or taste? [Decreased
ability to smell=upper respiratory infections, smoking, cocaine use, or a
neurologic lesion or tumor in brain; decreased ability to taste=upper respiratory
infections or lesions on facial nerve (VII); changes in perceptions of smell=zinc
deficiency or menopause in some women]
• Do you have difficulty chewing or swallowing food? For how long? Do you have
any pain? [Dysphagia (difficulty swallowing)=esophageal disorders, anxiety,
poorly fitting dentures, or a neurologic disorder; difficulty chewing, swallowing
or moving tongue may be a late sign of oral cancer; malocclusion=difficulty
swallowing or chewing]
• Do you have a sore throat? For how long? Describe. How often do you get sore
throats? [Throat irritation and soreness=sinus drainage, viral or bacterial infection;
sore throat that persists without healing=throat cancer]
• Do you experience hoarseness? How long? [Upper respiratory infections,
allergies, hypothyroidism, overuse of voice, smoking or inhaling other irritants,
and cancer of larynx]
Past
• Have you ever had any oral, nasal, or sinus surgery?
• Do you have a history of sinus infections? Describe your symptoms. Do you use
nasal sprays? (What type? How much? How often?) [Overuse of nasal
sprays=nasal irritation, nosebleeds, and rebound swelling]
Family
• Family history of mouth, throat, nose, or sinus cancer?
Lifestyle
• Do you smoke or use smokeless tobacco? How much? Are you interested in
quitting? [Cancer]
• Do you drink alcohol? How much and how often?
• Do you grind your teeth? [Grinding teeth (bruxism)=stress or slight malocclusion,
may precipate TMJ problems and pain]
• How do you care for your teeth or dentures? How often do you brush or use
dental floss? When was your last dental examination? [Regular checkups can help
detect early signs of gum disease and oral cancer]
• If have braces, how do you care for them? Do you avoid specific types of foods?
Describe your usual dietary intake for a day. [People with braces should avoid
 crunchy, sticky, and chewy foods]
• If wear dentures, how do they fit? [Poorly fitting dentures may lead to poor eating
habits, mouth sores or leukoplakia (thick white patches of cells, precancerous
condition)]
• Do you brush your tongue?
• How often are you in the sun? Do you use lip sunscreen products?

Objective:
• Inspect lips. [Pallor around lips (circumoral pallor)=anemia or shock; bluish
(cyanotic) lips=cold or hypoxia; reddish lips=ketoacidosis, carbon monoxide
poisoning, and COPD with polycythemia; lip edema=local or systemic allergic or
anaphylactic reaction]
• Inspect teeth and gums. [Smoking and drinking large quantities of coffee or
tea=yellow or brownish teeth; caries=brown dots or splotches; chalky white area
in tooth surface=caries before turns brown; malocclusion=upper or lower incisors
protrude; white spots on teeth=antibiotic therapy; receding gums=abnormal in
young clients] [Red swollen gums that bleed easily=gingivitis, scurvy and
leukemia; receding red gums with loss of teeth=periodontitis; enlarged reddened
gums (hyperplasia)=pregnancy, puberty, leukemia and some medications
(phenytoin); bluish-black or grey white line along gum line=lead poisoning]
• Inspect buccal mucosa. [Leukoplakia=chronic irritation and smoking; whitish
curdlike patches that scrape off over reddened mucosa and bleed easily=thrush
(candida albicans) infections; koplik’s spots (tiny whitish spots that lie over
reddened mucosa)=early sign of measles; canker sores and brown
patches=adrenocortical insufficiency]
• Inspect and palpate tongue. Observe for fasciculations (fine tremors). [Deep
longitudinal fissures=dehydration; black tongue=bismuth (peptobismol) toxicity;
black hairy tongue; smooth, reddish, shiny tongue without paillae=niacin or
vitamin b12 deficiencies, certain anemias and antineoplastic therapy; enlarged
tongue=hypothyroidism, acromegaly, or Down’s syndrome, angioneurotic edema
of anaphylaxis; small tongue=malnutrition; atrophied tongue or
fasciculations=cranial nerve (CN 12) damages]
• Assess the ventral surface of the tongue. [Leukoplakia, persistent lesions, ulcers,
or nodules=cancer]
• Inspect for Wharton’s ducts. [Lesions, ulcers, nodules, or hypertrophied duct
openings on either side of frenulum]
• Observe the sides of the tongue. [Canker sores on sides of tongue=chemotherapy;
leukoplakia, persistent lesions, ulcers, or nodules=cancer]
• Check strength of tongue. [Decreased tongue strength=twelfth cranial nerve-
hypoglossal- or with a shortened frenulum]
• Check the anterior tongue’s ability to taste. [Loss of taste discrimination=zinc
deficiency, a seventh cranial nerve (facial) defect, and certain medication use]
• Inspect hard (anterior) and soft (posterior) palates and uvula. [Torus
palatinus=normal protruberance in midline of hard plate] [Candidal
infection=white plaques on hard palate; deep purple, raised or flat
 lesions=Kaposi’s sarcoma; yellow tint to hard palate=jaundice; opening in hard
palate is known as a cleft palate]
• Note odor. [Fruity or acetone breath=diabetic ketoacidosis; ammonia odor=kidney
disease; foul odors=oral or respiratory infection or tooth decay; fecal breath
odor=bowel obstruction; sulfur odor (fetor hepaticus)=end stage liver disease]
• Assess the uvula. [Bifid uvula=submucous cleft palate; asymmetric movement or
loss of movement=cerebrovascular accident (stroke); Palate fails to rise and uvula
deviates to normal side=cranial nerve X (vagus) paralysis]
• Inspect the tonsils. [Red, enlarged, covered with exudates tonsils=tonsillitis]
• Inspect the posterior pharyngeal wall. [Bright red throat with white or yellow
exudates=pharyngitis; yellowish mucus on throat=postnasal sinus drainage]
Nose
• Inspect and palpate the external nose. [Nasal tenderness=local infection]
• Check patency of airflow through nostrils. [Client cannot sniff through a nostril
that is not occluded=swelling, rhinitis, or foreign object obstructing the nostrils]
• Inspect internal nose. [Nasal mucosa swollen and pale pink or bluish
gray=allergies; nasal mucosa red swollen=upper respiratory infection; Purulent
nasal discharge=acute bacterial rhinosinusitis; bleeding (epistaxis) or crusting on
lower anterior part of septum=local irritation; ulcers=use of cocaine, trauma,
chronic infection, or chronic nose picking; polyps=chronic allergies]
• Palpate sinuses. [Frontal or maxillary sinuses tender=allergies or acute bacterial
rhinosinusitis; large amount of exudates may cause crepitus on palpation]
• Percuss sinuses. [Frontal and maxillary sinuses tender=allergies or sinus
infection]
• Transilluminate the sinuses. [Absence of red glow=sinus filled with fluid or pus]

Heart and Neck Vessels Assessment

Subjective:
Present:
• Do you experience chest pain? When did it start? Describe type of pain, location,
radiation, duration, and how often you experience the pain. Rate pain. Does
activity make the pain worse? Did you have perspiration (diaphoresis) with chest
pain? [Chest pain can be cardiac, pulmonary, muscular or GI in origin]
• Do you experience palpations? [Abnormality of heart’s conduction system or
during heart’s attempt to increase cardiac output by increasing the heart rate]
• Do you tire easily? Do you experience fatigue? Describe when it started. Sudden
or gradual? Do you notice it at any particular time of day? [Fatigue is often
compromised cardiac output – worse in evening or as day progresses]
• Do you have difficulty breathing or shortness of breath (dyspnea)? [Congestive
heart failure, pulmonary disorders, coronary artery disease, myocardial ischemia,
and myocardial infarction]
• Do you wake up at night with urgent need to urinate (nocturia)? How many times
a night? [Increased renal perfusionduring periods of rest=nocturia; decreased
frequency=decreased cardiac output]
 • Do you experience dizziness? [May indicate decreased blood flow to brain due to
myocardial damage; inner ear syndromes, decreased cerebral circulation, and
hypotension]
• Do you experience edema in your feet, ankles or legs? [Heart failure]
• Do you have frequent heart burn? When does it occur? What relieves it? How
often? [GI pain may occur after meals and is relieved with antacids; cardiac pain
may occur anytime and is not relieved with antacids and worsens with activity]
• Have you ever had rheumatic fever? [40% of people with rheumatic fever develop
rheumatic carditis=inflammation of all layers of the hear, impairing contraction
and valvular function]
• Have you ever had heart surgery or cardiac balloon interventions? [Previous heart
surgery may change the heart sounds heard during auscultation]
• Have you ever had an ECG? When? Do you know the results? [Allows health
care team to evaluate for any changes in cardiac conduction or previous
myocardial infarction]
• Have you ever had a lipid profile? Do you know what your cholesterol levels
were? [Dyslipidemia=risk for developing coronary artery disease; elevated
cholesterol levels linked to development of atherosclerosis]
• Do you take medications or use other treatments for heart disease? How often do
you take them? Why do you take them? [Clients may not take medications
regularly due to unwanted side effects such as frequent urination or adverse
effects on sexual energy]
• Do you monitor your own heart rate or blood pressure? [Recommended if client is
taking cardiotonic or antihypertensive medications]
Family
• Family history of hypertension, myocardial infarction, coronary heart disease
(CHD), elevated cholesterol levels, or diabetes mellitus (DM)?
Lifestyle
• Do you smoke? How much and for how long?
• Stress? How do you cope with it?
• Describe what you eat in 24-hour period. [Elevated cholesterol level increases the
chance of fatty plaque formation in the coronary vessels]
• How much alcohol do you consume? [Excessive alcohol intake is linked to
hypertension]
• Do you exercise? What type and how often?
• Describe your ADL’s. Do fatigue, chest pain, or shortness of breath limit your
ability to perform ADL’s. Are you able to care for yourself? [Exertional dyspnea
or fatigue may indicate heart failure]
• Has your heart disease had any effect on your sexual activity? [Nitroglycerin can
be taken before intercourse as a prophylactic for chest pain]
• How many pillows do you use at night? Do you get up and urinate during the
night? Do you feel rested in morning? [If heart function is compromised, cardiac
output to the kidneys is reduced during episodes of activity; at rest, cardiac output
increases as does urinary output; orthopnea and nocturia=heart failure]
• How important is having a healthy heart to your ability to feel good about
 yourself and your appearance? What fears about heart disease do you have?

Objective:
• Observe jugular venous pulse. [Distended jugular veins with client more than 45
degrees=central venous pressure due to right ventricular failure, pulmonary
hypertension, pulmonary emboli, or cardiac tamponade]
• Evaluate jugular venous pressure. [Distention, bulging, or protrusion at 45, 60, or
90 degrees=right sided heart failure; pulmonary disease=elevated venous pressure
only during expiration; inspiratory increase in venouse pressure (Kussmaul’s
sign)=severe constrictive pericarditis]
• Auscultate carotid arteries with bell. Ask client to hold breath. [Bruit (blowing or
swishing sound)=occlusive arterial disease; inequal pulse=arterial constriction or
occlusion in one carotid]
• Palpate and rate carotid arteries. [Weak pulse=hypovolemia, shock or decreased
cardiac output; bounding, firm pulse=hypervolemia or increased cardiac output;
delayed upstroke=aortic stenosis; loss of elasticity=arteriosclerosis;
thrills=narrowing of artery]
• Inspect apical pulsation. [Heaves or lifts=enlarged ventricle from an overload of
work]
• Palpate the apical impulse. If cannot palpate, have client assume left lateral
position. [Apical impulse may be impossible to palpate in clients with pulmonary
emphysema; apical pulse larger than 1 – 2cm=cardiac enlargement]
• Palpate for abnormal pulsations. [Thrill or pulsation=grade IV or higher mumur]
• Auscultate heart rate and rhythm. [Bradycardia or tachycardia=decreased cardiac
output; irregular patterns=decreased cardiac output, heart failure, or emboli]
• If you detect irregular rhythm, auscultate for a pulse rate deficit. [Pulse
deficit=atrial fibrillation, atrial flutter, premature ventricular contractions, and
varying degrees of heart block]
• Auscultate S1 and S2. [Split S1 can be heard in healthy young adults at left lateral
sternal border; all split S2 in expiration is abnormal]
• Auscultate for extra heart sounds with diaphragm and bell. [Ejection sounds or
clicks; friction rub; pathologic S3 (ventricular gallop)=ischemic heart disease,
hyperkinetic states (anemia), or restrictive myocardial disease; pathologic S4
(atrial gallop) toward left side of precordium=coronary artery disease,
hypertensive heart disease, cardiomyopathy, and aortic stenosis; pathologic S4
toward right side of precordium=pulmonary hypertension and pulmonic stenosis;
S3 and S4 together create quadruple rhythm (summation gallop); opening snapps
early in diastole=mitral valve stenosis]
• Auscultate for murmurs with diaphragm and bell. [Midsystolic, pansystolic, and
diastolic murmurs]
• Ascultate with client assuming other positions. Left lateral position. [S3 or S4 heart
sound or murmur of mitral stenosis that was not detected supine may be revealed]
• Ask client to sit up and lean forward. [Murmur of aortic regurgitation may be
detected]
Peripheral Vascular System Assessetation

Subjective:
Present:
• Have you noticed any color, temperature, or texture changes in your skin? [Cold,
pale, clammy skin on extremities and thin, shiny skin with loss of hair=arterial
insufficiency; warm skin and brown pigmentation around ankles=venous
insufficiency]
• Do you experience pain or cramping in your legs? Describe. How often? Does it
occur with activity? Does it wake you from sleep? [Cramping pain in calves,
thighs, or buttocks and weakness with activity=arterial disease; heaviness and
aching aggravated by standing or sitting for long periods=venous disease; leg pain
that awakens clients=advanced chronic arterial occlusive disease]
• Do you have any leg veins that are ropelike, bulging, or contorted? [Varicose
veins]
• Do you have any sores or open wounds on your legs? Where? Are they painful?
[Ulcers associated with arterial disease=painful and often located on toes, foot, or
lateral ankle; venous ulcers=painless and occur on lower leg or medial ankle]
• Do you have any swelling in legs or feet? At what time of day is it worst? Any
pain with swelling? [Peripheral edema=obstruction of lymphatic flow or from
venous insufficiency due to incompetent valves or decreased osmotic pressure or
DVT]
• Do you have any swollen glands or lymph nodes? Do they feel tender, soft, or
hard? [Enlarged lymph nodes=local or systemic infection]
• For male clients, have you experienced a change in your usual sexual activity?
Describe. [Impotence may occur with decreased blood flow or an occlusion of the
blood vessels such as aortoiliac occlusion (Leriche’s syndrome)]
Past
• Describe any problems you had in the past with circulation in your arms and legs
(blood clots, ulcers, coldness, hair loss, numbness, swelling, or poor healing).
[Past DVT may lead to post-thrombotic syndrome leading to tissue damage]
• Have you had any heart or blood vessel surgeries or treatments such as coronary
artery bypass grafting, repair of an aneurysm, or vein stripping? [Previous
surgeries may alter the appearance of skin and underlying tissues]
Family
• Do you or does your family have a history of diabetes, hypertension, coronary
heart disease, intermittent claudication, or elevated cholesterol or triglyceride
levels? [These disorders cause damage to blood vessels]
Lifestyle
• Do you or did you smoke or use any tobacco products? How much and for how
long? Are you willing to quit? [Smoking cigarettes increases persons risk for
chronic arterial insufficiency]
• Do you exercise regularly? [Regular exercise improves peripheral vascular
circulation and decreases stress, pulse rate, and blood pressure thereby decreasing
risk for peripheral vascular disease]
 • For females, do you take oral or transdermal contraceptives? [Contraceptives
increase risk for thrombophlebitis, Raynaud’s disease, hypertension, and edema]
• Are you experiencing any stress? [Stress increases heart rate and blood pressure
and can contribute to vascular disease]
• How have problems with circulation affected ability to function? [Discomfort or
pain with chronic arterial disease and aching heaviness with venous disease may
limit clients ability to stand or walk for long periods]
• Do leg ulcers or varicose veins affect how you feel about yourself?
• Do you regularly take medications to improve circulation? [Cilostazol(Pletal) or
clopidogrel (Plavix) increase blood flow; Aspirin prevent blood clotting;
Pentoxifylline (Trental) reduces blood viscosity, improving blood flow; topical
medication Xenaderm (Trypsin) can improve wound oxygenation by increasing
blood flow]
• Do you wear support hose to treat varicose veins? [They reduce venous pooling
and increase blood return to heart]

Objective:
• Observe arm size and venous pattern. Look for edema. [Lymphedema (blocked
lymphatic circulation)=breast surgery; prominent venous patterning with
edema=venous obstruction]
• Observe coloration of hands and arms. [Raynaud’s disease (vascular disorder
caused by vasoconstriction or vasospasm of fingers or toes=rapid changes in color
(pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning,
throbbing, and coldness]
• Palpate client’s fingers, hands, arms and note temperature. [Cold
extremity=arterial insufficiency or Raynaud’s disease]
• Palpate to assess capillary refill time. [Capillary refill time exceeding 2
seconds=vasoconstriction, decreased cardiac output, shock, arterial occlusion, or
hypothermia]
• Palpate radial pulse. [Increased radial pulse volume=hyperkinetic state;
diminished or absent pulse=partial or complete arterial occlusion from Buerger’s
disease or sclroderma; obliteration of the pulse=compression by external sources
such as compartment syndrome]
• Palpate ulnar pulses. [Lack of resilience or inelasticity of artery
wall=arteriosclerosis]
• Palpate brachial pulse if suspect arterial insufficiency. [Brachial pulses are
increased, diminished or absent]
• Palpate the epitrochlear lymph nodes. [Enlarged epitrochlear lymph
nodes=infection in hand or forearm or generalized lymphadenopathy or a lesion in
the area]
• Perform Allen test. [With arterial insuffiency or occlusion of ulnar or radial
artery, pallor persists]

• Observe skin color while inspecting both legs from the toes to the groin. [Pallor,
especially when elevated=arterial insufficiency; cyanosis=venous insufficiency;
 rusty brownish pigmentation around ankles=venous insufficiency]
• Inspect distribution of hair. [Loss of hair on legs=arterial insufficiency]
• Inspect for lesions or ulcers. [Ulcers with smooth, even margins that occur at
pressure areas=arterial insufficiency; ulcers with irregular edges, bleeding, and
possible bacterial infection on medial ankle=venous insufficiency]
• Inspect for edema. [Bilateral edema=systemic problem such as congestive heart
failure or a local problem such as lymphedema or prolonged standing or sitting
(orthostatic edema); unilateral edema=venous stasis due to insufficiency or
obstruction or lymphedema; a difference between legs=muscular atrophy due to
stroke or from being in a cast for a prolonged time]
• Palpate edema. Note if pitting or non-pitting. [Pitting edema=systemic problems
such as congestive heart failure or hepatic cirrhosis and local infection such as
venous stasis due to insufficiency or obstruction or prolonged standing or sitting]
• Palpate bilaterally for temperature of feet and legs. [General coolness in one leg
or change in temp as go down leg=arterial insufficiency; increased
warmth=superficial thrombophlebitis]
• Palpate superficial inguinal lymph nodes. [Enlarged lymph nodes
(lympadenopathy)=local infection or generalized lympadenopathy; fixed
nodes=malignancy]
• Palpate femoral pulses. [Weak or absent pulses=partial or complete arterial
occlusion]
• Auscultate femoral pulses. [Bruits=partial obstruction of vessel and diminished
blood flow to lower extremities]
• Palpate popliteal pulses. [Absent pulse=occluded artery]
• Palpate dorsalis pedis pulse. [Weak or absent pulse=impaired arterial circulation]
• Palpate posterior tibial pulse. [Weak or absent pulse=partial or complete arterial
occlusion]
• Inspect for varicosities and thrombophlebitis. [Vericose veins; superficial vein
thrombophlebitis=redness, thickening, and tenderness along vein; aching and
cramping with walking or dorsiflexion of foot=positive Homan’s sign]
• Homan’s sign. [Pain=positive sign=DVT or superficial thrombophlebitis]
• Perform position change test for arterial insufficiency. [Marked pallor=arterial
insufficiency]
• Determine ankle-brachial pressure index (ABPI), aka Ankle branchial index
(ABI).
• Manual compression test. [Feel pulsation if valves in veins are incompetent]
• Trendelenburg test. [Rapid filling of superficial varicose veins from
above=retrograde filling past incompetent valves in veins]

Nervous System

Subjective:
Present:
• Do you experience any numbness or tingling? When and where does this occur?
[Brain, spinal cord, or peripheral nerve damage]
• Do you experience seizures? How often? [Epilepsy, metabolic disorders, head
injuries, and high fevers]
• Describe what happens before the seizures? Where do they start? Any initiating
factors? Do you lose control of your bladder? How do you feel afterward? Do you
take medications for seizures? Do you wear medical identification to alert others?
Do you take safety precautions? [Aura sensation precedes a seizure; where a
seizure starts and what occurs before and after indicates what type of seizure
(grand mal or petite mal) and its treatment; generalized seizures usually=bladder
incontenence; MedicAlert bracelet lets others know]
• Do you experience headaches? When and what do they feel like? [Morning
headaches that subside after arising may be an early sign of increased intracranial
pressure such as with a brain tumor]
• Do you experience dizziness or lightheadedness or problems with coordination or
balance? How often? Does it occur with activity? Any falling? DO you have any
clumsy movement? [Dizziness or lightheadedness=carotid artery disease,
cerebellar abscess, Meniere’s disease or inner ear infection; imbalance and
difficulty coordinating or controlling movements=neurologic diseases involving
cerebellum, basal gangli, extrapyramidal tracts, or the vestibular part of cranial
nerve VIII (acoustic); diminished cerebral blood flow and vestibular response
may increase the risk of falls]
• Have you noticed a decrease in your ability to smell or taste? [Decreased
smell=dysfunction of cranial nerve I (olfactory) or brain tumor; decreased
taste=dysfunction of cranial nerves VII (facial) or IX (glossopharyngeal)]
• Have you experienced ringing in ears or hearing loss? [Dysfunction of cranial
nerve VIII (acoustic)]
• Have you noticed any change in your vision? [Dysfunction of cranial nerve II
(optic), increased intracranial pressure, or brain tumors; damage to cranial nerves
III (oculomotor), IV (trochlear) or VI (abducens) may cause double or blurred
vision; transient blind spots=early sign of cerebrovascular accident (CVA)]
• Do you have difficulty understanding when people are talking to you? Do you
have difficulty making others understand you? Do you have difficulty forming
words or verbally interpreting your thoughts? [Injury to cerebral cortex can impair
ability to use or understand verbal language]
• Do you experience difficulty swallowing? [CVA, Parkinson’s disese, myasthenia
gravis, Guillain-Barre syndrome, or dysfunction of cranial nerves IX
(glossopharyngeal), X (vagus), or XII (hypoglossal)]
• Have you lost bowel or bladder control or do you retain urine? [Loss of bowel
control or urinary retention and bladder distention are seen with spinal cord injury
or tumors]
• Do you have muscle weakness? Where? [Unilateral weakness or paralysis=CVA,
compression of spinal cord, or nerve injury; progressive weakness=several
nervous system diseases]
• Do you experience any tremors? Where? [Tremors=degenerative neurologic
 disorders (Parkinson’s disease-three to six per second while muscles are at rest)
(Cerebellar disease and multiple sclerosis-variable rate)]
• Do you experience any loss of memory? [Recent memory (24 hrs)=amnestic
disorders, Korsakoff’s syndrome, delirium, and dementia; Remote memory (past
and history)=impaired cerebral cortex disorders]
Past
• Have you ever had any type of head injury with or without loss of consciousness?
Describe any physical or mental changes that have occurred as a result.
Treatment? [Head injuries can produce long-term neurologic deficits and affect
level of functioning]
• Have you ever had meningitis, encephalitis, injury to spinal cord, or stroke? Any
physical or mental changes as a result? Treatment? [Theses disorders affect long-
term physical and mental status of the client]
Family
• Do you have a family history of high blood pressure, stroke, Alzheimer’s disease,
epilepsy, brain cancer, or Huntington’s chorea? [May be genetic]
Lifestyle
• Do you take ay prescription or nonprescription medications? How much alcohol
do you drink? Do you use recreational drugs such as marijuana, tranquilizers,
barbiturates, or cocaine? [Prescription and nonprescription drugs can cause
various neurologic symptoms such as tremors or dizziness, altered level of
consciousness, decreased response times, and changes in mood and temperament]
• Do you smoke? [Nicotine constricts the blood vessels=decreased blood flow to
brain; risk for CVA]
• Do you wear your seat belt when riding in vehicles? Do you wear protective
headgear when riding a bicycle or playing sports? [Prevent head injury]
• Describe your usual daily diet. [Peripheral neuropathy=deficiency in niacin, folic
acid, or vitamin B12]
• Have you ever had prolonged exposure to lead, insecticides, pollutants, or other
chemicals? [Can alter neurologic status]
• Do you frequently lift heavy objects or perform repetitive motions? [Intervertebral
disc injuries may result when heavy objects are lifted improperly; peripheral
nerve injuries can result from repetitive movements]
• Can you perform your normal ADL’s? [Neurologic symptoms and disorders often
negatively affect the ability to perform activities of daily living]
• Has your neurologic problem changed the way you view yourself? Explain.
• Has your neurologic problem added much stress to your life? Describe.

Objective:
• Test CN I (olfactory). Client clear nose and identify smell per nostril. [Inability to
smell (neurogenic anosmia) or identify the correct scent=olfactory tract lesion or
tumor or lesion of the frontal lobe; loss of smell=congenital or due to other causes
such as nasal disease, smoking and use of cocaine]
• Test CN II (optic). Snellen chart. Newspaper reading. Confrontation Test.
Opthalmoscope. [Difficulty reading Snellen chart, missing letters, and
 squinting=abnormal] [Presbyopia] [Loss of visual fields=retinal damage or
detachment, with lesions of optic nerve, or with lesions of parietal cortex]
[Papilledema (swelling of optic nerve) results in blurred optic disc margins and
dilated, pulsating veins=increased intracranial pressure from intracranial
hemorrhage or a brain tumor; optic atrophy=brain tumor]
• Assess CN III (oculomotor), IV (trochlear), and VI (abducens). Inspect margins of
eyes. Extraocular movemtns. Pupillary response to light and accommodation.
[Ptsosis=weak eye muscles such as in myasthenia gravis] [Nystagmus=cerebellar
disorders; limited eye movement through six cardinal fields of gaze=increased
intracranial pressure; paralytic strabismus=paralysis of oculomotor, trochlear, or
abducens nerves] [Dilated pupil=oculomotor nerve paralysis; Argyll Robertson
pupils=CNS syphilis, meningitis, brain tumor, alcoholism; contricted, fixed
pupils=narcotics abuse or damage to pons; unilaterally dilated pupil unresponsive
to light or accommodation=damage to cranial nerve III (oculomotor); constricted
pupil unresponsive to light or accommodation=lesions of sympathetic nervous
system; bilateral muscle weakness=peripheral or central nervous system
dysfunction; unilateral weakness=lesion of cranial nerve V (trigeminal)]
• Assess CN V (trigeminal).