Inspects Face for Symmetry Assessment

Head and Face 1. Notes size and shape of head. 2. Inspects face for symmetry. 3. Inspects the scalp for tenderness, lesions, flakiness, masses. 4. Inspects and palpates the hair, noting distribution and texture of hair. o The head is symmetric, round, erect, and in midline and appropriately related to body size (normocephalic). No lesions are visible. Hair is evenly distributed. 5. Palpates the head and scalp. 6. Palpates the temporal artery. 7. Assesses trigeminal nerve CN V, sensory and motor. Test Motor Function o Ask the patient to bite down, Temporal and masseter muscles contract bilaterally. Test Sensory Function o The client correctly identifies sharp and dull stimuli and light touch to the forehead, cheeks, and chin with eyes closed. 8. Assesses facial nerve CN VII. o Test Motor Function Ask the client to:        Smile Frown and wrinkle forehead Show teeth Puff out cheeks Purse lips Raise eyebrows Close eyes tightly against resistance 9. Notes color of skin, eyes, & lips. Assesses Ocular Structures 1. Inspects lids, lashes, pupils, sclera, lens, and conjunctiva for normal appearance. The lower lid margin rests on the lower border of the iris. No white sclera is above or below the iris. Lower eyelid is upright. Eyelashes are evenly distributed. Bulbar conjunctiva is clear, moist, and smooth. Sclera is white. Iris is round, flat, and evenly colored. Pupil is round, with a regular border and is centered in the iris 2. Assess pupil size, direct and consensual light reaction. Pupils are equal in size (3mm to 5mm) 3. Tests pupillary light reflexes (PERRLA). Pupils are equal, round, reactive to light, and accommodate Eyes Assesses Visual Function 1. Measures visual acuity using the Snellen chart or handheld chart Optic Nerve CN II. The top, or first, number is always 20, indicating the distance from the client to the chart. The bottom, or second, number refers to the last full line the client could read. 2. Assesses extraocular muscle function by evaluating the corneal light reflex and six cardinal movement of gaze. CN III (Oculomotor), CN IV (Trochlear), CN VI (Abducens). Movement is smooth and symmetric throughout all six directions Starts at the midline, move the penlight to the left, then straight up, then straight down. Drop your hand. Position the penlight at the midline. Now move the penlight to the right, then straight up, then straight down. Ears Assesses External Ear 1. Inspect auricle and auditory meatus for appearance, pain, discharge. Ears are equal in size bilaterally. The auricle aligns with the corner of each eye. 2. Assess targus for pain. Screens for Hearing Ability 1. Uses watch or whisper to test hearing acuity, Auditory Nerve (CN VIII). 2. Performs the Rinne and Weber Test. Perform the Weber test by using a tuning fork placed on the center of the head or forehead and asking whether the client hears the sound better in one ear or the same in both ears. Vibrations are heard equally well in both ears. Perform the Rinne test by using a tuning fork and placing the base on the client’s mastoid process. When the client no longer hears the sound, note the time interval, and move it in front of the external ear. When the client no longer hears a sound, note the time interval. Air conduction sound is normally heard longer than bone conduction (AC ˃BC) Nose Assesses the Nose 1. Inspects external portions of nose for deviation in shape, size, color, discharge. The nasal structure is smooth and symmetric. The nasal septum is intact midline, and free of ulcers or perforations. There is no sign of discharge. 2. Assesses for patency of nostrils. Client can sniff through each nostril 3. Assesses olfactory Nerve, CN I. Client correctly identifies scent (i.e. alcohol pad) presented to each nostril. 4. Palpates Sinuses. Mouth, Throat, and Oral Cavity 1. Inspects lips, teeth, gums, tongue, throat and oral mucosa for: breaks, cracks, lesions, growths, and appearance. Lips are smooth and moist without lesions or swelling. Oral/Buccal Mucosa appears pink in light-skinned clients; tissue pigmentation typically increases in darkskinned clients, which may include freckling or dark pigmentation on ventral surface of tongue and floor of mouth. Gums are pink, moist, and firm with tight margins to the tooth, 32 pearly whitish teeth with smooth surfaces and edges. Tongue should be pink, moist, a moderate size with papillae (little protuberances) present. No lesions are present. 2. Notes movement of tongue, palate and uvula, Glossopharyngeal, CN IX. 3. Verbalizes assessment of gag reflex, Vagus Nerve CN X. 4. Notes presence and appearance of tonsils. 5. Assess position of tongue when protruding from mouth , Hypoglossal Nerve, Cranial Nerve XII. Assesses the Neck 1. Inspects head movement. Neck movement should be smooth and controlled with 45-degree flexion, 55-degree extension, 40-degree lateral abduction, and 70-degree rotation. 2. Inspects neck for symmetry. Neck is symmetric, with head centered and without bulging masses. 3. Palpates position of the trachea. 4. Palpates the thyroid gland. The thyroid is usually nonpalpable unless the client is extremely thin. 5. Assess shoulder shrug, Spinal Nerve CN XI. Have patient turn head to each side against resistance and shrug shoulders against resistance Assesses for Enlargement of Lymph Nodes 1. Palpates preauricular, post auricular and occipital nodes. 2. Palpates tonsillar, sub maxillary and sub mental nodes. 3. Palpates cervical and supraclavicular lymph nodes. Preauricular nodes (front of ears) Postauricular nodes (behind the ears) Occipital nodes (posterior base of skull) Tonsillar nodes (angle of the mandible, on the anterior edge of the sternocleidomastoid muscle) Submandibular nodes (medial border of the mandible); do not confuse with the lobulated submandibular gland Submental nodes (a few centimeters behind the tip of the mandible); use one hand Superficial cervical nodes (superficial to the sternomastoid muscle) Posterior cervical nodes (posterior to the sternocleidomastoid and anterior to the trapezius in the posterior triangle) Deep cervical chain nodes (deep within and around the sternomastoid muscle) Supraclavicular nodes (hook fingers over clavicles and feel deeply between the clavicles and the sternomastoid muscles)