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Physical Assessment

Assessment Mouth: Observe for any body and breath odor in relation to activity level

Normal Findings

Actual Findings

Analysis

No body odor or minor body odor relative to work or exercise; no breath odor

Smells foul

Body odor or breath other indicates of lack of hygiene or com!lication in some body !arts or !resence of bacteria Fundamentals of nursing by "o#ier !! $%&

Skin: Inspect skin for any lesions and redness in any part of the clients body . Skin intact; no bruises; no cuts or any sign of skin lesions "rimary a#e midline and $ith Cranial III, IV, VI No lesions except a lump on ri ht flank. !edness can be seen on the sacral area

'ye movement de!endent (N & 0Abducens1 on (ranial Nerves ) $ and & * muscles they innervate+ , Allows smooth coordinated movement in all directions of both eyes muscle 5 moves eye simultaneously , -here.s some overla! between actions of muscles/nerves (N ) 0Oculomotor1 All other muscles eye movement 3 also raises lid * mediates down 0de!ression1 when looking towards nose; also rotates internally+ 2ateral rectus muscle

left extra ocular mo%ement $eakness. &ixed

)he left eye has percei%ed less li ht stimulus *a defect in the then the opposite eye so the pupil dilates $ith the same li ht stimulus that caused constriction $hen the normal eye $as stimulated.

a#e does not follo$ sensory or afferent path$ay+

3 moves eye laterally test ob'ect (N $ 0-rochlear1 Su!erior obli4ue "rimary a#e midline and $ith left extra ocular mo%ement $eakness. &ixed constricted pupil approximately (mm bilaterally. Slu to li ht. ishly reacti%e

!u!ilary constriction+ V. Cannot elicit masseter and

temporalis muscles.

Cranial V Sensory6 Ask !t to close eyes -ouch of ) areas 0o!hthalmic maxillary * mandibular1 lightly noting whether !atient detects stimulus+ 7otor6 Pal!ate tem!oralis * mandibular areas as !atient clenches * grinds teeth Cranial VII Observe facial symmetry 8rinkle Forehead Motor component,face of be

asymmetrical, droopin component elicited. cannot

left side of face. Sensory

,"ee! eyes closed against resistance ,Smile !uff out cheeks 9vula midline 5 (N : Stick out tongue say ;Ahh< 3 use tongue de!ressor if can.t see 5 !alate/uvula rise (N : => ?ag @eflex !rovoked with tongue blade or 4 ti! 5 (N : => I-., -. .eak a reflex,

unable to s$allo$, moans $hen i%en pain stimulation. -II. )on ue in midline but de%iates to the left side of the mouth symmetrical.

,-ongue midline when !atient sticks it out (N =% check strengthby directing !atient !ush ti! into inside of either cheek while you !ush from outside -I. /nable to fully test

because patient is incoherent, ho$e%er no mo%ement can be seen from the left shoulder

(ranial AB -urn head to 2 into @ hand function of @ Sternocleidomastoid , -urn head to @ into 2 hand 02 S(71Shrug shoulders into your hands