NR 509 Physical Assessment

360 degree scan of room - Danielle Intro - My name is Danielle Hanlon and this is my physical examination assignment for NR 509 Trevor Intro - My name is Trevor Barnum and I give permission for this examination to be recorded and submitted to Chamberlain College of Nursing for grading purposes **Start Exam** Introduction - Hi my name is Danielle and I will be doing your examination today. Inspect face - No discoloration or lesions Inspect head - Midline and symmetrical Palpate lymph nodes - -preauricular (front of ears) -posterior auricular (behind ears) -occipital (base of occiput) -tonsilar (lower jaw) -submandibular (lower mandible) -submental (below chin) -anterior cervical -posterior cervical (in front of upper trap) -supraclavicular (on top of clavicle) No enlargement. Equal bilaterally. Cranial nerve 5 - trigeminal - Motor (Palpate masseter) "Clench your jaw" No distortions and he has great strength Sensory "Close your eyes and tell me where you feel my touch" Forehead, R cheek, L cheek, chin, nose Correctly identifies sensations Cranial nerve 5 is intact Cranial nerve 7 - facial - "I will ask you to make different facial expressions" Smile, frown, raise eyebrows, puff out cheeks, pucker lips Expressions are equal bilaterally Cranial nerve 7 is intact Inspect outer ears - No lesions or nodules bilaterally Symmetrical Inspect inner ears w/ otoscope - Say x2 (check both ears) External auditory canal clear No redness, swelling or drainage Tympanic membrane pearly gray No effusion noted in middle ear Palpate ears - Pinna x2 Tragus x2 Any tenderness? No nodules or tenderness noted of the pinna or tragus Cranial nerve 8 - vestibulocochlear - Whisper test "Cover one ear. I am testing ___ ear. Say aloud what you hear me whisper. 1-2-3. Repeat with other ear. 4-5-6" Hearing is intact bilaterally. Cranial nerve 8 is intact. Inspect eyes - Pull down lower eyelid Conjunctiva pink and clear, no drainage or lesions. Sclera white and clear. Cranial nerve 2 - optic nerve - "Will test central and peripheral vision" Central Snellen pocket eye chart Stand 6ft away Cover one eye, so testing ______ eye Read the smallest line of letters you can Repeat on other side then with both eyes 20/20 vision (normal) in R eye, L eye and both eyes Peripheral Trevor stands up "look straight ahead" Do you see my hands now? Tell me when you do Next to ears, above head, and below waist?? Peripheral vision is normal Cranial nerve 2 is intact Cranial nerve 3 - oculomotor - Pupil response to light bilaterally "Stare at my nose" Pupil constricts x2 Pupils are 2-3 mm and are equal, round and reactive to light Cranial nerves 3, 4 (trochlear), 6 (abducens) - Continuing to test cranial nerve 3 in addition to 4 and 6 "Follow my finger with your eyes only" H and convergence Extraocular movements are intact. Cranial nerves 3, 4, and 6 intact. Inspect outer nose - midline straight no noticeable deformity or swelling Inspect inner nose - Tip nose up with thumb Otoscope Look at turbinates - moist, pink, no swelling or bogginess Look MEDIALLY - septum straight, no deviation *look bilaterally Palpate frontal and maxillary sinuses - "Any tenderness?" No tenderness of the frontal or maxillary sinuses Inspect mouth - Lips pink and moist Open mouth No signs of tooth decay Gums healthy pink - no redness or swelling Otoscope Buccal mucosa pink and moist Upper hard and soft palates intact, pink and moist Tongue smooth, pink and moist Under tongue no nodules, drainage; pink and moist Posterior pharynx pink