NR509 Immersion/ NR 509 Immersion (Latest 2022 /
2023) : Advanced Physical Assessment - Chamberlain
College of Nursing
Introduction - ,,,correct answer,,,..___________, my name is ____________, I will be
doing your exam today. I'll begin with inspecting your face. I'll note that I don't see any
discolorations or lesions & the head is midline & symmetrical.
Lymph nodes - ,,,correct answer,,,..Next, I'll palpate the lymph nodes. I'll begin with the
preauricular lymph nodes, right in front of the ear, and postauricular, right behind the
ear. Then I will palpate her occipital lymph nodes in the back of the head. And then I'm
gonna move forward and palpate the tonsillar lymph nodes. Come under the jawline, the
submandibular lymph nodes, and the submental. Now I will go to the anterior cervical
lymph nodes, and the posterior cervical lymph nodes. And I will end with the
supraclavicular lymph nodes right about the clavicles. I do not feel any enlargement,
and they are equal bilaterally.
Face - ,,,correct answer,,,..I'm testing trigeminal nerve, which is cranial nerve # 5.
Palpating over the masseter muscle as the pt clenches the jaw. I don't feel any
distortions & my pt has great strength. Now, I'm testing the sensory portion of the
trigeminal nerve. I'll ask my pt to close your eyes & let me know where you feel my
touch. (>> Forehead, right cheek, left cheek, chin, nose)
Next, I'll test the facial nerve, which is cranial nerve # 7. I'm going to ask you to do some
facial expressions. I'm going to have you smile, next, frown for me. Now raise your
eyebrows & puff up your cheeks, pucker your lips. I notice all expressions have bilateral
symmetry.
Ears - ,,,correct answer,,,..Now, I'm going to inspect the ears. I'm looking for nodules or
skin lesions. They're both symmetrical, no nodules or skin lesions are noted. I'm going
to look inside the ear canal with the otoscope. I see that the external auditory canal is
clear, there's no swelling, redness, drainage or cerumen. The tympanic membrane is
pearly gray & there is no effusion in the middle ear. I'll do the other ear. Looking into the
external auditory canal. I see there is no swelling, redness, drainage, or cerumen. Pt's
tympanic membrane is pearly gray & there's no effusion in the middle ear. Next, I'm
going to palpate pinna for any nodules or tenderness. Now the tragus. No nodules or
tenderness are noted.
Acustic nerve CN8 - ,,,correct answer,,,..I will be testing your acoustic nerve, which is
cranial nerve # 8, which is hearing. I'll be performing a whisper test. I want you to cover
one of your ears & I will stand behind you, cover my mouth & whisper 3 words & I want
you to repeat them to me (1, 2, 3) & let's do the other side (4, 5, 6). Hearing is intact
bilaterally.
,Eyes - ,,,correct answer,,,..I'm going to assess the pt's eyes. I'm going to look at the
conjunctiva. I notice that they're pink & clear, no drainage or lesions & the sclera is
white & clear. I'm going to test cranial nerve # 2, the optic nerve, covering central vision.
Using the Snellen eye pocket chart, I'm going to stand 6 ft away & ask the pt to cover 1
eye & read the lowest line possible (LTFPH). Repeat with the other eye. Now with both
eyes. The pt has normal vision, 20/20 in the L eye, R eye, & both eyes.
Cranial nerve 2 - ,,,correct answer,,,..I'll continue with cranial nerve # 2, the optic nerve,
this time assessing peripheral vision. Please stand, so we can be at the same eye level.
I'm going to ask the pt to look straight ahead & not move their head ((hands right above
shoulders, move hands in "come" motion)) Can you see my hands now? >> Let me
know when you do>> I'm going to cover above, ((w/hands on either side of face, move
hands)) Do you see them now? >> Let me know when you do>> Now from below
((hands on pt sides, bring hands upward)) Do you see them now? >> Let me know
when you do. The pt's peripheral vision is normal. Again, I'm checking cranial nerve # 2,
the optic nerve for pupil response to light. I'm using the ophthalmoscope head & turning
on my light. Please look at my nose. I notice that the pupil constricts. I will check the
other eye. The pupils are about 2-3 mm's & both respond to light equally.
Cranial nerves 3,4,&6 - ,,,correct answer,,,..Next, I'm going to be checking cranial nerves
# 3, the ocular motor, cranial nerve # 4, the trochlear, & cranial nerve # 6, the abducens.
I will choose an H pattern to assess the extraocular muscles of the eye. If you'll follow
my finger, with your eyes only. All EOMs are intact equally.
Nose - ,,,correct answer,,,..I'm going to inspect the nose. I see that it's midline, there's no
obstruction, fracture or swelling. I'll begin by inserting the speculum of the otoscope
inside the nose. I see pink & moist turbinates & the septum is midline, straight & there's
no deviation. On the other side, I see a straight septum, the turbinates are pink & moist.
There's no swelling or bogginess.
Next, I'll palpate the pt's sinuses beginning with the frontal sinuses. Let me know if you
feel any tenderness. The maxillary sinuses, tenderness? No tenderness noted.
Mouth - ,,,correct answer,,,..Now, I'm going to inspect the throat & mouth. The lips, I see
they are pink & moist. Can you open your mouth? I don't see any signs of decay or
cracks in the teeth. The gums look pink & there is no redness or swelling. The buccal
mucosa on both sides is moist & pink. Upper hard & soft palates are intact, pink &
moist. The tongue is smooth, pink & moist. If you'll lift your tongue up, please. I don't
see any nodules or drainage & it's pink & moist on the floor of the mouth. Now I'll look at
the posterior pharynx & it's pink & there is no post nasal drainage. ((Grade tonsils if
present, +1 normal or +2 mid-line, bilateral))
Cranial nerve 9, 10 & 12 - ,,,correct answer,,,..Cranial nerve # 9 the glossopharyngeal,
which is the gag reflex & I won't not be testing for that. I'll check cranial nerve # 10,
which is the vagus nerve. I'll have the pt go ahead & open your mouth again ((w/my light
shining in pt mouth)) & say "ahhh" The uvula rises symmetrically with phonation. Then
, we have cranial nerve #12, the hypoglossal. I'll have you stick your tongue out & move it
side to side.
Next, I'm palpating the TMJ. I'm palpating both sides. Please open your mouth & close.
Do you have any tenderness? I don't feel any subluxation, crepitus, clicking, or
tenderness.
Neck and Throat - ,,,correct answer,,,..There are no deformities in the neck & it's
symmetrical. Next, I'll palpate the trachea; it's midline. Now, I'll palpate the thyroid gland.
by finding the cricoid process. With one hand in the suprasternal notch, right here, with
the other hand.And I will put my fingers on either side, between those two points,
landmarks, and I'm actually gonna retract a little bit on one side and ask her to swallow.
And I'm feeling the thyroid as it rises for size in any nodules. And now, when we retract
on the opposite side, and ask her to swallow. No nodules noted.
Throat - ,,,correct answer,,,..I'm palpating the carotid arteries, they're normal & bounding.
I'll auscultate the carotid arteries, checking for bruits bilaterally. Take a breath in. Hold it.
Breathe. Take a breath in. Hold it. Breathe.
Neck ROM - ,,,correct answer,,,..I'm checking ROM of the neck. Please flex your neck by
taking your chin down to your chest. Now straighten your neck & look up to the ceiling,
extension, now look forward. I want you to look over your R shoulder, rotation. Now your
L shoulder, rotation. I want you to do a flexion to the side, ear to your shoulder, lateral
flexion. Other side, lateral flexion. They're all intact equally.
Next, I'll test cranial nerve # 11, which is the spinal accessory nerve. I'm going to put
resistance on your shoulders & please shrug them. They are equal & intact.
Heart/Chest - ,,,correct answer,,,..(Have patient sitting) I'm going to assess your heart
sounds ((5 areas, diaphragm->bell)). I'll start with the aortic valve (2nd IS, R sternal
border). Pulmonic valve (2nd IS, L sternal border). Erb's point (3rd IS, L sternal border).
Tricuspid (4th IS, L sternal border) & mitral (midclavicular line, 5th IS). I'm inspecting the
anterior chest & there aren't any obvious deformities in symmetry.
I'll auscultate the lung sounds in the anterior lung fields (x6 areas). Normal breaths in &
out through your mouth. Breath sounds are clear. I'll proceed to the posterior chest
(auscultate 8 areas). Normal breaths in & out through your mouth.
Upper extremities - ,,,correct answer,,,..I'm checking the upper extremities. Inspecting the
joints of the hands. If you'll extend your hands out. Don't see redness, swelling or
deformities of the finger joints. I'm checking for cap refill (1 finger ea. hand). Nail bed
turns pink in less than 3 secs, bilaterally. Next, I'll check the radial pulses bilaterally, if
you'll just face your palms inward please. They're equal, 2+ bilaterally. I'm going to
assess hand grips. If you'll grip my hands tight, strength is 5/5.
ROM Upper extremities - ,,,correct answer,,,..Now I'm going to assess pt's ROM (1
side/Immersion). I'll begin by assessing passive ROM of the elbow. Flexion & extension.
I would do the same on the other side. I'm now going to check the strength of the biceps
& triceps. Please, flex your elbows & push against my hands. Now, pull back towards
2023) : Advanced Physical Assessment - Chamberlain
College of Nursing
Introduction - ,,,correct answer,,,..___________, my name is ____________, I will be
doing your exam today. I'll begin with inspecting your face. I'll note that I don't see any
discolorations or lesions & the head is midline & symmetrical.
Lymph nodes - ,,,correct answer,,,..Next, I'll palpate the lymph nodes. I'll begin with the
preauricular lymph nodes, right in front of the ear, and postauricular, right behind the
ear. Then I will palpate her occipital lymph nodes in the back of the head. And then I'm
gonna move forward and palpate the tonsillar lymph nodes. Come under the jawline, the
submandibular lymph nodes, and the submental. Now I will go to the anterior cervical
lymph nodes, and the posterior cervical lymph nodes. And I will end with the
supraclavicular lymph nodes right about the clavicles. I do not feel any enlargement,
and they are equal bilaterally.
Face - ,,,correct answer,,,..I'm testing trigeminal nerve, which is cranial nerve # 5.
Palpating over the masseter muscle as the pt clenches the jaw. I don't feel any
distortions & my pt has great strength. Now, I'm testing the sensory portion of the
trigeminal nerve. I'll ask my pt to close your eyes & let me know where you feel my
touch. (>> Forehead, right cheek, left cheek, chin, nose)
Next, I'll test the facial nerve, which is cranial nerve # 7. I'm going to ask you to do some
facial expressions. I'm going to have you smile, next, frown for me. Now raise your
eyebrows & puff up your cheeks, pucker your lips. I notice all expressions have bilateral
symmetry.
Ears - ,,,correct answer,,,..Now, I'm going to inspect the ears. I'm looking for nodules or
skin lesions. They're both symmetrical, no nodules or skin lesions are noted. I'm going
to look inside the ear canal with the otoscope. I see that the external auditory canal is
clear, there's no swelling, redness, drainage or cerumen. The tympanic membrane is
pearly gray & there is no effusion in the middle ear. I'll do the other ear. Looking into the
external auditory canal. I see there is no swelling, redness, drainage, or cerumen. Pt's
tympanic membrane is pearly gray & there's no effusion in the middle ear. Next, I'm
going to palpate pinna for any nodules or tenderness. Now the tragus. No nodules or
tenderness are noted.
Acustic nerve CN8 - ,,,correct answer,,,..I will be testing your acoustic nerve, which is
cranial nerve # 8, which is hearing. I'll be performing a whisper test. I want you to cover
one of your ears & I will stand behind you, cover my mouth & whisper 3 words & I want
you to repeat them to me (1, 2, 3) & let's do the other side (4, 5, 6). Hearing is intact
bilaterally.
,Eyes - ,,,correct answer,,,..I'm going to assess the pt's eyes. I'm going to look at the
conjunctiva. I notice that they're pink & clear, no drainage or lesions & the sclera is
white & clear. I'm going to test cranial nerve # 2, the optic nerve, covering central vision.
Using the Snellen eye pocket chart, I'm going to stand 6 ft away & ask the pt to cover 1
eye & read the lowest line possible (LTFPH). Repeat with the other eye. Now with both
eyes. The pt has normal vision, 20/20 in the L eye, R eye, & both eyes.
Cranial nerve 2 - ,,,correct answer,,,..I'll continue with cranial nerve # 2, the optic nerve,
this time assessing peripheral vision. Please stand, so we can be at the same eye level.
I'm going to ask the pt to look straight ahead & not move their head ((hands right above
shoulders, move hands in "come" motion)) Can you see my hands now? >> Let me
know when you do>> I'm going to cover above, ((w/hands on either side of face, move
hands)) Do you see them now? >> Let me know when you do>> Now from below
((hands on pt sides, bring hands upward)) Do you see them now? >> Let me know
when you do. The pt's peripheral vision is normal. Again, I'm checking cranial nerve # 2,
the optic nerve for pupil response to light. I'm using the ophthalmoscope head & turning
on my light. Please look at my nose. I notice that the pupil constricts. I will check the
other eye. The pupils are about 2-3 mm's & both respond to light equally.
Cranial nerves 3,4,&6 - ,,,correct answer,,,..Next, I'm going to be checking cranial nerves
# 3, the ocular motor, cranial nerve # 4, the trochlear, & cranial nerve # 6, the abducens.
I will choose an H pattern to assess the extraocular muscles of the eye. If you'll follow
my finger, with your eyes only. All EOMs are intact equally.
Nose - ,,,correct answer,,,..I'm going to inspect the nose. I see that it's midline, there's no
obstruction, fracture or swelling. I'll begin by inserting the speculum of the otoscope
inside the nose. I see pink & moist turbinates & the septum is midline, straight & there's
no deviation. On the other side, I see a straight septum, the turbinates are pink & moist.
There's no swelling or bogginess.
Next, I'll palpate the pt's sinuses beginning with the frontal sinuses. Let me know if you
feel any tenderness. The maxillary sinuses, tenderness? No tenderness noted.
Mouth - ,,,correct answer,,,..Now, I'm going to inspect the throat & mouth. The lips, I see
they are pink & moist. Can you open your mouth? I don't see any signs of decay or
cracks in the teeth. The gums look pink & there is no redness or swelling. The buccal
mucosa on both sides is moist & pink. Upper hard & soft palates are intact, pink &
moist. The tongue is smooth, pink & moist. If you'll lift your tongue up, please. I don't
see any nodules or drainage & it's pink & moist on the floor of the mouth. Now I'll look at
the posterior pharynx & it's pink & there is no post nasal drainage. ((Grade tonsils if
present, +1 normal or +2 mid-line, bilateral))
Cranial nerve 9, 10 & 12 - ,,,correct answer,,,..Cranial nerve # 9 the glossopharyngeal,
which is the gag reflex & I won't not be testing for that. I'll check cranial nerve # 10,
which is the vagus nerve. I'll have the pt go ahead & open your mouth again ((w/my light
shining in pt mouth)) & say "ahhh" The uvula rises symmetrically with phonation. Then
, we have cranial nerve #12, the hypoglossal. I'll have you stick your tongue out & move it
side to side.
Next, I'm palpating the TMJ. I'm palpating both sides. Please open your mouth & close.
Do you have any tenderness? I don't feel any subluxation, crepitus, clicking, or
tenderness.
Neck and Throat - ,,,correct answer,,,..There are no deformities in the neck & it's
symmetrical. Next, I'll palpate the trachea; it's midline. Now, I'll palpate the thyroid gland.
by finding the cricoid process. With one hand in the suprasternal notch, right here, with
the other hand.And I will put my fingers on either side, between those two points,
landmarks, and I'm actually gonna retract a little bit on one side and ask her to swallow.
And I'm feeling the thyroid as it rises for size in any nodules. And now, when we retract
on the opposite side, and ask her to swallow. No nodules noted.
Throat - ,,,correct answer,,,..I'm palpating the carotid arteries, they're normal & bounding.
I'll auscultate the carotid arteries, checking for bruits bilaterally. Take a breath in. Hold it.
Breathe. Take a breath in. Hold it. Breathe.
Neck ROM - ,,,correct answer,,,..I'm checking ROM of the neck. Please flex your neck by
taking your chin down to your chest. Now straighten your neck & look up to the ceiling,
extension, now look forward. I want you to look over your R shoulder, rotation. Now your
L shoulder, rotation. I want you to do a flexion to the side, ear to your shoulder, lateral
flexion. Other side, lateral flexion. They're all intact equally.
Next, I'll test cranial nerve # 11, which is the spinal accessory nerve. I'm going to put
resistance on your shoulders & please shrug them. They are equal & intact.
Heart/Chest - ,,,correct answer,,,..(Have patient sitting) I'm going to assess your heart
sounds ((5 areas, diaphragm->bell)). I'll start with the aortic valve (2nd IS, R sternal
border). Pulmonic valve (2nd IS, L sternal border). Erb's point (3rd IS, L sternal border).
Tricuspid (4th IS, L sternal border) & mitral (midclavicular line, 5th IS). I'm inspecting the
anterior chest & there aren't any obvious deformities in symmetry.
I'll auscultate the lung sounds in the anterior lung fields (x6 areas). Normal breaths in &
out through your mouth. Breath sounds are clear. I'll proceed to the posterior chest
(auscultate 8 areas). Normal breaths in & out through your mouth.
Upper extremities - ,,,correct answer,,,..I'm checking the upper extremities. Inspecting the
joints of the hands. If you'll extend your hands out. Don't see redness, swelling or
deformities of the finger joints. I'm checking for cap refill (1 finger ea. hand). Nail bed
turns pink in less than 3 secs, bilaterally. Next, I'll check the radial pulses bilaterally, if
you'll just face your palms inward please. They're equal, 2+ bilaterally. I'm going to
assess hand grips. If you'll grip my hands tight, strength is 5/5.
ROM Upper extremities - ,,,correct answer,,,..Now I'm going to assess pt's ROM (1
side/Immersion). I'll begin by assessing passive ROM of the elbow. Flexion & extension.
I would do the same on the other side. I'm now going to check the strength of the biceps
& triceps. Please, flex your elbows & push against my hands. Now, pull back towards
