PERSON ASSESSMENT FORMAT

The Official Nursing Assessment Format Of Saint Mary’s University

HEALTH HISTORY

CURRENT HEALTH PROBLEM

FOUR (4) PARTS

1) USUAL HEALTH STATUS

o BEST QUESTION TO ASK: “HOW WOULD YOU DESCRIBE YOUR HEALTH

UPTO THIS TIME?”

2) CHRONOLOGICAL STORY –narrative section where the client chief complaint is

documented in proper order

o WHAT TO INCLUDE?
❖ When the symptoms started
❖ Characteristics of the onset signs and symptoms
❖ Specific dates when the problem was experienced
❖ How often the problem occurs
❖ Exact location of the distress
❖ Characteristics of the complaint
❖ Activity involved in the problem
❖ Phenomena or symptoms associated with the chief complaint
❖ Factors that aggravate or alleviate the symptoms or the problem

3) RELEVANT FAMILY HISTORY- ask the client about the family diseases that run in their
family

4) DISABILITY ASSESSMENT- nurse explores how the problem has interfered with the
clients daily activities

PAST HEALTH HISTORY-

WHAT TO INCLUDE:

❖
CHILDHOOD ILLNESSES
❖
CHILDHOOD IMMUNIZATION UNCLUDING DATES
❖
ALLERGIES
❖
HOSPITALIZATIONS
❖ PREVIOUS MEDICAL CONDITIONS
SURGICAL HISTORY
WHAT TO INCLUDE:
❖ ACCIDENTS AND INJURIES
❖ SURGERIES (MINOR AND MAJOR)

OBSTETRIC HISTORY
WHAT TO INCLUDE:
❖ NUMBER OF PREGNANCIES (GTPAL) INCLUDING COMPLICATED PREGNANCIES

ACCIDENTS
WHAT TO INCLUDE:
❖ TYPES OF ACCIDENTS AND THE SPECIFIC DATES IF POSSIBLE

PATIENT EDUCATIONAL NEEDS- pertains to the different health practices that the patient needs to
know to hasten his recovery and/or to improve his health status.
 FAMILY RISKS FACTORS
WHAT TO INCLUDE:
❖ AGES OF THE SIBLINGS, PARENTS AND GRAND PARENTS AND THEIR CURRENT
HEALTH PROBLEMS AND THE CAUSE OF DEATH (IF APPLICABLE)
❖ HABITS
❖ HEALTH MAINTENANCE PRACTICES - LIFESTYLE

MEDICATIONS

WHAT TO INCLUDE:
❖ LIST OF DRUGS, DOSE ROUTE AND FREQUENCY

P-PSYCHOSOCIAL

SIGNIFICANT OTHERS
Pertains to the available person capable of giving emotional, physical or financial support that helps in
hastening the recovery of the patient.

COPING MECHANISM- unconscious defense mechanism of the person to cope up with the current
status that he is having
Two types:
1. Problem- focused –pertains to the activities of the individual to control the intensity/impact
of the problem or to eliminate it to oneself
E.g. seeking for a medical advice, shouting to convey the need for help.
2. Emotion- focused – pertains to the activities or mechanisms that the patient use to strengthen
his or her capacity to cope up with the current stress that the patient is having at the present
A. Denial- avoidance to accept a certain fact
B. Displacement- shifting of emotion to a neutral or less dangerous problem or person
C. Dissociation- separation of a group of mental or behavioral processes from the person’s
identity or consciousness
D. Identification- process by which a person tries to act like someone he or she admires
E. Intellectualization- use of excessive reasoning or logic to avoid experiencing a disturbing
feeling
F. Introjection- intense identification in which a person incorporate qualities or values of
another person or group into his own ego structure
G. Isolation – splitting off of emotional components of thought which can be temporary or
long-term
H. Projection- attributing one’s thought or impulse to other person
I. Rationalization- offering a socially acceptable to justify or make acceptable or
unacceptable impulses
J. Reaction formation- development of conscious attitudes and behavior patterns that are
opposite to what one really feels
K. Regression- manifest behavior characteristics of an earlier level of development
L. Sublimation- acceptance of socially approved substitute goal for a drive whose normal
goal of expression is blocked
M. Undoing- act that partially negates a previous ones
N. Conversion- conflicts that can be converted into physical symptoms
O. Fantasy-use of imagination
P. Fixation- persistence of inappropriate behavior at an early stage
Q. Substitution- making up of something

RELIGION- religious affiliation of the patient

PRIMARY LANGUAGE- language or dialect that the patient uses as a means communication (can
speak and can understand)

PRIMARY SOURCES OF HEALTHCARE – institution where the patient usually seeks medical advice
 FINANCIAL RESOURCES RELATED TO ILLNESS- source of finances to sustain hospitalization and
other healthcare needs

OCCUPATION- the patient’s source of living

EDUCATIONAL ATTAINMENT- highest educational degree that the patient acquired
 Educational needs- healthcare practices that the patient needs to know to sustain optimal
health and to prevent further complication

GENERAL APPEARANCE (also called as the General Survey)

COMPONENTS:
 APPEARANCE

❖ OBSERVE BODY BUILD, HEIGHT AND WEIGHT in relation to the

client’s age, life-style and health

❖ OBSERVE THE CLIENT’S POSTURE AND GAIT (standing, sitting and

walking)

STANCE – the manner to which a person stands. To assess the patients

posture while standing, the nurse must view the patient from lateral,
anterior and posterior perspectives

NORMAL: when STANDING

ANTERIOR: the center of gravity (halfway between the umbilicus and the
symphysis pubis) falls between the feet.
POSTERIOR: shoulder and hips are level; the spine is straight and the
main body weight is borne well forward on the outer sides of the feet.
LATERAL: the line of gravity falls along the ears, center of the knees and
in front of the ankles.

NORMAL: when SITTING

The nurse must assess the patient in lateral view. The head and the trunk
are in the same position if standing but the lumbar curve is less anteriorly
convex because of hip flexion. The weight of the body is centered on the
buttocks and thigh. Both feet are on the flat surface and forearms are
supported to prevent upward or downward pulling of the shoulder girdle.
The popliteal spaces should be at least 1 “ away from the edge of the bed
to avoid pressure on the bloodvessels.

❖ NOTE BREATH AND BODY ODOR in relation to activity level

❖ OBSERVE THE CLIENT’S OVERALL HYGIENE AND GROOMING
relate these to the person’s activities prior to assessment
❖ APPROPRIATENESS OF CLOTHING
❖ OBSERVE FOR SIGNS OF DISTRESS IN POSTURE (e.g. bending over
because of abdominal pain) OR FACIAL EXPRESSION (e.g. wincing or
labored breathing)
❖ NOTE OBVIOUS SIGNS OF ILLNESS (e.g. skin color or breathing)
 MENTAL STATUS
❖ ASSESS THE PATIENT’S ATTITUDE (cooperative, hostile, withdrawn or
aggressive)

AFFECT- outward manifestation of the patient’s internal feeling

❖ Assess the appropriateness of the client’s response according to his/her responses.
❖ DEVIATIONS:
BLUNTED AFFECT- showing little or slow-to- respond facial expression
BROAD AFFECT- displaying full range of emotional expressions
FLAT AFFECT- showing no facial expression
INAPPROPRIATE AFFECT- displaying a facial expression that is in congruent with mood or
situation
RESTRICTED AFFECT- displaying one type of expression, usually somber or serious
 ORIENTATION- assessment of patient’s orientation to time, date and place
❖ WHAT TO ASK:
❖ WHERE ARE YOU NOW?
❖ WHAT DAY TODAY?
❖ DO YOU GET CONFUSED SOMETIMES?

MEMORY
❖ IMMEDIATE
❖ RECENT
❖ REMOTE
❖ NICE TO KNOW! THE MEMORY CENTER OF THE BRAIN IS THE HIPPOCAMPUS AND
THE NEUROTRANSMITTERS RESPONSIBLE ARE SEROTONIN AND ACETYLCHOLINE

SPEECH
❖ LISTEN TO THE QUANTITY OF SPEECH (AMOUNT AND PACE), QUALITY (LOUDNESS,
CLARITY AND INFLECTION) AND ORGANIZATION (COHERENCE OF THOUGHT,
OVERGENERALIZATION AND VAGUENESS)
WRITTEN as: understandable, moderate pace that exhibits thought association

❖ LISTEN TO THE RELEVANCE AND ORGANIZATION OF THOUGHTS

WRITTEN as: logical sequence; makes sense and has sense of reality

NONVERBAL BEHAVIOR

E- ELIMINATION

STOOL – no normal range. Basis of comparison is the stool pattern and consistency is the patient’s
pattern before hospitalization.
- assess the patient’s stool pattern and its consistency
URINE- normal urine output is 30ml/hour or 1ml/kg/hr. However, in most cases urine output must be
equal or 5ml less than the fluid input.

ABDOMEN- method : REMEMBER: ATE IAPerPal ni DOMEN

Inspection: Inspect for the skin color, contour and asymmetry and abdominal movement
Auscultation: Auscultate the vascular (bell of the stethoscope) and bowel sounds (diaphragm) including
peritoneal friction rub
Percussion:
Palpation: light palpation first then the deep palpation

MEASURE THE ABDOMINAL GIRTH AS NECESSARY!

7 F’S that can cause abdominal distention:

Fecal impaction
Food
Flatus
Fluid accumulation
Fetus
Foreign materials
Fibrous tumor

TOILETING ABILITY- patient’s ability to defecate or produce a waste product called feces and his
ability to go to the Comfort Room for stool evacuation

R- REST AND ACTIVITY

CURRENT ACTIVITY LEVEL – pertains to the activities that the patient can and can’t tolerate
ADL’S- current activities of the patient.
SLEEP
SLEEP PATTERN ACCORDING TO AGE (KOZIER)
DEVELOPMENTAL NORMAL SLEEP PATTERN
AGE
NEWBORN - Sleeps 14-18 hours/day
- Sleep cycles last 45-60 minutes
INFANT - Sleeps 12-14 hrs / day
- Sleeps longer at night (8-10 hrs) and has scheduled naps
- At 12 mos, naps twice a day
TODDLER -Sleeps 10-12 hours a day
- Midmorning naps are decreased
- Normal sleep-awake cycle is established at 2-3 years of age
PRE-SCHOOLER - Sleeps 11 hrs at night
- Second nap eliminated at 3 years old
- At 5 years old, daytime naps are relinguished
SCHOOL AGE -Sleeps about 10 hours at night
- Sleep time remains relatively constant
ADOLESCENTS -Sleeps about 8-9 hours a day
YOUNG ADULT - Sleeps at 7-9 hrs/day
MIDDLE- AGED - Sleeps about 7 hrs/day
ADULT
ELDERLY ADULT - Sleeps about 6 hrs/day

BODY FRAME
CAN BE CLASSIFIED AS:
Mesomorph – muscular
Endomorph- chubby (pear shape or apple shape)
Ectomorph- thin and tall
Waist- hip Ratio: w/h
NORMAL: GIRLS = .8”
BOYS = 1”

POSTURE –
KYPHOTIC
LORDOTIC
SCOLIOTIC

GAIT- assessed to determine the client’s mobility and risk for injury due to falling
PHASES OF GAIT ASSESSMENT:

A. STANCE PHASE- the heel of the right foot strikes the ground. Body weight is spread over the ball
of the right foot while the left heel pushes off and leaves the ground
B. SWING PHASE- the legs from behind moves in front of the body.

TECHNIQUE:
Let the client walk in a 10 feet distance in a hallway and the nurse will observe the following:
• Head is erect
• Toes and kneecaps point forward
• Heel strikes the ground before the toe
• Feet are dorsiflex in the swing phase
• Arm opposite the swing through foot and move forwards at the same time
• Instep fails along the line of gravity
• Steps are appropriate
• Gait is smooth, coordinated and rhythmic
• Gait produces minimal body swing from side to side and directs movements straight ahead.
• Gait starts and stops with ease.

 TERMS ASSOCIATED WITH GAIT (Joyce Black)

1) ATAXIC- staggering and unsteady
2) DOUBLE STEP- alternate steps differing in length or rate
 3) DYSTONIC- irregular and nondirective
4) DYSTROPHIC OR BROAD-BASED- legs far apart.
5) WADDLING GAIT- weight shifting from side to side
6) EQUINE- high steps
7) FESTINATING- walking on toes at an accelerating pace
8) HELICOPOD- feet making a half circle with each step
9) HEMIPHLEGIC- paralyzed limb swings outward; foot drags; arms on the affected side does not
swing freely
10) PARKINSONIAN- short, accelerating steps; shuffling; forward-leaning posture; head, hips and
knees flexed; difficulty starting and stopping
11) SCISSORS- legs crossed while walking with short, slow steps
12) SPASTIC- stiff, short steps; toes catch and drag; legs held together, hips and knees flexed
13) STEPPAGE: foot and toes lifted high; heel comes down heavily
14) TABETIC- high steps; foot slaps down

COORDINATION
UPPER EXTREMITIES
Finger to nose
Finger to nose to the nurse finger
Alternating pronation-supination of the hands on the knees

LOWER EXTREMITIES
Heel down opposite shin
Toe or ball of the foot to the nurse’s finger

BALANCE
TECHNIQUES:
ROMBERG’S TEST
STANDING ON ONE FOOT STANCE WITH EYES CLOSED
HEEL-TOE WALKING
TOE OR HEEL WALKING
MUSCLE
STRENGTH

Muscles Technique
Deltoid Client holds arm up while the nurse tries to resist it
Biceps Client fully extends each arms and tries to flex it while the
nurse attempts to hold the arm in extension
Triceps Client flexes each arm and then tries to extend it against
the nurse’s attempt to keep the arm on flexion
Wrist and finger muscles Client spreads the fingers and resists as the nurse attempts
to push the fingers together
Grip strength Client grasp the nurse’s index and middle fingers while
the nurse tries to pull the fingers out
Hip muscles Client is in supine with both legs extended. The client
raises one leg at a time while the nurse attempts to hold it
down
Hip abduction Client is in supine with both legs extended. The nurse
holds the lateral aspect of the client’s knees while the
client tries to spread the knees
Hip adduction Client is in supine with both legs extended in abducted
position. The nurse’s hands are placed between the knees
and the client tries to bring the legs together.
Hamstring Client in supine with both knees bent. Client resists while
the nurse attempts to straighten them
Quadriceps Client in supine with knees partially extended. The client
resists while the nurse attempts to flex the knee
Muscles of the ankles Client resists while the nurse attempts to dorsiflex the foot
and feet and again resist while the nurse attempts to flex the foot
 Muscle strength grading
Grade Defining Characteristics
0 Complete absence of muscle movement
1 No movement, contraction of the muscle is palpable
2 Full muscle movement against gravity,with support
3 Full range of motion against gravity
4 Full range of motion against gravity and minimal
resistance
5 Full range of motion against gravity and against full
resistance

MUSCLE TONE- normal condition of tension of the muscle at rest

NORMOTONIC- normally firm muscles
ATONIC- lacking tone

MOTOR FUNCTION
FINE
GROSS

RANGE OF MOTION

PAIN RELIEF MEASURE

NON-PHARMACOLOGIC
PHARMACOLOGIC

MOBILITY/USE OF ASSISSTIVE DEVICE

USE OF CRUTCHES AND CANE

S-SAFE ENVIRONMENT

ALLERGIES – MEDICATIONS, FOOD AND ENVIRONMENT

EYES/ VISION-PERRLA (PUPILS EQUALLY ROUND AND REACT TO LIGHT AND
ACCOMODATION)

TECHNIQUES:
• Inspect the pupils color, shape, symmetry in size
NORMALLY: Black in color, equal in size at 3-7mm in diameter (KOZIER); round, flat border, iris flat
and round
• Assess the pupils direct and consensual reaction to light to determine the Oculomotor and Trochlear
nerve
DIRECT PUPILS REACTION: illuminated pupils constrict
CONSENSUAL PUPILS REACTION- non-illuminated pupil constricts
• Assess for the reaction to accommodation
NORMAL: pupils constrict when looking at near object and dilate at far object
• Assessing peripheral visual fields
NORMAL: When looking straight ahead, client can see objects in the periphery

HEARING/ HEARING AID

TECHNIQUES:
• Assess client’s response to whispered voice at 1-2 ft away
NORMAL: able to repeat nonconsecutive numbers
• Perform watch tick test (1-2 in away)
 NORMAL: Able to hear the tickling on both ears
• Weber’s test
NORMAL: WEBER TEST NEGATIVE – sound is heard in both ears or is localized at the center of the
head
• Rinne test
NORMAL: Air conducted (AC) hearing is greater than bone-conducted (BC) hearing

SKIN INTEGRITY
LESIONS- describe the type or structure, the color, the distribution and the configuration

TYPES of PRIMARY LESIONS

M
P
P
P
N
T
V
B
P

SURGICAL INCISIONS (determine the site/ location)

MUCOUS MEMBRANE

TEMPERATURE
ROUTE AND THE VALUE

TYPES OF FEVER
• REMITTENT
• INTERMITTENT
• RELAPSING

LAB ANALYSIS
WBC
NEUTROPHILS-
LYMPHOCYTES-
BASOPHILS-
EOSINOPHILS-
MONOCYTES-

O- OXYGENATION

ACTIVITY INTOLERANCE
AIRWAY CLEARANCE
RESPIRATION
• VARIATIONS:
1) EUPNEA- NORMAL 12-20 CPM
2) TACHYPNEA- ABNORMALLY RAPID BREATHING
3) BRADYPNEA- ABNORMALLY SLOW BREATHING
4) APNEA- CESSATION OF BREATHING

• RHYTHM
• CHYNE-STOKE – TACHYPNEA- APNEA- TACHYPNEA
• KAUSSMAUL BREATHING- TACHY-BRADY-TACHY
• BIOT’S- EUPNEA- EUPNEA- APNEA-EUPNEA-EUPNEA
EASE AND EFFORT
DYSPNEA AND ORTHOPNEA
• LUNG SOUNDS

VARIATIONS:
STRIDOR- high pitch; common in patient with laryngeal obstruction
STERTOR- snoring respiration
WHEEZE-
BUBBLING
RALES/CRACKLES

CHEST MOVEMENTS
INTERCOSTAL RETRACTION
SUBSTERNAL RETRACTION
SUPRASTERNAL RETRACTION

COLOR
• JAUNDICE
• CYANOSIS
• PALLOR
• PINKISH
• ERYTHEMATOUS

CAPILLARY REFILL –blanching test; usually 1-2 secs; in some authors 2-3 secs

PULSE OXYMETRY
PERIPHERAL PULSES
GRADING
GRADE DEFINING CHARCTERISTICS
O NO PULSE
1 THREADY
2 WEAK
3 NORMAL
4 BOUNDING

APICAL PULSE

APICAL PULSE COMMON SITE

AORTIC 2ND ICS,RIGHT
PULMONIC 2ND ICS,LEFT
ERB’S POINT 3RD ICS LEFT
TRICUSPID VALVE 4TH ICS, LEFT
MITRAL VALVE 5TH ICS, LEFT (PMI)

BLOOD PRESSURE

EDEMA- assess the edema (location, color, temperature,shape and degree of indentation on the skin
GRADING OF EDEMA
GRADE CHARACTERISTICS
1+ BARELY DETECTABLE
2+ INDENTATION OF LESS THAN
5mm
3+ INDENTATION OF 5-10 mm
4+ INDENTATION OF MORE THAN
10 mm

HOMAN’S SIGN
LABORATORY ANALYSES
HGB
 HCT
PLATELET
ABG’S
PARAMETER NORMAL VLUE
PH 7.35-7.45
PaO2 80-100mmHg
PaCO2 22-26
HCO3 35-45

O2 THERAPY
DELIVERY STEM VOLUME OF O2 CONCENTRATION
OF O2
NASAL CANNULA 2-6L 24-45%
MASK
• SIMPLE 5-8L 40-60%
• PARTIAL 6-10 L 60-90%
REBREATHER
• NON- 10-15L 95-100%
REBREATHER
• VENTURI MASK 4-10 L 20-40%
FACE TENT 4-8 L 30-50%
MIST TENT 15L 30%

N- NUTRITION

HOSPITAL OR DIET RESTRICTIONS

THERAPEUTIC DIETS FOR SPECIFIC CLIENTS

DIAGNOSIS DIETS
ACNE LOW FAT DIET
ACUTE GSTROENTERITIS CLEAR LIQUID DIET
AGN LOW PROTEIN, LOW SODIUM
ADDISON’S DISEASE HIGH SODIUM, LOW POTASSIUM
IRON DEF ANEMIA HIGH IRON
PERNICIOUS ANEMIA HIGH PROTEIN, HIGH VIT B.
SICKLE CELL ANEMIA HIGH LIQUID DIET
ANGINA PECTORIS LOW CHOLESTEROL DIET
GOUTY ARTHRITIS PURINE RESTRICTED DIET
ADHD FINGER FOODS
BIPOLAR D/O FINGER FOODS
BURN HIGH CALORIE AND HIGH
PROTEIN DIET
CELIAC DISEASE GLUTEN-FREE DIET
CHOLECYSTITIS HIGH PROTEIN, HIGH
CARBOHYDRATE, LOW FAT
DIET
CHF LOW SODIUM, LOW
CHOLESTEROL
CRETINISM HIGH CALCIUM, HIGH PROTEIN
CROHN’S DISEASE HIGH PROTEIN, HIGH
CARBOHYDRATE, LOW FAT
DIET
CUSHING’S DISEASE HIGH POTASSIUM, LOW SODIUM
CYSTIC FIBROSIS HIGH CALORIE, HIGH SODIUM
CYSTITIS ACID-ASH/ ALKALINE-ASH DIET
DECUBITUS ULCER HIGH PROTEIN, HIGH VITAMIN C
 DM WELL-BALANCED DIET
DIARRHEA HIGH K AND HIGH Na
DIVERTICULITIS LOW RESIDUE
DIVERTICULOSIS HIGH RESIDUE WITHOUT SEEDS
DUMPING SYNDROME HIGH FAT, HIGH PROTEIN, DRY
HEPATIC ENCEPHALOPATHY LOW PROTEIN
HEPATITIS HIGH PROTEIN, HIGH CALORIE
HIRSCHPRUNG DISEASE HIGH CALORIE, LOW RESIDUE,
HIGH PROTEIN
HYPERPARATHYROIDISM LOW CALCIUM
HYPERTENSION SALT RESTRICTED
HYPERTHYROIDISM HIGH CALORIE, HIGH PROTEIN
HYPOPARATHYROIDISM HIGH CALCIUM, LOW
PHOSPHOROUS
HYPOTHYROIDISM LOW CALORIE, LOW
CHOLESTEROL
KAWASAKI DISEASE CLEAR LIQUID
LIVER CIRRHOSIS LOW PROTEIN
MENIERE’S DISEASE LOW SODIUM
MYOCARDIAL INFARCTION LOW FAT, LOW CHOLESTEROL,
LOW SODIUM
NEPHROTIC SYNDROME LOW SODIUM, HIGH PROTEIN,
HIGH CALOREI
OSTEOPOROSIS HIGH CALCIUM, HIGH VIT D
PANCREATITIS LOW FAT
PEPTIC ULCER DISEASE HIGH FAT, HIGH
CARBOHYDRATE, LOW PROTEIN
PKU LOW PROTEIN
PIH HIGH PROTEIN
TONSILLITIS CLEAR LIQUID
RENAL COLIC LOW SODIUM, LOW PROTEIN
RF CHRONIC LOW PROTEIN, LOW SODIUM
LOW POTASSIUM

FLUID INTAKE
INTRAVENOUS FLUID
HEIGHT AND WEIGHT
IBW

TISSUE TURGOR (skin or tongue turgor)

ABILITY chew, swallow, tolerate food and feed self
LAB ANALYSIS (Na, Cl, K, glucose, cholesterol and total albumin or protein_
BLOOD GLUCOSE MONITORING

ASSESING THE SPINAL AND CRANIAL NERVES

SPINAL NERVES ASSESSMENTS

SPINAL NERVES TECHNIQUE
C4-C5 Shoulders are shrugged against down ward
pressure of the examiner’s hand
C5-C6 Arms are pulled up from resting position
against resistance
From flexed position, arms is straightened out
C7 against resistance
Index finger is held firmly thumb against
resistance to pull it away
C8 Let the patient grasp a certain object (fine
object 1st)
L2-L4 Leg is lifted from the bed against resistance
From flexed position to, knee is extended
against resistance
L5-S1 Knee is flexed against resistance
L5 Foot is pulled up toward nose against
resistance
S1 Foot is pushed down against resistance

CRANIAL NERVE ASSESSMENT

CRANIAL NERVES TECHNIQUE

C1 (OLFACTORY) Ask the client to close his or her eyes then let
him or her identify the different aroma
C2 (OPTIC) Ask the client to read snellen chart, check
visual fields by confrontation and conduct an
ophthalmic examination
C3 (OCULOMOTOR) Asses the six ocular muscle movements and
pupil reaction
C4 (TROCHLEAR) Asses the six ocular muscle
C5 (TRIGEMINAL) While client looks upward, lightly touch the
lateral sclera of the eye to elicit blink reflex,
to test the light sensation, have client close
eyes, wipe a wisp of cotton cover client’s fore
head and Para nasal sinuses, to test deep
sensation, use alternating blunt and sharp ends
of safety pin over the same areas.
C6 (ABDUCENS) Asses the direction of his or her gaze
C7 (FACIAL) Ask client to smile, raises the eye brows,
frown puff out cheeks, close eyes tightly; ask
client to identify various tastes placed on tip
and sides of tongue. (May use sugar, salt,
lemon juice and quinine and let him identify
the taste)
Asses for balance and assess clients ability to
C8 (VESTIBULOCOCHLEAR) hear spoken words and vibration of the tuning
fork
Use tongue blade on posterior tongue while
client says “ah” to elicit gag reflex. Apply
C9 (GLOSSOPHARYNGEAL) tastes in the posterior tongue for
identification. Ask client to move tongue from
side to side then up and down.
C10 (VAGUS) Asses the client’s voice for hoarseness
Ask client to shrug shoulders against
C11 (ACCESSORY) resistance from your hands and turn head to
side against resistance from your hands
C12 (HYPOGLOSSAL) Ask client to protrude tongue at the midline,
and then move it side to side.

***jbtaroma***