ADULT

ASSESSMENT
HEAD TO FOOT EXAMINATION
EAR ASSESSMENT
◦ WATCH TEST
◦ TUNING FORK TEST
◦ WEBER TEST
◦ RINNE TEST
◦ VESTIBULAR ASSESSMENT
VESTIBULAR ASSESSMENT
◦ Test for falling
◦ Test for past pointing
◦ Gaze nystagmus evaluation
◦ Dix hallpike maneuver
Test for Falling- Romberg sign
Test for past pointing
Gaze Nystagmus Evaluation
DIX HALLPIKE MANEUVER
Otoscopic examination
Fit in Mind
◦ The otoscope is never inserted blindly into
the external canal because of the risk of
perforating the tympanic membrane.

◦ Before performing an otoscopic

examination and inserting the speculum,
check the auditory canal for foreign
bodies. Instruct the client not to move the
head during the examination to avoid
damage to the canal and tympanic
membrane.
 Nose, Mouth, Throat
◦ See for redness, swelling, discharge
◦ Press frontal sinuses(below eyebrows),
maxillary sinuses ( Located below
cheek bones)….. Should have no pain.
◦ inner surface of lips for color, moisture,
cracking, lesions
◦ Teeth for debris, decay
◦ Alignment of jaw by having client bite
◦ Gums for bleeding, lesions, discoloration, retraction of gingival
margins
◦ Tongue for color, surface characteristics, moisture, white patches,
nodules, ulcer
◦ Uvula is inspected for midline location, nurse asks to say “ahh”
and watches for the soft palate and uvula to rise in the X.ask the
client to stick out the tongue (should protrude in midline)
Hypoglosal nerve
◦ To assess gag reflex, touch posterieor pharynx with the end of a
tongue blade……the client should gag momentarily.
Lungs
◦ Inspection
◦ Skin color, rate and quality of respiration, lumps, lesions,
shape of chest wall
◦ Palpation
◦ Skin temperature, moisture, tenderness, lumps, lesions,
masses
Tectile and vocal fremitus
Percussion
◦ Anterior
view and
posterior
view
Lateral view
Resonance is normal sound
Hyper resonance is for air collection
Dull is for lung density
Ausculatation
◦Same like percussion
Normal breath sound
Normal breath sound
Abnormal breath sounds
CRACKLES
Wheeze or Rhonchi
Pleural Rub
Heart Auscultation-
 OLFACTORY 1 OPTIC 2
OCULOMOTOR 3
TROCHLEAR 4
ABDUCENS 6

TRIGEMINAL 5

FACIAL 7

ACOUSTIC 8

GLOSSOPHARYNGEAL 9

ACCESSORY 11

HYPOGLOSSAL 12

VAGUS 10
Cranial nerves
Functions