PHYSICAL ASSESSMENT 1

I. PHYSICAL ASSESSMENT

AREA METHOD FINDINGS INTERPRETATION

INTEGUMENTA Inspection With 60% partial Abnormal
RY and palpation thickness thermal
In a partial thickness burn
burn on face, or second degree burn it
neck, nape, front, involves the epidermis and
Skin back and both some portion of the
upper extremeties dermis, the second layer of
and palm size on the skin. This type of burn
the legs. With may be further categorized
blister formation as superficial or deep,
depending on how much
of the dermis is involved.
(https://www.emedicinehealth.co
m/thermal_heat_or_fire_burns/a
rticle_em.htm#what_are_the_sy
mptoms_of_thermal_burns)

Hair Inspection Hair is short and Normal

black with visible
white hair.
Evenly
distributed. No
alopecia, lice and
dandruff. Scalp is
dry.

Abnormal
With singed-face
and nasal hair and Partial thickness burn may
eyebrows or may not be painful (it
may be so deep that nerve
endings may be
destroyed), may be moist
or dry (so deep that sweat
glands are destroyed), may
or may not turn white
when area is touched, hair
is usually gone
(https://www.emedicinehealth.co
m/thermal_heat_or_fire_burns/a
rticle_em.htm#what_are_the_sy
mptoms_of_thermal_burns)
PHYSICAL ASSESSMENT 2

Nails Inspection Fingernail plate Normal

and Palpation shape is on a
convex curvature
and untrimmed.
Capillary refill of
2 seconds.

HEAD Head is rounded

(normocephalic
Skull and Face Inspection and symmetric, Normal
and palpation with frontal,
parietal, and
occipital
prominences)
with no presence
of lesions, masses
or foreign bodies.
Scalp has no
tenderness on
palpation.
Symmetric facial
features &
movements.
Eyes and Vision Inspection Eyebrows have Normal
evenly distributed
hair,
symmetrically
aligned. No
discoloration of
eyelids & lids
closes
symmetrically.
Pupils equally
rounded 3 mm in
diameter, reactive
to light and
accommodation.
When looking
straight ahead,
patient can see
objects in the
periphery.
Able to read
newsprint in close
PHYSICAL ASSESSMENT 3

distance.
Ears and Hearing Inspection Color of ears are Normal
and palpation same as facial
skin. Symmetrical
ears and equal in
size aligned on
the outer canthus
of the eye. No
presence of
tenderness,
masses and
discharge. Pinna
recoils
immediately.

Nose and Sinuses Inspection Nose is midline, Normal

and palpation symmetric and
straight on the
face without
swelling, bleeding
or lesions. Patient
can breathe
normally in both
nostrils. No nasal
flaring. No
presence of
bumps and
tenderness; no
pain reported.

Mouth and Inspection Lips are swollen, Abnormal

Oropharynx inflamed and dry.

With 20 adult Normal

PHYSICAL ASSESSMENT 4

teeth.
Normal
Uvula is in the
middle; tonsils
are pink without
hypertrophy.
Tongue easily
moves in all
directions,
pinkish, moist
and with gag
reflex.
NECK
Neck Muscles Inspection Symmetrical with Normal
and palpation head in central
position.
Symmetrical
movement of
neck muscles.
Movement Abnormal
through very
limited range of
motion with
complaint of
discomfort. With
difficulty of
turning head.
Lymph nodes Palpation Lymph nodes are Normal
non-palpable.

Trachea and Palpation In midline Normal

thyroid gland position, non-
palpable lobes,
Gland is not
enlarged and rises
as patient
swallows.

Chest Inspection Symmetrical Normal

(chest expansion)
respiratory effort
without use of
accessory
muscles. No
tenderness and
masses.
PHYSICAL ASSESSMENT 5

Noted pale pink Abnormal

appearance with
associated
swelling and
small blisters.

Lungs Percussion, RR – 17 breaths Normal

palpation & per minute
Auscultation without use of
accessory
muscles upon
inspiration and
expiration.
With clear breath
sounds.
Cardiovascular Palpation and There were no Normal
System auscultation visible pulsations
on the aortic and
pulmonic areas.
There is no
presence of
heaves or lifts.

With normal Normal

strength and
regular radial
pulse
(35 bpm)
With a grading
Normal
pulse (On a four-
point scale) of 2+.
Gastrointestinal Inspection, Noted pale pink
System Auscultation, appearance with
Palpation associated
swelling and
small blisters.
PHYSICAL ASSESSMENT 6

Symmetric Normal
contour, not
distended.
Symmetrical
movements cause
by respirations.
With audible
sounds of 2-3
bowel
sounds/minute.
RUQ: 2
RLQ: 2
LLQ: 1
LUQ: 3
Upper Extremities Inspection Noted pale pink
appearance with
associated
swelling and
small blisters.
Lower Extremities Inspection With 1% of Abnormal
partial thickness
thermal burn on
right thigh
Muscles Inspection Equal in size both Normal
and Palpation sides of the body,
smooth
coordinated
movements,
100% of normal
full movement
against gravity
and full
resistance.
Bones and Joints Inspection No deformities or Normal
swelling, joints
move smoothly.
MENTAL
STATUS
Can express
Language oneself by
Inspection speech. Normal
PHYSICAL ASSESSMENT 7

Orientation Inspection Oriented to a Normal

person, place,
date or time.
Able to
Attention span Inspection concentrate as Normal
evidence by
answering the
questions
appropriately.
A total of 15
Level of Inspection points indicative Normal
Consciousness of complete
orientation and
alertness.
MOTOR
FUNCTION
Gross Motor and
Balance
Inspection Has upright Normal
 Walking
posture and
gait
steady gait with
opposing arm
swing unaided
and maintaining
balance.

Pain sensation
Inspection Repeatedly and Normal
rhythmically
touches the nose.

Inspection Can alternately Normal

supinate and
pronate hands at
rapid pace.

Inspection Perform with Normal

coordinating and
rapidity.

Inspection Perform with Normal

accuracy and
PHYSICAL ASSESSMENT 8

rapidity.

Rapidly touches
each finger to
Inspection thumb with each Normal
hand.

Able to
discriminate
Inspection between sharp Normal
and dull sensation
when touched
with needle
(safety pin) and
cotton.

CRANIAL NERVES

CRANIAL NERVE METHOD FINDINGS INTERPRETATION

I Olfactory Ask client to Client able to Normal

close eyes distinguish
and identify different smells
different
mild aromas
such as
scented
alcohol, face
powder and
coffee.
II Optic Ask client to Client able to Normal
read page of read newsprint
a book and and determine
determine far objects
objects about
20 ft. away
III Oculomotor Assess ocular Client able to Normal
movements exhibit normal
and pupil EOM in
reaction different
directions and
normal reaction
PHYSICAL ASSESSMENT 9

of pupils to
light and
accommodation
IV Trochlear Ask client to Client able to Normal
move move eyeballs
eyeballs obliquely
obliquely
V Trigeminal Elicit blink Client blinks Normal
reflex by whenever sclera
lightly is lightly
touching touched; able to
lateral sclera feel the wisp of
(using cotton over the
cotton); to area touched;
test able to
sensation, discriminate
wipe a wisp blunt and sharp
of cotton stimuli
over client’s
forehead for
light
sensation and
use
alternating
blunt and
sharp ends of
safety pin to
test deep
sensation

Assess skin Client is able to Normal

sensation as sense and
of distinguish
ophthalmic different stimuli
branch above
Client able to
Ask client to clench teeth Normal
clench teeth
VI Abducens Ask client to Client able to Normal
move eyeball move eyeballs
laterally laterally
VII Facial Ask client to Client able to Normal
do different do different
facial facial
expressions expressions
such as such as smiling,
smiling, frowning and
frowning and raising of
raising of eyebrows; able
eyebrows; to identify
PHYSICAL ASSESSMENT 10

ask client to different tastes

identify such as sweet,
various tastes salty and bitter
placed on the taste
tip and sides
of the mouth:
sweet candy,
salty crackers
and coffee
VIII Acoustic Assess Client able to Normal
client’s hear loud and
ability to soft spoken
hear loud and words; able to
soft spoken hear ticking of
words; do the watch on both
watch tick ears
test
IX Glossopharynge Apply taste Client able to Normal
al on posterior identify
tongue for different tastes
identification such as sweet,
(sweet candy, salty and bitter
salty crackers taste; able to
and coffee); move tongue
ask client to from side to
move tongue side and up and
from side to down; able to
side and up swallow
and down; without
ask client to difficulty, with
swallow and (+) gag reflex
elicit gag
reflex
through
sticking a
clean tongue
depressor
into client’s
mouth
X Vagus Ask client to Client able to Normal
swallow; swallow with
assess minimal
client’s difficulty; has
speech for
absence of
hoarseness hoarseness in
speech
XI Spinal accessory Ask client to Client able to Normal
shrug shrug shoulders
shoulders and turn head
and turn head from side to
PHYSICAL ASSESSMENT 11

from side to side against

side against resistance from
resistance nurse’s hands
from nurse’s
hands
XII Hypoglossal Ask client to Client able to Normal
protrude protrude tongue
tongue at at midline and
midline, then move it side to
move it side side
to side
PHYSICAL ASSESSMENT 12

II. PHYSICAL ASSESSMENT

AREA METHOD FINDINGS INTERPRETATION

INTEGUMENTA Inspection With 60% partial Abnormal
RY and palpation thickness thermal
In a partial thickness burn
burn on face, or second degree burn it
neck, nape, front, involves the epidermis and
Skin back and both some portion of the
upper extremeties dermis, the second layer of
and palm size on the skin. This type of burn
the legs. With may be further categorized
blister formation as superficial or deep,
depending on how much
of the dermis is involved.
(https://www.emedicinehealth.co
m/thermal_heat_or_fire_burns/a
rticle_em.htm#what_are_the_sy
mptoms_of_thermal_burns)

Hair Inspection Hair is short and Normal

black with visible
white hair.
Evenly
distributed. No
alopecia, lice and
dandruff. Scalp is
dry.

Abnormal
With singed-
facial hair and Partial thickness burn may
eyebrows or may not be painful (it
may be so deep that nerve
endings may be
destroyed), may be moist
or dry (so deep that sweat
glands are destroyed), may
or may not turn white
when area is touched, hair
is usually gone
(https://www.emedicinehealth.co
m/thermal_heat_or_fire_burns/a
rticle_em.htm#what_are_the_sy
mptoms_of_thermal_burns)
PHYSICAL ASSESSMENT 13

Nails Inspection Fingernail plate Normal

and Palpation shape is on a
convex curvature
and untrimmed.
Capillary refill of
2 seconds.

HEAD Head is rounded

(normocephalic
Skull and Face Inspection and symmetric, Normal
and palpation with frontal,
parietal, and
occipital
prominences)
with no presence
of lesions, masses
or foreign bodies.
Scalp has no
tenderness on
palpation.
Symmetric facial
features &
movements.
Eyes and Vision Inspection Eyebrows have Normal
evenly distributed
hair,
symmetrically
aligned. No
discoloration of
eyelids & lids
closes
symmetrically.
Pupils equally
rounded 3 mm in
diameter, reactive
to light and
accommodation.
When looking
straight ahead,
patient can see
objects in the
periphery.
Able to read
newsprint in close
PHYSICAL ASSESSMENT 14

distance.
Ears and Hearing Inspection Color of ears are Normal
and palpation same as facial
skin. Symmetrical
ears and equal in
size aligned on
the outer canthus
of the eye. No
presence of
tenderness,
masses and
discharge. Pinna
recoils
immediately.

Nose and Sinuses Inspection Nose is midline, Normal

and palpation symmetric and
straight on the
face without
swelling, bleeding
or lesions. Patient
can breathe
normally in both
nostrils. No nasal
flaring. No
presence of
bumps and
tenderness; no
pain reported.

Mouth and Inspection Lips are swollen, Abnormal

Oropharynx inflamed and dry.

With 20 adult Normal

PHYSICAL ASSESSMENT 15

teeth.
Normal
Uvula is in the
middle; tonsils
are pink without
hypertrophy.
Tongue easily
moves in all
directions,
pinkish, moist
and with gag
reflex.
NECK
Neck Muscles Inspection Symmetrical with Normal
and palpation head in central
position.
Symmetrical
movement of
neck muscles.
Movement Abnormal
through very
limited range of
motion with
complaint of
discomfort. With
difficulty of
turning head.
Lymph nodes Palpation Lymph nodes are Normal
non-palpable.

Trachea and Palpation In midline Normal

thyroid gland position, non-
palpable lobes,
Gland is not
enlarged and rises
as patient
swallows.

Chest Inspection Symmetrical Normal

(chest expansion)
respiratory effort
without use of
accessory
muscles. No
tenderness and
masses.
PHYSICAL ASSESSMENT 16

Noted pale pink Abnormal

appearance with
associated
swelling and
small blisters.

Lungs Percussion, RR – 17 breaths Normal

palpation & per minute
Auscultation without use of
accessory
muscles upon
inspiration and
expiration.
With clear breath
sounds.
Cardiovascular Palpation and There were no Normal
System auscultation visible pulsations
on the aortic and
pulmonic areas.
There is no
presence of
heaves or lifts.

With normal Normal

strength and
regular radial
pulse
(35 bpm)
With a grading
Normal
pulse (On a four-
point scale) of 2+.
Gastrointestinal Inspection, Noted pale pink Abnormal
System Auscultation, and moist
Palpation appearance with
associated
swelling.

Symmetric
contour, not
PHYSICAL ASSESSMENT 17

distended.
Symmetrical Normal
movements cause
by respirations.
With audible
sounds of 2-3
bowel
sounds/minute.
RUQ: 2
RLQ: 2
LLQ: 1
LUQ: 3
Upper Extremities Inspection Noted pale pink Abnormal
and moist
appearance with
associated
swelling.
Lower Extremities Inspection With 1% of Abnormal
partial thickness
thermal burn on
right thigh
Muscles Inspection Equal in size both Normal
and Palpation sides of the body,
smooth
coordinated
movements,
100% of normal
full movement
against gravity
and full
resistance.
Bones and Joints Inspection No deformities or Normal
swelling, joints
move smoothly.
MENTAL
STATUS
Can express
Language oneself by
Inspection Normal
speech.

Orientation
Inspection Normal
Oriented to a
person, place,
date or time.
PHYSICAL ASSESSMENT 18

Attention span Able to

concentrate as
Inspection evidence by Normal
answering the
questions
appropriately.
Level of A total of 15
Consciousness points indicative
Inspection Normal
of complete
orientation and
alertness.
MOTOR Normal
FUNCTION Has upright
posture and
Gross Motor and steady gait with
Balance opposing arm
swing unaided
and maintaining
balance.

Inspection
 Walking
gait

Pain sensation
Able to Normal
discriminate
between sharp
and dull sensation
when touched
with needle
(safety pin) and
cotton.

CRANIAL NERVES

CRANIAL NERVE METHOD FINDINGS INTERPRETATION

I Olfactory Ask client to Client able to Normal

close eyes distinguish
PHYSICAL ASSESSMENT 19

and identify different smells

different
mild aromas
such as
scented
alcohol, face
powder and
coffee.
II Optic Ask client to Client able to Normal
read page of read newsprint
a book and and determine
determine far objects
objects about
20 ft. away
III Oculomotor Assess ocular Client able to Normal
movements exhibit normal
and pupilEOM in
reaction different
directions and
normal reaction
of pupils to
light and
accommodation
IV Trochlear Ask client to Client able to Normal
move move eyeballs
eyeballs obliquely
obliquely
V Trigeminal Elicit blink Client blinks Normal
reflex by whenever sclera
lightly is lightly
touching touched; able to
lateral sclera feel the wisp of
(using cotton over the
cotton); to area touched;
test able to
sensation, discriminate
wipe a wisp blunt and sharp
of cotton stimuli
over client’s
forehead for
light
sensation and
use
alternating
blunt and
sharp ends of
safety pin to
test deep
sensation
PHYSICAL ASSESSMENT 20

Assess skin Client is able to Normal

sensation as sense and
of distinguish
ophthalmic different stimuli
branch above
Client able to
Ask client to clench teeth Normal
clench teeth
VI Abducens Ask client to Client able to Normal
move eyeball move eyeballs
laterally laterally
VII Facial Ask client to Client able to Normal
do different do different
facial facial
expressions expressions
such as such as smiling,
smiling, frowning and
frowning and raising of
raising of eyebrows; able
eyebrows; to identify
ask client to different tastes
identify such as sweet,
various tastes salty and bitter
placed on the taste
tip and sides
of the mouth:
sweet candy,
salty crackers
and coffee
VIII Acoustic Assess Client able to Normal
client’s hear loud and
ability to soft spoken
hear loud and words; able to
soft spoken hear ticking of
words; do the watch on both
watch tick ears
test
IX Glossopharynge Apply taste Client able to Normal
al on posterior identify
tongue for different tastes
identification such as sweet,
(sweet candy, salty and bitter
salty crackers taste; able to
and coffee); move tongue
ask client to from side to
move tongue side and up and
from side to down; able to
side and up swallow
and down; without
ask client to difficulty, with
PHYSICAL ASSESSMENT 21

swallow and (+) gag reflex

elicit gag
reflex
through
sticking a
clean tongue
depressor
into client’s
mouth
X Vagus Ask client to Client able to Normal
swallow; swallow with
assess minimal
client’s difficulty; has
speech for absence of
hoarseness hoarseness in
speech
XI Spinal accessory Ask client to Client able to Normal
shrug shrug shoulders
shoulders and turn head
and turn head from side to
from side to side against
side against resistance from
resistance nurse’s hands
from nurse’s
hands
XII Hypoglossal Ask client to Client able to Normal
protrude protrude tongue
tongue at at midline and
midline, then move it side to
move it side side
to side
PHYSICAL ASSESSMENT 22

III. PHYSICAL ASSESSMENT

AREA METHOD FINDINGS INTERPRETATION

INTEGUMENTA Inspection With 60% partial Abnormal
RY and palpation thickness thermal
In a partial thickness burn
burn on face, or second degree burn it
neck, nape, front, involves the epidermis and
Skin back and both some portion of the
upper extremeties dermis, the second layer of
and palm size on the skin. This type of burn
the legs. With may be further categorized
blister formation as superficial or deep,
depending on how much
of the dermis is involved.
(https://www.emedicinehealth.co
m/thermal_heat_or_fire_burns/a
rticle_em.htm#what_are_the_sy
mptoms_of_thermal_burns)

Hair Inspection Hair is short and Normal

black with visible
white hair.
Evenly
distributed. No
alopecia, lice and
dandruff. Scalp is
dry.

Nails Inspection Fingernail plate Normal

and Palpation shape is on a
convex curvature
and untrimmed.
Capillary refill of
2 seconds.

HEAD Head is rounded

(normocephalic
Skull and Face Inspection and symmetric, Normal
and palpation with frontal,
parietal, and
occipital
prominences)
with no presence
of lesions, masses
or foreign bodies.
PHYSICAL ASSESSMENT 23

Scalp has no
tenderness on
palpation.
Symmetric facial
features &
movements.
Eyes and Vision Inspection Eyebrows have Normal
evenly distributed
hair,
symmetrically
aligned. No
discoloration of
eyelids & lids
closes
symmetrically.
Pupils equally
rounded 3 mm in
diameter, reactive
to light and
accommodation.
When looking
straight ahead,
patient can see
objects in the
periphery.
Able to read
newsprint in close
distance.
Ears and Hearing Inspection Color of ears are Normal
and palpation same as facial
skin. Symmetrical
ears and equal in
size aligned on
the outer canthus
of the eye. No
presence of
tenderness,
masses and
discharge. Pinna
recoils
immediately.

Nose and Sinuses Inspection Nose is midline, Normal

and palpation symmetric and
straight on the
PHYSICAL ASSESSMENT 24

face without
swelling, bleeding
or lesions. Patient
can breathe
normally in both
nostrils. No nasal
flaring. No
presence of
bumps and
tenderness; no
pain reported.

Mouth and Inspection Lips are pinkish Normal

Oropharynx and moist in
appearance .

With 20 adult Normal

teeth.

Uvula is in the
middle; tonsils Normal
are pink without
hypertrophy.
Tongue easily
moves in all
directions,
pinkish, moist
and with gag
reflex.
NECK
Neck Muscles Inspection Symmetrical with Normal
and palpation head in central
position.
Symmetrical
movement of
neck muscles.
Movement Abnormal
through very
limited range of
motion with
complaint of
discomfort. With
difficulty of
turning head.
PHYSICAL ASSESSMENT 25

Lymph nodes Palpation Lymph nodes are Normal

non-palpable.

Trachea and Palpation In midline Normal

thyroid gland position, non-
palpable lobes,
Gland is not
enlarged and rises
as patient
swallows.

Chest Inspection Symmetrical Normal

(chest expansion)
respiratory effort
without use of
accessory
muscles. No
tenderness and
masses.

With presence of
scarring on the Abnormal
skin.

Lungs Percussion, RR – 17 breaths Normal

palpation & per minute
Auscultation without use of
accessory
muscles upon
inspiration and
expiration.
With clear breath
sounds.
Cardiovascular Palpation and There were no Normal
System auscultation visible pulsations
on the aortic and
pulmonic areas.
There is no
presence of
heaves or lifts.

With normal Normal

strength and
PHYSICAL ASSESSMENT 26

regular radial
pulse
(35 bpm)
With a grading
pulse (On a four- Normal
point scale) of 2+.
Gastrointestinal Inspection, With presence of Abnormal
System Auscultation, scarring on the
Palpation skin.

Symmetric
contour, not
distended.
Symmetrical
movements cause Normal
by respirations.
With audible
sounds of 2-3
bowel
sounds/minute.
RUQ: 2
RLQ: 2
LLQ: 1
LUQ: 3
Upper Extremities Inspection With presence of Abnormal
foul smelling
fibrinous
exudates on both
upper extremities
Lower Extremities Inspection With 1% of Abnormal
partial thickness
thermal burn on
right thigh
Muscles Inspection Equal in size both Normal
and Palpation sides of the body,
smooth
coordinated
movements,
PHYSICAL ASSESSMENT 27

100% of normal
full movement
against gravity
and full
resistance.
Bones and Joints Inspection No deformities or Normal
swelling, joints
move smoothly.
MENTAL
STATUS
Can express
Language oneself by
Inspection speech. Normal

Orientation
Inspection Oriented to a Normal
person, place,
date or time.

Attention span Able to

Inspection concentrate as Normal
evidence by
answering the
questions
appropriately.
Level of A total of 15
Inspection Normal
Consciousness points indicative
of complete
orientation and
alertness.
MOTOR
FUNCTION
Gross Motor and
Balance
Inspection Has upright Normal
 Walking
posture and
gait
steady gait with
opposing arm
swing unaided
and maintaining
balance.

Pain sensation
Inspection Repeatedly and Normal
rhythmically
PHYSICAL ASSESSMENT 28

touches the nose.

Inspection Can alternately Normal

supinate and
pronate hands at
rapid pace.

Inspection Perform with Normal

coordinating and
rapidity.

Inspection Perform with Normal

accuracy and
rapidity.

Rapidly touches
Inspection each finger to Normal
thumb with each
hand.

Able to
Inspection discriminate Normal
between sharp
and dull sensation
when touched
with needle
(safety pin) and
cotton.

CRANIAL NERVES

CRANIAL NERVE METHOD FINDINGS INTERPRETATION

I Olfactory Ask client to Client able to Normal

close eyes distinguish
and identify different smells
different
mild aromas
such as
PHYSICAL ASSESSMENT 29

scented
alcohol, face
powder and
coffee.
II Optic Ask client to Client able to Normal
read page of read newsprint
a book and and determine
determine far objects
objects about
20 ft. away
III Oculomotor Assess ocular Client able to Normal
movements exhibit normal
and pupil EOM in
reaction different
directions and
normal reaction
of pupils to
light and
accommodation
IV Trochlear Ask client to Client able to Normal
move move eyeballs
eyeballs obliquely
obliquely
V Trigeminal Elicit blink Client blinks Normal
reflex by whenever sclera
lightly is lightly
touching touched; able to
lateral sclera feel the wisp of
(using cotton over the
cotton); to area touched;
test able to
sensation, discriminate
wipe a wisp blunt and sharp
of cotton stimuli
over client’s
forehead for
light
sensation and
use
alternating
blunt and
sharp ends of
safety pin to
test deep
sensation

Assess skin Client is able to Normal

sensation as sense and
of distinguish
ophthalmic different stimuli
PHYSICAL ASSESSMENT 30

branch above
Client able to
Ask client to clench teeth Normal
clench teeth
VI Abducens Ask client to Client able to Normal
move eyeball move eyeballs
laterally laterally
VII Facial Ask client to Client able to Normal
do different do different
facial facial
expressions expressions
such as such as smiling,
smiling, frowning and
frowning and raising of
raising of eyebrows; able
eyebrows; to identify
ask client to different tastes
identify such as sweet,
various tastes salty and bitter
placed on the taste
tip and sides
of the mouth:
sweet candy,
salty crackers
and coffee
VIII Acoustic Assess Client able to Normal
client’s hear loud and
ability to soft spoken
hear loud and words; able to
soft spoken hear ticking of
words; do the watch on both
watch tick ears
test
IX Glossopharynge Apply taste Client able to Normal
al on posterior identify
tongue for different tastes
identification such as sweet,
(sweet candy, salty and bitter
salty crackers taste; able to
and coffee); move tongue
ask client to from side to
move tongue side and up and
from side to down; able to
side and up swallow
and down; without
ask client to difficulty, with
swallow and (+) gag reflex
elicit gag
reflex
through
PHYSICAL ASSESSMENT 31

sticking a
clean tongue
depressor
into client’s
mouth
X Vagus Ask client to Client able to Normal
swallow; swallow with
assess minimal
client’s difficulty; has
speech for absence of
hoarseness hoarseness in
speech
XI Spinal accessory Ask client to Client able to Normal
shrug shrug shoulders
shoulders and turn head
and turn head from side to
from side to side against
side against resistance from
resistance nurse’s hands
from nurse’s
hands
XII Hypoglossal Ask client to Client able to Normal
protrude protrude tongue
tongue at at midline and
midline, then move it side to
move it side side
to side
PHYSICAL ASSESSMENT 32