cranial nerves & head to toe Flashcards
CN I
olfactory
test by sense of smell, on health history
CN II
optic
test by visual acuity & confrontation
CN III, IV, VI
ocularmotor, trochlear, abducens
test by six cardinal fields
CN V
trigeminal nerve
test by clenching jaw & light touch on face
CN VII
factial
test by having pt smile, wrinkle forehead, puff out cheeks
CN VIII
Acoustic
test by whisper test
CN IX, X
glossopharyngeal and vagus
test by having pt say “ahhh,” check gag reflex, swallowing, and taste
taste checking in health history
CN XI
spinal accessory
test resistance of head rotation & shrug shoulders
CN XII
hypoglossal
test by having pt stick out tongue & wiggle tongue
Head to Toe
1st two steps
hand hygiene
pt’s general appearance
Vital Signs (HtT, 2nd step)
pulse respirations temperature BP pain
Head & Face (HtT, 3rd step)
- inspect & palpate scalp
- inspect face, expression, symmetry
- palpate temporal artery
- palpate temporomandibular joint as it opens & closes
- palpate sinuses
- have pt clench jaw & palpate (CN V)
- have pt smile, wrinkle forehead & puff cheeks (CN VII)
Eyes (HtT, 4th step)
- inspect external eye structures
- inspect conjuntiva, sclera, cornea & iris
- corneal light reflex
- test confrontation (CN II)
- 6 cardinal positions (CN III, IV, VI)
- test pupil: sze, rxn to light, accommodation
- darken room, ophthalmoscope-inspect ocular fundus: red reflex, disc, vessels, & retinal background
Ears (HtT, 5th step)
- inspect external ear, skin condition & auditory meatus
- move auricle & push tragus for tenderness
- w/ otoscope- inspect canal, tympanic membrane for color, position, landmarks, & integrity
- test hearing- whisper test (CN VIII)
- Wever & Rhine, AC>BC
- tuning fork on top of head
Nose (HtT, 6th step)
-inspect the external nose
symmetry
lesions
-w/ speculum, inspect the nares
nasal mucosa
septum
turbinatesMouth & Throat (HtT, 7th step)
- w/ penlight inspect mouth: buccal mucosa, teeth & gums, tongue, floor of mouth, palate, & uvula
- note mobility of uvula as person says “ahhh,” & test gag reflex (CN IX, X)
- have person stick out tongue and move it side to side (CN XII)
Neck (HtT, 8th step)
- inspect the neck: symmetry, lumps, pulsations
- palpate the cervical lymph nodes
- inspect & palpate carotid pulse, listen for bruits
- palpate the trachea midline & have them swallow (tests thyroid)
- test ROM & muscle strength against resistance: shrug shoulders, head side to side, & head back & forward (CN XI)
Heart (HtT, 9th step)
- inspect the precordium for any pulsations or heave
- palpate the apical pulse & note location
- palpate the precordium for any abnormal thrill
- auscultate apical rate & rhythm & carotids
- auscultate heart sounds w/ diaphragm
- auscultate heart sounds w/ bell (for murmurs)
- turn person to left side & auscultate apex w/ bell
Peripheral Vascular System (HtT, 10th step)
- inspect lower legs for varicose veins, ulcers, discoloration, hair loss
- cap refill, <3sec
- assess pulses (bilaterally): radial, ulnar, brachial, popliteal, posterior tibial, dorsalis pedis
Lungs (HtT, 11th step)
- inspect the chest & expansion (equally)
- palpate for expansion, lumps, or tenderness, & spinous processes
- percuss over lung fields
- percuss costovertebral angle, noting any tenderness (kidneys)
- auscultate breath sounds, compare bilaterally, note 28 points of auscultation
Abdomen (HtT, 12th step)
- inspect abdomen
- auscultate bowel sounds
- auscultate abdominal aorta
- percuss all quadrants
- palpate all quadrants: light palpation, deep palpation
Neurological (HtT, 13th step)
- Test sensation in selected areas on face, arms or hands, and legs or feet: superficial pain, light touch
- Test position sense of finger, one hand; their finger to your finger and then move your hand
- Test stereognosis, using a familiar object
- Test cerebellar function of the upper extremities using finger-to-nose test; patient’s eyes closed
- Elicit deep tendon reflexes: biceps, triceps, brachioradialis
- Test cerebellar function of the lower extremities by asking the person to run each heel down the opposite shin
- Elicit deep tendon reflexes: patellar and Achilles
Musculoskeletal (HtT, 14th step)
- Ask the person to walk across the room in his/her regular walk, turn, and then walk back toward you in heel-to-toe fashion
- Ask the person to walk on the toes for a few steps, then to walk on the heels for a few steps
- Stand close and check Romberg’s sign; feet together, hands at side, eyes closed for 20 seconds
- Ask the person to hold the edge of the bed and to perform a shallow knee bend, one for each leg
- Stand behind and check the spine as the person touches the toes
- Check the range of motion of spine, hyperextends, rotates, and laterally bends
Normal Response
skin
warm, dry, intact
skin turgor good
no lesions, birthmarks
Normal Response
hair
normal distribution & texture
Normal Response
Nails
no clubbing or discolorations
Normal Response
head
normocephalic, no lesions, lumps or tenderness
face- symmetric
Normal Response
eyes
visual fields full by confrontation
EOMs intact, no lesions or redness
Pupils- PERRLA, red flex & optic disc normal
Normal Response
ears
no mass, lesion, or tenderness
tympanic membrane-pearly gray, no perforation
whispered words heard bilaterally
Normal Response
nose
no deformities or tenderness
Nares- patent, septum midline, no sinus tenderness
Normal Response
mouth
mucosa pink, no lesions or bleeding
tongue- symmetric, uvula rises, tonsil +1, gag reflex present
Normal Response
neck
supple w/ full ROM, no masses, tenderness, lymphadenopathy, trachea midline, thyroid non palpable, no JVD, no carotid bruits
Normal Response
spine & back
no scoliosis, no tenderness over spine, no CVA tenderness
Normal Response
thorax & lungs
clear to auscultation, no tenderness on palpation
Normal Response
heart
S1, S2 regular, no S3, S4, no murmurs or bruits noted
Normal Response
abdomen
soft, non-tender, bowel sounds present in all 4 quadrants
Normal Response
extremities
color (tan-pink), no cyanosis, no edema, peripheral pulses present +2 bilaterally
Normal Response
musculoskeletal
TMJ- no crepitation or slipping, extremities have full ROM, no pain or crepitation, muscle strength +2 bilaterally
Normal Response
neurologic
appearance, behavior, speech appropriate, A&O x3, cranial nerves I-XII intact, deep tendon reflexes intact & +2
Deep Tendon Reflexes
4+ very brisk, hyperactive w/ clonus, indicative of disease
3+ brisker than average, may indicate disease, probably normal
2+ average, normal
1+ diminished, low normal, or occurs only w/ reinforcement
0 no response
Muscle strength
- 5 full ROM against gravity & resistance, normal
- 4 full ROM against gravity & some resistance, good
- 3 full ROM w/ gravity, fair
- 2 full ROM w/ gravity eliminated, poor
- 1 slight contraction, trace
- 0 no contraction, zero
