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Foundations > cranial nerves & head to toe > Flashcards

cranial nerves & head to toe Flashcards

1
Q

CN I

A

olfactory

test by sense of smell, on health history

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2
Q

CN II

A

optic

test by visual acuity & confrontation

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3
Q

CN III, IV, VI

A

ocularmotor, trochlear, abducens

test by six cardinal fields

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4
Q

CN V

A

trigeminal nerve

test by clenching jaw & light touch on face

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5
Q

CN VII

A

factial

test by having pt smile, wrinkle forehead, puff out cheeks

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6
Q

CN VIII

A

Acoustic

test by whisper test

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7
Q

CN IX, X

A

glossopharyngeal and vagus
test by having pt say “ahhh,” check gag reflex, swallowing, and taste
taste checking in health history

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8
Q

CN XI

A

spinal accessory

test resistance of head rotation & shrug shoulders

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9
Q

CN XII

A

hypoglossal

test by having pt stick out tongue & wiggle tongue

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10
Q

Head to Toe

1st two steps

A

hand hygiene

pt’s general appearance

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11
Q

Vital Signs (HtT, 2nd step)

A 
pulse
respirations
temperature
BP
pain
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12
Q

Head & Face (HtT, 3rd step)

A
  • 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)
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13
Q

Eyes (HtT, 4th step)

A
  • 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
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14
Q

Ears (HtT, 5th step)

A
  • 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
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15
Q

Nose (HtT, 6th step)

A 
-inspect the external nose
    symmetry
    lesions
-w/ speculum, inspect the nares
    nasal mucosa
    septum
    turbinates
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16
Q

Mouth & Throat (HtT, 7th step)

A
  • 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)
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17
Q

Neck (HtT, 8th step)

A
  • 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)
18
Q

Heart (HtT, 9th step)

A
  • 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
19
Q

Peripheral Vascular System (HtT, 10th step)

A
  • inspect lower legs for varicose veins, ulcers, discoloration, hair loss
  • cap refill, <3sec
  • assess pulses (bilaterally): radial, ulnar, brachial, popliteal, posterior tibial, dorsalis pedis
20
Q

Lungs (HtT, 11th step)

A
  • 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
21
Q

Abdomen (HtT, 12th step)

A
  • inspect abdomen
  • auscultate bowel sounds
  • auscultate abdominal aorta
  • percuss all quadrants
  • palpate all quadrants: light palpation, deep palpation
22
Q

Neurological (HtT, 13th step)

A
  • 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
23
Q

Musculoskeletal (HtT, 14th step)

A
  • 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
24
Q

Normal Response

skin

A

warm, dry, intact
skin turgor good
no lesions, birthmarks

25
Q

Normal Response

hair

A

normal distribution & texture

26
Q

Normal Response

Nails

A

no clubbing or discolorations

27
Q

Normal Response

head

A

normocephalic, no lesions, lumps or tenderness

face- symmetric

28
Q

Normal Response

eyes

A

visual fields full by confrontation
EOMs intact, no lesions or redness
Pupils- PERRLA, red flex & optic disc normal

29
Q

Normal Response

ears

A

no mass, lesion, or tenderness
tympanic membrane-pearly gray, no perforation
whispered words heard bilaterally

30
Q

Normal Response

nose

A

no deformities or tenderness

Nares- patent, septum midline, no sinus tenderness

31
Q

Normal Response

mouth

A

mucosa pink, no lesions or bleeding

tongue- symmetric, uvula rises, tonsil +1, gag reflex present

32
Q

Normal Response

neck

A

supple w/ full ROM, no masses, tenderness, lymphadenopathy, trachea midline, thyroid non palpable, no JVD, no carotid bruits

33
Q

Normal Response

spine & back

A

no scoliosis, no tenderness over spine, no CVA tenderness

34
Q

Normal Response

thorax & lungs

A

clear to auscultation, no tenderness on palpation

35
Q

Normal Response

heart

A

S1, S2 regular, no S3, S4, no murmurs or bruits noted

36
Q

Normal Response

abdomen

A

soft, non-tender, bowel sounds present in all 4 quadrants

37
Q

Normal Response

extremities

A

color (tan-pink), no cyanosis, no edema, peripheral pulses present +2 bilaterally

38
Q

Normal Response

musculoskeletal

A

TMJ- no crepitation or slipping, extremities have full ROM, no pain or crepitation, muscle strength +2 bilaterally

39
Q

Normal Response

neurologic

A

appearance, behavior, speech appropriate, A&O x3, cranial nerves I-XII intact, deep tendon reflexes intact & +2

40
Q

Deep Tendon Reflexes

A

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

41
Q

Muscle strength

A
  • 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

Foundations (2 decks)

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