Test 2 Flashcards
CN I
olfactory
smell test
CN II
occipital
visual fields by confrontation
CN II and III
occipital
oculomotor
pupil size/shape
rxn to light (direct/consensual)
accomodation
CN II, IV, VI
oculomotor
trochlear
abducens
extraocular movements
convergence
CN VIII
vestibulocochlear
whisper test
CN IX and X
glossopharyngeal
vagus
speech
swallow
soft palate and uvual rise
CN XII
hypoglossal
tongue midline
stick out
side to side
light, tight, dynamite
CN XI
accessory
shrug against force
turn head against force
CN V
trigeminal
temporal/masseter strength
sharp/dull
light touch
CN VII
facial
symmetry of movement
normal lymph nodes
may not be palpable
may feel 1+ small, soft, nontender nodes
tonsilar node
if it pulsates, it’s the carotid artery
if it’s small, hard, tender deep between mandible and SCM, probably styloid process
abnormal findings in lymph nodes
enlargement and/or tenderness suggests infection
enlargement, firm/hard, fixed to skin or underlying tissues, suggests malignancy
lesions in drainage areas for axillary nodes suggest malignant involvement
enlarged, tender cervical nodes
pharyngitis
preauricular lymph node location
tragus
postauricular lymph node location
mastoid process
occipital lymph node location
base of posterior skull
tonsillar lymph node location
angle of mandible
submandibular lymph node location
midway along mandible
submental lymph node location
under chin, a few cm behind tip of mandible
superficial cervical chain location
superficial to SCM
posterior lymph node locations
along anterior edge of trapezius (between SCM and trapezius)
deep cervical chain location
deep to SCM (hook fingers under SCM
supraclavicular
deep in angle of SCM and clavicle (pt raises shoulders)
trachea palpation
place fingers along sides of trachea and note space between it and SCM
thyroid gland inspection
tip patient’s head back
tangential lighting down from tip of patient’s chin - inspect region below cricoid cartilage for gland
pt sips water and extends neck again and swallows - watch for upward movement of thyroid gland, noting countour and symmetry
thyroid gland landmarks
notched thyroid cartilage cricoid cartilage (below)
thyroid isthmus (over 2nd, 3rd, 4th tracheal rings)
thryoid gland palpation
posterior approach
pt flexes neck slightly
place fingers just below cricoid cartilage
patients swallows - feel thyroid isthmus rising up under tingertips
head ROS
severe/frequent headaches
neck ROS
swollen glands/lumps
thyroid ROS
hot/cold preference
sweat more/less than others
eyes ROS
changes blurred vision pain flashes of light floaters double vision redness excessive tearing discharge growths on eyelids light sensitivity
ears ROS
hearing trouble with ears earaches discharge tinnitus dizziness
nose ROS
breathing changes in nose/sinuses discharge URI sense of smell changes
mouth and throat ROS
changes difficulty eating/swallowing hoarseness smoking bleeding gums toothache lesions
head normal documentation
hair of average texture, scalp without lesions, normocephalic/atraumatic
eyes normal documentation
vision 20/30 in each eye.
visual fields full by confrontation.
conjunctive pink; sclera white.
pupils 4mm constricting to 2mm, round, regular, equally reactive to light.
extraocular movements intact.
disc margins sharp, without hemorrhages, exudates.
no arteriolar narrowing or A-V nicking.
ears normal documentation
canals clear, TM’s intact with good cone of light. acuity good to whispered voice
nose normal documentation
mucosa pink, septum midline. no sinus tenderness.
mouth and pharynx normal documentation
oral mucosa pink.
dentition good.
tongue midline, uvula midline, tonsils absent, pharynx without erythema or exudate.
neck normal documentation
neck supple.
trachea midline.
thyroid isthmus barely palpable, lobes not felt.
lymp nodes normal documentation
no cervical nodes palpable bilaterally
organs in LRQ
right ureter right bladder right ovary, uterus, fallopian tube right prostate, spermatic cord part of small intestine, rectum, ascending colon, cecum appendix
organs in URQ
liver gallbladder duodenum ascending/transverse colon pancreas (head) right ureter right kidney
organs in ULQ
descending colon left kidney pancreas (body and tail) spleen stomach transverse colon left ureter
organs in LLQ
bladder descending colon left ovary, uterus, fallopian tube left prostate, spermatic cord small intestine sigmoid colon left ureter
normal liver span
6-12 cm at right midclavicular line
4-8 cm at midsternal line
normal width of aorta
less than 3 cm
bladder distension
distended bladder palpated above symphysis pubis
holds ~300ml urine
brain can inhibit detrusor contractions if voiding is inconvenient up to 400-500ml
abdomen exam order
inspection
auscultation
percussion
palpation
abdomen inspection
skin symmetry protuberance masses peristalsis pulsations
abdomen inspection normal findings
skin color normal for ethnicity, warm and dry, no scars or lesions.
L and R quadrants symmetrical, no protuberance, masses, visible peristalsis.
abdomen auscultation
use diaphragm in all 4 quadrants for:
bowel sounds (frequency and character) - 2-3 min if no sounds
abdominal aorta for bruits (then palpate, noting size)
abdomen auscultation normal findings
bowel sounds present in all 4 quadrants, frequent but not continuous.
normal sounds: clicks and gurgles.
no aortic bruits.
normal aorta
abdomen percussion
percuss all 4 quadrants, assess tympany and dullness.
tympany indicates air, dullness indicates solid organs, masses, fluid, feces.
abdomen percussion expected findings
tympany in all 4 quadrants, dullness in RUQ when percussing liver border.
dullness on LLQ caused by constipation/fecal matter buildup in colon.
abdomen palpation
lightly palpate all 4 quadrants, note tenderness/masses.
deep palpation of all 4 quadrants, note guarding/rebound tenderness.
palpate liver.
palpate spleen.
abdomen palpation normal findings
no tenderness or masses upon palpation, no guarding or rebound tenderness upon deep palpation.
liver spans 6-12 cm along midclavicular line, 4-8 cm along midsternal line.
spleen not palpable.
abdomen ROS questions
pain diarrhea/constipation changes in bowel fxn indigestion N/V, hematemesis regurgitation loss/change of appetite difficulty/pain swallowing jaundice
abdomen documentation
abdomen is protuberant with active bowel sounds.
soft, nontender; no palpable masses or hepatosplenomegaly.
liver span 7 cm in right MC; edge smooth and palpable 1cm below right costal margin.
spleen and kidneys not felt.
no CVA tenderness.
anatomical joins to be examined
jaw neck shoulders elbows fingers hips knees ankles toes spine
muscle strength 0/5
no contraction
muscle strength 1/5
slight contraction
muscle strength 2/5
full ROM with gravity eliminated
muscle strength 3/5
full ROm against gravity
muscle strength 4/5
full ROM against gravity, some resistance
muscle strength 5/5
full ROM against gravity, full resistance. normal muscle strength
level of consciousness
single most critical and sensitive symptomatic indicator of neurlogical integrity
conscious/alert
easily aroused
lethargic
drifts off to sleep when not sitmulated
obtunded
sleeps most of the time
stuporous
semi comatose, responds only to persistent pain, withdraws from pain
comatose
completely unconscious, no response to pain or any external stimuli
increasing stimuli
auditory
tactile
painful
auditory stimuli
talk to patient in normal tone
tactile stimuli
shake patient gently
painful stimuli
trapezius squeeze sternal rub supraorbital pressure mandibular pressure nail pressure achilles tendon squeeze
testing for orientation
Person: what is your name
Place: where are you
Time: today’s date
Purpose: why are you here
tests for cerebellar fxn
rapid alternating movements
romberg test
gait
tandem walk
DTR: 0
no response
DTR: 1
slight response. hypoactive. can be normal for older adult.
DTR: 2
average response
DTR: 3
brisker than average, not necessarily abnormal
DTR: 4
indicates very brisk, hyperactive response. symptomatic of CNS disease
negative Babinski test
downward contraction of toes
positive Babinski test
dorsiflexion of big toe and fanning of other toes
from CNS lesion in corticospinal tract - also seen in intoxicated patients or in infants
negative Romberg test
normal findings. patient maintains upright posture. minimal swaying.
positive Romberg test
balance lost when eyes are closed.
2 ways to measure for crutches
- measure from axilla to heel of foot and add 2.5 cm
2. with elbow bent at 30 degrees fit 2-3 fingers between top of crutch and axilla
four point gait
- begin in tripod position (crutches in front of body and on side of each foot)
- move right crutch forward
- move left foot forward to level of left crutch
- move left crutch forward
- move right foot forward to level of right crutch.
three point gait
- tripod position
- advance both crutches and affected leg
- move stronger leg forward, stepping on floor
two point gait
- tripod position
- move left crutch and right foot forward
- move right crutch and left foot forward
swing-to-gait
- tripod
- both crutches forward
- lift and swing legs to crutches, letting crutches support body weight
swing through gait
- tripod
- both crutches forward
- lift and swing legs through and beyond crutches
ascending stairs with crutches
- place weight on crutch
- advance unaffected leg to stair and transfer weight from crutches to unaffected leg
- crutches now aligned with unaffected leg on stair
descending stairs with crutches
- place weight on unaffected leg
- put both crutches on lower stair, step down with unaffected leg, transfer body weight to crutches
- crutches aligned with unaffected leg on stairs
sitting down in a chair with crutches
- hold both crutches in one hand
- patient transfers weight to crutches and unaffected leg
- patient grasps arm of chair with free hand and lowers self into chair
cane
- -on side of strong leg
- -cane forward 15-25 cm (6-10 in, body weight on both legs
- -pt stands straight, looks straight ahead, moves involved leg forward, even with cane
- -advance strong leg past cane
- -move involved leg forward, even with strong leg
- -repeat
walker
patient stands straight in center of walker, grasps handgrips on upper bars
lifts walker, 15-20cm (6-8 in) forward and set down
steps forward one foot at a time
if unilateral leg weakness is present, step forward with weaker leg
bathing technique: assessment
safety vital status ROM medical device patient preference skin integrity pain
never leave bedside without 2-3 rails raised and locked, bed in low position
if connected to IV: remove gown, remove IV bag from pole, slide IV bag and tubing through arm of gown
bathing technique: face
wash eyes with warm water, from inner to outer canthus.
soak crusts 2-3 min
bathing technique: upper extremities and trunk
distal to proximal.
raise/support arm above head to wash axilla.
long firm strokes.
bathing technique: hand and nails
soak in water 3-5 min
bathing technique: abdomen
bathe, rinse, dry: keep covered between washing and rinsing
bathing technique: lower extremities
expose leg by folding blanket toward midline.
strokes from ankle to knee, knee to thigh for circulation.
assess for DVT.
bathing technique: foot and nails
soak for 10 min (not for DM patients)
bathing technique: back
buttocks and anus front to back.
clean, rinse, dry.
oral hygiene: assessment
for safety
inspect: lips, teeth, mucosa, gums, palate, tongue, identify oral disease/problems
oral hygiene: techniques
semi-fowler position
brush 45 degree to gum line
tips of bristles rest against and penetrate under gum line
brush tongue, avoiding gag reflex
rinse teeth with alcohol-free antiseptic mouthwash for 30s
oral hygiene: flossing
up and down motion
principles of surgical asepsis/sterile technique
- -all items in sterile field must be sterile
- -sterile barrier permeated by punctures, tears, moisture = contaminated
- -any doubt = unsterile
- -sterile persons/items only touch sterile areas; unsterile persons/items only touch unsterile areas
- -movement around/in sterile field must not compromise/contaminate sterile field
- -out of vision or below waist = contaminated
- -prolonged air exposure = finish procedures ASAP
catheter sizes
infants: 5-6 Fr
children: 8-10 Fr
young girls: 12 Fr
women: 14-16 Fr
men: 16-18 Fr
catheter insertion/lubrication length
males: lubricate 6-7 in; insert 5-7 in + 2 in
females: lubricate 1-2 in; insert 2-3 in + 2 in
