Fundamentals of Nursing Exam 2 Study Guide PDF

**[CHAPTER 29 & 30 STUDY GUIDE EXAM 2]** **[FUNDAMENTALS OF NURSING]** **[VITAL SIGNS]** **[ASSESSMENT]** **[DEFINITIONS]** Bradycardia---abnormally slow heart rate below 60 bpm Tachycardia---abnormally fast heart rate more than 100 bpm Antipyretics---medications that reduce fever, acetaminop...

**[CHAPTER 29 & 30 STUDY GUIDE EXAM 2]** **[FUNDAMENTALS OF NURSING]** **[VITAL SIGNS]** **[ASSESSMENT]** **[DEFINITIONS]** Bradycardia---abnormally slow heart rate below 60 bpm Tachycardia---abnormally fast heart rate more than 100 bpm Antipyretics---medications that reduce fever, acetaminophen, anti-inflammatories, salicylates (aspirin), indomethacin. Dysrhythmia---When an interval is interrupted by an early or late heartbeat or missed beat. Pulse Deficit---Failure of the heart to transmit a pulse wave to peripheral pulse sites. Bradypnea---rate of breathing regular but abnormally slow (less than 12 breaths/min) Tachypnea---rate of breathing regular by abnormally rapid (greater than 20 breaths/min) Hyperpnea---respirations are labored, increased in depth and increased in rate (greater than 20 breaths/min) usually due to exercise Apnea---Respirations cease for several seconds persistent cessation results in respiratory arrest Hyperventilation---Rate and depth of respirations increase "Hypocarbia" sometimes occurs. Hypoventilation---Respiratory rate is abnormally low and depth of ventilation is depressed "Hypercarbia" occurs. Cheyne Stokes Respirations---respiration rate and depth are irregular, characterized by altering periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses breathing slows and becomes shallow concluding apnea before respiration resumes. Kussmaul's Respirations---respirations are abnormally deep, regular and increased rate Biot's Respirations---respirations are abnormally shallow for 2 to 3 breaths followed by irregular period of apnea. Arteriosclerosis---Vessel walls lose elasticity and are replaced with fibrous tissue. Hypertension---increased blood pressure or high blood pressure above 120/80 Hypotension---decreased blood pressure or low blood pressure. if it is associated with pallor, skin mottling, clamminess, confusion, increased HR, or decreased urine output, it is life threatening and need to be reported to HCP immediately below 120/80 Kotoff---is the sound of the beats during blood pressure measurement Orthostatic Hypotension---measuring the blood pressure, sitting, lying and standing, patient could have the following blurred vision, light headedness, this can be a result of hypertensive medications. This is a risk factor for falls in older adults. Subjective Data---the way the patient perceives how they are feeling Objective Data---actual findings the nurse gathers during assessment, blood pressure, pulse, respirations, lung sounds, SpO2 Skin Turgor\-- is the measurement of the skins elasticity. Petechiae---non-blanching, pinpoint size , red or purple spots, indication of blood clotting disorders, drug reactions, or liver disease. Ventricle Gallop---occurs before S2 premature rush of blood into the ventricle creating an S3 stroke (not normal) sounds like Ken-TUCK-y Atrial Gallop---occurs before the S1 premature making an S4 stroke (not normal) sounds like TEN-nes-see Thrill---Sound like a purring cat Bruit---When the lumen of the blood vessel is narrowed it distributes the blood flow. As it passes through the narrowed section it creates a sound or turbulence causing a blowing or swishing sound. - [Delegation of vital signs] - Vital signs can only be delegated if the patient is stable. Orthostatic BP measuring, apical pulse cannot be delegated. - [What to do in case vitals are incorrect/unexpected] - ASSESS the patient, communicate error with NAP, document both findings, and check equipment for proper function. **[VITAL SIGNS]** - Vital signs serve as a baseline for future exams of your patient - Temperature - Normal range (96.8-100.4 F) - Pulse - Normal range (60-100 bpm) - Pulse Oximetry - Normal (95% O2 saturation or greater) - Respirations - Normal (12 to 20 Breaths per minute) - Blood Pressure - Normal range (120/80) - Pulse pressure - Normal (30-50 mmHg) - Pupils - Normal (3-7 mm) - Fingernails - Normal (160 degrees) - Skin - Warm, pink and dry - Body temperature is the difference between the amount of heat produced by the body processes and the amount lost to external environment. - **Calculation of body temp from Celsius to Fahrenheit** Celsius Temp X [1.8] = [+ 32 degrees] = Fahrenheit temperature - **Calculation of body temp from Fahrenheit to Celsius** Fahrenheit Temp \- [32 degrees] / [1.8] = Celsius Temperature **[PULSE SITES]** - Temporal-Over temporal bone, above and lateral to the eye - Carotid-Along the medial edge of the sternocleidomastoid muscle in neck - Apical-Fourth to fifth intercostal space at the left of the midclavicular line - Brachial-Groove between biceps and triceps at the antecubital fossa - Radial-Thumb side of wrist - Ulnar-Pinky side of wrist - Femoral-Below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine - Popliteal-Behind the knee - Posterior tibial-Inner side of ankle below the medial malleolus - Dorsalis Pedis-Top of the foot, between extension tendons of great and first toe **[PULSE STRENGTH]** - 0- ABSENT - 1-DEMINSHED - 2-EXPECTED - 3-FULL, INCREASED - 4-BOUNDING, ANEURYSMAL **[STETHOSCOPE]** - Ear pieces - Binaruls - Tubing - Bell chest piece (Low pitched sounds) - Diaphragm chest piece (High pitched sounds) **[DIFFERENT STRENGTHS OF HEARTBEAT]** - Bounding - Full or Strong - Normal and Expected - Diminished or barely palpable - Absent **[FACTORS THAT INFLUENCE RESPIRATIONS]** 1. Exercise 2. Acute pain 3. Anxiety 4. Smoking 5. Body position 6. Medications 7. Neurological injuries 8. Hemoglobin function **[CONDITIONS THAT AFFECT ARTERIAL BLOOD FLOW]** - Peripheral vascular disease - Hypothermia - Pharmacological vasoconstrictions - Hypotension - Peripheral edema **[FACTORS AFFECTING SpO2]** - Outside light sources - Carbon monoxide - Patients movement - Jaundice - Intravascular dyes - Black or brown nail polish - Dark skin pigment **[FACTORS THAT INTERFERE WITH ARTERIAL PULSATIONS]** - Peripheral vascular disease - Hypothermia - Pharmacological vasoconstrictors - Low cardiac output and hypotension - Peripheral edema - Tight probe records venues pulsations **[BLOOD PRESSURE]** - Blood moves from an area of high pressure to an area of low pressure, measured in mm of mercury (mmHg) **[FACTORS AFFECTING BLOOD PRESSURE]** - Age - Stress - Gender - Medications - Diuretics - Beta adrenergic blockers - Vasodilators - Calcium channel blockers - Angiotensin converting enzyme drugs (ACE inhibitors) - Angiotensin II receptor blockers (ARB's) - Activity - Smoking **[CATEGORIES OF BLOOD PRESSURE]** - Normal 120/80 Follow up 1 year - Elevated 120-129/80 Follow up 3-6 Mo - Hypertension Stage 1 130-139/80-89 Follow up 3-6 Mo (therapy) - Hypertension Stage 2 above 140/90 Follow up 1 Mo (therapy) - **[PURPOSE OF PHYSICAL EXAM]** - Gather baseline data - Supplement, confirm, refute subjective data - Identify and confirm nursing diagnoses - Make clinical decisions about changing health status and management - Evaluate the outcomes of care **[ASSESSMENTS USED]** - Olfaction---smell - Palpation---gently touching the patient - Percussion---tapping the skin under your own fingertips - Auscultation---listening to the body with a stethoscope **[ABUSE]** - NURSES ARE MANDATED REPORTERS **BOX 30.3** **Clinical Indicators of Abuse** +-----------------------------------+-----------------------------------+ | **Physical Findings** | **Behavioral Findings** | +===================================+===================================+ | **Child Abuse** | | +-----------------------------------+-----------------------------------+ | Vaginal or penile discharge | Problem sleeping or eating, | | | anxiety, depression | | Blood on underclothing | | | | Fear of certain people or places | | Pain, itching, or unusual odor in | | | genital area | Play activities recreate the | | | abuse situation | | Genital injuries | | | | Regressed behavior | | Difficulty sitting or walking | | | | Sexual acting out | | Pain while urinating; recurrent | | | urinary tract infections | Knowledge of explicit sexual | | | matters | | Foreign bodies in rectum, | | | urethra, or vagina | Preoccupation with others' or own | | | genitals | | Sexually transmitted infections | | | | Profound and rapid personality | | Pregnancy in young adolescent | changes | | | | | | Rapidly declining school | | | performance | | | | | | Poor relationship with peers | +-----------------------------------+-----------------------------------+ | **Intimate Partner Violence** | | +-----------------------------------+-----------------------------------+ | Injuries and trauma inconsistent | Overuse of health services | | with reported cause | | | | Thoughts of or attempted suicide | | Multiple injuries involving head, | | | face, neck, breasts, abdomen, and | Eating or sleeping disorders | | genitalia (black eyes, orbital | | | fractures, broken nose, fractured | Anxiety and panic attacks | | skull, lip lacerations, broken | | | teeth, vaginal tears) | Pattern of substance abuse | | | (follows physical abuse) | | X-ray films showing old and new | | | fractures in different stages of | Low self-esteem | | healing | | | | Depression, problems with eating | | Abrasions, lacerations, | or sleeping | | bruises/welts | | | | Sense of helplessness | | Burns from cigarettes or other | | | cause | Guilt | | | | | Human bites | Smoking | | | | | Unexplained injuries (e.g., | Stress-related complaints | | bruises, fractures, and welts) | (headache, anxiety) | | | | | Strangulation marks on neck from | Financial dependence on abuser | | rope burns or bruises; throat | | | pain, voice changes, trouble | Isolation from others | | swallowing; damage to hyoid bone | | | | Unsafe sexual behaviors | | Stress-related disorders such as | | | irritable bowel syndrome, | | | exacerbation of asthma, or | | | chronic pain | | +-----------------------------------+-----------------------------------+ | **Older-Adult Abuse** | | +-----------------------------------+-----------------------------------+ | Injuries and trauma inconsistent | Dependent on caregiver | | with reported cause (scratch, | | | bruise, or bite) | Physically and/or cognitively | | | impaired | | Hematomas, bruises at various | | | stages of resolution | Combative, verbally aggressive | | | | | Unexplained bruises or welts, | Wandering | | pattern bruises | | | | Minimal social support | | Burns | | | | Prolonged interval between injury | | Bruises, chafing, excoriation on | and medical treatment | | wrist or legs (restraints) | | | | Life circumstances do not match | | Fractures inconsistent with cause | size of patient's estate | | described | | | | Uncommunicative or isolated | | Dried blood | | | | | | Overmedication or undermedication | | | | | | Exposure to severe weather, cold | | | or hot | | | | | | Torn, bloody underwear or vaginal | | | and anal bruises | | | | | | Sunken eyes or loss of weight | | | | | | Extreme thirst | | | | | | Bed sores | | +-----------------------------------+-----------------------------------+ Edema is present when areas of the skin become swollen or edematous from a buildup of fluid in the tissues. Direct trauma and impairment of venous return are two common causes of edema. Inspect edematous areas for location, color, and shape. The formation of edema separates the surface of the skin from the pigmented and vascular layers, masking skin color. Edematous skin also appears stretched and shiny. Palpate edematous areas to determine mobility, consistency, and tenderness. When pressure from the examiner's fingers leaves an indentation in the edematous area, it is called pitting edema. To assess the degree of pitting edema, press the edematous area firmly with the thumb for several seconds and release. The depth of pitting, recorded in millimeters, determines the degree of edema (Ball et al., 2019). For example, 1+ edema equals a 2-mm depth, 2+ edema equals a 4-mm depth, 3+ equals 6 mm, and 4+ equals 8 mm (Fig. 30.6).  Illustration of index finger applying pressure on skin shows four ranges as: +1, 2 millimeters deep; +2, 4 millimeters deep; +3, 6 millimeters deep; and +4, 8 millimeters deep; **[NAILS]** A diagram of a nail Description automatically generated Normal nail bed range---160 Clubbing---180 or more Clubbing is caused by chronic lack of oxygen or heart, pulmonary disease. **[PUPILS]** Pupils and irises. Observe the pupils for size, shape, equality, accommodation, and reaction to light. They are normally black, round, regular, and equal in size (3--7 mm in diameter) (Fig. 30.13). The iris should be clearly visible.  Chart shows size of black filled spheres increasing from 2 to 9 while moving from left to right. PERRLA Pupils equal, round, reactive to light, and accommodations Testing for accommodations---ask pt to gaze at a distant object on the wall, then at the a testing object ( 4 inches from the bridge of the nose) patient should have equal pupillary response. **[LIPS]** - Inspect for color, texture, hydration, contour, and lesions. Lips should be pink, if blue means cyanosis, or lack of oxygen Lips should be symmetrical, if one side is drooping it could mean stroke or neurological deficits. Bright pink lips could mean carbon monoxide poisioning **[SKIN COLOR]** - Bluish---cyanosis deoxygenated hemoglobin - Pallor---decrease in color---decrease blood flow - Loss of pigmentation---vitiligo---congenital - Yellow-Orange---jaundice---increased bilirubin - Red---Erythema---increased blood flow - Tan Brown---increased melanin **[TRACHEA/THYROID GLAND]** A diagram of the human body Description automatically generated Thyroid gland. The thyroid gland lies in the anterior lower neck, in front of and to both sides of the trachea. The gland is fixed to the trachea, with the isthmus overlying the trachea and connecting the two irregular, cone-shaped lobes (Fig. 30.30). Inspect the lower neck overlying the thyroid gland for obvious masses, symmetry, and any subtle fullness at the base of the neck. Ask the patient to hyperextend the neck, which helps tighten the skin for better visualization. Offer the patient a glass of water and, while observing the neck, have the patient swallow. This maneuver helps to visualize an abnormally enlarged thyroid. Normally the thyroid cannot be visualized. Advanced practice nurses examine the thyroid by palpating for more subtle masses. Carotid artery and jugular vein. This part of the examination is described under examination of the vascular system (see later section). Trachea. The trachea is a part of the upper respiratory system that you directly palpate. It is normally located in the midline above the suprasternal notch. Masses in the neck or mediastinum and pulmonary abnormalities cause displacement laterally. Have the patient sit or lie down during palpation. Determine the position of the trachea by palpating at the suprasternal notch, slipping the thumb and index fingers to each side. Note if the finger and thumb shift laterally. Do not apply forceful pressure because this elicits coughing. **[THORAX AND LUNGS]** Right side---3 lobes Left side---2 lobes  **[SIX LANDMARKS OF THE HEART]** PNUEMONIC: Pitcher: Aortic 1^st^ base---pulmonic 2^nd^ base---second pulmonic area 3^rd^ base---tricuspid Home base---mitral Duggout---Epigastric A diagram of a person\'s chest Description automatically generated Assess the cardiac system through the anterior thorax. Form a mental image of the exact location of the heart (Fig. 30.37). In the adult it is in the center of the chest (precordium), behind and to the left of the sternum, with a small section of the right atrium extending to the right of the sternum. The base of the heart is the upper part, and the apex is the bottom tip. The surface of the right ventricle composes most of the anterior surface of the heart. A section of the left ventricle shapes the left anterior side of the apex. The apex touches the anterior chest wall at approximately the fourth to fifth intercostal space just medial to the left midclavicular line. This is the apical impulse or point of maximal impulse (PMI). **[CARDIOVASCULAR ASSESSMENT]** **ASSESSMENT** **RATIONAL** ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Determine whether patient experiences leg cramps; numbness or tingling in extremities; sensation of cold hands or feet; pain in legs; or swelling or cyanosis of feet, ankles, or hand. These signs and symptoms indicate vascular disease. If patient experiences leg pain or cramping in lower extremities, ask whether walking or standing for long periods or sleeping aggravates or relieves it. Relationship of symptoms to exercise clarifies whether problem is vascular or musculoskeletal. Pain caused by vascular condition tends to increase with activity. Musculoskeletal pain usually is not relieved when exercise ends. Ask patients whether they wear tight-fitting garters, socks, or hosiery and sit or lie in bed with legs crossed. Tight hosiery around lower extremities and crossing legs can impair venous return. Reconsider previous heart risk factors (e.g., smoking, exercise, nutritional problems). These predispose patient to vascular disease. Assess medical history for heart disease, hypertension, phlebitis, diabetes mellitus, or varicose veins. Circulatory and vascular disorders influence findings gathered during examination. **[VENOUS & ARTERIAL INSUFFICENCY]** TABLE 30.25 Assessment Criterion. Venous Arterial Color Normal or cyanotic Pale; worsened by elevation of extremity; dusky red extremity is lowered ------------- -------------------- -------------------------------------------------------------------------- Temperature Normal Cool (blood flow blocked to extremity) Pulse Normal Decreased or absent Edema Often marked Absent or mild **[ABDONMINAL ASSESSMENT]** ---------------------- ASSESSMENT RATIONALE ---------------------- If patient has abdominal or low back pain, assess character of pain in detail (location, onset, frequency, precipitating factors, aggravating factors, type of pain, severity, course). Pattern of characteristics of pain helps determine its source. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Carefully observe patient's movement and position, including lying still with knees drawn up, moving restlessly to find comfortable position, and lying on one side or sitting with knees drawn to chest. Positions assumed by patient reveal nature and source of pain, including peritonitis, renal stone, and pancreatitis. Assess normal bowel habits and stool character; ask whether patient uses laxatives. Data compared with physical findings help identify cause and nature of elimination problems. Determine whether patient has had abdominal surgery, trauma, or diagnostic tests of gastrointestinal (GI) tract. Surgical or traumatic alterations of abdominal organs cause changes in expected findings (e.g., position of underlying organs). Diagnostic tests change character of stool. Assess whether patient has had recent weight changes or intolerance to diet (e.g., nausea, vomiting, cramping, especially in last 24 hours). Data can indicate alterations in upper GI tract (stomach or gallbladder) or lower colon. Assess for difficulty in swallowing, belching, flatulence (gas), bloody emesis (hematemesis), black or tarry stools (melena), heartburn, diarrhea, or constipation. These characteristic signs and symptoms indicate GI alterations. Ask whether patient takes antiinflammatory medication (e.g., aspirin, ibuprofen, steroids) or antibiotics. Pharmacological agents cause GI upset or bleeding. Ask patient to locate tender areas before examination begins. Assess painful areas last to minimize discomfort and anxiety. Inquire about family history of cancer, kidney disease, alcoholism, hypertension, or heart disease. Data can reveal risk for alterations identifiable during examination. Determine whether female patient is pregnant; note last menstrual period. Pregnancy causes changes in abdominal shape and contour. Assess patient's usual intake of alcohol. Chronic alcohol ingestion causes GI and liver problems, including liver, colon, and pancreatic cancer (ACS, 2020a). Review patient's history for the following: health care occupation, hemodialysis, intravenous drug user, household or sexual contact with hepatitis B virus (HBV) carrier, heterosexual person with more than one sex partner in previous 6 months, sexually active homosexual or bisexual male, international traveler in area of high HBV infection rate. Risk factors for HBV exposure. **FIG. 30.64** **Range of motion of hand and wrist.** **(A) Metacarpophalangeal flexion and hyperextension. (B) Finger flexion: thumb to each fingertip and to base of little finger. (C) Finger flexion, fist formation. (D) Finger abduction. (E) Wrist flexion and hyperextension. (F) Wrist radial and ulnar movement.** **Set of six illustrations depict range of motion of hand and wrist.** **A. Movement of fingers 30 degrees up from horizontal plane is hyperextension and 90 degrees down is flexion.** **B. Thumb touches bas of little finger.** **C. Fist.** **D. Spreading fingers wide apart.** **E. Movement of fingers 70 degrees up from horizontal plane is hyperextension and 90 degrees down is flexion.** **F. Movement of hand 20 degrees to the left is hyperextension radial and 55 degrees to the right is ulnar.**  **TABLE 30.32** **Terminology for Normal Range-of-Motion Positions** **Term Range of Motion Examples of Joints** **Flexion** **Movement decreasing angle between two adjoining bones; bending of limb** **Elbow, fingers, knee** ----------------------- ---------------------------------------------------------------------------- -------------------------- **Extension** **Movement increasing angle between two adjoining bones** **Elbow, knee, fingers** **Hyperextension** **Movement of body part beyond its normal resting extended position** **Head** **Pronation** **Movement of body part so that front or ventral surface faces downward** **Hand, forearm** **Supination** **Movement of body part so that front or ventral surface faces upward** **Hand, forearm** **Abduction** **Movement of extremity away from midline of body** **Leg, arm, fingers** **Adduction** **Movement of extremity toward midline of body** **Leg, arm, fingers** **Internal rotation** **Rotation of joint inward** **Knee, hip** **External rotation** **Rotation of joint outward** **Knee, hip** **Eversion** **Turning of body part away from midline** **Foot** **Inversion** **Turning of body part toward midline** **Foot** **Dorsiflexion** **Flexion of toes and foot upward** **Foot** **Plantar flexion** **Bending of toes and foot downward** **Foot** **Joints are typically free from stiffness, instability, swelling, or inflammation. There should be no discomfort when applying pressure to bones and joints. In older adults, joints often become swollen and stiff, with reduced ROM resulting from cartilage erosion and fibrosis of synovial membranes (see Chapter 38). If a joint appears swollen and inflamed, palpate it for warmth. A goniometer is an instrument with two flexible arms and a 180-degree protractor in the center. It is frequently used by physical and occupational therapists to measure the precise degree of motion in a joint and is mainly for patients who have a suspected reduction in joint movement.** **GLASGOW COMA SCALE** +-----------------------+-----------------------+-----------------------+ | **ACTION** | **RESPONSE** | **SCORE** | +=======================+=======================+=======================+ | **Eyes open** | **Spontaneously** | **4** | | | | | | | **To speech** | **3** | | | | | | | **To pain** | **2** | | | | | | | **None** | **1** | +-----------------------+-----------------------+-----------------------+ | **Best verbal | **Oriented** | **5** | | response** | | | | | **Confused** | **4** | | | | | | | **Inappropriate | **3** | | | words** | | | | | **2** | | | **Incomprehensible | | | | sounds** | **1** | | | | | | | **None** | | +-----------------------+-----------------------+-----------------------+ | **Best motor | **Obeys commands** | **6** | | response** | | | | | **Localized pain** | **5** | | | | | | | **Flexion | **4** | | | withdrawal** | | | | | **3** | | | **Abnormal flexion** | | | | | **2** | | | **Abnormal | | | | extension** | **1** | | | | | | | **Flaccid** | | +-----------------------+-----------------------+-----------------------+ | | **TOTAL SCORE** | **3 to 15** | +-----------------------+-----------------------+-----------------------+ **If the patient is not conscious enough to follow commands, try to elicit the pain response. Apply firm pressure with the thumb over the root of the patient's fingernail. The normal response to the painful stimuli is withdrawal of the body part from the stimulus. A patient with serious neurological impairment exhibits abnormal posturing in response to pain. A flaccid response indicates the absence of muscle tone in the extremities and severe injury to brain tissue.** **CRANIAL NERVES** **NUMBER. NAME TYPE FUNCTION METHOD** +-------------+-------------+-------------+-------------+-------------+ | **I** | **Olfactory | **Sensory** | **Sense of | **Ask | | | ** | | smell** | patient to | | | | | | identify | | | | | | different | | | | | | nonirritati | | | | | | ng | | | | | | aromas such | | | | | | as coffee | | | | | | and | | | | | | vanilla.** | +=============+=============+=============+=============+=============+ | **II** | **Optic | **Sensory** | **Visual | **Use | | | Sensory** | | acuity** | Snellen | | | | | | chart or | | | | | | ask patient | | | | | | to read | | | | | | printed | | | | | | material | | | | | | while | | | | | | wearing | | | | | | glasses.** | +-------------+-------------+-------------+-------------+-------------+ | **III** | **Oculomoto | **Motor** | **Extraocul | **Assess | | | r** | | ar | six | | | | | eye | directions | | | | | movements: | of gaze.** | | | | | inward, up | | | | | | and inward, | **Measure | | | | | up and | pupillary | | | | | outward, | reaction to | | | | | down and | light | | | | | outward** | reflex and | | | | | | accommodati | | | | | **Pupil | on** | | | | | constrictio | | | | | | n | | | | | | and | | | | | | dilation** | | | | | | | | | | | | **Opening | | | | | | the eye** | | +-------------+-------------+-------------+-------------+-------------+ | **IV** | **Trochlear | **Motor** | **Downward, | **Assess | | | ** | | inward eye | six | | | | | movements** | directions | | | | | | of gaze.** | +-------------+-------------+-------------+-------------+-------------+ | **V** | **Trigemina | **Sensory | **Sensory | **Lightly | | | l** | and motor** | nerve to | touch | | | | | skin of | cornea with | | | **Motor | | face** | wisp of | | | nerve to | | | cotton. | | | muscles of | | **Motor | Assess | | | jaw** | | nerve to | corneal | | | | | muscles of | reflex. | | | | | jaw** | Measure | | | | | | sensation | | | | | | of light | | | | | | pain and | | | | | | touch | | | | | | across skin | | | | | | of face.** | | | | | | | | | | | | **Palpate | | | | | | temples as | | | | | | patient | | | | | | clenches | | | | | | teeth.** | +-------------+-------------+-------------+-------------+-------------+ | **VI** | **Abducens* | **Motor** | **Lateral | **Assess | | | * | | movement of | six | | | | | eyeballs** | directions | | | | | | of gaze.** | +-------------+-------------+-------------+-------------+-------------+ | **VII** | **Facial | **Sensory | **Facial | **As | | | Taste Have | and motor** | expression* | patient | | | patient | | * | smiles, | | | identify | **Taste** | | frowns, | | | salty or | | | puffs out | | | sweet taste | | | cheeks, and | | | on front of | | | raises and | | | tongue.** | | | lowers | | | | | | eyebrows, | | | | | | look for | | | | | | asymmetry.* | | | | | | * | | | | | | | | | | | | **Have | | | | | | patient | | | | | | identify | | | | | | salty or | | | | | | sweet taste | | | | | | on front of | | | | | | tongue.** | +-------------+-------------+-------------+-------------+-------------+ | **VII** | **Auditory* | **Sensory** | **Hearing** | **Assess | | | * | | | ability to | | | | | | hear spoken | | | | | | word.** | +-------------+-------------+-------------+-------------+-------------+ | **IX** | **Glossopha | **Sensory | **Taste** | **Ask | | | ryngeal** | and motor** | | patient to | | | | | **Ability | identify | | | | | to | sour or | | | | | swallow** | sweet taste | | | | | | on back of | | | | | | tongue.** | | | | | | | | | | | | **Use | | | | | | tongue | | | | | | blade to | | | | | | elicit gag | | | | | | reflex.** | +-------------+-------------+-------------+-------------+-------------+ | **X** | **Vagus** | **Sensory | **Sensation | **Ask | | | | and motor** | of | patient to | | | | | pharynx** | say "ah." | | | | | | Observe | | | | | **Movement | movement of | | | | | of vocal | palate and | | | | | cords** | pharynx.** | | | | | | | | | | | **Parasympa | **Assess | | | | | thetic | speech for | | | | | innervation | hoarseness. | | | | | to glands | ** | | | | | of mucous | | | | | | membranes | **Assess | | | | | of the | heart rate, | | | | | pharynx, | presence of | | | | | larynx, | peristalsis | | | | | organs in |.** | | | | | the neck, | | | | | | thorax | | | | | | (heart and | | | | | | lungs), and | | | | | | abdomen** | | +-------------+-------------+-------------+-------------+-------------+ | **XI** | **Spinal | **Motor** | **Movement | **Ask | | | accessory** | | of head and | patient to | | | | | shoulders** | shrug | | | | | | shoulders | | | | | | and turn | | | | | | head | | | | | | against | | | | | | passive | | | | | | resistance. | | | | | | ** | +-------------+-------------+-------------+-------------+-------------+ | **XII** | **Hypogloss | **Motor** | **Position | **Ask | | | al** | | of tongue** | patient to | | | | | | stick out | | | | | | tongue to | | | | | | midline and | | | | | | move it | | | | | | from side | | | | | | to side.** | +-------------+-------------+-------------+-------------+-------------+