316RLE

• Orientation

  Person, Place, Time
• Categories of Consciousness

  • Full consciousness
  • Lethargy
  • Obtundation
  • Stupor
  • Coma

  
• Glasgow Coma Scale

  • Highest or best possible score 15
  • A score of < 8 indicates coma
  • Lowest or worst possible score 3

  
• Glasgow Coma Scale Scores and Corresponding Injury Severity

  • GCS Score of 3 to 8: Severe
  • GCS Score of 9 to 12: Moderate
  • GCS Score of 13 to 15: Mild

  
• Cranial Nerves

  • Olfactory (I)
  • Optic (II)
  • Oculomotor (III)
  • Trochlear (IV)
  • Trigeminal (V)
  • Abducens (VI)
  • Facial (VII)
  • Vestibulo-Cochlear (VIII)
  • Glossopharyngeal (IX)
  • Vagus (X)
  • Spinal Accessory (XI)
  • Hypoglossal (XII)
• Pure Sensory Cranial Nerves

  • Olfactory (I) - smell
  • Optic (II) - vision
  • Auditory (VIII) - hearing
• Pure Motor Cranial Nerves

  • Oculomotor (III) - eyeball & eyelid movt, pupil constriction
  • Trochlear (IV) - move eyes to side & down
  • Abducens (VI) - move eyes to side
  • Spinal accessory (XI) - controls trapezius & sternocleidomastoid muscles
  • Hypoglossal (XII) - controls tongue movements
• Mixed Function Cranial Nerves

  • Trigeminal (V) - chewing; face & mouth, touch & pain; corneal reflex
  • Facial (VII) - facial expression; tears & saliva, taste
  • Glossopharyngeal (IX) (gag reflex); taste; carotid BP
  • Vagus (X) – impulses for sensation to lower pharynx & larynx; taste muscles for movement of soft palate, pharynx & larynx (gag reflex); swallowing, motor & sensory functions of visceral organs (glands, digestive sys); aortic BP
• Olfactory Nerve Assessment


  1. Present various odors occluding one nostril at a time

  2. Note the client's ability to identify the odor
• Optic Nerve Assessment


  1. Test visual acuity

  2. Test visual fields (peripheral vision)

  3. Examine optic disc with an ophthalmoscope

  
• Oculomotor Nerve Assessment


  Check size and shape of pupils and pupillary reactions to light and accommodation

  
• Oculomotor, Trochlear, Abducens Nerves Assessment

  1. Evaluate 6 cardinal positions of gaze; note for nystagmus

  2. Perform cover/ uncover test
• Trigeminal Nerve Assessment


  1. Assess the client's ability to chew and strength to bite

  2. Assess the client's ability to distinguish light touch and pain
• Facial Nerve Assessment


  1. Assess symmetry of facial movements

  2. Ask the client to identify various distinct flavors placed on the anterior 2/3 of the tongue
• Acoustic Nerve Assessment


  Assess client's ability to hear spoken words and vibration of tuning fork
• Glossopharyngeal Nerve Assessment


  1. Ask client to move tongue from side to side, up and down

  2. Test for the gag reflex

  3. Apply tastes on posterior tongue for identification
• Vagus Nerve Assessment


  1. Ask client to swallow and note swallowing and vocal cord movement

  2. Assess client's speech for hoarseness
• Spinal Accessory Nerve Assessment

  Assess strength of the sternocleidomastoid and upper trapezius muscles
• Hypoglossal Nerve Assessment


  1. Test strength and articulation of the tongue

  2. Ask the client to stick out the tongue and then returns it to the mouth
• Finger to Nose Test


  • Patient should be able to do this at a reasonable rate of speed, trace a straight path, and hit the end points accurately
• Rapid Alternating Hand Movements


  • The movement should be performed with speed and accuracy
• Heel to Shin Test

  • The movement should trace a straight line along the top of the shin and be done with reasonable speed
• Romberg Test


  • Positive = swaying away or loss of balance = Sensory ataxia
• Tandem Gait


  • Observed for inequality of steps and difficulty maneuvering; Good test for alcohol abuser = Truncal ataxia
• Reflex

  An involuntary and nearly instantaneous movement in response to a stimulus
• Biceps Reflex


  The nurse places the thumb firmly over the biceps tendon of the patient, with the nurse's fingers curling around the elbow, tap briskly. The forearm will flex at the elbow.
• Triceps Reflex


  Identified the triceps tendon and tapped just above the insertion. There is extension of the forearm
• Brachioradialis Reflex


  Placed the thumb of the hand supporting the patient's elbow on the biceps tendon while tapping the brachioradialis tendon with the other hand. Observe three potential reflexes as you tap.
• Knee Jerk / Patellar Reflex

  Let the knees swing free by the side of the bed. Placed one hand on the quadriceps and feel its contraction. Extension of the leg.
• Ankle Jerk


  With the patient seated, placed one hand underneath the sole and dorsiflexed the foot slightly and tapped on the Achilles tendon. Dorsiflexion of the foot.
• Reflex Rating Scale


  • 5+ Sustained clonus
  • 4+ Very brisk, hyper reflexive, with clonus
  • 3+ Brisker or more reflexive than normal
  • 2+ Normal
  • 1+ Low normal, diminished
  • 0.5+ A reflex that is only elicited with reinforcement
  • 0 No response
• Clonus Test


  1. Hold the relaxed lower leg in your hand

  2. Sharply dorsiflex the foot and hold it dorsiflexed

  3. Feel for oscillations between flexion and extension of the foot indicating clonus
• Reinforcement Techniques


  1. Ask the patient to clench their teeth

  2. If testing lower extremity reflexes: have the patient hook together their flexed fingers and pull apart = Jendrassik maneuver
• Terms to Remember


  • Defecation
  • Constipation
  • Obstipation
  • Diarrhea
  • Flatulence
  • Fecal impaction
  • Pyrosis
  • Fecal incontinence
  • Feces
  • Stool
  • Acholic stool
  • Melena
  • Hematochezia
  • Steatorrhea
• Focused Abdominal Assessment


  1. Inquire about a history of abdominal disease

  2. Ask the client to describe the usual bowel pattern and characteristics

  3. Ask about problems with weight loss or gain, a change in appetite or taste, food intolerance, belching, nausea or vomiting, pain or indigestion with eating, difficulty swallowing, diarrhea or constipation, bowel incontinence, flatulence, changes in bowel habits or stool characteristics, hemorrhoids, rectal pain or itching, pain in the abdomen, ascites or jaundice
• Terms to remember


  • Defecation – bowel movements (BM)
  • Constipation – passage of hard stool, no passage of stool for a period of time
  • Obstipation- collection of hardened feces in the colon
  • Diarrhea- frequent passage of watery stools
  • Flatulence- presence of excess gas (tympanites)
  • Fecal impaction – collection of hardened feces in the folds of the rectum
  • Pyrosis – heart burn
  • Fecal incontinence – involuntary elimination of bowel movements (Encopresis)
  • Feces – waste products of digestion in the colon
  • Stool – waste products of digestion expelled into the external environment
  • Acholic stool (clay-colored stool) – absence of bile pigment stercobilin in biliary obstruction
  • Melena - black, tarry stool due to Upper GI bleeding
  • Hematochezia – passage of stool with bright red blood due to lower GI bleeding
  • Steatorrhea – greasy, fatty foul-smelling stool due to presence of undigested fats
  • Emesis – vomiting
  • Hematemesis – vomiting of blood
  • Dysphagia – difficulty swallowing
  • Odynophagia – painful swallowing
  • Satiety – feeling of having had eaten enough
  • Enema – administration of fluid or medication into the colon through a rectal tube
  • Ageusia – absence of sense of taste
  • Cachexia – severe weight loss and severe wasting
  • Gastric gavage – feeding through NGT
  • Gastric lavage – irrigation of the stomach through NGT
  • Gastrostomy feeding – gastrostomy tube
  • Jejunostomy feeding – jejunostomy tube
• Subdivision of abdomen


  • Four Quadrants
  • Nine Regions
• Abdominal Quadrants


  • Right Upper Quadrant
  • Left Upper Quadrant
  • Right Lower Quadrant
  • Left Lower Quadrant

  
• Abdominal Regions


  • Right Hypochondriac
  • Epigastric
  • Left Hypochondriac
  • Ascending Colon
  • Transverse Colon
  • Descending Colon
  • Right Lumbar
  • Umbilical
  • Left Lumbar
  • Right Iliac
  • Hypogastric
  • Left Iliac

  
• Equipment - stethoscope, marking pen, ruler