NR-509-Immersion-Physical-Assessment-Study-guide-1.docx - NR 509 Immersion \u2013 Physical Assessment Steps 1 Greet patient 2 Inspect face \u2013 no

NR-509-Immersion-Physical-Assessment-Study-guide-1.docx -...

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NR 509 Immersion – Physical Assessment Steps1) Greet patient2) Inspect face no discoloration or lesions present3) Inspect head – midline, symmetrical4) Palpate lymph nodes:PreauricularPostauricularOccipitalTonsillarSubmandibularSubmentalAnterior cervicalPosterior cervical Supraclavicular*No enlargement, equal bilaterally.5) Cranial nerve #5 (TRIGEMINAL)Motor: palpate masseter muscle and have patient clench teeth-no distortions, great strengthSensory: have patient close eyes and touch face with q-tip, have them verbalize where on face you are touching- Pt. verbalized appropriate areas that were touched. Cranial nerve # 5 is intact.6) Cranial nerve # 7 (FACIAL)Facial expressions: smile, frown, puff cheeks—symmetric and equal bilaterally, pucker lips—tight7) Inspect ears—no nodules or skin lesions present, symmetricalUse otoscope to inspect external auditory canal. Pull ear up and back.- No swelling, redness, drainage or cerumen.-Tympanic membrane is pearly gray, no effusion present in middle ear.*Repeat on other side.Palpate pinnae & tragus - no nodules or tenderness
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8) Cranial nerve # 8 (ACOUSTIC)Whisper test- Have patient cover one ear- Whisper 3 words- Repeat on other side*Hearing intact bilaterally.9) Inspect eyes—conjunctiva clear and pink, no drainage or lesions present; sclera white and clear.10) Cranial nerve #2 (OPTIC)Snellen eye chart—tests central vision-Stand 6 feet away from patient.-Have patient cover 1 eye and read smallest line.-Repeat with other eye.-Repeat with both eyes.*Report as 20/20 vision in R eye, L eye, and both eyes.Continuing assessment of cranial nerve # 2—test peripheral vision.- Stand at eye level with patient and have patient look straight ahead.- Test peripheral vision from behind shoulders, above head, and from below at waist.Continuing assessment of cranial nerve # 2—test pupillary response.- Use light on ophthalmoscope and ask patient to stare at your nose.- Come from side of eye to front. Both pupils constrict, 2 to 3 cm in diameter, respond to light.11) Cranial nerves #3 (OCULOMOTOR), #4 (TROCHLEAR), & #6 (ABDUCENS)Star or “H” pattern—checking extraocular muscles of the eyeAll extraocular movements are intact equally.
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  • Fall '15
  •  Motor,  Palpate pinnae

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