Critical Elements/Ouch!
Three things to verify on client wristband.
What are the client's name, date of birth, and MRN?
The functions of the four lobes of the brain.
Assessing the olfactory nerve (I).
The three layers of the skin.
What are the epidermis, the dermis, and the subcutaneous layers?
Qualifiers related to client allergies.
What are allergies to food, medicine, and/or the environment?
Things to look for in the external auditory canal.
What are inflammation, cerumen, discharge, foreign bodies, or hearing devices?
Assessing the three parts of the trigeminal nerve (V).
What are using a cotton ball on the chin, cheek, and forehead, pressing down on client's chin opposed by clenched jaw, and the corneal reflex?
Assessing the optic nerve (II).
What are using the Confrontation test to assess peripheral vision and the Snellen chart to assess visual acuity?
Abnormal characteristics of skin lesions represented by ABCDEF.
What are asymmetry, border, color, diameter, evolution, and funny looking?
Questions assessing the client's level of consciousness (A&O x 4).
What are oriented to person, place, time, and situation?
What is pulling the pinna up and back for adults and down for children under 3 yo?
Assessing the glossopharyngeal and vagus nerves (IX and X).
What are observing the rise of the soft palate (pharyngeal movement) when the client says "ahh" and testing the gag reflex with a tongue blade?
Assessing the vestibulocochlear nerve (VIII) - (AKA acoustic or auditory nerve).
What is using the whispered voice test in each ear? Whisper the 3 item sequence up to two times in the same ear; use a different 3 item sequence in the second ear up to two times - client must score 3 out of 6 items to pass?
Nail disorder associated with chronic obstructive pulmonary disease (COPD).
What is clubbing
The things you are looking for in the client's chart before entering the room.
What are the provider orders, as well as any lab/diagnostic results, vital signs, MAR, and nurses' notes?
Pupil assessment represented by the acronym PERRLA.
What is the Pupils are Equal, Round, Reactive to Light, and Accommodation? Also assess size of pupil.
Assessing the spinal accessory nerve (XI).
What are pushing against a client's shoulder shrug and against the head moving side-to-side (resistance)?
Assessing the facial nerve (VII).
What is looking for asymmetry or involuntary movements of the face during a client's smile, frown, eyebrow lift, showing teeth, and puffing cheeks?
Six bony prominence locations prone to skin breakdown.
What are the heels, sacrum, elbows, scapula, back of the head, greater trochanter, ears, etc.
Represented by the acronym SOCRATES.
In relation to pain, what are site, onset, character, radiation, associated symptoms, time/duration, exacerbates/ameliorates (makes worse or better), and severity (0-10)?
The seven lymph nodes that you will assess.
What are the preauricular, posterior auricular, occipital, posterior cervical, submental, submandibular, and supraclavicular lymph nodes?
Assessing the oculomotor, trochlear, and abducens nerves (III, IV, and VI).
Assessing the hypoglossal nerve (XII).
What is looking for symmetry when having the client stick out their tongue and moving it side to side?
The parts of skin palpation.
What are skin turgor and the extremities (warmth, tenderness, edema [pitting 0-4+])?