Cranial Nerves
Cranial nerve that is tested by using a tongue blade to touch the palate and have the patient say "ah." Also known as the gag reflex
Glossopharyngeal (IX)
First step when assessing a patient.
Inspection
What does PERRLA stand for?
Pupils, Equal, Round, Reactive to, Light and, Accomodation
The patient is at risk for developing a pressure injury.
When is blood glucose sampling obtained on a patient?
30 minutes prior to eating.
Physical assessment for oxygenation.
Monitoring RR
Observing breathing pattern
Checking for symmetry
Auscultating lung sounds anterior and posterior
Cranial nerve that the PN assesses by observing for jaw symmetry when patient opens mouth and touching the patient's eye with a wisp of cotton.
Trigeminal (V)
Assessment of a patient with an irregular radial rate, rhythm or force.
Take the apical pulse for 1 minute.
What is the neuro status of a patient with a Glascow Coma Scale (GCS) of 15?
Patient is responsive and responsive to stimuli.
What is a stage IV pressure injury?
A pressure injury involving the epidermis, dermis, subcutaneous tissue and muscle.
A radiologic study includes the following questions prior to the study
possibility of pregnancy, asthma, allergies to contrast media (iodine) and other food and drugs.
Methods to mobilize secretions. (6)
1. Adequate hydration
2. inhalation therapy
3. postural drainage
4. Percussion
5. Vibration
6. Suction
Cranial nerve that is tested by having the patient stick their tongue out while the PN observes for any lateral deviations.
Hypoglossal (XII)
Positions in order for auscultating heart sounds.
Aortic, pulmonic, Erb's, Tricuspid, Mitral
A neurological test of balance.
Romberg test
Wound depth, length, width and undermining.
Prior to sending down a lab specimen the PN must do the following.
Check patient label to patient arm band
Check order to patient label
Least invasive tool for monitoring oxygenation.
Pulse oximeter
Normal findings of this cranial nerve are indicated by equal, brisk pupil constriction to light and dilation when looking at a far object.
Oculomotor (III)
Acronym for pain assessment.
COLDSPA
How does the PN test for pupillary accommodation?
Moves focus of vision from a distant point to a near object and a near object to a distant point while observing the pupillary response.
A pressure injury that exposes the epidermis and dermis.
Stage 2
A PN can obtain consent prior to a procedure. True or False.
FALSE. Only a doctor can obtain consent.
Class of respiratory medications that increases HR, can cause tremors and palpitations.
Bronchodilators
Cranial nerves that are working to test vision fields.
Oculomotor (III), Trochlear (IV), Abducens (VI)
Assessment for Jugular Vein Distention.
Lay patient flat (supine) and observe the neck for bugling veins. Raise head of bed to 45 degrees (semi fowlers) and observe for any vein distention in the neck. Vein distention at 45 degrees indicates JVD which is a sign of heart failure.
Obtunded versus stuporous.
Obtunded-opens eyes to loud voice, responds slow w/ confusion, unaware of enviroment
Stupor- awakens to vigorous shaking or painful stimuli, returns to unresponsive sleep
A wound that is open with organs coming out.
Evisceration
Blood test that includes blood glucose, serum electrolytes, blood enzymes and blood lipids.
Chemistry Panel
Class of respiratory medications that can cause hypotension, dry mouth and urinary retention.
Antihistamines