advanced adult care nursing manual

Kingdom of Saudi Arabia

Ministry of Higher Education

University of Hail

College of Nursing

ADVANCED ADULT CARE NURSING PRACTICE (NURS 314)

MEDICAL-SURGICAL DEPARTMENT

KINGDOM OF SAUDI ARABIA


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TOPIC OUTLINE

Advanced Cardiac System Care

Applying a Cardiac Monitor

Administering a Blood Transfusion

Advanced Respiratory System Care

Measuring Arterial Oxygen Saturation

Care of a Patient with a Chest Drainage System

Measuring Output from a Chest Drainage System

Care of Patient With Sensorineural Disorders

Administering an Eye Irrigation

Administering an Ear Irrigation

Care of a Client With Hearing Aid

Care of a Client With Eye Prosthesis

Care of Patient With Neurological System Disorders

Assessing the Neurological System

Assessing Level of Consciousness Using the Glasgow Coma Scale

Assessing the Patients Mental Status

Assessing Cranial Nerves

Assessing Deep Tendon Reflexes

Care of Patient With Integumentary System Disorders

Assisting with Hydrotherapy for Burn Injury

Care of Patient with Burn Injury (Closed Method)

Care of Patient with Burn Injury (Open Method)

Care of Patient With Renal System Disorders

Administering a Continuous Closed Bladder Irrigation

Caring for a Patients Vascular Access on Hemodialysis

Caring for a Patients Peritoneal Dialysis Catheter

Care of Patient With Musculoskeletal System Disorders

Assessing the Musculoskeletal System

Caring for a Patient in Skin Traction

Caring for a Patient in Skeletal Traction

Care of Patient With Immobilization Device (Cast, Splint, or Collar Brace)

Applying a Sling

Assisting With Cast Application

Caring for a Cast

Care of a Patient During Cast Removal



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ADVANCED CARDIAC

SYSTEM CARE



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Applying a Cardiac Monitor Purpose(s):

a. To diagnose/monitor cardiac arrhythmias in all patients at significant risk of an immediate, life-threatening arrhythmia, specifically in:

Patients who have been resuscitated from cardiac arrest.

Patients in the early phase of acute coronary syndromes (ST-elevation or NonST-elevation MI, unstable angina/rule-out MI).

Patients with unstable coronary syndromes and newly diagnosed high-risk coronary lesions.

Patients who have undergone cardiac surgery.

Patients who have undergone nonurgent percutaneous coronary intervention (PCI) with complications;

Patients who have undergone implantation of an automatic defibrillator lead or a pacemaker lead and are considered pacemaker dependent.

Patients with a temporary pacemaker or transcutaneous pacing pads;

Patients with AV block;

Patients with arrhythmias complicating Wolff-Parkinson-White syndrome with rapid anterograde conduction over an accessory pathway.

Patients with long-QT syndrome and associated ventricular arrhythmias;

Patients receiving intraaortic balloon counterpulsation.

Patients with acute heart failure/pulmonary edema.

Patients with indications for intensive care.

Patients undergoing diagnostic/therapeutic procedures requiring conscious sedation or anesthesia; and Patients with any other hemodynamically unstable arrhythmia.

Equipment:

Cardiac monitor

Lead wires

Pregelled (gel foam) electrodes (number varies from 3 to 5)

Soap and water if necessary

Gauze pads

PPE, as indicated



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Assessment:

1. Review the patients medical record and plan of care for information about the patients need for cardiac monitoring.

2. Assess the patients cardiac status, including heart rate, blood pressure, and auscultation of heart sounds. 3. Inspect the patients chest for areas of irritation, breakdown, or excessive hair that might interfere with

electrode placement.

4. Electrode sites must be dry, with minimal hair. 5. The patient may be sitting or supine, in a bed or chair.

Nursing Diagnosis:

1. Decreased Cardiac Output 2. Impaired Gas Exchange 3. Acute Pain 4. Anxiety 5. Excess Fluid Volume 6. Deficient Knowledge 7. Activity Intolerance

IMPLEMENTATION

Steps: Rationale

3 Follow Standard Protocol. a. Verify or Check Doctors Order.

b. Identify the patient. c. Introduce yourself and explain the procedure. d. Provide privacy and position comfortably. e. Perform hand hygiene and wear PPE as

indicated.

This ensures that the correct intervention is

performed on the correct patient.

Identifying the patient ensures the right patient

receives the intervention and helps relive anxiety.

This ensures the patients privacy.

This prevents the spread of microorganisms.

4 Connect the correlated sensors to the sockets of the machine according to the parameters needed.

Proper connection ensures proper functioning.



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Parameters / Channels for data display:

a. Electrocardiogram (ECG) b. Respirations/impedance pneumography via the ECG leads c. Intermittent noninvasive blood pressure (NIBP) d. Oxyhemoglobin saturation (SpO2) e. pEtCO2 (partial pressure of end-tidal CO2, capnography) f. Body temperature g. Intra-arterial pressure



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5 Press the power switch then enter patients data. This ensures correct setup.

6 Raise the bed to a comfortable working height. Having the bed at the proper height prevents back and muscle strain.

7 Expose the patients chest and determine electrode positions, based on which system and

leads are being used.

NOTE: If necessary, clip the hair from an area

about 10 cm in diameter around each electrode

site. Clean the area with soap and water and dry it

completely to remove skin secretions that may

interfere with electrode function.

This ensures correct functioning.

These actions allow for better adhesion of the

electrode and thus better conduction. Alcohol,

benzoin, and antiperspirant are not recommended to

prepare the skin.

Electrode Name Color Position System/

Configuration

RA White Right Arm 3 Electrode

5 Electrode

LA Black Left Arm 3 Electrode

5 Electrode

LL Red Left Leg 3 Electrode

5 Electrode

RL Green Right Leg 5 Electrode

C Brown Central Chest

Over Sternum

5 Electrode



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Electrode system:

a. 3-lead/electrode (red, yellow, green) or (red, yellow, black) - choice of limb leads

Modified central lead one (MCL1)

Place the RA / White or right

arm) below the right clavicle,

the second (LA / Black or left

arm) below the left clavicle, and

the third (LL / Red or left leg)

just below the left pectoral

muscle.

MCL1 configuration (best lead

for identification of bundle

branch blocks): red wire on the

left shoulder just below the

clavicle, black (or green) on the

right shoulder, yellow in 4th

intercostal space on the right

sternal border (the V1 position)

then select lead I. Alternatively,

black (or green) in the V6



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electrode position then select to

lead II (this gives a simulated

lead V6).

Limb lead II is the most

common monitoring lead

configuration, because it

normally produces the largest

positive R wave.

b. 4-lead/electrode (red, yellow, green, black) - choice of limb leads



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c. 5-lead/electrode (red, yellow, green, black, white) - limb leads plus a chest lead (using the white wire, usually placed in the V1 position)

Electrode Name Color

USA Europe

RA White Red

LA Black Yellow

LL Red Green

RL Green Black

C Brown White



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8 Remove the backing from the pregelled electrode. Press the electrodes on the site firmly to ensure a

tight seal.

NOTE: Check the gel for moistness. If the gel is dry,

discard it and replace it with a fresh electrode.

Gel acts as a conduit and must be moist and secured

tightly.

Pregelled, disposable electrode

9 Connect the appropriate lead wire to each electrode according to inscription.

This ensures accuracy of reading.

10 Check waveform for clarity, position, and size.

NOTE: Use the gain control to adjust the size of the

rhythm tracing, and use the position control to

adjust the waveform position on the monitor. To

verify that the monitor is detecting each beat,

compare the digital heart rate display with an

auscultated count of the patients heart rate.

This ensures accuracy of reading.

11 Set the upper and lower limits of the heart rate alarm, based on the patients condition or unit

policy.

Setting the alarm allows for audible notification if the

heart rate is beyond limits. The default setting for

the monitor automatically turns on all alarms; limits

should be set for each patient.

12 Press the RECORD key to obtain a rhythm strip for baseline. Check the strip for Patients name and

room number, date, time, and rhythm

identification.

A rhythm strip provides a baseline.

13 Place the rhythm strip in the appropriate location in the patients chart.

This secures the result in the chart.

14 Return the patient to a comfortable position. Remove PPE and perform hand hygiene.

Repositioning promotes patient comfort.

Removing PPE reduces the risk for infection

transmission and contamination of other items.

Hand hygiene prevents transmission of

microorganisms.



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NOTE: Lower bed height and adjust the head of

bed to a comfortable position.

Lowering the bed promotes patient safety.

15 Document the following: a. Date and time that monitoring begins; b. Monitoring lead used in the medical record;

and

c. Changes in the patients condition (or as stated by facilitys policy).

Heart Rate (bpm) Interpretation

Above 100 Tachycardia (fast)

60-100 Normal (adult)

Below 60 Bradycardia (slow)

This ensures continuity of care.



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Administering a Blood Transfusion Purpose(s):

a. To increase the oxygen carrying capacity of the blood

Acute and chronic anemia

Congestive heart failure

Thalassemia

Sickle cell disease

b. To restore circulating blood volume

Acute bleeding (25 to 30% of blood loss)

Major surgery

c. To treat deficiencies in plasma proteins and clotting factors

Thrombocytopenia

Fibrinogen deficiency, e.g. disseminated intravascular coagulation (DIC)

Cirrhosis of the liver

Hepatitis

Hemophilia

Von Willebrand disease

Factor XIII deficiency

Severe leukopenia Equipment:

Blood product

Blood administration set (tubing with in-line filter and Y for saline administration)

0.9% normal saline for IV infusion

Venous access; if peripheral site, preferably initiated with a 20-gauge catheter or larger

3 way stopcock

Clean gloves

IV infusion set

Additional PPE, as indicated

Tape (hypoallergenic)

Pressure infusion bag (optional)



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Assessment:

1. Obtain a baseline assessment of the patient, including vital signs, heart and lung sounds, and urinary output. 2. Review the most recent laboratory values, in particular, the complete blood count (CBC). 3. Ask the patient about any previous transfusions, including the number he or she has had and any reactions

experienced during a transfusion.

4. Inspect the IV insertion site, noting that the gauge of the IV catheter is a 20 gauge or larger. Nursing Diagnosis:

1. Risk for Injury 2. Deficient Fluid Volume 3. Decreased Cardiac Output 4. Excess Fluid Volume 5. Ineffective Peripheral Tissue Perfusion

IMPLEMENTATION

Steps Action Rationale


b. Identify the patient. c. Introduce yourself and explain the

procedure.

d. Provide privacy and position comfortably.

e. Perform hand hygiene.

This ensures that the correct intervention is performed on

the correct patient.

Identifying the patient ensures the right patient receives the

intervention and helps relive anxiety.


Hand hygiene prevents the spread of microorganisms.

4 Two nurses compare and validate the following information:

a. Medical order for transfusion of blood product;

b. Informed consent; c. Patient identification number; d. Patient name; e. Blood group and type; f. Expiration date; g. Inspection of blood product for

clots; and

h. Cross-matching.

Most agencies require two registered nurses to verify the

following information: unit numbers match; ABO group and

Rh type are the same; expiration date (after 35 days, red

blood cells begin to deteriorate).

ABO group of compatible packed red blood cells/

whole blood

Re

cip

ien

t

AB

O b

loo

d

gro

up

Group O B A AB

AB X X X X

A X X

B X X

O X



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ABO group of compatible fresh frozen

plasma/cryoprecipitate

Re

cip

ien

t

AB

O b

loo

d

gro

up

Group O B A AB

AB X

A X X

B X X

O X X X X

Rh Negative patients should always receive Rh Negative

blood products.

Rh Positive patients can receive either Rh Negative or Rh

Positive blood products.

Source: http://www.rch.org.au/emplibrary/bloodtrans/RCH-BLOOD-

PRODUCT-ADMINISTRAION.pdf

NOTE: Blood is never administered to a patient without an

identification band. If clots are present, return blood to the

blood bank.

Blood Type Composition Indication

a. Whole blood Cells and plasma (hematocrit 40%) Volume replacement and oxygen carrying capacity (25% blood volume lost)

b. Packed red blood cells Red blood cells (RBCs), some plasma (hematocrit 75%)

RBCs mass ,symptomatic anemia

c. Platelets Platelets (3x1010

platelets/unit),

plasma with some RBCs and WBCs

Bleeding due to decreased platelets

d. Fresh frozen plasma Plasma including all coagulation factor complement

Bleeding in patient with coagulation factor

deficiencies

e. Cryoprecipitate Fibrinogen >150mg/bag, antihemophilic factor 80-110

units/bag, von Willebrand factor

von Willebrand disease, hypofibrinoginemia,

hemophilia A

f. Antihemophilic factor Factor VIII Hemophilia A

g. Factor IX concentrate Factor IX Hemophilia B

h. Albumin Albumin 5%, 10% Hypoproteinemia, burns, volume expansion by 5% to 25%

i. Globulin/ Granulocyte concentrate

IgG antibodies Hypogammaglobulinemia, recurrent infection

j. Antithrombin Antithrombin III Antithrombin III deficiency, risk of thrombosis



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5 Obtain baseline vital signs before beginning transfusion.

Any change in vital signs during the transfusion may indicate

a reaction.

6 Prime blood administration set with normal saline.

Normal saline is the solution of choice for blood product

administration. Solutions with dextrose may lead to

clumping of red blood cells and hemolysis.

One-Way Blood Set

(1) Blood chamber and filter; (2) Tube 3.0 x 4.0; (3) Precision Roller clamp; (4) Flashbulb; (5) Male

luer-lock; (6) Hypodermic needle

Two-Way Blood Set

(1) Spike protector; (2) Vented spike for tubing; (3) Vented air cap; (4) On/Off roller clamp; (5)

Tube 3.0 x 4.0; (6) Chamber cover; (7) Blood chamber; (8) Blood filter; (9) Precision roller clamp;

(10) Flashbulb; (11) Male luer-lock and cap



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7 Connect the blood administration set to the 3-way stopcock.

This ensures ease of connection to primary IV line.

Application of pressure infusion bag.

8 Stop the infusion of the primary intravenous line. Then start transfusion of

blood slowly (10 drops per minute for the

first 15 minutes). Stay with the patient.

This ensures patient safety.



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9 Observe patient for the following: a. Flushing; b. Dyspnea; c. Itching; d. Hyperthermia

These signs and symptoms may be an early indication of a

transfusion reaction.

10 After the observation period (5 to 15 minutes), increase the infusion rate to the

calculated rate to complete the infusion

within the prescribed time frame (4 hours).

If no adverse effects occurred during this time, the infusion

rate is increased. If complications occur, they can be

observed and the transfusion can be stopped immediately.

Verifying the rate and device settings ensures patient

receives correct volume of solution. Transfusion must be

completed within 4 hours due to potential for bacterial

growth in blood product at room temperature.

11 Reassess vital signs after 15 minutes. Stop transfusion immediately in case of

suspected transfusion reaction.

Vital signs must be assessed as part of monitoring for

possible adverse reaction. Facility policy and nursing

judgment will dictate frequency.

12 Discontinue transfusion according to standard practice. Again, recheck vital

signs.

If a transfusion reaction is suspected, the blood must be

stopped. Do not infuse the normal saline through the blood

tubing because you would be allowing more of the blood

into the patients body, which could complicate a reaction.

Besides a serious life-threatening blood transfusion

reaction, the potential for fluidvolume overload exists in

elderly patients and patients with decreased cardiac

function.

13 Discard blood bag according to hospital policy.

Proper disposal of equipment

reduces transmission of microorganisms and potential

contact with blood and body fluids.

14 Remove PPE and perform hand hygiene. Removing PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents

transmission of microorganisms.

15 Document the following: a. Date and time of transfusion; b. Type of blood product; and c. Any untoward reaction.


TRALI - Transfusion related acute lung injury

TA-GVHD - Transfusion-associated-graft-versus-host disease



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ADVANCED

RESPIRATORY SYSTEM

CARE



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Measuring Arterial Oxygen Saturation Purpose(s):

a. To rapidly verify, both audibly and visually, adequate patient oxygenation.

Equipment:

Pulse oximeter with an appropriate sensor or probe

Alcohol wipe(s) or disposable cleansing cloth

Nail polish remover (if necessary)

PPE, as indicated

Assessment:

1. Assess the patients skin temperature and color, including the color of the nail beds. Temperature is

a good indicator of blood flow. Warm skin indicates adequate circulation. In a well-oxygenated

patient, the skin and nail beds are usually pink. Skin that is bluish or dusky indicates hypoxia

(inadequate amount of oxygen available to the cells).

2. Check capillary refill; prolonged capillary refill indicates a reduction in blood flow.

3. Assess the quality of the pulse proximal to the sensor application site.

4. Auscultate the lungs.

5. Note the amount of oxygen and delivery method if the patient is receiving supplemental oxygen.

Nursing Diagnosis:

1. Risk for Decreased Cardiac Tissue Perfusion

2. Risk for Ineffective Cerebral Tissue Perfusion

3. Impaired Gas Exchange

4. Ineffective Airway Clearance

5. Activity Intolerance

6. Decreased Cardiac Output

7. Excess Fluid Volume

8. Anxiety

9. Risk for Aspiration



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IMPLEMENTATION


3 Follow Standard Protocol.

a. Verify or Check Doctors Order.

b. Identify the patient.

c. Introduce yourself and explain the

procedure.


e. Perform hand hygiene and put on PPE if

indicated.



Identifying the patient ensures the right

patient receives the intervention and helps

relive anxiety.


Hand hygiene and PPE prevent the spread of

microorganisms. PPE is required based on

Transmission Precautions.

4 Select an adequate site for application of the

sensor.

a. Use the patients index, middle, or ring

finger.

.

b. Check the proximal and capillary refill at

the pulse closest to the site.

Inadequate circulation can interfere with the

saturation of peripheral oxygen (SpO2) reading.

Fingers are easily accessible.

Brisk capillary refill and a strong pulse indicate

that circulation to the site is adequate.



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c. If circulation at the site is inadequate,

consider using the earlobe, forehead, or

bridge of nose.

d. Use a toe only if lower extremity

circulation is not compromised

These alternate sites are highly vascular

alternatives.

Peripheral vascular disease is common in lower

extremities.

5 Cleanse the selected area with the alcohol

wipe or disposable cleansing cloth.

.

Allow the area to dry. If necessary, remove nail

polish and artificial nails after checking pulse

oximeters manufacturer instructions.

Skin oils, dirt, or grime on the site can interfere

with the passage of light waves. Research is

conflicting regarding the effect of dark color

nail polish and artificial nails; refer to facility

policy and pulse oximeters manufacturer

instructions.

6 Attach sensor to selected site making sure

photodetectors of the light sensors are aligned

opposite each other.

Secure attachment and proper alignment

promote satisfactory operation of the

equipment and accurate recording of the SpO2.



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7 Turn on the oximeter.

NOTE: Observe pulse waveform/intensity

display and audible beep. Compare oximeter

pulse rate with clients radial pulse.

Audible beep represents the arterial pulse, and

fluctuating waveform or light bar indicates the

strength of the pulse. A weak signal will

produce an inaccurate recording of the SpO2.

Tone of beep reflects SpO2 reading. If SpO2

drops, tone becomes lower in pitch.

8 Leave sensor in place until oximeter reaches

constant value and pulse display reaches full

strength during each cardiac cycle. Read SpO2 on digital display.

NOTE: Reading may take 10-30 seconds.

This ensures a correct value.

9 Set the alarm limits for high and low pulse rate

settings.

Alarm provides additional safeguard and

signals when high or low limits have been

surpassed.

10 Check oxygen saturation at regular intervals, as

ordered by primary care provider, nursing

assessment, and signaled by alarms. Monitor

hemoglobin level.

Monitoring SpO2 provides ongoing assessment

of patients condition. A low hemoglobin level

may be satisfactorily saturated yet inadequate

to meet a patients oxygen needs.

11 Remove sensor on a regular basis and check

for skin irritation or signs of pressure (every 2

hours for spring-tension sensor or every 4

hours for adhesive finger or toe sensor).

Prolonged pressure may lead to tissue

necrosis. Adhesive sensor may cause skin

irritation.

12 Clean nondisposable sensors according to the

manufacturers directions. Remove PPE, if

used.

Cleaning equipment between patient use

reduces the spread of microorganisms.


transmission and contamination of other

items. Hand hygiene prevents the spread of

microorganisms.



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13 Document the following:

a. SpO2 reading;

b. Amount of oxygen therapy;

c. Oxygen delivery method used;

d. Type of sensor and location; and

e. Other relevant assessment.

SpO2 (%) Interpretation

95-100 Normal

90-94 Mild hypoxemia

85-89 Moderate hypoxemia

Below 85 Severe hypoxemia




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Care of a Patient with a Chest Drainage System Purpose(s):

a. To re-establish the normal intrathoracic pressure (6 mmHg) by removing air (pneumothorax)

and/or fluid (pleural effusion, e.g. hemothorax, hydrothorax, chylothorax, empyema) through a

closed drainage system.

b. To evacuate any pooling of blood in the mediastinum (hemomediastinum) following cardiothoracic

surgery, thoracotomy, or esophageal surgery and chest trauma that can cause cardiac tamponade.

Equipment:

Bottle of sterile normal saline or water

Disposable gloves


Foam tape or bands

Prescribed drainage system, if changing is required

Rolled Towel

Assessment:

1. Assess the patients vital signs. Significant changes from baseline may indicate complications.

2. Assess the patients respiratory status, including oxygen saturation level. If the chest tube is not

functioning appropriately, the patient may become tachypneic and hypoxic.

3. Assess the patients lung sounds. The lung sounds over the chest tube site may be diminished due to

the presence of fluid, blood, or air.

4. Assess the patient for pain. Sudden pressure or increased pain indicates potential complications. In

addition, many patients report pain at the chest tube insertion site and request medication for the

pain.

5. Assess the patients knowledge of the chest tube to ensure that he or she understands the rationale

for the chest tube.

Nursing Diagnosis:

1. Risk for Activity Intolerance

2. Risk for Impaired Gas Exchange

3. Deficient Knowledge

4. Acute Pain

5. Anxiety



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IMPLEMENTATION






procedure.

d. Provide privacy and position

comfortably.

e. Perform hand hygiene and put on PPE

if indicated.




receives the intervention and helps relive

anxiety.





4 Check the tube connections and chest

drainage system.

a. Water seal drainage system: The tube

should be 1 inch below water level

submerged in sterile normal saline. The

short tube is left open to atmosphere.

b. Disposable chest drainage unit: The

water seal chamber should be at 2cm

level. If negative pressure is indicated,

the suction setting from the source

should be set at 80mmHg or higher

(more negative). The suction level can

be also adjusted using the suction dial

on the side of the chest drain from

10cmH2O to 40cmH2O.

To ensure patency of the tubes and ensure tight

fit. If tube is submerged too deep in the water,

a higher intrapleural pressure is needed to

expel air. Short tube is open to atmosphere

which allows air to escape from the bottle.



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Chest tube

Water seal drainage system



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Disposable chest drainage unit

5 Assess the drainage output in the tubing

and collection bottle noting the color and

amount.

NOTE: Mark the date and time at the fluid

level on the drainage bottle.

This will show the amount of fluid loss and how

fast the fluid is collecting in the drainage

system.



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6 Ensure that the connections are securely

taped and that the chest tube is secured to

the clients wall.

NOTE: Make sure tubing does not loop with

movements of patient.

Kinking, looping, or pressure on the drainage

tubing can produce back pressure forcing

drainage back to the pleural space or block the

drainage.

7 Position patient comfortably. Reposition

the patient every 2 hours.

NOTE: When the patient is lying on the

affected side, place rolled towels at the side

of the tubing.

Proper positioning helps breathing and

promotes better air exchange. Frequent

position changes promote drainage, prevent

complications, and provide comfort. Rolled

towels prevent occlusion of the chest tube by

the clients weight.

8 Put the arm and shoulder of the affected

side through range-of-motion exercises

several times daily.

NOTE: Some pain medication may be

necessary.

Exercise helps to avoid ankylosis of the

shoulder (stiffness or fixation of the joint) and

assist in lessening postoperative pain.

9 Avoid aggressive chest tube manipulation

(milking the tube).

NOTE: If necessary, a gentle technique such

as squeezing hand over hand along the

tubing and releasing the tubing between

squeezes in the direction of the drainage

bottle as per doctors order.

Constant attention to maintaining the patency

of the tube will facilitate prompt expansion of

the lung and minimize complications.

Studies have shown that these techniques

(milking and stripping the tube) do not improve

chest tube patency.

10 Check for fluctuations of fluid during

inhalation or exhalation and air leaks as

indicated by constant bubbling in the water

seal bottle.

If fluctuation stops, it means either lung is

expanded or system is obstructed, or suction

motor is not operating properly.

Leaking and trapping can result in tension



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pneumothorax.

11 Observe the dressing site at least every 4

hours.

NOTE: Inspect the dressing for excessive

drainage, such as bleeding or foul-smelling

discharge.

The dressing provides an occlusive seal to the

site, preventing air from being drawn.

12 Assess that the drainage system is safely on

the floor, lower than the client.

The drainage system needs to be lower than

the client to ensure adequate drainage.

13 Encourage deep breathing and coughing

every 2 hours.

Removes secretions so lung expands.

14 Report for signs of:

a. Rapid, shallow breathing;

b. Cyanosis;

c. Hemorrhage; and

d. Any symptoms (e.g., pressure in the

chest).

Provides baseline and information about

procedure related complications.

15 Remove PPE, if used and perform hand

washing. Document assessment and

nursing care




microorganisms.




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Measuring Output from a Chest Drainage System Purpose(s):

a. To measure the amount of chest drainage.

Equipment:

Bottle of normal saline or water

Disposable gloves


Foam tape or bands

Prescribed drainage system, if changing is required

Assessment:

1. Assess the patients vital signs. Significant changes from baseline may indicate complications.

2. Assess the patients respiratory status, including oxygen saturation level. If the chest tube is not

functioning appropriately, the patient may become tachypneic and hypoxic.

3. Assess the patients lung sounds. The lung sounds over the chest tube site may be diminished

due to the presence of fluid, blood, or air.

4. Assess the patient for pain. Sudden pressure or increased pain indicates potential complications.

In addition, many patients report pain at the chest tube insertion site and request medication

for the pain.

5. Assess the patients knowledge of the chest tube to ensure that he or she understands the

rationale for the chest tube.

Nursing Diagnosis

1. Risk for Activity Intolerance


3. Acute Pain

4. Anxiety



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IMPLEMENTATION






procedure.


comfortably.

e. Perform hand hygiene and put on

PPE if indicated.









4 Expose the chest tube insertion site

only.

Maintains privacy.

5 Check that all connections are taped

securely.

Prevents any leakage of air into the closed system.

6 Measure the drainage output at the

end of each shift.

a. Note the amount and type of fluid

drainage.

b. Mark the level on the container or

by placing a small piece of tape at

the drainage level to indicate date

and time.

NOTE: The drainage system is removed

and replaced if full.

Provides an accurate record of the clients output.



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7 Subtract the total amount of previous

drainage from the total amount of

current drainage.

The difference will indicate the amount of

drainage since the last measurement.

8 Dispose of the fluid according to facility

policy.

Prevents transmission of infection.

9 Remove gloves, and additional PPE, if

used. Perform hand hygiene.




microorganisms.


a. Site of the chest tube;

b. Amount and type of drainage;

c. Amount of suction applied;

d. Bubbling / tidaling;

e. Subcutaneous emphysema;

f. Type of dressing in place; and

g. Patients pain level and pain relief.




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CARE OF PATIENT WITH

SENSORINEURAL DISORDERS



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Administering an Eye Irrigation Purpose(s)

a. To remove secretions or foreign bodies.

b. To cleanse and soothe the eye.

c. To instill ophthalmic medication.

Equipment:

Sterile irrigation solution (warmed to 37C [98.6F])

Sterile irrigation set (sterile container and irrigating or bulb syringe)

Emesis basin or irrigation basin

Washcloth

Waterproof pad

Towel

Disposable gloves


Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR)

Assessment:

1. Assess the patients eyes for redness, erythema, edema, drainage, or tenderness. 2. Assess the patient for allergies. 3. Verify patient name, dose, route, and time of administration. 4. Assess the patients knowledge of the procedure. If patient has a knowledge deficit about the procedure, this

may be an appropriate time to begin patient education.

5. Assess the patients ability to cooperate with the procedure.

Nursing Diagnosis:

1. Deficient Knowledge 2. Acute Pain 3. Risk for Injury

IMPLEMENTATION

Steps: Action Rationale




c. Introduce yourself and explain the procedure.






receives the intervention and helps relive

anxiety.





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indicated. microorganisms. PPE is required based on


4 Have patient sit or lie with head tilted toward side of affected eye.

NOTE: Protect patient and bed with a waterproof pad.

Gravity aids flow of solution away from

unaffected eye and from the inner canthus of

the affected eye toward the outer canthus.

5 Wipe from inner canthus to outer canthus. Clean lids and lashes with washcloth moistened with normal

saline or the solution ordered for the irrigation.

NOTE: Use a different corner of washcloth with each

wipe.

Materials lodged on lids or in lashes may be

washed into eye. This cleaning motion protects

nasolacrimal duct and other eye.



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6 Place curved basin at cheek on the side of the affected eye to receive irrigating solution.

NOTE: If patient is able, ask him or her to support the

basin.

Gravity aids flow of solution.

7 Expose lower conjunctival sac and hold upper lid open with the nondominant hand.

Solution is directed into lower conjunctival sac

because the cornea is sensitive and easily

injured. This also prevents reflex blinking.

8 Fill the irrigation syringe with the prescribed fluid. Hold irrigation syringe about 2.5 cm (1 inch) from eye.

Direct flow of solution from inner to outer canthus

along conjunctival sac.

This minimizes the risk for injury to the cornea.

Directing solution toward the outer canthus

helps to prevent the spread of contamination

from the eye to the lacrimal sac, the lacrimal

duct, and the nose.



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9 Irrigate until the solution is clear or all the solution has

been used.

NOTE: Use only enough force to remove secretions

gently from the conjunctiva. Avoid touching any part

of the eye with the irrigating tip.

Directing solutions with force may cause injury

to the tissues of the eye as well as to the

conjunctiva. Touching the eye is uncomfortable

for the patient and may cause damage to the

cornea.

10 Pause irrigation and have patient close the eye periodically during procedure.

Movement of the eye when the lids are closed

helps to move secretions from the upper to the

lower conjunctival sac.

11 Dry periorbital area after irrigation with gauze sponge. Offer a towel to the patient if face and neck are wet.

Leaving the skin moist after irrigation is

uncomfortable for the patient.

12 Assist the patient to a comfortable position. This ensures patient comfort.

13 Remove PPE. Perform hand hygiene. Removing PPE reduces the risk for infection transmission and contamination of other items.

Hand hygiene prevents the spread of

microorganisms.

14 Evaluate the patients response to medication within appropriate time frame.

The patient needs to be evaluated for

therapeutic and adverse affects from the

medication.

15 Document the following: a. Site; b. Type of solution and volume used; c. Length of time irrigation performed; d. Pre- and postprocedure assessments; e. Characteristics of any drainage; and f. Patients response to the treatment. g. Date, time, dose route of administration of

medication on the CMAR/MAR.




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Administering an Ear Irrigation Purpose(s):

a. To clean the external auditory canal (e.g. certain foreign bodies and accumulation of cerumen) or

apply heat in the ear canal. To instill otic medication.

Equipment:

Prescribed irrigating solution (warmed to 37C [98.6F])

Irrigation set (container and irrigating or bulb syringe)

Waterproof pad

Emesis basin

Cotton-tipped applicators

Disposable gloves


Cotton balls

Computer-generated Medication Administration Record (CMAR) or Medication Administration

Record (MAR)

Assessment:

1. Assess the affected ear for redness, erythema, edema, drainage, or tenderness.

2. Assess the patients ability to hear.

3. Assess the patient for allergies.

4. Verify patient name, dose, route, and time of administration.

5. Assess the patients knowledge of medication and procedure.

6. If the patient has a knowledge deficit about the medication, this may be an appropriate time to begin

education about the medication.


Nursing Diagnosis:

1. Acute Pain

2. Impaired Skin Integrity

3. Risk for Injury




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IMPLEMENTATION






procedure.


comfortably.


indicated.









4 Have the patient sit up or lie with head tilted

toward side of the affected ear. Have the

patient support basin under the ear to

receive the irrigating solution.

NOTE: Protect the patient and bed with a

waterproof pad.

Gravity causes the irrigating solution to flow from

the ear to the basin.

5 Clean pinna and meatus of auditory canal, as

necessary, with moistened cotton-tipped

applicators dipped in warm tap water or the

irrigating solution.

Materials lodged on the pinna and at the meatus

may be washed into the ear.

6 Fill bulb syringe with warm solution.

Priming the tubing allows air to escape from the

tubing. Air forced into the ear canal is noisy and



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NOTE: If an irrigating container is used, prime

the tubing.

therefore unpleasant for the patient.

7 Straighten auditory canal by pulling

cartilaginous portion of pinna up and back for

an adult.

Straightening the ear canal allows solution to

reach all areas of the canal easily.

8 Direct a steady, slow stream of solution

against the roof of the auditory canal, using

only enough force to remove secretions.

NOTE: Do not occlude the auditory canal with

the irrigating nozzle. Allow solution to flow

out unimpeded.

Directing the solution at the roof of the canal

helps prevent injury to the tympanic membrane.

Continuous in-and-out flow of the irrigating

solution helps to prevent pressure in the canal.



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9 When irrigation is complete, place a cotton

ball loosely in auditory meatus and have

patient lie on side of affected ear on a towel

or absorbent pad.

The cotton ball absorbs excess fluid, and gravity

allows the remaining solution in the canal to

escape from the ear.

10 Assist the patient to a comfortable position. This ensures patient comfort.

11 Remove PPE. Perform hand hygiene. Removing PPE reduces the risk for infection



microorganisms.

12 Evaluate the patients response to the

procedure.

a. Return to patients bedside 10 to 15

minutes to remove cotton ball and assess

drainage.

b. Evaluate the patients response to

medication within appropriate time

frame.

The patient needs to be evaluated for any

adverse effects from the procedure. Drainage or

pain may indicate injury to the tympanic

membrane. The patient needs to be evaluated for

therapeutic and adverse effects from the

medication.


a. Site;

b. Type of solution and volume used;

c. Length of time irrigation performed;

d. Characteristics of any drainage;

e. Patients response to the treatment; and

f. Date, time, dose, route of administration

of medication on the CMAR/MAR.

Timely documentation helps to ensure patient

safety.



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Care of a Client With Hearing Aid

Purpose(s):

1. To ensure good operation before using.

2. To make sounds more audible and prevent patient from additional hearing injuries.

Equipment:

Overbed table

Soft towel and washcloth

Brush or wax loop

Storage case

Disposable gloves (if drainage is present)

Assessment:

1. Sign and symptoms of hearing loss (muffled quality of speech and other sounds, difficulty

understanding words specially in crowds, need to turn up volume of radio or television, withdrawal

from conversations, avoidance of some social setting).

2. Assess the patients knowledge of proper ear care. If the patient has a knowledge deficit about the

device and procedure, this may be an appropriate time to begin education.


4. Activities of daily living

5. Hearing acuity test

Nursing Diagnosis:

1. Impaired social interaction

2. Diminished sensory perception (auditory)



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IMPLEMENTATION






procedure.


comfortably.

e. Perform hand hygiene and put on

PPE if indicated.









4 Clean the hearing aid.

a. Wipe with soft wash cloth.

b. Open battery door, and allow it to air

dry.

c. Wash ear canal wash cloth moistened

with soap and water.

d. Rinse and dry.

Maintains normal sound transmission in the ear

canal.



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Types of Hearing Aid

5 Insert the hearing aid.

a. Check the battery.

b. Turn the hearing aid off and

volume control down.

c. Guiding the aid along clients

cheek, bring it to the ear.

This ensures function.

This ensures safety.

This ensures ease of application.

6 Hold the hearing aid so that the canal-

long portion with holes is in the bottom.


7 Use other hand to pull-up and back on

outer ear gently push aid into ear until it

is in place.


8 Adjust volume gradually to comfortable

level for talking.

Gradual adjustments prevent exposing patient to

harsh squeal or feedback.



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9 Remove PPE, if used. Perform hand

hygiene.

Prevents transmission of microorganisms.

10 Document assessment and nursing care. This ensures continuity of care.



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Care of a Client With Eye Prosthesis

Purpose(s):

1. To clean the eye socket, the surrounding tissue, and the prosthesis to prevent infection and discomfort.

2. To examine the condition of the prosthesis and surrounding tissue.

Equipment:

Soft wash cloth or cotton gauze square

Wash basin with warm water or saline

4x4 gauze pads

Mild soap

Facial tissues

Bath towel

Suction device (bulb syringe)

Disposable gloves

Nursing Assessment:

1. Unusual discomfort of the eye socket or irritation/redness of the surrounding tissue of the eye may indicate

conjunctivitis, debris under the eye prosthesis, or lack of proper hygiene of the eye area.

2. Any infection or irritation that does not subside needs prompt medical attention.

3. Assess the patients ability to insert and remove the eye prosthesis. Determine the usual method of cleansing

the eye and the socket at home, and follow that routine as near as possible.

Nursing Diagnosis:

1. Ineffective health maintenance

2. Bathing/hygiene self-care deficit

3. Disturbed sensory perception (visual)



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IMPLEMENTATION






procedure.



indicated.

This ensures that the correct intervention is performed

on the correct patient.





microorganisms. PPE is required based on Transmission

Precautions.

4 With thumb, gently retract lower eyelid against

lower orbital ridge.

Maneuver breaks suction causing prosthesis to rise and

slide out of socket.

5 Exert slight pressure below eyelid if prosthesis

does not slide out use bulb syringe or medicine

dropper bulb to apply direct suction to

prosthesis.

Eases removal of prosthesis.

6 Place prosthesis in palm of hand and clean it

mild soap and water or plain saline by rubbing

between thumb and index finger.

Soap is less irritating than detergent. Tears and

secretions containing microorganisms may collect on

surface of prosthesis.

7 Rinse well under running tap water and dry

with soft wash cloth or facial tissue.

Soft cloth or tissue maintains shinny appearance of

prosthesis paper towel may dull finish.

8 If client is not to have prosthesis reinserted,

store in sterile saline or water in plastic storage

case. Label clients name and room number.

Prevents misplacement of prosthesis.

9 Clean eyelid margins and socket.

a. Retract upper and lower eyelid with thumb

and index finger.

b. Wash socket with washcloth or gauze

square moistened in warm water or saline.

c. Remove excess moisture with gauze pads.

d. Wash eyelid margins with mild soap and

water wipe from inner to outer canthus

using a clean part of cloth with each wipe.

e. Dry eyelid using the same method.

Exposes the eye socket.

Removes secretions that may contain microorganisms.

Removes moisture that can harbor microorganisms.

Prevents secretions from entering tear duct in inner

canthus.



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10 Moisten prosthesis with water or saline. Makes insertion easier because dry plastic would rub

against tissue surface.

11 Retract clients upper eyelid with index finger

or thumb of nondominant hand.

Correct positioning of prosthesis ensures proper fit.

12 With dominant hand, hold prosthesis so that

notched or pointed edge is positioned toward

nose and the iris faces outward.

Prosthesis will fit evenly into socket.

13 Slide prosthesis up under upper eyelid then

push down lower lid to allow prosthesis to slip

in to place. Gently wipe away excess fluid if

necessary.

Prevents dislodgement.

14 Remove PPE, if used. Perform hand hygiene. Prevents transmission of microorganisms.

15 Document assessment and nursing care. This ensures continuity of care.



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CARE OF PATIENT WITH

NEUROLOGICAL SYSTEM DISORDERS



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Assessing the Neurological System Purpose(s):

To demonstrate techniques for a practical and reasonably comprehensive examination of the nervous system.

Equipment:

Clean gloves

Percussion hammer

Sharp objects (e.g. paper clips, sterile pins, toothpicks)

Coin

Pen and paper

Cotton

Cotton swab

Tuning fork, 128 Hz (low-pitched)

Assessment:

1. Assess the patients behavior. 2. Assess the patients level of arousal. 3. Assess the patients thought processes and speech, thought content, perception, and insight and

judgment.

4. Assess the patients motor system. 5. Assess the patients sensory system. 6. Assess for other signs of neurological impairment. 7. Assess a comatose patient.

Nursing Diagnosis:

1. Altered level of Consciousness 2. Ineffective Cerebral Tissue Perfusion 3. Impaired Physical Mobility 4. Unilateral Neglect 5. Acute Confusion 6. Chronic Confusion 7. Impaired memory 8. Impaired verbal communication



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IMPLEMENTATION




c. Introduce yourself and explain the procedure.

d. Provide privacy.

e. Perform hand hygiene and put on PPE, if indicated.







microorganisms.

4 Place the patient in a comfortable position (sitting, lying or standing).

Assess the patients behavior, noting:

a. Facial expression observe for variations in facial expression;

b. Posture observe the patients body position during movement and at rest;

c. Affect observe for appropriateness of facial expressions with voice and body

movements; and

d. Grooming observe for grooming and personal hygiene.

This ensures comfort.

Expressions of anxiety, depression, apathy, anger,

elation; facial immobility suggests parkinsonism.

Abnormal positions suggest neurologic deficits such

as paralysis.

Anger, hostility, suspiciousness, or evasiveness

suggest paranoid patient. Elation and euphoria

suggest manic syndrome. Flat affect and remoteness

suggest schizophrenia. Apathy (dulled affect with

detachment and indifference) suggests dementia,

anxiety, or depression.

Grooming and personal hygiene may deteriorate in

depression, schizophrenia, and dementia.

Excessive fastidiousness may be seen in an obsessive

compulsive disorder. One-sided neglect may result

from a lesion in the opposite parietal cortex, usually

the nondominant side.



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5 Assess the patients level of arousal using, as needed, and in this order:

a. Verbal stimuli speak to the patient in a normal tone to test for alertness or in a

loud voice to test for lethargy;

b. Tactile stimuli shake the patient gently to test for obtundation; and

c. Painful stimuli apply a painful stimulus to test for stupor, e.g., pinch a tendon,

rub the sternum, or roll a pencil across a

nail bed.

NOTE: Coma if no response to repeated

painful stimuli.

An alert patient opens the eyes, looks at you, and

responds fully and appropriately to stimuli (arousal

intact). A lethargic patient appears drowsy but opens

the eyes and looks at you, responds to questions,

and then falls asleep.

An obtunded patient opens the eyes and looks at

you, but responds slowly and is somewhat confused.

Alertness and interest in the environment are

decreased.

A stuporous patient arouses from sleep only after

painful stimuli. Verbal responses are slow or even

absent. The patient lapses into an unresponsive state

when the stimulus ceases. There is minimal

awareness of self or the environment.

6 Assess the logic, relevance, organization, and coherence of the patients thought

processes and speech.

a. Circumstantiality speech with unnecessary detail but has meaningful

connection.

b. Derailment (Loosening of Associations) speech in which a person shifts from

one subject to others that are unrelated.

c. Flight of Ideas continuous speech in which changes are abrupt from topic to

topic.

d. Neologisms speech of distorted or invented words.

e. Incoherence speech that is largely incomprehensible or disordered

produced by severe flight of ideas.

f. Blocking sudden interruption of speech due to losing the thought.

This evaluates how patients express their thoughts.

Suggests obsession.

Suggests schizophrenia, manic episodes, and other

psychotic disorders.

Suggests manic episodes.

Suggests schizophrenia, other psychotic disorders,

and aphasia.

Suggests severely disturbed psychotic persons

(usually schizophrenic).

Suggests schizophrenia.



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g. Confabulation fabrication of facts or events in response to questions, to fill in

the gaps in an impaired memory.

h. Perseveration persistent repetition of words or ideas.

i. Echolalia repetition of the words and phrases of others.

j. Clanging rhyming speech.

Suggests amnesia.

Suggests schizophrenia and other psychotic

disorders.

Suggests manic episodes and schizophrenia.

Suggests manic episodes and schizophrenia.

7 Assess the patients thought content. a. Compulsions repetitive behaviors or

mental acts.

b. Obsessions recurrent, uncontrollable thoughts, images, or impulses.

c. Phobias persistent, irrational fears with compelling desire to avoid the

stimulus.

d. Anxieties apprehensions, fears, tensions, or uneasiness as focused

(phobia) or free floating (feeling of

impending doom).

e. Feelings of Unreality sense that things in the environment are strange, unreal,

or remote.

f. Feelings of Depersonalization sense that one self is different, changed, or

unreal, or has lost identity or become

detached from ones mind or body.

g. Delusions false, fixed, personal beliefs, e.g., grandiose, somatic, and

persecution.

This evaluates what patients think about themselves

or their environment. Abnormal thought may be

divided into the following categories: abnormal

perceptions, abnormal convictions, abnormal

preoccupations and impulses, and abnormalities in

the sense of self.

8 Assess the patients perception. a. Illusions misinterpretations of real

external stimuli (e.g., visual, auditory,

tactile, gustatory, kinesthetic, or

visceral).

b. Hallucinations false perception that occurs in the waking state in the

absence of external stimuli (e.g.,

auditory, visual, olfactory or gustatory,

tactile, or somatic).

Suggests grief reactions, delirium, acute and

posttraumatic stress disorders, and schizophrenia.

Suggests delirium, dementia, posttraumatic stress

disorder, schizophrenia, and alcoholism.



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9 Assess the patients insight and judgment. a. Insight note if patient is aware that a

particular mood, thought, or perception

is abnormal or part of an illness.

b. Judgment note the patients responses to family situations, jobs, use of money,

and interpersonal conflicts.

Suggests psychotic disorders and neurologic

disorders.

Suggests delirium, dementia, mental retardation, and

psychotic states.

10 Assess the patients motor system. Inspect and palpate muscles for:

a. Size/Bulk compare the size and contours of muscles (e.g., Atrophy refers

to a loss of muscle bulk or wasting,

Hypertrophy refers to an increase in

bulk with proportionate strength,

Pseudohypertrophy refers to increased

bulk with diminished strength);

b. Strength ask the patient to move actively against resistance (e.g.,

Hemiparesis refers to weakness of one

half of the body, Hemiplegia refers to

paralysis of one half of the body,

Paraplegia refers to paralysis of the legs,

Quadriplegia refers to paralysis of all 4

limbs);

Grade Interpretation

0 No muscular contraction or complete paralysis

1 A barely detectable or palpable muscular

contraction or partial paralysis.

2

Active movement of body part with gravity

eliminated, or cannot raise body

part/weakness.

3 Active movement against gravity, or can raise

and lower body part.

4

Active movement against gravity and some

resistance, or can raise body part with minimal

strength to push and pull.

5 Active movement against gravity and

full/strong resistance, or normal.

c. Tone feel the muscle resistance to passive stretch;

d. Involuntary movements tremors, tics, or fasciculations; and

Suggests motor neuron diseases, disuse of the

muscles, rheumatoid arthritis, and protein-calorie

malnutrition.

Suggests Duchenne muscular dystrophy.

Decreased resistance suggests disease of the

peripheral nervous system, cerebellar disease, or the

acute stages of spinal cord injury. Marked floppiness

indicates hypotonic or flaccid muscles. Increased

resistance that varies, commonly worse at the

extremes of the range, is called spasticity. Resistance

that persists throughout the range and in both

directions is called lead-pipe rigidity.



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e. Flexion and extension of limbs (Select as indicated.)

Upper Limbs:

Test flexion (C5 and C6 - biceps) and extension (C6, C7, and C8 -

triceps) at the elbow by having

the patient pull and push against

your hand.

Test extension at the wrist (C6, C7, and C8 - radial nerve) by

asking the patient to make a fist

and resist by pulling it down.

Test the grip (C7, C8, and T1). Ask the patient to squeeze two

of your fingers as hard as

possible and not let them go.

NOTE: To avoid getting hurt by

hard squeezes, place your own

middle finger on top of your

index finger. Testing both grips

simultaneously with arms

extended or in the lap facilitates

Symmetric weakness of the proximal muscles

suggests a myopathy or muscle disorder.

Symmetric weakness of distal muscles suggests a

polyneuropathy, or disorder of peripheral nerves.

Weakness of extension is seen in peripheral nerve

disease (e.g., radial nerve damage) and in central

nervous system disease producing hemiplegia (e.g.,

stroke or multiple sclerosis).

A weak grip may be due to either central or

peripheral nervous system disease. It may also result



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comparison.

Test finger abduction (C8 and T1 - ulnar nerve). Position the

patients hand with palm down

and fingers spread. Instructing

the patient not to let you move

the fingers, try to force them

together.

Test opposition of the thumb (C8 and T1 - median nerve). The

patient should try to touch the

tip of the little finger with the

thumb, against your resistance.

Lower Limbs:

Test flexion at the hip (L2, L3, and L4 - iliopsoas) by placing

your hand on the patients thigh

and asking the patient to raise

the leg against your hand.

Test adduction at the hips (L2, L3, and L4 - adductors). Place

your hands firmly on the bed

between the patients knees.

Ask the patient to bring both

from painful disorders of the hands.

Weak finger abduction indicates ulnar nerve

disorder.

Weak opposition of the thumb indicates median

nerve disorders such as carpal tunnel syndrome.



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legs together.

Test abduction at the hips (L4, L5, and S1 - gluteus medius and

minimus). Place your hands

firmly on the bed outside the

patients knees. Ask the patient

to spread both legs against your

hands.

Test extension at the hips (S1 - gluteus maximus). Have the

patient push the posterior thigh

down against your hand.

Test extension at the knee (L2, L3, and L4 - quadriceps). Support

the knee in flexion and ask the

patient to straighten the leg

against your hand. The

quadriceps is the strongest

muscle in the body, so expect a

forceful response.

Test flexion at the knee (L4, L5, S1, and S2 - hamstrings) Place

the patients leg so that the knee

is flexed with the foot resting on

the bed. Tell the patient to keep

the foot down as you try to

straighten the leg.



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Test dorsiflexion (mainly L4 and L5) and plantar flexion (mainly

S1) at the ankle by asking the

patient to pull up and push

down against your hand.

11 Assess the patients cerebellar function.

a. Test balance in walking/gait.

Ask the patient to walk heel-to-toe in a straight line.

A gait that lacks coordination, with reeling and

instability, is called ataxic. Ataxia may be due to

cerebellar disease, loss of position sense, or

intoxication.

Tandem walking may reveal an ataxia not previously

obvious.



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Ask the patient to walk on the toes, then on the heels.

Ask the patient to hop in place on each foot alternately.

Ask the patient to do a shallow knee bend, first on one leg, then on the

other. Support the patients elbow if

you think the patient is in danger of

falling.

NOTE: Rising from a sitting position

without arm support and stepping up

on a sturdy stool are more suitable

tests than hopping or knee bends

when patients are old or weak.

Walking on toes and heels may reveal distal muscular

weakness in the legs. Inability to heel-walk is a

sensitive test for corticospinal tract weakness.

Difficulty with hopping may be due to weakness, lack

of position sense, or cerebellar dysfunction.

Difficulty suggests proximal weakness (extensors of

the hip), weakness of the quadriceps (the extensor of

the knee), or both.

People with proximal muscle weakness involving the

pelvic girdle and legs have difficulty with both of

these activities.



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b. Test balance in standing.

Romberg test. The patient should stand with feet together and eyes

open and then close both eyes for 20

to 30 seconds without support.

Test for pronator drift. The patient should stand for 20 to 30 seconds

with both arms straight forward,

palms up, and with eyes closed.

Instruct the patient to keep the arms

up and eyes shut, tap the arms briskly

downward. NOTE: A person who

cannot stand may be tested for a

pronator drift in the sitting position.

c. Test coordination and skilled movements.

In ataxia due to loss of position sense, vision

compensates for the sensory loss. The patient stands

fairly well with eyes open but loses balance when

they are closed, a positive Romberg sign.

In cerebellar ataxia, the patient has difficulty

standing with feet together whether the eyes are

open or closed.

The pronation of one forearm suggests a

contralateral lesion in the corticospinal tract;

downward drift of the arm with flexion of fingers and

elbow may also occur. These movements are called a

pronator drift.

A weak arm is easily displaced and often remains so.

A patient lacking position sense may not recognize

the displacement and, if told to correct it, does so

poorly. In cerebellar incoordination, the arm returns

to its original position but overshoots and bounces.

In cerebellar disease, one movement cannot be

followed quickly by its opposite and movements are

slow, irregular, and clumsy. This abnormality is called

dysdiadochokinesis. Upper motor neuron weakness

and basal ganglia disease may also impair rapid

alternating movements, but not in the same manner.



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Rapid alternating movements (RAM):

Palm-to-thigh test. Show the patient how to strike one hand on the thigh,

raise the hand, turn it over, and then

strike the back of the hand down on

the same place. Ask the patient to

repeat these alternating movements

as rapidly as possible. Repeat with

the other hand. NOTE: The

nondominant hand often performs

somewhat less well.

Finger-to-thumb test. Show the patient how to tap the distal joint of

the thumb with the tip of the index

finger, again as rapidly as possible.

Again, observe the speed, rhythm,

and smoothness of the movements.

NOTE: The nondominant side often

performs less well.

Hand-to-heel test. Ask the patient to tap your hand as quickly as possible

with the ball of each foot alternately.

Note any slowness or awkwardness.

NOTE: The feet normally perform less

well than the hands.

Point-to-point movements:

Finger-to-nose test. Ask the patient to touch your index finger and then

his or her nose alternately several

times. Move your finger about so that

the patient has to alter directions and

extend the arm fully to reach it.

Observe the accuracy and

smoothness of movements and

watch for any tremor.

In cerebellar disease, movements are clumsy,

unsteady, and inappropriately varying in their speed,

force, and direction. The finger may initially

overshoot its mark, but finally reaches it fairly well.

Such movements are termed dysmetria. An intention

tremor may appear toward the end of the movement.

These maneuvers test position sense and the

functions of both the labyrinth and the cerebellum.

Cerebellar disease causes incoordination that may

get worse with eyes closed. Inaccuracy that appears

with eyes closed suggests loss of position sense.

Repetitive and consistent deviation to one side

(referred to as past pointing), worse with the eyes

closed, suggests cerebellar or vestibular disease.



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Finger-to-finger test. Hold your finger in one place so that the patient can

touch it with one arm and finger

outstretched. Ask the patient to raise

the arm overhead and lower it again

to touch your finger. After several

repeats, ask the patient to close both

eyes and try several more times.

Repeat on the other side.

Heel-to-knee test. Ask the patient to place one heel on the opposite knee,

and then run it down the thigh to the

big toe. Repeat on the other side.

Repetition with the patients eyes closed tests for

position sense. Cerebellar disease causes

incoordination.

12 Assess the patients sensory system. a. Test superficial sensations.

Patterns of testing include: 1. Both shoulders (C4); 2. Inner and outer aspects of the

forearms (C6 and T1);

3. Thumbs and small fingers (C6 and C8);

4. Front of both thighs (L2); 5. Medial and lateral aspects of

both calves (L4 and L5);

6. Small toes (S1); and 7. Medial aspect of each buttock

(S3).

If client does not perceive the touch or if hypersensitivity is felt,

determine boundaries by testing at

about every inch (2.5 cm) and note

the area of sensory loss. NOTE:

Stimulate first at a point of reduced

sensation, and move by progressive

steps until the patient detects the

change.

Meticulous sensory mapping helps to establish the

level of a spinal cord lesion and to determine if a

more peripheral lesion is in a nerve root, a major

peripheral nerve, or one of its branches.

Dermatome Map



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Wait 2 seconds before moving to a new site. NOTE: Vary the pace of

testing.

Test first with wisp of cotton (light touch), then tests for pain with

toothpick or sterile needle (first the

dull, then the sharp end). Alternate

dull and sharp ends when moving

from spot to spot.

Tests temperature sensation if pain perception is abnormal.

Compare symmetric areas on the two sides of the body. Also compare the

distal with the proximal areas of the

extremities.

b. Test deep vibratory sensation by placing a vibrating tuning fork on a metatarsal

joint and distal interphalangeal joint and

having the patient identify when the

vibration is felt and when it stops. If

This is important so that the patient does not merely

respond to a repetitive rhythm.

Repetitive testing in a proximal direction reveals a

gradual change to normal sensation at the wrist. This

pattern fits neither a peripheral nerve nor a

dermatome (area of skin mainly supplied by a single

spinal nerve). If bilateral, it suggests the glove and

stocking sensory loss of a polyneuropathy, often

seen in alcoholism and diabetes.

Anesthesia is absence of touch sensation,

hypesthesia is decreased sensitivity, and

hyperesthesia is increased sensitivity.

Analgesia refers to absence of pain sensation,

hypalgesia to decreased sensitivity to pain, and

hyperalgesia to increased sensitivity.

Hemisensory loss due to a lesion in the spinal cord or

higher pathways. Symmetric distal sensory loss

suggests a polyneuropathy.



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vibration sense is impaired, proceed to

more proximal bony prominences (e.g.,

wrist, elbow, medial malleolus, patella,

anterior superior iliac spine, spinous

processes, and clavicles).

c. Test deep kinesthetic sensation (position sense) by holding the clients finger or toe

on the sides and moving it up or down.

Instruct client to keep his eyes closed and

identify the direction of the movement.

Repeat several times on each side,

avoiding simple alternation of the stimuli.

If position sense is impaired, move

proximally to test it at the ankle joint. In

a similar fashion, test position in the

fingers, moving proximally if indicated to

the metacarpophalangeal joints, wrist,

and elbow.

d. Test discriminative sensation. (Select as indicated.)

Stereognosis. Assess by placing a familiar object (e.g., a coin or a

button) in the palm of the patients

hand and having him identify it.

Vibration sense is often the first sensation to be lost

in a peripheral neuropathy. Common causes include

diabetes and alcoholism. Vibration sense is also lost

in posterior column disease, as in tertiary syphilis or

vitamin B12 deficiency.

When testing vibration and position sensation, first

test the fingers and toes. Testing vibration sense in

the trunk may be useful in estimating the level of a

spinal cord lesion.

These prevent extraneous tactile stimuli from

revealing position changes that might not otherwise

be detected.

A disproportionate decrease in or loss of

discriminative sensations suggests disease of the

sensory cortex if touch and position sense is normal



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Graphesthesia. Assess by drawing a number or letter in the palm of

patients hand using the blunt end of

a pen or pencil and having the patient

identify what was drawn. NOTE:

When motor impairment, arthritis, or

other conditions prevent the patient

from manipulating an object well

enough to identify it, test the ability

to identify numbers.

2-point discrimination. Instruct the patient to close his eyes. Touch a

finger pad in two places

simultaneously using the sharp ends

of two opened paper clips, pins, or

toothpicks. Then move the points

together gradually and ask the

patient say one or two each time

the sharp ends are moved. Alternate

the double stimulus irregularly with a

one-point touch. Note distance and

location at which the patient can no

longer feel 2 separate points. NOTE:

Find the minimal distance at which

the patient can discriminate one from

two points (normally less than 5 mm

on the finger pads).

or only slightly impaired.

Stereognosis, number identification, and two-point

discrimination are also impaired by posterior column

disease.

Astereognosis refers to the inability to recognize

objects placed in the hand, suggests a lesion in the

sensory cortex.

The inability to recognize numbers suggests a lesion

in the sensory cortex.

This test may be used on other parts of the body, but

advanced adult care nursing manual

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