NURS 241: Health Assessment Validation Notes

Vital sign should be taken for 5 Minutes
General Survey
Physical Appearance:
What is your name?
Can you state your age?
Do you know where you are?
Patient has stated her age
Her level of consciousness is alert and oriented x 4
Her skin color is intact and even
Her facial features are symmetric
She is female
Body Structure:
Her statue appears appropriate for her age
For nutrition, her weight appear to be appropriate for her height and body build
Her body structure is symmetric and bilateral to each other
Her posture is erect
Her position was relaxed on the chair
Mobility:
Her gait is smooth, even and well balanced
She did not use any form of assistive device.
Behavior:
Her facial expression is appropriate to the situation
Her speech is within normal limits; there is no repeating of words or fleet of ideas
Her dressing is appropriate for the season
Her personal hygiene is clean and well groomed
Her mood and affect is pleasant and not flat
Cranial Nerve
Cranial nerve 1: Olfactory:
Sensory: Test of smell
Ask the patient to compress one side of the nose at a time and sniff: To check for nasal patency
Ask the patient to close their eye
Ask the patient to occlude one nostril at a time and ask them what do they smell
Cranial Nerve 2: Optic:
Sensory: Visual Acuity and Visual fields
I have previously tested for my patient’s visual acuity using the Snellen Chart It is 20/20 without corrective lenses
Testing for visual fields using the confrontational test. Up and Down
Cranial Nerve 3: Oculomotor
Motor: PERRLA: Extra ocular Movement
Going to test for PERRLA. First I would perform the direct and consensual eye movement
Performing Accommodation by moving the penlight near.
The pupil are equal, round, reactive to light and accommodate
Next I would test for cranial nerve 3, 4- which is trochlear and 6- which is Abducens, using the extra ocular movement.
Cranial 4- is an inferior medial eye movement
Cranial 6- is medial eye movement
Perform the corneal light reflex by shining light on the breach of the nose. If there was an abnormality I would person the cover/uncover test.
Cranial Nerve 5: Trigeminal:
Sensory: Sensation of skin of face:
Use a cotton and touch the forehead, checks and chin
Motor:
Palpate the temporal and masseter muscle
Ask the patient to clench their jaw and try to separate it
Cranial Nerve 7: Facial
Sensory:
Put sugar in their mouth and ask what did you taste. Taste on the 2/3 anterior of the tongue
Motor:
Ask the patient to raise their eyebrows, show their teeth, smile, puff out their checks, close their eye tightly
Cranial Nerve 8: Acoustic
Sensory:
Perform the whisper test. By whispering Samford and Nursing by asking them to occlude their ear and whispering the words
Perform the Weber test. Ask the patient if they can hear in both ears.
Perform the Rinne test. Air conduction is greater than bone conduction.
Cranial Nerve 9: Glossopharyngeal:
Sensory:
Taste in posterior 1/3 of the tongue
Motor:
Is testing gag reflex by stimulating the posterior pharyngeal wall.
Cranial Nerve 10:Vagus
Motor:
Open your mouth and say “AH”. I will watch the uvula rise and fall symmetrically.
Cranial Nerve 11: Spinal Accessory
Motor:
Shrug should movement against resistance.

Shrug your head against resistance
Both muscle 5/5 in strength
Cranial Nerve 12: Hypoglossal
Motor:
Ask the patient to protrude their tongue and push their tongue to their checks.

Neurological System:
Motor/Coordination:
I have already assessed the my patient gait in general survey
Rapid alternating movement: touching your finger against each other and turning your hand in your thighs
Point to Point Movement: finger to nose touching and heel to shin by moving your leg on your other leg
Romberg test: put your hand out and your legs together for 20 seconds
Tandem Walking: put your leg in front of the other leg
Shallow Knee Bend: bend down a little
Sensory
Pain and light touch: do it on your hand and leg
Position sense: pull the hand up and down than ask the patient whether it is up and down. Do it on the hand and leg
Vibration Sensation: Use the turning folk vibration place it on the hand and leg and ask where she feels the vibration
Discriminative Sensation:
Stereognosis: place something in her hand and ask what are you holding
Graphesthesia: write a number on her hand and ask what is the number in both arms. 3 and 5
Two point Discrimination: touch a part of the body and ask where you touched. Both the hand and leg
Point localization: