HEMODIALYSIS

● TWO TYPES OF DIALYSIS

○ Hemodialysis - Procedure during which a patient’s blood is circulated through a
dialyzer to remove waste products and excess fluid.
Peritoneal Dialysis - Procedure that uses the lining of the patient’s peritoneal cavity as the
semipermeable membrane for exchange of fluid and solutes.
● PRINCIPLES
○ Diffusion - Movement of solutes (waste products) from an area of sa concentration
to an area of lower density density concentration.
○ Osmosis - Movement of water through a semipermeable membrane from an area of
lower solute concentration to an area of higher solute concentration.
○ Ultrafiltration - Process whereby water is removed from the blood by means of a
pressure gradient between the patient’s blood and the dialysate.
● COMPLICATIONS WITH NURSING RESPONSIBILITIES 6
Atherosclerotic cardiovascular disease. Leading cause of death among patients undergoing
○
hemodialysis. The use of erythropoietin (Epogen) before the start of dialysis has been shown to have a

significant effect on hematocrit values for the first 19 months after starting dialysis (Fink et al., 2001).

However, increased dialyzer clotting may occur, which is prevented by adjusting heparin doses, and

dialyzer solute clearances may decrease slightly (Eschbach & Adamson, 1989).

Hypotension. May occur during the treatment as fluid is removed. Nurses must note nausea and
○
vomiting, diaphoresis, tachycardia, and dizziness which are common signs of hypotension.

Painful muscle cramping may occur. A nurse should recognize this usually late in dialysis as fluid
○
and electrolytes rapidly leave the extracellular space.

Exsanguination may occur. Check if blood lines separate or dialysis needles accidentally become
○
dislodged.

Dysrhythmias. Note and observe such complication for this may occur from electrolyte and pH
○
changes or from removal of antiarrhythmic medications during dialysis.

Air embolism (rare). Assess if there is any air entrance to the vascular system.
○
Chest pain. Monitor among patients with anemia or arteriosclerotic heart disease.
○
Dialysis disequilibrium results from cerebral fluid shifts. Assess for signs and symptoms which
○
includes headache, nausea and vomiting, restlessness, decreased level of consciousness, and

seizures. It is more likely to occur in acute renal failure or when blood urea nitrogen levels are very high

(exceeding 150 mg/dL).

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● RESPONSIBILITIES OF A DIALYSIS NURSE
○ Before
- Obtain an accurate weight measurement. The weight measurement will help
determine the amount of fluid that will need to be removed during
hemodialysis so that your patient can return to his dry weight.
- Obtain a complete set of vital signs, assess the overall condition of the
patient and document your findings. Patients undergoing hemodialysis are
prone to the development of dysrhythmias; when assessing the heart rate, be
sure to also take note of the rhythm.
- Make sure that the access site is functioning properly. Assess for bleeding at
the site, oozing or drainage, redness, warmth, and patient complaints of pain
at the site because these are key signs of infection and should be reported to
the healthcare provider.
- Reviewing the patients' lab work, home medications and activities and letting
the doctors know about changes in their patients' conditions

○ During
- Maintain and manage dialysis machines, systems, and equipment
- Monitor and assess vital signs of dialysis patient
- Instruct and counsel the patient & their families on dialysis nursing care
issues
- Monitor patient reaction to treatment interventions
- Administer medications as prescribed by nephrologists or physicians
○ After
- Obtain a set of vital signs and a weight measurement and assess the access
site
- Compare the findings with the predialysis results and report anything not
VATwithin the defined limits as predetermined by the healthcare provider.
- Continually assessed for infection by looking for elevations in temperature
and white blood cell count and assessing for warmth and redness at or
around the access site.
- Monitor the patient closely for signs of confusion, decreased level of
consciousness, and sudden severe headaches because these neurologic
changes could be related to a potentially life-threatening complication known
as disequilibrium syndrome and must be reported immediately.
- Determine when the next ordered labs will be collected and keep a lookout
for the results to review

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● TYPES OF AV ACCESS

○ Arteriovenous Fistula (AVF) - Created surgically (usually in the forearm) by joining

(anastomosing) an artery to a vein, either side or end to side. Needles are inserted
into the vessel to obtain blood flow adequate to pass through the dialyzer. The
arterial segment of the fistula is used for arterial flow to the dialyzer and the venous
segment for reinfusion of the dialyzed blood. This access will need time, (2 to 3
months) to “mature” before it can be used. As the AVF matures, the venous segment
dilates due to the increased blood flow coming directly from the artery. Once
sufficiently dilated it will then accommodate two large-bore ( 14-, 15-, or 16-gauge)
needles that are inserted for each dialysis treatment. The patient is encouraged to
perform hand exercises to increase the size of these vessels (ie., squeezing a rubber
ball for forearm fistulas) to accommodate the large-bore needles. Once established,
this access has the longest useful life and thus is the best option for vascular access
for the chronic hemodialysis patient.

○ Arteriovenous Graft (AVG) - Can be created by subcutaneously interposing a

biologic, semibiologic, or synthetic graft material between an artery and vein. Usually
a graft is created when the patient’s vessels are not suitable for creation of an AV
fistula. Patients with compromised vascular systems (eg., from diabetes) will require
a graft because their native vessels are not suitable for creation of an AV Fistula.
Grafts are usually placed in the arm but may be placed in the thigh or chest area.
Stenosis, infection, and thrombosis are the most common complications that result
in loss of this access. It is not at all uncommon to see a dialysis patient with
numerous “old” or “non functioning” accesses present on their arms. The patient is

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 asked to identify which is the current access in use and it is checked carefully for the
presence of a bruit and thrill.

’
● COMMON MEDICATIONS IN DIALYSIS

Medication What it is for

Red blood cells stimulating The kidneys help to make red blood cells in the
agents body.
When you are on dialysis, it means your kidneys are
not working well enough to make red blood cells.
The medications that help make red blood cells are:

Darbepoetin (Aranesp)
• Given once a week during hemodialysis
• Erythropoietin (Eprex)

Given 3 times a week during hemodialysis. Some

hemodialysis patients make enough red blood cells, so
not all patients need to receive this medication.

Iron Many patients coming to dialysis have low iron. The

doctor often prescribes iron sucrose (Venofer) to
patients who are starting dialysis.

It is given during each treatment through the dialysis

machine into your bloodstream for the first 4 weeks,
then 1 or 2 times a month after that.

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 Phosphorus binders The binders prevent the body from absorbing the
phosphorus from the foods eaten. The most common
medication is calcium carbonate. It must be taken at the
beginning of each meal. If your calcium levels also
become too high, or if calcium carbonate doesn’t work
well, the dnoctor can also prescribe lanthanum
carbonate (Fosrenol)or sevelamer (Renagel).

B-complex Vitamin & folic Use of a B-complex vitamin along with folic acid is a
acid good protection for when patients don't have an
appetite.

Active vitamin D Calcitriol (Rocaltrol) for example, to increase calcium

levels in the blood, which keeps bones healthy and help
lower blood levels of parathyroid hormone, which is
often increased when someone is on hemodialysis.

Topical creams & Many dialysis patients have itching and dry skin. The
antihistamines itching can frequently be treated with topical hydrating
agents or topical cortisone along with oral
antihistamines.

● HEMODIALYSIS MACHINE ILLUSTRATION

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 ● AT LEAST ONE HEMO FLOW SHEET WITH ACTU
●
● AL PATIENT DATA

REFERENCES:
Bare, B., Cheever, K., & Hinkle, J. (2010). Brunner & Suddarth’s Textbook of Medical - Surgical
Nursing (Twelfth Edition, Vol. 1). Wolters Kluwer | Lippincott Williams & Wilkins.

List of Dialysis Nurse Responsibilities and Duties. (2012). Great Sample Resume.
https://www.greatsampleresume.com/job-responsibilities/nursing/dialysis-nurse#:~:text=Maintain%2
0and%20manage%20dialysis%20machines

Lynn, R. (2019). Common Drugs Prescribed for Dialysis Patients. Davita Kidney Care.
https://www.davita.com/treatment-services/prescription/common-drugs-prescribed-for-dialysis-patie
nts

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 SPA
● LITHOTRIPSY
○ Description- the process by which fluid moves across a semipermeable membrane
from an area of low solute concentration to an area of high solute concentration; the
process continues until the solute concentrations are equal on both sides of the
membrane.
○ Purposes
■ Lithotripsy allows persons with certain types of stones in the urinary system
to avoid an invasive surgical procedure for stone removal. In order to aim the
waves, your doctor must be able to see the stones under X-ray or ultrasound.
○ Indications & Contraindications
Indications:
- small stones less than 10 mm in size.
- nephrolithiasis within transplant kidneys
Contraindications:
- Pregnancy
- coagulopathy or use o\f platelet aggregation inhibitors
- aortic aneurysms\
- severe untreated hypertension
- untreated urinary tract infections.
(Urol, 2018)
○ Patient Preparations
■ Follow a strict clear liquid diet the day before the procedure
■ Do not eat or drink anything after 12:00 midnight the night before the
procedure
■ If patient is under blood thinning medications, these should be withhold 7
days prior to the procedure
■ Inform the patient to plan a friend or family member to drive them home after
the procedure as they will feel drowsy after lithotripsy.
■ Remove any clothing, jewelry or other objects that may interfere the
procedure
○ Nursing Responsibilities
■ Before
- Explain the procedure and purpose to the patient
- Check the patient’s complete medical history to ensure the patient is
in good health before undergoing the procedure
- Check if the patient is sensitive or has any allergies to any
medications and anesthetic agents
- Give a sedative to the patient to help them relax
- Check all of the patient’s medications (prescription and
over-the-counter) and herbal supplements is taking.
■ During

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 - Insert an IV line on the patient’s arm or hand
- Assist the patient in moving around to get a position wherein the stone
is directly accessible/seen
- Instruct the patient to remain still and keep relaxed
■ After
- Provide instructions for home care and necessary follow up
- Encourage patient to increase fluid intake to assist in the passage of
stone fragments
- Inform the patient to expect hematuria, but is should disappear within
4 to 5 days
- Check patient’s vital signs especially the temperature
○ Picture

○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

● REHABILITATION
○ Description - Making able again; relearning skills or abilities or adjusting existing
functions. It is a dynamic, health-oriented process that assists an ill person or a
person with disability (restriction in performance or function in everyday activities) to
achieve the greatest possible level of physical, mental, spiritual, social, and
economic functioning.

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○ Purposes - The rehabilitation process helps the patient achieve an acceptable
quality of life with dignity, self-respect, and independence and is designed for people
with physical, mental, or emotional disabilities.
○ Indications
■ Loss of independence, which is a source of self-respect and dignity
■ Increased potential for discrimination or abuse
■ Increased social isolation
■ Added burden on spouse who may also have impaired health
■ Less access to community services and health care
■ Less access to religious institutions
■ Increased vulnerability to declining health secondary to other disorders,
reduced physiologic reserve, or preexisting impairments of mobility and
balance
■ Fears and doubts about ability to learn or relearn self-care activities,
exercises, and transfer and independent mobility techniques
■ Inadequate support system for successful rehabilitation
○ Contraindications
■ All the diseases in the acute period.
■ 10 days after preventive vaccination.
■ Infectious and parasitic diseases before expiration of the isolation.
■ Cardiovascular failure in the stages of sub compensation or compensation.
■ Epilepsy with a frequency of generalized convulsive attacks more than 1 time
in 3 months, with simple and complex partial convulsive attacks more than 1
time in a month.
■ Hydrocephalus in the stage of decompensation.
■ Strongly expressed infringements of intellectual-mental development.
■ Profound disturbances of the pelvic organs.
■ Hyperkinetic syndrome and other behavioral disorders, making it impossible
to be among children.
■ Deep mental disability, severe immobility, severe disorders of tonus, severe
hyperkinesis.
○ Patient Preparations
■ The patient understands how rehabilitation works
■ The patient prepares itself mentally and emotionally
■ For patients with impaired physical mobility, they must have adequate energy
resources and metabolic requirements to do rehabilitation exercises.
○ Nursing Responsibilities
■ Before
- Present a safe environment for the patient
- The nurse always emphasizes the patient’s assets and strengths,
positively reinforcing his or her efforts to improve self-concept and
self-care abilities.
- The nurse assumes the roles of caregiver, teacher, counselor, patient
advocate, and consultant.

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 ■ During
- The nurse actively listens, encourages, and shares the patient’s
successes.
- The nurse develops a plan of care designed to facilitate rehabilitation,
restore and maintain optimum health, and prevent complications.
- The nurse helps the patient identify strengths and past successes and
develop new goals.
- Aids in coping with the disability, self-care, mobility, skin care, and
bowel and bladder management.
- The nurse is often the case manager responsible for coordinating the
total rehabilitative plan, collaborating with and coordinating the
services provided by all members of the health care team.
■ After
- A nurse may visit the patient in the hospital, interview the patients and
the family and review the ADL sheet to learn which activities the
patients can perform.
- Give explanation about progressive activity to patient
○ Picture

○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

● LASER AND EYE CENTER

○ Description
■ Laser - A device that stimulates atoms or molecules to emit light at particular
wavelengths and amplifies that light, typically producing a very narrow beam

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 of radiation. The emission generally covers an extremely limited range of
visible, infrared, or ultraviolet wavelengths.
■ Eye Center - The Center aims to provide the most accurate diagnoses and
the best care possible for various eye diseases, including glaucoma, cataract,
diabetic retinopathy and other diabetes-related problems, dry eye disease,
age-related macular degeneration, and diseases in the retina, among many
others.
○ Purposes
■ Farsightedness (Hyperopia) - Laser eye surgery can correct this by
reshaping the cornea to have a steeper curve.
■ Nearsightedness (Myopia) - Healthcare professionals can correct this
through laser eye surgery by reshaping the cornea.
■ Astigmatism - It is possible to correct this irregular curvature of the cornea
with laser eye surgery in some cases.

○ Indications & Contraindications

INDICATIONS CONTRAINDICATIONS

● Have refractive eye error. ● Have had a change in their eye

● Are aged 20 years or older.
● Have a prescription that has not
changed significantly in the last 12
months.
prescription in the last 12 months.
● Take medications that may cause
changes in vision.
● Are in their 20s or younger, although
some experts recommend not being
under 18 years.
● Have thin corneas, which may not be
stable following laser surgery.
● Are pregnant or nursing.

○ Patient Preparations
■ Not wear any make-up, perfume or lotion a day before, and on the day of the
procedure. These products may leave debris around the eye and eyelashes,
which increases the chance of infection.
■ Wear comfortable clothes.
■ Eat a light meal and stay hydrated to ensure a stable circulation for the
surgery.
■ Arrange for transportation home from surgery.
○ Nursing Responsibilities

■ Before
- Explain the purpose and procedure of the test
- Inform the patient that he/she will experience little to no discomfort
■ During

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 - Instruct the patient to relax and to remain still
- Remain with the patient throughout the procedure
■ After
- Interpret the results
- Monitor the patient appropriately
- Counsel the patient regarding the results, type of treatment and
possible need for further testing
○ Picture
○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

● CT SCAN
○ Description - is an imaging method in which the lungs are scanned in successive
layers by a narrow-beam x-ray. The images produced provide a cross-sectional view
of the chest. CT scans can distinguish fine tissue density
○ Purposes - CT may be used to define pulmonary nodules and small tumors
adjacent to pleural surfaces that are not visible on routine chest x-ray, and to
demonstrate mediastinal abnormalities and hilar adenopathy, which are difficult to
visualize with other techniques.
○ Indications
- Appendicitis
- Brain injury
- Bowel obstruction
- Detection of blood clots or infection
- Pleural effusion
○ Contraindications
- Allergy to iodine contrast
- Renal problems
- 2 years old and below
- Pregnant women
- Persons with complications after previous administration of a contrast
medium
○ Patient Preparations
- Remove all jewelries prior to the procedure n
- For a CT scan with contrast, do not eat anything prior to it for 6-8 hours.
- Encourage patient to drink only clear liquids
○ Nursing Responsibilities
■ Before
- Instruct the client to remove a ny jewelry prior to the procedure
- Assist the client in changing in hospital gown
- Explain the procedure and answer any questions
- Inform the client that he/she will be asked to hold his/her breath
■ During
- Instruct the client to remain still
- Remain with the client during the procedure

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 - Tell the client to close their eyes but not sleep during the procedure
■ After
- Encourage client to drink water to promote excretion of the dye
- Inform the client that gray/white stools are normal 48-72 hours after
CT scan due to the dye

○ Picture

○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

● MRI
○ Description - is a noninvasive, painless technique that is used to examine both the
physiologic and anatomic properties of the heart. It uses magnetic fields and
radiofrequency signals to create sectioned images of various body structures. MRIs
yield a much more detailed diagnostic image than CT scans.76
○ Purposes - used to characterize pulmonary nodules, stage bronchogenic carcinoma
(assessment of chest wall invasion), and evaluate inflammatory activity in interstitial
lung disease, acute pulmonary embolism, and chronic thrombotic pulmonary
hypertension (Kauczor & Kreitner, 2000).
○ Indications
■ Neuroimaging
● Posterior fossa
● Demyelinating diseases (characterized by the loss of myelin sheath)
● Dementia
● Cerebrovascular disease
● Infectious disease
● Epilepsy
■ Cardiovascular
● Myocardial ischemia
● Cardiomyopathies

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 ● Myocarditis
● Iron overload
● Vascular disease
● Congenital heart disease
■ Musculoskeletal
● Spinal imaging
● Assessment of joint disease
● Soft tissue tumors
■ Liver and gastrointestinal
● Lesions of the liver, pancreas and bile ducts
■ Angiography
● Stenosis
● aneurysms

○ Contraindications
For patients with:
- Permanent pacemakers
- Artificial heart valves and defibrillators
- 1st trimester pregnancy
- Allergy to contrast dye
- Implanted insulin pumps, or implanted transcutaneous electrical nerve
stimulation devices, because the magnetic field could cause malfunction
- Internal metal devices (eg, aneurysm clips)
○ Patient Preparations
- Remove any jewelry or metallic object prior to the procedure to prevent
alteration of results.
- Depending on the area being scanned, the client may avoid eating or drinking
for 6-8 hours prior to the procedure.
○ Nursing Responsibilities
■ Before
- Explain the procedure to the client and answer his/her questions
properly.
- Instruct the client to remove all metallic objects, including jewelry,
watches, and hairpins.
- If NPO was ordered, ensure that the patient complied with it.
■ During
- Instruct the client to stay still as much as possible.
- Inform the client that the loud sounds coming from the machine are
normal.
■ After
- Do documentation and aftercare
- Instruct client to drink water to flush out the dye
- Help the patient sit and stand up slowly.
○ Picture

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 h
○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

● ULTRASOUND
○ Description- High-frequency sound waves echoing off body tissues are converted
electronically into images; used to assess tissues deep within the body
○ Purposes - Diagnostic ultrasound, also called sonography or diagnostic medical
sonography, is an imaging method that uses sound waves to produce images of
structures within your body. The images can provide valuable information for
diagnosing and directing treatment for a variety of diseases and conditions.
○ Indications
- Pregnant women
- Abdominal ascites
- Myositis
- Abdominal aortic aneurysms
○ Contraindications
- Presence of pacemaker
- Areas with diminished pain or heat sensitivity
- Low platelet count
○ Patient Preparations
○ Abdominal Ultrasound and Abdominal Ultrasound with Doppler (Liver, spleen,
gallbladder, kidneys, pancreas, abdominal aorta, biliary system)
- (Exam time: 30 min; visit time about 1-1/2 hours
- Adults: Do not eat or drink eight hours before an exam.
- Children: Do not eat or drink four hours before study or skip one meal.
- Take medications with a small sip of water.
- If you are diabetic, please take your insulin.
● Pelvic Ultrasound (Uterus, ovaries, fallopian tubes, urinary bladder)
- (Exam time: 30 min; visit time about 1-1/2 hours)
- Our protocol is to include transvaginal ultrasound for females.
- Eat normally.
- One hour before your exam, drink 32 ounces of water.
- Do not empty your bladder before your exam.
● Bladder Ultrasound
- For both male and female patients, one hour before your exam, drink 32 ounces of
water.
● Prostate-Transrectal Ultrasound
- Two hours before your exam, do a cleansing with a Fleet enema #1.
- Follow preparations for prostate ultrasound
● Transvaginal Ultrasound
- Drink 32 ounces of any liquid one hour before the exam. Do not urinate before the
exam so you arrive at the exam with a full bladder.
● Hysterosonogram
- No unprotected sexual relations during the first 10 days of your menstrual cycle.

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Ultrasound-Guided Biopsies
● Ultrasound breast biopsy
- You must be off aspirin, blood thinners and vitamin E for seven days prior to your
biopsy.
● Liver biopsy / paracentesis / thoracentesis / prostate biopsy
- Do not eat or drink after midnight the day before your biopsy.
- You must be off aspirin, blood thinners and vitamin E for seven days before your
biopsy.

○ Nursing Responsibilities
■ Before
- Explain procedure to the client and answer his/her questions
- Assist the client to change into hospital gown
- Inform the client that he/she may feel a little discomfort on the applied
pre ssure and application of cold gel during the procedure
■ During
- Assist in application of jelly if needed
- Encourage the client to breathe normally during the exam unless
he/she is asked to hold breath for visualization
- Instruct client to remain still and keep relaxed
■ After
- Do documentation and aftercare
- Wipe off the conductive gel from the client’s skin
- Inform client that he/she can resume with their daily activities
○ Picture
○ DAILY JOURNAL AND SIGNATURES OF THE STAF
● X - RAY
○ Description - a common imaging test used to help view the inside of the body
without making an incision.
○ Purposes - X - ray is performed to:
■ Examine an area where you’re experiencing pain or discomfort
■ Monitor the progression of diagnosed disease
○ Indications & Contraindications

INDICATIONS CONTRAINDICATIONS

● To rule our fractions ● Pregnancy

● Detects masses, foreign bodies, ● Weight of patient (limited only to 350
arthritis, or other bone or joint lbs.)
pathologies (e.g., tumor)
● Assessment of cardiopulmonary
disease and joint or spinal disease

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 ○ Patient Preparations
■ Patient should wear loose, comfortable clothing so that they can move
around easily
■ Patient should remove any jewelry or other metallic items from the body
■ For X - rays to examine gastrointestinal tract, patient may be asked to do
fasting and avoid or limit drinking certain liquids
○ Nursing Responsibilities
■ Before
- Explain the purpose and procedure
- Assess for test contraindication: make sure patient is not pregnant
- Ascertain that jewelry and metallic objects are removed
■ During
- Encourage patient to follow positional instructions
■ After
- Evaluate patient outcomes
- Provide support and counseling to the patient
○ Picture
○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

● EEG
○ Description - measures and records electrical impulses from the cortex of the brain
by means of electrodes attached to the patient’s scalp.
○ Purposes – the main purpose of EEG is to detect problems in the electrical activity
of the brain that are associated with certain brain disorders. EEG is also performed
to determine level of brain activity when someone is in a coma.
○ Indications & Contraindications

INDICATIONS CONTRAINDICATIONS

● Diagnose epilepsy, tumor, abscesses, ● Febrile and provoked seizures

infarcts, injuries, hematomas,
cerebrovascular diseases, narcolepsy,
tremors and Alzheimer’s disease
● Ascertain brain death
● Monitor epilepsy episodes
● Identify vagus nerve stimulation or
surgery
(concussive, hypoglycemic)
● Headaches, migraines and ticks
● Autism
● Intellectual impairment without a history
of seizure
● Psychiatric symptoms/ behavior
disturbance

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 ○ Patient Preparations
■ Patient should be deprived of sleep on the night before the EEG
■ Antiseizure agents, tranquilizers, stimulants, and depressants should be
withheld 24 to 48 hours before EEG as these can alter EEG wave patterns
■ Patient is omitted from eating chocolate, coffee, tea and cola drinks due to its
stimulating effect.
○ Nursing Responsibilities
■ Before
- Explain the test purpose and procedure to the patient
- Take note for special instructions that may apply to the patient
- Inform the patient that food is permitted and should not skip meals.
However, coffee, tea, colas and other caffeine - containing products
should be withheld
- Shampoo hair the evening before the test; use only shampoo and no
conditioners and oils
- Withhold medications such as anticonvulsants, tranquilizers,
barbiturates and other sedatives for 24 to 48 hours before the test
unless otherwise ordered.
■ During
- Instruct patient to relax, remain quiet, and close the eyes
- Promote a relaxed and quiet environment
- Look for unusual recorded eye movement and body activity as these
motions can alter brain wave patterns
- Be alert for seizure activity
■ After
- Shampoo the hair to remove gel and adhesive
- Observe safety
- precautions and seizure precautions
- Resume medications unless ordered (consult with the physician first)
- Provide emotional support and teaching to help the patient adjust.
○ Picture
○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

● ECG
○ Description - The electrical impulse that travels through the heart can be viewed by
means of electrocardiography, the end product of which is an ECG.

○ Purposes - The electrocardiogram (ECG or EKG) is a noninvasive routine

examination of the electrical activity of the heart that is used to reflect underlying
heart conditions.
■ To help identify primary conduction abnormalities, cardiac arrhythmias,
cardiac hypertrophy, pericarditis, electrolyte imbalance, myocardial ischemia,
and the site and extent of myocardial infarction.

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 ■ To monitor recovery from an MI.
■ To evaluate the effectiveness of cardiac medication.
■ To assess pacemaker performance.
■ To determine effectiveness of thrombolytic therapy and the resolution of
ST-segment depression or elevation and T-wave changes.

○ Indications & Contraindications

INDICATIONS CONTRAINDICATIONS

● Evaluation of patients to detect ● No absolute contraindications to

myocardial injury, ischemia, and the performing an ECG exist, other than
presence of prior infarction, and in the patient refusal. Some patients may have
assessment of patients with electrolyte allergies or, more commonly,
abnormalities, drug toxicities, and sensitivities to the adhesive used to affix
implanted defibrillators and the leads; in these cases,
pacemakers. hypoallergenic alternatives are available
from various manufacturers.
● Diagnosis of disorders of the cardiac
rhythm and in the evaluation of
syncope.
● Assessment of metabolic disorders and
side effects of pharmacotherapy,
● Evaluation of primary and secondary
cardiomyopathic processes, among
others

○ Patient Preparations
■ Equipment - The various components of an electrocardiogram (ECG) (ie, P
wave, QRS complex, and T wave) have different and distinct amplitudes and
frequencies. Devices that record these signals must make use of various
signal filtering and amplification algorithms to produce a clinically useful
signal while excluding unwanted signals (such as those resulting from
skeletal muscle, respiratory variation, and electromagnetic interference from
nearby equipment).

■ Positioning - T6

○ Nursing Responsibilities
■ Before
● Explain the procedure to the patient.
● Ensure to empty the bladder.
● Encourage the patient to cooperate.
● Explain the need to darkened the examination field.

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 ● Explain that a vasodilated (amyl nitrate) may be given. The patient
may be asked to inhale a gas with a slightly sweet odor while changes
in heart functions are recorded.

■ During
● Inform that a conductive gel is applied to the chest area. A conductive
gel will be applied to his chest and a quarter-sized transducer will be
placed over it. Warn him that he may feel minor discomfort because
pressure is exerted to keep the transducer in contact with the skin.
● Position the patient on his left side.
● Explain that the transducer is angled to observe different areas of the
heart and that he may be repositioned on his left side during the
procedure.

■ After
● Remove the conductive gel from the patient’s skin.
● Inform the patient that the study will be interpreted by the physician.
● Instruct the patient to resume regular diet and activities.

○ Picture

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B.

○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

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● 2D ECHO
○ Description - a noninvasive examination of the heart that visualizes cardiac
structures and provides information about cardiac function
○ Purposes - it is used to monitor the functioning of the heart and its valves and to
detect heart defects and other heart related problems
○ Indications & Contraindications

INDICATIONS CONTRAINDICATIONS

● Monitor cardiac patients ● Acute myocardial infarction within 2

● Evaluate abnormalities of blood flow days
and myocardial disease ● Heart failure exacerbation
● ● Acute pericarditis
Severe symptomatic aortic stenosis
● Uncontrolled arrhythmias
● Hypertension
● Unstable angina

○ Patient Preparations
■ For TTE, no specific preparation is required prior to the test, making it easier
and more advantageous than other tests when it comes to preparation.
■ For stress echocardiography, the individual must not eat or drink anything for
three hours before the test. Loose and comfortable clothing must be worn.
Also, it is important to inform the physician if you are taking medicines such
as sildenafil (Viagra).
■ TEE is mostly done for hospitalized patients. Fasting for several hours is
required before this test, and the exact duration for fasting is informed by the
treating physician. The patient must inform the physician about allergies to
any medications. Dentures must be removed prior to the test.

○ Nursing Responsibilities
■ Before
- Explain the purpose, procedure and benefits of 2D Echo
- Make sure the patient must empty their bladder.
- As sure the patient that although there is no pain involved there
may be some discomfort
- Explain that the conductive gel is necessary to permit easier
movement of the transducer
■ During
- Inform that a conductive gel is applied to the chest area
- Position the patient on his left side
■ After
- Remove the conductive gel from the patient’s skin
- Interpret test outcomes

22
 - Counsel the patient about cardiac disorders and for further possible
need of testing or treatment
○ Picture
○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

● ENDOSCOPY/ COLONOSCOPY
○ Description - the visual examination of the large intestine from the anus to the
ileocecal valve by means of a flexible fiber - optic or video colonoscopy, which can
also produce photographs of the area
○ Purposes - to check for the abnormalities in the entire colon and to look for changes
such as swollen, irritated tissues, polyps or cancer in the large intestine and rectum
○ Indications & Contraindications

INDICATIONS C7ONTRAINDICATIONS

● Clarification of the localization of the ● Pregnant women near term

process.
● Visual examination of pathological
changes revealed during examination,
clarification of their prevalence
● Control over the effectiveness of
treatment (both conservative and
surgical).
● Continuation.. Indications and
contraindications to endoscopy of the
stomach (iliveok.com)
● Patients with bleeding disorders
● Patients who had a recent acute
myocardial infarction, abdominal
surgery, ischemic bowel disease or
inflamed abdomen (peritonitis,
diverticulitis, colitis)

○ Patient Preparations
■ The patient must follow a special diet
● No solid food the day before the exam 8 hours before the exam
● Drinks are limited to clear liquids for up to 72 hours
● Avoid red liquids
■ The patient must take a laxative the night before the colonoscopy
■ Aspirin and aspirin containing products should be discontinued 1 week before
the exam because of potential bleeding or hemorrhage
■ Iron preparations should be discontinued 3 to 4 days before the test as this
may interfere with visualization and makes the stool viscous and difficult to
clear
○ Nursing Responsibilities
■ Before
● Provide information about the procedure
● Ensure that the patient has complied with the bowel preparation
● Provide reassurance

23
 ● Explain to the patient that air may be introduced through the
colonoscope.
● Instruct patient to:
○ Empty the bladder prior to the procedure
○ Remove all metallic objects from the area to be examined
○ Cooperate and follow directions
■ During
● Assist with patient positioning
● Instruct patient to bear down
● Change the position of the patient
● Encourage patient to take slow, deep breaths
■ After
● Observe the patient closely for signs of bowel perforation
● Instruct patient to resume a normal diet, fluids, and activity as advised
by the doctor
● Monitor any rectal bleeding
● Encourage increased fluid intake
○ Picture
○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

● RADIATION
○ Description - Radiation is a type of nuclear scan that can find cancer, infection or
inflammation in the body. There will be a small amount of a radioactive substance
into the bloodstream.
○ Purposes - It is used to help detect some cancer cells and to help show cells that
are rapidly reproducing or responding to an infection in the body.
○ Indications & Contraindications

INDICATIONS CONTRAINDICATIONS

● Lymphoma ● Pregnancy
● Fever without known cause ● Breastfeeding mothers
● Certain lung infections
● Osteomyelitis
● Sarcoidosis

○ Patient Preparations
■ Laxatives, suppositories, and tap water enemas are carried out before
scanning
■ The patient may eat breakfast the day of imaging
■ The patient must lie quiet without moving
■ There will be a radionuclide injected 24 to 96 hours before imaging
■ The patient must eat a low - residue lunch and clear liquid supper the day
before the test.

24
 ○ Nursing Responsibilities
■ Before
- Explain the purpose, procedure, benefits, and risks of the test.
- Ensure that patient has complied with the diet and bowel preparation
given before the test
- Inform the patient that the imaging time is 45 to 90 minutes per
imaging session
■ During
- Reassure the patient that the follow - up imaging is a routine
■ After
- Interpret the outcome and monitor the patient appropriately
- Counsel the patient regarding side effects (i,e,, rash, hives, and
tachycardia) that may occur 1 day after injection
- Observe and report the side effects that may occur to the patient
○ Picture
○ DAILY JOURNAL AND SIGNATURES OF THE STAFF

REFERENCES:
Bare, B., Cheever, K., & Hinkle, J. (2010). Brunner & Suddarth’s Textbook of Medical - Surgical
Nursing (Twelfth Edition, Vol. 1). Wolters Kluwer | Lippincott Williams & Wilkins.

Dunning, M. B., & Fischbach, F. T. (2011). Nurses’ Quick Reference to Common Laboratory &
Diagnostic Tests (Fifth Edition). Wolters Kluwer | Lippincott Williams & Wilkins.

General Ultrasound Preparation. (n.d.). Cedars-Sinai.

https://www.cedars-sinai.org/programs/imaging-center/preparing-for-your-exam/general-ultrasound.
html

Lithotripsy. (2020). John Hopkins Medicine.

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/lithotripsy

Portnov, A. (2021, October 17). Indications and contraindications to endoscopy of the stomach. I
Live! Ok!
https://m.iliveok.com/health/indications-and-contraindications-endoscopy-stomach_110738i15993.ht
ml

Preparing For Rehab. (2022). Rehab Spot.

https://www.rehabspot.com/treatment/before-begins/preparing-for-rehab/

What Does A Rehabilitation Staff Nurse Do? (2019). Association of Rehabilitation Nurses.
https://rehabnurse.org/about/roles/rehabilitation-staff-nurse

25
 CD
● WHAT IS A COMMUNICABLE DISEASE?
○ A communicable disease is an illness caused by an infectious agent or its toxic
products. Communicable diseases may be transmitted directly or indirectly to a
healthy person through an agent, a vector, or an inanimate object.
● WHAT IS AN INFECTION?
- Is defined as the entry and multiplication of an infectious agent in or on the
tissue of a host. If the agent fails to cause injury to the host’s cell or tissue, the
pathogen is said to be colonizing the cell or tissue without causing harm. If the
pathogens multiply and cause clinical signs and symptoms, the infection
becomes symptomatic. If the infectious disease can be transmitted directly or
indirectly fom one person to another, it is considered communicable and is
referred to as an infectious disease (Potter and Perry, 2005).

● 6 LINKS OF INFECTION WITH ILLUSTRATION, DESCRIPTION, COMMON EXAMPLES

1. Infectious Agent (bacteria, viruses, fungi, parasites, protozoa)
● Are microbes capable of producing a disease. The number of
organisms affect their ability to cause a disease, as well as the
susceptibility of the host.

2. Reservoir (human, animal, nonliving)

● The reservoir of the infection can be a human, animal, plant, the soil, or
other substances where an infection agent lives and multiplies until it
can infect a susceptible host.
3. Portal of Exit (secretion, excretion)

26
 ● The route in which the organism leaves the reservoir. It usually
corresponds to the site where the agent is localized.
4. Mode of Transmission (contact, mechanical, vertical)
● The means by which the infectious agent passes from the portal of exit
from the reservoir to the susceptible host. This is the easiest link to
break in the chain of infection.
5. Portal of Entry (GIT, GUT, integumentary)
● The venue where the organism infiltrates the susceptible host. The
infective microbes use the same avenues when they exit from the
reservoir. Controlling the portal of entry involves maintaining the
integrity of the protective tissues of the host.
6. Susceptible Host (individual)
● Refers to an individual who has the potential to contact an infection.
The human body has many defenses against the entry and
multiplication of microorganisms. When the host’s defenses are good,
infection will not take place; otherwise, the microbes can cause an
infectious disease.

● DISCUSS: UNIVERSAL AND ISOLATION PRECAUTIONS WITH EXAMPLES

● 10 BACTERIAL & 10 VIRAL DISEASES (6 LINKS WITH SIGNS AND SYMPTOMS)
○ Bacterial Diseases
■ Tuberculosis
■ Leprosy
■ Tetanus
■ Leptospirosis
■ Pneumonia
■ Cholera
■ Botulism
■ Pseudomonas Infection
■ MRSA Infection
■ E.Coli Infection

○ Viral Diseases
■ Dengue
■ Yellow Fever
■ Ebola
■ Gastroenteritis
■ Influenza
■ Varicella
■ HIV/AIDS
■ Viral Hepatitis
■ Human Papilloma (HPV)
■ M Infectious Mononucleosis

27
 ● COLOR CODING OF HOSPITAL WASTE WITH PICTURES
https://doh.gov.ph/sites/default/files/publications/Health_Care_Waste_Management_Manual.pdf

COLOR CODING (DOH) PICTURE

Black - Non-infectious dry waste.

Green - Non-infectious wet waste (kitchen,

dietary, etc.)

Yellow - Infectious & Pathological waste.

Yellow with Black Band - Chemical waste

including those with heavy metals.

Orange - Radioactive waste

Red - Sharps and pressurized containers.

● CURRENT/NEW CASES, UPDATES ABOUT COMMUNICABLE DISEASES, ETC.

https://www.w ho.int/emergencies/diseasep-outbreak-new

ORTHO
● STAGES OF BONE HEALING
1. Hematoma Formation - the blood vessels in the injured bone and surrounding
periosteum are damaged, a hematoma forms. The hematoma forms a clot which
consists of fibrous proteins that stops the bleeding. The tissues arounds the bone
often become inflamed and swollen.
2. Callus Formation - The internal callus forms between the ends of the bones, as well
as in the marrow cavity if an injury occurs in the diaphysis of a long bone. The

28
 external callus forms a bone - cartilage collar around the opposing ends of the bone
fragments that stabilizes the ends of the broken bone.
3. Callus Ossification - Woven, spongy bone replaces the internal and external
calluses which further stabilizes the broken bone.
4. Bone Remodeling - Compact bone replaces woven bone, and part of the internal
callus is removed, restoring the medullary cavity. While the external callus is reduced
in size by osteoclast activity.

● TYPES OF FRACTURES

TYPES OF FRACTURES, DESCRIPTION, PICTURES

AND THEIR CAUSES

Complete Fracture - Involves a break across

the entire cross-section of the bone and is
frequently displaced (removed from its normal
position).

Causes:
- Accidental injury
- Falls from high elevations
- Falls on ice
- Overuse such as in sports
- Osteoporosis - which weakens bones
- Metabolic diseases and deficiencies in
certain nutrients

29
Incomplete Fracture - (e.g., greenstick
fracture) involves a break through only part of
the cross-section of the bone.

Causes:
- Commonly occur with a fall
- Results from the bending of a bone.
Any force that bends a long bone, such
as an arm or leg bone, without fully
breaking it.

Comminuted Fracture - One that produces

several bone fragments.

Causes:
- Trauma
- Car accidents
- Falls from great height

30
Closed Fracture (Simple Fracture) - One that
does not cause a break in the skin.

Causes:
- Result of direct blow by high-energy
trauma of an outside force on the bone.

Open Fracture (Compound/Complex) - One

in which the skin or mucous membrane
extends to the fractured bone.

Causes:

31
 ● TYPES OF CASTS
Cast - Rigid external immobilizing device molded to contours of body part.
TYPES OF CASTS, DEFINITION, AND PICTURES
INDICATION/S

Short-arm Cast - Extends from below to the

palmar crease, secured around the base of the
thumb. If the thumb is included, it is known as a
thumb spica or gauntlet cast.

Indication/s:
- Torus fractures of the radius and ulna
- Nondisplaced Salter-Harris type I
fractures of the distal radius (may be
clinical rather than a radiographic
diagnosis)
- Clinically suspected scaphoid
(navicular) fractures (thumb spica cast)

Long-arm Cast - Extends from the axillary fold

to the proximal palmar crease. The elbow
usually is immobilized at a right angle.

Indication/s:
- Mid to proximal forearm fractures
- Elbow fractures
- Dislocations, distal humeral fractures

Short-leg Cast - Extends from below the knee

32
to the base of the toes. The foot is flexed at a
right angle in a neutral position.

Indication/s:
- Minor fibula fractures (including
suspected Salter-Harris type I fractures
of the distal fibula)
- Toddler’s fractures
- Severe ankle sprains
- Stable fractures of metatarsals
- Fractures of the mid- and hindfoot

Long-leg Cast - Extends from the junction of

the upper and middle third of the thigh to the
base of the toes. The knee may be slightly
flexed.

Indication/s:
- Reduced tibial fractures
- Nondisplaced supracondylar fractures
of the femur

Walking Cast - A short- or long-leg cast

reinforced for strength.

Indication/s:
- Most often used in the treatment of
injuries or conditions impacting the
ankle or the calf.

33
 Body Cast - Encircles the trunk.

Indication/s:
- Treating disorders of the cervical,
thoracic, and lumbar spine such as
fractures and scoliosis, or it may be
applied following some types of surgery
on the spine.

Shoulder Spica Cast - A body jacket that

encloses the trunk, shoulder, and elbow.

Indication/s:
- Indicated in patients who are
hemodynamically unstable and in whom
internal or external fixation is not
possible.

Hip Spica Cast - Encloses the trunk and a

lower extremity. A double hip spica cast
includes both legs.

Indication/s:
- Broken bone in the pelvis, hip, or thigh
- Undergo surgery for hip dysplasia or
Perthes disease

● TYPES OF TRACTION
○ Definitions
○ Indication
○ pictures
TRACTION - the application of a pulling force to a part of the body that is used to:
→ minimize muscle spasms
→ reduce, align and immobilize fractures
→ reduce deformity
→ increase space between opposing surfaces.

34
 TYPES OF TRACTIONS, DEFINITION, AND PICTURES
INDICATION/S

Straight or running traction - applies the

pulling force in a straight line with the body part
resting on the bed.

INDICATION:
→ lower extremity fractures

Balanced suspension traction - supports

affected extremity off the bed and allows some
patient movement without disruption of the line of
pull

INDICATION:
→ some types of femur fractures

Manual traction - traction that can be applied

with the hands that is used to improve neck and
low back mobility, range of motion and overall
function.

INDICATION:
→ minimal neck and back pain

SKIN TRACTION
→ used to control muscle spasms
→ to immobilize an area before surgery

35
Buck’s extension traction - unilateral/bilateral
skin traction to the lower leg that

INDICATION:
→ Immobilize fractures of the proximal femur
before surgical fixation

Cervical head halter - a cloth, halterlike sling for

traction of the neck that can be applied when a
patient is sitting or lying down, continuously or
intermittently.

INDICATIONS:
→ Minor neck injuries without obvious fractures
→ Neck muscle spasm
→ Conservative treatment of cervical disk lesions

Pelvic belt - uses a girdle - like belt attached

around the abdominal/ lumbosacral area to
stabilize the pelvis and is popular among women
as a tool to prevent changes in pelvic alignment
in addition to reduce lumbopelvic pain

INDICATIONS:
→ treat back pain
→ muscle spasms
→ relieve lumbar and pelvic pain

SKELETAL TRACTION

36
→ applied directly to the bone
→ to treat fractures of the femur, tibia, and cervical spine

Lumbar Traction - process of applying a

stretching force to the lumbar vertebrae through
body weight, weights and/or pulleys to distract
individual joints of the lumbar spine

INDICATIONS:
→ treat herniated discs, sciatica, degenerative
disc disease, pinched nerves and many other
back conditions
→ relieves pressure on the spine

Dunlop’s Traction - a traction is placed along the

axis of the forearm at right angle to the humerus
by means of a broad sling placed around the
upper arm.

INDICATION:
→ reduction in supracondylar fractures of the
humerus in children

Halo Traction - there is a metal hollow attached

to the skull via pins. May be ambulatory and the
patient may need assistance with balance.

INDICATIONS:
→ cervical or high thoracic vertebrae fractures or
dislocations
→ postoperative immobilization after cervical
fusion

● CAST CARE (HOME MANAGEMENT)

○ DO NOT submerge or hold cast in water for a long time even if it is water resistant
○ Take a short bath/ shower to avoid casts from being wrapped for too long as this
might cause sweat
○ Keep the cast away from dirt, sand or powder
○ Do not pull out the padding from the cast
○ Do not put any powder or deodorants to itching skin
○ Do not break off the rough edges of the cast or trim the cast before asking a doctor

37
 ○ Inspect the skin around the cast. If itching and shows redness around the cast,
contact a doctor
○ Inspect cast regularly to check any cracks or soft spots
● TRACTION CARE (NURSING RESPONSIBILITIES)
○ Before
○ During
○ After
https://nurseszone.in/nurseszone/nursing-management-of-patients-in-traction/52.html
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Skin_traction/
Nursing Management of Patients in Traction
NEURO & ICU
● GLASGOW COMA SCALE2
○ Importance - Assessing the patient’s response to tactile stimuli (if unconscious),
pupillary response to light, corneal and gag reflexes, and motor function.
○ Components: Eye, Verbal and Motor Responses
■ There were three components of the GCS: eyes (four), fingers (two), thumb
(three), thumb pointer (one), finger pointing (two), and incomprehensible
sounds.
■ There is a GCS that can objectively rate whether or not the patient has a
degree of impaired consciousness when acute medical and trauma occurs.
Psychosocial responsiveness measures eye openings, motor coordination,
and verbal abilities, such as how responsive a person is.
○ Scoring
x
○ Interpretation
■ A GCS of 8 or less indicates a severe injury that has dramatically affected the
person’s state of consciousness.
■ Scores between 9 and 12 indicate a moderate injury but are also normal
scores in a recovery ward.
■ Minor injuries rarely score less thtan 13 on a Glasgow Coma Scale
assessment.

● PUPILLARY ASSESSMENT
○ Importance - Papillary assessment is an important part of neurological assessment
because the changes in size, equity and reactivity of pupils can show vital diagnostic
information of the patient.
○
●

ADULT CHILDREN

38
Pupillary Size: Pupillary Size:

Equality: Equality:

Reactivity: Reactivity:

● CRANIAL NERVE ASSESSMENT

○ Tabular format: 12 Cranial Nerves - Methods/ Techniques of Assessment,
Abnormal and Normal Findings, Nursing Responsibilities (B,D,A)

CRANIAL NERVE TYPE FUNCTION

I (Olfactory) Sensory Carries smell impulses from the nasal mucous

membrane to the brain.

II (Optic) Sensory Visual acuity and visual fields from eye to brain.

III (Oculomotor) Motor Muscles that move the eye and lid, pupillary
constriction, lens accommodation.

IV (Trochlear) Motor Controls lateral eye movements.

V (Trigeminal) Mixed Facial sensation, corneal reflex, mastication.

VI (Abducens) Motor Muscles that move the eye.

VII (Facial) Mixed Facial expression and muscle movement, salivation

and tearing, taste, sensation in the ear.=

VIII (Acoustic) Sensory Hearing and equilibrium.

IX (Glossopharyngeal) Mixed Taste, sensation in pharynx and tongue,

pharyngeal muscles, swallowing.

X (Vagus) Mixed Muscles of pharynx, larynx, and soft palate;

sensation in external ear, pharynx, larynx, thoracic
and abdominal viscera; parasympathetic
innervation of thoracic and abdominal organs.

XI (Spinal Accessory) Motor Sternocleidomastoid and trapezius muscles.

XII (Hypoglossal) Motor Movement of the tongue.

39
 yGUIDELINES FOR ASSESSING CRANIAL NERVE FUNCTION
Equipment
General
● Examination gloves
Cranial Nerve Examination
● Cotton-tipped applications
● Newsprint to read
● Ophthalmoscope
● Paper clip
● Penlight
● Snellen chart
● Sterile cotton ball
● Substances to smell or taste such as soap, coffee, vanilla, salt, sugar, lemon juice
● Tongue depressor
● Tuning fork
Motor and Cerebellar Examination
● Tape Measure

Sensory Examination
● Cotton ball
● Objects to feel such as a quarter or key
● Paper clip
● Test tubes containing hot and cold water
● Tuning fork (low-pitched)

Reflex Examination
● Cotton-tipped applicator
● Reflex (percussion) hammer

ASSESSMENT PROCEDURE NORMAL & ABNORMAL FINDINGS

CN I (Olfactory): Normal Findings: Client correctly identifies

1. For all assessments of the cranial nerves,
have the client sit in a comfortableb position at
your eye level.
Ask the client to clear the nose to remove any
mucus, then to close eyes, occlude one nostril,
and identify a scented object that you are
holding such as soap, coffee, or vanilla. Repeat
procedure for the other nostril.
scent presented to each nostril.
**Some older clients’ sense of smell may be
decreased.
Abnormal Findings: Inability to smell
(neurogenic anosmia) or identify the correct
scent may indicate olfactory tract lesion or
tumor or lesion of the frontal lobe. Loss of smell
may also be congenital or due to other causes

40
 such as nasal or sinus problems. It may also be
caused by injury of nerve tissue at the top of
the nose or the higher smell pathways in the
brain due to viral upper respiratory infection.
Smoking and use of cocaine may also impair
one’s sense of smell.

CN II (Optic): Normal Findings: Client has 20/20 vision OD

a. Use a Snellen chart to assess vision in each
eye.
(right eye) and OS (left eye).
Abnormal Findings: Abnormal findings include
difficulty reading Snellen charts
, missing letters, and squinting.

CN II (Optic): Normal Findings: Client reads print at 14

b. Ask the client to read a newspaper or
magazine paragraph to assess near vision. inches without difficulty.

Abnormal Findings: Client reads print by

holding closer than 14 inches or holds print
farther away as in presbyopia, which occurs
with aging.

CN II (Optic): Normal Findings: Full visual fields.

c. Assess visual fields of each eye by
confrontation.
Abnormal Findings: Loss of visual fields may
be seen in retinal damage or detachment, with
lesions of the optic nerve, or with lesions of the
parietal cortex.

CN II (Optic): Normal Findings: Round red reflex is present,

d. Use an ophthalmoscope to view the retina optic disc is 1.5 mm, round or slightly oval,
and optic disc of each eye. well-defined margins, creamy pink with pear
physiologic cup. Retina is pink.

Abnormal Findings: Papilledema (swelling of

the optic nerve) results in blurred optic disc
margins and dilated, pulsating veins.
Papilledema occurs with increased intracranial
pressure from intracranial hemorrhage of a

41

CN III (Oculomotor), CN IV (Trochlear), and VI
(Abducens):
a. Inspect margins of the eyelids of each eye.
CN III (Oculomotor), CN IV (Trochlear), and VI
(Abducens):
b. Assess extraocular movements. If
nystagmus is noted, determine the direction of
the fast and slow phases of movement.
brain tumor. Optic atrophy occurs with brain
tumors.
Normal Findings: Eyelid covers about 2 mm of
the iris.
Abnormal Findings: Ptosis (drooping of the
eyelid) is seen with weak eye muscles such as
in myasthenia gravis.
Normal Findings: Eyes move in a smooth,
coordinated motion in all directions (the six
cardinal fields).
Abnormal Findings: Some abnormal eye
movements and possible causes follow:
● Nystagmus (rhythmic oscillation of the
eyes): cerebellar disorders
● Limited eye movement through the six
cardinal fields of gaze: increased
intracranial pressure.
● Paralytic strabismus: paralysis of the
oculomotor, trochlear, or abducens
nerves.
42
CN III (Oculomotor), CN IV (Trochlear), and VI
(Abducens):
c. Assess pupillary response to light (direct and
indirect) and accommodation in both eyes.
CN V (Trigeminal):
a. Test motor function. Ask the client to clench
the teeth while you palpate the temporal and
masseter muscles for contraction.
CN V (Trigeminal):
b. Test sensory function. Tell the client: “I am
going to touch your forehead, cheeks, and chin
with the sharp or dull side of this paper clip.
Please close your eyes and tell me if you feel a
sharp or dull sensation. Also tell me where you
feel it.
Vary the sharp and dull stimulus in the facial
areas and compare sides. Repeat test for light
touch with a wisp of cotton.
Normal Findings: Bilateral illuminated pupils
constrict simultaneously. Pupil opposite the one
at illuminated constricts simultaneously.
Abnormal Findings: Some abnormalities and
their implications follow:
● Dilated pupil (6-7 mm): oculomotor
nerve paralysis.
● Argyll Robertson pupils: CNS syphilis,
meningitis, brain tumor, alcoholism.
● Constricted, fixed pupils: narcotics
abuse or damage to the pons.
● Unilaterally dilated pupil unresponsive
to light or accommodation: damage to
cranial nerve III (oculomotor).
● Constricted pupil unresponsive to light
or accommodation: lesions of the
sympathetic nervous system.
● Bilateral muscle weakness is seen with
peripheral or central nervous system
dysfunction.
Normal Findings: Temporal and masseter
muscles contract bilaterally.
Abnormal Findings: Decreased contraction in
one of both sides. Asymmetric strength in
moving the jaw may be seen with lesion or
injury of the 5th cranial nerve.
Pain occurs with clenching of the teeth.
Normal Findings: The client correctly identifies
sharp and dull stimuli and light touch to the
forehead, cheeks, and chin.
Abnormal Findings: Inability to feel and
correctly identify facial stimuli occurs with
lesions of the trigeminal nerve or lesions in the
spinothalamic tract or posterior columns.
43
**To avoid transmitting infection, use a new
object with each client. Avoid “stabbing” the
client with the object’s sharp side.

CN V (Trigeminal): Normal Findings: Eyes blink bilaterally.

c. Test corneal reflex. Ask the client to look Abnormal Findings: Absent corneal reflex
away and up while you lightly touch the cornea may be noted with lesions of the trigeminal
with a fine wisp of cotton. Repeat on the other nerve or lesions of the motor part of cranial
side. nerve VII (facial).

**Reflex may be absent or reduced in clients

who wear contact lenses.

44
CN VII (Facial): Normal Findings: Clients smiles, frowns,
wrinkles forehead, shows teeth, puffs out
a. Test motor function. Ask the client to: cheeks, purse lips, raises eyebrows, and closes
● Smile eye against resistance. Movements are
● Frown and wrinkle forehead symmetric.
● Show teeth
● Puff out cheeks Abnormal Findings: Inability to close eyes,
● Purse lips wrinkle forehead, or raise forehead along with
● Raise eyebrows paralysis of the lower part of the face on the
● Close eyes tightly against resistance affected side is seen with Bell’s palsy (a
peripheral injury to cranial nerve VII [facial]).
Paralysis of the lower part of the face on the
opposite side affected may be seen with a
central lesion that affects the upper motor
neurons, such as from stroke.

45
CN VII (Facial): Normal Findings: Client identifies correct
flavor.
b. Sensory function of CN VII is not routinely
tested. If testing is indicated, however, touch **In some clients, the sense of taste may be
the anterior two-thirds of the tongue with a decreased.
moistened applicator dipped in salt, sugar, or
lemon juice. Abnormal Findings: Inability to identify correct
flavor on anterior two-thirds of the tongue
Ask the client to identify the flavor. If the client suggests impairment of cranial nerve VII
is unsuccessful, repeat the test using one of the (facial).
other solutions. If needed, repeat the test using
the remaining solution.

**Make sure that the client leaves the tongue

protruded to identify the flavor. Otherwise, the
substance may move to the posterior third of
the tongue (vagus nerve innervation). The
posterior portion is tested similarly to evaluate
functioning of cranial nerves IX and X. The
client should rinse the mouth with water
between each taste test.

CN VIII (Acoustic/Vestibulocochlear): Normal Findings: Client hears whispered

Test the client’s hearing ability in each ear and
perform the Weber and Rinne tests to assess
the cochlear (auditory) component of cranial
nerve VIII.
words from 1-2 feet.
Weber Test: Vibration heard equally well in both
ears.
Rinne Test: AC>BC (air conduction is twice as

**The vestibular component, responsible for Abnormal Findings: Vibratory sound

equilibrium, is not routinely tested. In comatose lateralizes to good ear in sensorineural loss. Air
clients, the test is used to determine integrity of condition is longer than bone conduction, but
the vestibular system. not twice as long, in a sensorineural loss.

CN IX (Glossopharyngeal) and CN X (Vagus):
a. Test motor function. Ask the client to
open mouth wide and say “ah” while
you use a tongue depressor on the
client’s tongue.
Norm\al Findings: Uvula and soft palate rise
bilaterally and symmetrically on phonation.
Abnormal Findings: Soft palate does not rise
with bilateral lesions of cranial nerve X (vagus).
Unilateral rising of the soft palate and deviation
of the uvula to the normal side are seen with a
unilateral lesion of cranial nerve X (vagus).

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CN IX (Glossopharyngeal) and CN X (Vagus):
b. Test the gag reflex by touching the
posterior pharynx with the tongue
depressor.
**Warn the client that you are going to do this
and that the test may feel a little uncomfortable.
CN IX (Glossopharyngeal) and CN X (Vagus):
c. Check the client’s ability to swallow by
giving the client a drink of water. Also
note the client’s voice quality.
CN XI (Spinal Accessory):
a. Ask the client to shrug the shoulders
against resistance to assess the
trapezius muscle.
CN XI (Spinal Accessory):
b. Ask the client to turn the head against
resistance, first to the right then to the
left, to assess the sternocleidomastoid
muscle.
CN XII (Hypoglossal):
To assess strength and mobility of the tongue,
ask the client to protrude tongue, move it to
each side against the resistance of a tongue
depressor, and then put it back in the mouth.
Normal Findings: Gag reflex intact. Some
normal clients may have a reduced or absent
gag reflex.
Abnormal Findings:An absent gag reflex may
be seen with lesions of cranial nerve IX
(glossopharyngeal) or X (vagus).
Normal Findings: Client swallows without
difficulty. No hoarseness noted.
Abnormal Findings: Dysphagia or hoarseness
may indicate a lesion of cranial nerve IX
(glossopharyngeal) or X (vagus), or other
neurologic disorder.
Normal Findings: There is symmetric, strong
contraction of the trapezius muscles.
Abnormal Findings: Asymmetric muscle
contraction or drooping of the shoulder may be
seen with paralysis or muscle weakness due to
neck injury or torticollis.
Normal Findings: There is strong contraction
of sternocleidomastoid muscle on the side
opposite the turned face.
Abnormal Findings: Atrophy with
fasciculations may be seen with peripheral
nerve disease.
Normal Findings: Tongue movement is
symmetric and smooth, and bilateral strength is
apparent.
Abnor mal Findings: Fasciculations and
atrophy of the tongue may be seen with
peripheral nerve disease. Deviation to the
affected side is seen with a unilateral lesion.
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NURSING RESPONSIBILITIES (B,D,A)

● NEUROVASCULAR ASSESSMENT
○ Tabular format: 5 Ps + edoma and temperature - Methods/ Techniques of
assessment, abnormal and normal findings

○
● ELECTROENCEPHALOGRAM (EEG)
○ Importance
○ Nursing considerations
■ Before
■ During
■ After
○ Diagnostic tests

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