NCMB 316 RLE

Level of Consciousness (LOC) • Assess ability to hear spoken words &

Auditory /
• Awareness vibration of tuning fork
Acoustic /
• Arousal 8 • Weber test ; tuning fork on top (ask if
Vestibulo-
any vibration felt)
cochlear
Glasgow Coma Scale (GCS) Rinne test ; mastoid process
• Mild 13 – 15 • Upside down tongue
• Mod 9 – 12 • Ask to move tongue side to side, up,
Glosso-
• Severe 3 – 8 9 down
pharyngeal
• Tongue depressor ; gag reflex
Eyes Verbal Motor • Sensory ; taste on posterior 1/3
1 None None None / flaccid • Ask to swallow ; note swallowing &
Extending 10 Vagus vocal cord movement
2 To pain Incoherent
(Decerebrate) • Assess hoarseness
Inappropriate Flexing • Sternocleidomastoid muscle
3 Stimu to voice
words (Decorticate) Spinal • Move head against resistance of hand
11
4 Spontaneous Confused Withdraw fr pain accessory • Shrug shoulder → observe & palpate
5 Oriented Localized pain contraction
6 Obeys commands • Push tongue to side of mouth against
12 Hypoglossal resistance applied to cheek
• Observe asymmetry, deviation
Cranial Nerves
• Olfactory 1 
Pure sensory • Optic 2 Occulus dexter right eye
• Acoustic 8 Occulus sinister left eye
• Oculomotor 3
• Trochlear 4
Pure motor CN • Abducens 6 Cerebellar fxn assessment
• Spinal accessory 11 1. Identify pt
• Hypoglossal 12 2. Explain procedure
3. Finger to nose test ; most popular test for coordination
• Trigeminal 5
• Dysmetria ; missing the mark
• Facial 7
Mixed fxn 4. Rapid alternating of hand movement
• Glossopharyngeal 9
• Dysdiadochokinesia
• Vagus 10
5. Rapid alternating of fingers
• Dysdiadokinesia
Assessing CN
6. Heel to shin test
• Present diff. odors
1 Olfactory • Cerebellar dysfxn
• Eyes closed
7. Romberg test
• Snellen chart / jaeger card ; 14 inches • Pt stand up & close his eyes
away fr pt’s eye • Loss of balance ; (+) Romberg test
• Test visual fields ; peripheral vision • = Vestibular dysfxn
2 Optic
• Ophthalmoscope – check optic disk 8. Tandem gait
 flame shaped hemorrhage = HPN ; • Toe of 1st foot touch the heel of next 1 per step
yellowish spots = cholesterol/DM • Assess balance
• Check size & shape pupils • Truncal ataxia
3 Oculomotor • Outside to inner 9. Documentation
• Penlight • Assessed in pt
4 Trochlear
• Forehead, cheek, chin ; sterile Brainstem reflex
5 Trigeminal
pin/toothpick 1. Oculo-cephalic reflex (OCR)
• Eval 6 cardinal positions of gaze ; note • Reflex eye movement during head movement
nystagmus (uncontrollable movement) • (-) doll’s eye ; severe brain dmg
6 Abducens
• Middle → upper right → back to middle • (+) doll’s eye ; eyes move opposite to head
→ middle right → lower movement
• Assess symmetry of facial movements 2. Caloric reflex test
7 Facial • Sensory ; ask to identify flavors on ant. • Cold, Opposite, Warm, Same ; Nystagmus
2/3 of tongue • Cold in ear → opposite direction ; abnormal

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 NCMB 316 RLE

Deep Tendon Reflex (DTR) Normal Abnormal

• Sites ; Bi- & tri-ceps, brachioradialis, patellar, achilles • Scaphoid ; concave
Process: • Proturbent
1. Identify pt Contour • Flat, round
• Distended ; measure
2. Explain procedure girth
3. Biceps reflex ; forearm flex at elbow Movement & • Slight aortic • (-) ab. resp & vigorous
4. Triceps ; forearm extension pulsation pulsation pulsation
5. Brachioradialis ; flexion & supination of forearm,
Peristaltic
6. Patellar ; knee extension • Not visible • Visible
waves
7. Achilles ; dorsiflexion of foot, slight jerking of foot
• Lighter than • Purple, yellow, pale,
8. Documentation Color
general skin tone redness, bruises
Striae • Old, silvery, white • Red
Reflex Grade
Bowel • “borborygmi” ; • Hypo-/hyper-active
0 Absent
sounds stomach growling • (-)
+1 Hypoactive
Vascular
+2 Normal • (-) bruits • (+) bruits
sounds
+3 Hyperactive without clonus
• Tympany • Hyer-resonance
+4 Hyperactive with clonus
Tone • Dullness ; spleen enlarged area of
+5 Sustained clonus
& liver dullness
• Midclavicular line ;
6 – 12 cm
Abdomen Liver ht. • > hepatomegaly
 Terms • Midsternal line ; 4
Constipation – 8 cm
• Passage of hard stool, no passage for a period of time • @ costovertebral • (+) pain after strike =
Kidney
Obstipation angles rebound tenderness /
percussion
• Hardened undigested in colon • (-) tenderness blumberg’s sign
Fecal impaction
• Hardened feces in folds of rectum Dorsal recumbent position – before procedure
Hematochezia Supine – procedure
• Stool w/bright red bld ; lower GI bleeding
Steatorrhea Auscultation direction
• Greasy, fatty foul smelling stool ; d/t fat • RLQ → RUQ → LUQ → LLQ
Dysphagia
Percussion direction
• Diff. swallowing
Odynophagia • LLQ → RLQ → RUQ → LUQ
• Painful swallowing
Satiety
Rehabilitation
• Feeling of having had eaten enough
• Health-oriented process ; assists ill person / w/disability
Grey turner’s sign
• To achieve greatest possible lvl ; physical, mental,
• Ecchymosis in flank
spiritual, social & economic fxning
Cullen’s sign
• Ecchymosis in around peri-umbilical
Nursing considerations
• Physical
Tests for Appendicitis
• Psychological
• Blumberg’s sign ; rebound tenderness
• Coordination
• Rovsing’s ; RLQ pain during LLQ pressure
• Safety
• Psoas ; RLQ pain (raising R leg fr hip while applying
pressure on lower thigh) • Resources
• Obturator ; RLQ pain (hip & knee flexed & legs rotated
Assistive Devices
internally)
1. Wheelchair
2. Walker
3. Crutches
4. Cane

Psoas sign Obturator sign • “Mechanical aids”

• Any equipment ; improve fxnal capabilities of indiv
w/disabilities
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 NCMB 316 RLE

Walker Types of Crutches

Purposes Underarm /
• Maintain balance Loftrand Platform
Axillary
• Prov. +al, supp ; wide area of contact w/flr
• Allow ambulatory independence
• (+) – very stable mobility aid
• (-) – bulky, can’t be used in small areas, crowded places

Types of Walker
Pick-up Walker Rolling Walker
Parts

 ht of pt’s arm on walker hand grip ; 20 – 30˚ flexion at elbows

Demo
Getting up
• Both hands on armrest of chair → push yourself up →
standing → grab walker Demo
Crutch stance
Sitting
• Tripod position ; 4 inches anteriorly 6 inches laterally
• Reach both hands to chair → back grasp armrest → sit
• Ht adjusted accdg to pt’s ht
carefully
Four-point gait
Walking
• Weakness in both legs/poor coordination
• Affected side 1st ; walker → bad side (affected) → good
• Ppl w/polio, arthritis, cerebral palsy
• Most stable ; (-) slowest
Stairs
• L crutch → R leg (bad) → R crutch → L leg (good)
Going up • Fold walker → turn sideways (beside bad leg),
• R crutch → L leg (bad) → L crutch → R leg (good)
good side (railings)
Good 1st • Walker → good → bad
3-point gait
Going down • Fold walker → turn sideways (beside bad leg), • Involvement of 1 extremity
good side (railings) • Lower extrem. fracture, amputation
Bad 1st • Walker → bad → good •  Must be able to bear entire body wt on unaffected
• Both crutch + bad leg → good

Crutches
2-point gait
Purposes
• Most difficult ; req more balance
• Supp body wt, assist weak muscles, prov joint stability
• Progression of 4-point gait, resembles normal walking
• Relieve pain
• R crutch + L leg (bad) → L crutch + R leg
• Prev further injury & prov improvement of fxn
• Allow greater independence Tripod gait
• Both leg affectation ; paraplegic pt
Types of Crutch Walking
• Learning to swing
NWB Non weight bearing • Separate crutches → both legs
TDWB / Touch down wt bearing / • R crutch → L crutch → drag both legs
TTWB Toe touch wt bearing
Swing-to gait
PWB Partial wt bearing
• Limited use of lower extrem & trunk instability
WBTT / Wt bearing to tolerance / • Both crutch → both legs
FWB Full wt bearing
Swing-through gait
•  not safe as swing-to ; fastest gait pattern
• Both crutch → both legs pass thru crutch
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 NCMB 316 RLE

Cane Demo
• Pt w/greater balance & supp • Assist pt w/grasping trapeze → slide 1 arm
• Types under thighs & 1 arm under trunk
• 1 tip
• Quad cane
•  rubber caps ; prev slipping
• Handle of cane ; lvl of greater trochanter, 30˚ elbow flexion
w/ trapeze
Demo
Walking
• Cane on good leg • Pt lift w/trapeze &/ push w/feet on count of 3
• Cane + good leg → bad leg • Ask abt lvl of comfort & adjust (if necessary)

Stairs
• Maintain neck & spinal alignment ff injury/surg
• Cane on good leg, other hand on handrail
Going up • ↓er head of bed ; as pt can tolerate
• Good leg → bad leg + cane
• Place pillow bet. legs ; use of pull sheet bet.
• Cane on good leg shoulders & knees can faci turning
Going down
• Cane → bad leg → good leg • Cross pt’s arms on chest
Logrolling
• Position ; 2 nurses on side where pt will be
Wheelchair turned, 1 nurse on other side
• Roll pull sheet
• Count of 3 ; turn pt w/smooth, coord. effort

• Assess pt ; presence of paralysis

• ↓er bed to wheelchair ht
• Lock wheel of bed
• Wheelchair → unaffected side
• Lock brakes → raise foot & leg supp.
• Give hearing aids / glasses
Bed →
 Notes: • Take BP ; orthostatic HPN
Wheelchair
• Check brakes time to time (loosen over time) (Hemiplegic) • Pt’s hands on your shoulder → Assist to sit
• Use brakes before leaning/bending forward • Give slippers
•  lean more than length of armrests • Pt’s hand on your shoulders → move to
• Choose smooth path wheelchair w/good body mechanics (pt’s legs
• Assistance is must in bet. yours)
• Power chair ; adjust speed you can easily handle • Position pt comfortably
•  greasy surface
• Curbs ; anti-tip bar Doors • Caregiver 1st before wheelchair
Ramps • Going down ; caregiver 1st
Transferring client
Assess before moving Types of Paralysis
• Physical abilities (muscle strength, presence of paralysis, Hemiplegia – 1 side of body affected
skin traction, cast extremities) Diplegia – both sides ; both legs than arms
• Ability of client to understand instruction Monoplegia – 1 limb affected ; arm
• Client’s wt Triplegia – 3 limbs ; both arms & a leg
• Medications client’s receiving Quadraplegia – 4 limbs
• Own strength & ability to move client

 observe proper body mechanics Traction

• Pulling/drawing asso. w/counter traction ; reduce fracture
Prep → re-align fractured
1. Greet & identify pt • Skeletal, Skin, Manual
2. Explain
3. Adjust position ; IV pole, tubes, catheter Purposes
4. Prov hearing aid & glasses ; if used • Relieve pain ; relieve muscle spasm
5. Head of bed to ↓est. Lock wheels. Pillows near headboard • Prev / correct deformity
6. Assist pt ; supine w/knees flexed (soles flat on bed) • ↓ / immobilize fracture

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 NCMB 316 RLE

Principles • Distal
• Position ; supine (line of pull = line w/deformity) • Used when strong force needed
•  friction
• Allow wt hang freely ;  rest on bed flr • Perkin’s
• Skeletal ; never interrupted • Fracture ; shaft
• Continuous to be effective • Tx of tibia, femur fr subtrochanter region & distally
• Ropes unobstructed • Trochanteric of femur, ↓ 45 – 50 y/o
• Knots in rope  touch pulley • Denham pin inserted thru upper end of tibia for # of
femur, mid tibia for # of condyles of tibia
Types of Traction
Skeletal
• More pulling ; 25 – 40 lbs.
• Reqs. tongs, pins, screws ; weight directly to bone
• Invasive ; under GA, RA, LA (anesthesia)
• Compli • Distal tibial
• Pressure ulcer, constipation, urinary stasis, • Certain tibial plateau
pneumonia, anorexia, infection, venous stasis w/DVT •  saphenous vein
• Place thru fibula ;  peroneal nerve
Interventions • Maintain partial hip & knee flexion
• Maintain effective traction
• “ position • Balance Skeletal Traction (BST)
• Prev skin breakdown
• Monitor neurovascular status
• Prov. pin site care

Types of Skeletal Traction

• Cervical skeletal traction
• Gardner-Wells tongs
• Commonly used ; less likely to pull out of place
than Crutchfield tongs
• Holes drilled to sides of skull
Parts of Balkan Frame / Orthopedic Bed:
• Traction ; stabilize cervical spinal cord
• 4 vertical bars, 2 horizontal bars, 3 cross bars
• Pt ; immobile until injury heals
• Pulleys
• Hanging trapeze
• Firm mattress
• Fracture board
• Suspension bag ; 5% traction wt
• Traction bag w/wts ; 10% TBW
• Ropes ; Suspension (longest), Traction, Tie
• Halo device
Skin
• Temporary ; 5 – 7 lbs.
• Weights ; attached thru non-/adhesive tape w/straps, cuffs
•  invasive ; bedside
• Compli
• Skin breakdown, nerve pressure, circulatory
impairment
• Femoral • Ensure effective traction, monitor & manage pot. compli
• Upper
• Acetabular fractures Types
• Buck’s traction / Extension
• Old children ; Femoral neck/shaft
• Undisplaced fracture (fractured but intact)
• Correct minor flexed deformities of hip/knee
• Can use tape/pre-made boot
•  > 4.5 kg &  to obtain/hold reduction (alignment)

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 NCMB 316 RLE

Manual
• Done by HC personnel/operator
• Prov very specific & controlled distraction force to joint/ext.

• Hamilton Russel Cast

• Buck’s w/sling ; in more distal femur fracture • Hard covering ; supp. fractured body part
• Can be modified → hip & knee exerciser • Stockinet → padding sheet → fiberglass / plaster

Purposes (CHIPSS)
C – correct deformity
H – hold broken bone in place as it heals
I – immobilize bone esp after surg
P – prev/↓ muscle contractions
• Bryant’s S – supp, maintain & realign bone
• Infant/small child ; femoral shaft fracture S – serve as mold of limb ; making artificial limb
• Gallows + Buck’s
• ↓ 18 mons. old ; stretch soft tissue, genital hip Casting Materials
dysplasia Plaster of Paris Synthetic (Fiberglass)
• Raise mattress, infant’s hips off bed ; 15˚ • Gypsum is precursor (Ca • Polymer resin
• Rarely used today sulphate dihydrate) • Moldable plastic
• White • Variety of colors
• Dries ; 1 – 3 days (shiny) • Dries ; 20 – 30 mins
• Lighter, cooler, waterproof

Characteristic of good cast

• White, shiny, odorless
• Forearm skin traction
• Light in wt
• Elevation any injury ; tx diff. clavicle fractures =
•  too tight / loose
excellent cosmetic result
• Resonant (percussion)
• Risk ; skin loss
• Adhesive strip w/ace wrap
Principles
• Stockinet & padding 1st before cast
• Apply cast ; inclu joint above & below affected
• “ circular motion & smoothen w/palm
• Supp palm  fingertips

Caring a cast while it dries:

• Dunlop’s • Keep cast uncovered to dry
• 5 – 7 y/o ; Supracondylar (elbow) & transcondylar • Check ; cracks/breaks
fractures / when closed reduction diff/traumatic • Always clean
• Elbow flexed 45˚ • Turn pt q 2 hrs
• Forearm skin traction w/wt on upper arm •  resting cast on hard surfaces / sharp edges
• Place plastic lining @ edge of cast (if near groin)

Health Teaching
• Keep cast always clean
• Report cracks/breaks
• Head Halter • Rough edges ; padded (protect fr irritations)
• Simple type cervical traction •  using any obj in scratching skin under cast
• Neck pain mgt • May use hairdryer ; relieve itchiness
•  > 2.3kg •  warm air
• Can only be used few hrs @ a time ; sitting/lying •  powder / lotion inside cast
• Cover cast while eating ; prev food spills fr entering
• Elevate cast on cloth-covered pillow above hrt lvl (↓ swell)
• Encourage pt → move fingers/toes ; prom circulation
•  abduction bar ; turning/lifting

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 NCMB 316 RLE

• Report alarming signs Bandage scissor Cut wadding sheet & stockinet
• Fever, Pain Trimming knife Smoothen edges of cast
• Swelling, Drainag, Discoloration Newspaper Protect the floor/area
• Numbness / tingling ; paresthesia Disposable gloves Protect the hands of operator
• Cold fingers / toes Pail of water @ room temp. To wet the cast
Used in bivalving, windowing &
Stryker cast cutter
Assessment removal of cast
Pain Cast spreader To widen a bivalve cast
• Ask pt if he feels any pain & if ↑ing
• Ask pain on passive extension
• Ask pt ; identify loc, character, intensity Types of Cast Location Uses
• Aggravating, relieving, precipitating factors Unilateral hip Thigh fractures ; hold
Chest to foot on 1 leg
• Mgt spica hip / thigh muscles &
• Elevate ; venous return Same as uni. but to tendons in place after
1 & ½ hip spica
• Cold packs knee of other leg surg
• Analgesic agents Chest to feet ; bar bet.
Bilateral long Pelvis, hip / thigh
• May indicate compartment syndrome (6 P’s) both legs (hips & legs
leg hip spica fracture
• Pain immobilized)
• Puffiness
• Pallor
• Paresthesia
• Paralysis
• Pulselessness
Circulatory fxn
• Assess capillary refill ; 1 – 2 sec.
Temperature Short leg hip Hold hip muscles &
• Warm to touch ; normal Chest to thighs / knees
spica tendons after surg
Neurologic
• Numbness / tingling
Tarsals & metatarsals
• Absence / diminished sensation Walking cast
w/callus formation
Infection
• Swelling above/below cast
• Foul odor, drainage, stain (mark circumference)
Massive bone injury
Basket cast
Cast techniques of patella
Bivalving
• Cutting cast into 2 halves ; relieve tightness
Patellar tendon
• Compartment syndrome Tibia-fibula w/callus
bearing

Windowing Quadrilateral /
• Put window @ site of open wound Ischial wt Femur shaft w/callus
• Visualization, dressing, med appli bearing

Reinforcing
• Reapplication ; regain strength
Pantalon Pelvis
Petalling the cast
• Pulled stockinet over cast & taped down ; if edges of cast
are rough & crumbling ; prev skin irritation
• Cut a tape ; 4 inch strips Delvit 3rd of tibia-fibula
• Place half inside of cast & pulled it over the top of cast
• Anchor remaining tape to outside of the cast Distal 3rd femur &
Cast brace
proximal 3rd tibia
Materials & Instruments Uses Cast in the Trunk & Neck
Plaster of Paris / Fiberglass Casting materials Lower dorso-lumbar
Body Encircles trunk
Stockinet Protect the skin spine
Wadding sheet/gauze Serve as padding

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 NCMB 316 RLE

Neck & trunk Morning Hyperglycemia

• Insulin Waning
Cervical & upper
Minerva • ↑ glucose fr bedtime → morning
dorsal spine
• ↑ evening dose or intermediate/long
• Dawn Phenomenon
• ↑ glucose @ 3am
Thoraco-lumbar spine • Delay time of evening intermediate insulin
Rizzer’s jacket Correct scoliosis (S- • Somogyi effect
shape) • ↓ 2 – 3 am ; ↑ after 3 am
• ↓ evening dose ↑ bedtime snack
Around trunk to
shoulder, arm, hand Upper portion of
Mixing
Shoulder spica humerus & shoulder
• Air → NPH
joint
• Air → regular → withdraw
• Reinsert needle → NPH → withdraw
Cervical Neck only (collar)
•  RI 1st ;  contaminated w/CHON of NPH
Delayed compli
Sliding Scale
• Malunion – heal incorrectly
• Fixed amounts
• Non-union – edges of broken bone  come together
• Delayed union – take longer to heal

Categories of Insulin
Agent Onset Peak Dur. Indication
Lispro 10 – 15 1 hr Post prandial
Rapid (Humalog) min hypergly &
acting 2–4 prev
Aspart 5 – 15 40 – 50 hr nocturnal
“-log” (Novolog) min min hypoglycemi
a
20 – 30 mins.
Short Regular
½-1 2–3 4–6 before meal ;
(Humalog R,
hr hr hr alone or
“R” Novolin R)
w/long acting
NPH 2 – 4 hr
Interme- 4 – 12 16 – 20 Taken after
Injection sites
diate Humulin N, 3 – 4 hr hr hr food Front / lateral thigh
Iletin II Lente) • Easy access & slower absorption ; longer-acting
Glargine Abdomen
Long
(Lantus)
1 hr
Cont.
24 hr
Basal dose ; • Faster absorption
Detemir (no peak) OD • Less affected by muscle activity on exercise
(Levemir)
Buttocks
 Regular insulin – can be thru IV
• Upper outer quadrant ; small children
Lateral arm
Complications of Insulin therapy
• Child w/little SC fat
Local allergic reaction
• IM ; cause bruising
• 1 – 2 hrs after insulin admin.
• May disappear w/cont. insulin use
Rotation of sites
• May prescribe antihistamine ; 1 hr before admin.
• Clockwise & 1 inch away fr 1st site
• Arm → 1 inch fr site (use whole site) → ab → thigh →
Systemic allergic reaction
opposite thigh
• Spreads into generalized urticaria (hives)
• Tx ; desensitization (small doses, gradually ↑ing)
Healthy Blood Sugar Levels
Time (-) Diabetes (+) Diabetes
Insulin Lipodystrophy
Fasting 70 – 99 mg/dL 80 – 130 mg/dL
• Lipoatrophy ; Loss of fat @ site
1 – 2 hrs after meal < 140 mg/dL < 180 mg/dL
• -hypertrophy ; fat @ site d/t repeated use of injection site
A1C test < 5.7% < 7%
• Rotation of site important

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