N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide sensation. Have the patient close her eyes. Hold the patient's middle finger or great toe and move the finger or toe rapidly up and down before stopping at the up, down, or straight position; ask the patient to identify theposition.  Normal: The patient can determine the position of the finger or toe.  Deviations from normal: The patient cannot determine the position ofthe finger or toe. o Assess the patient's tactile discrimination. Have the patient close his eyes. Using a paper clip that has been straightened and then bent in half, touch the patient with either one point or two. Have the patient say whether he feels one or two points.  Normal: The normal patient can distinguish one or two points within the following distances, depending on the part of the body stimulated: • Fingertips = 2.8 mm • Palms = 8-12 mm • Chest or forearm = 40mm • Back = 50-70 mm • Upper arm or thigh = 75 mm • Toes = 3-8 mm  Deviations from normal: The patient is unable to distinguish one or two points. o Assess the patient's stereognosis. Stereognosis refers to the patient's ability torecognize common objects by touching them. Have the patient close his eyes. Place a common object (a key, a pencil, a coin, or a paperclip) in the patient's hand and ask him to identify each object.  Normal: The patient can identify theobjects.  Deviations from normal: The patient cannot identify the objects. o Assess the patient's pain sensation. Break a tongue depressor so that one end is pointed (sharp) and the other end is rounded (dull). Have the patient close her eyes. Testing different parts of the body use one end of the tongue depressor or the other to presson the patient's body; instruct the patient to say "sharp" or"dull."  Normal: The patient is able to discriminate "sharp" and"dull."  Deviations from normal: The patient is not able to discriminate "sharp"and "dull." o Assess the patient's temperature sensation. Typically, if the patient's pain perception is within normal limits, the test for temperature sensation is not routinely done. Using glasses or test tubes of very warm and cold water, touch various parts of the body with one or the other. Instruct the patient to say hot or cold when he feels the sensation.  Normal: The patient can differentiate between the hot and cold sensations.  Deviations from normal: The patient cannot differentiate between the hot and cold sensations. o Assess the patient's reflexes using the percussion hammer. When testing reflexes, always test and compare both sides of the body to evaluate symmetry. Reflexes:

©2017

Achieve Test Prep

Page 27

of 135