N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide Biceps Flex the patient's arm at the elbow with palm down; place your thumb over the biceps tendon and tap your thumb with the percussion hammer Triceps Flex the patient's arm at the elbow with palm down; place your thumb over the triceps tendon (located about one inch above the elbow) and tap the tendon with the percussion hammer The elbow will extend slightly Brachioradialis Rest the patient's arm on his leg and tap the radius 1-2 inches above the wrist on the thumb side of the wrist The forearm will flex slightly and the fingers may extend slightly Patellar Have the patient sit on the bed or table with legs hanging freely; tap the patellar tendon (directly below the kneecap) with the percussion hammer The quadriceps muscle will contract causing the leg to extend or kick out Achilles Have the patient sit on the bed or table with legs hanging freely; slightly flex the ankle by supporting the foot; tap the Achilles tendon just above the heel The foot will flex downward toward the sole of the foot. Babinski (Plantar) Using the handle of the percussion hammer, start at the patient's heel and stroke the lateral border of the sole of the patient's foot from the heel to the ball of the foot and then across the ball of the foot toward the great toe A negative Babinski is a normal finding and is present when the patient's toes bend downward; a positive Babinski is present when the toes spread outward and the great toe moves upward Evaluation It is important to compare all findings with previous findings to determine if there are changes to any abnormal neurological findings. Record and report any significant deviations from the normal. In many agencies, there may be diagrams for documenting areas of neurological abnormalities. 2.3 Musculoskeletal No special equipment is needed for the musculoskeletal exam. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Much of the musculoskeletal exam can be done in the course of the normal assessment; for example, the nurse can assess the patient's joints while performing other parts of the assessment. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, Reflex How to Test Normal Response Biceps muscle will contract slightly causing the elbow to flex slightly

©2017

Achieve Test Prep

Page 28

of 135