Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide o Finger to nose and to nurse's finger: Have the patient touch his nose with his index finger and alternate touching the nurse's finger held approximately 18 inches from the patient. § Normal: The patient can perform the movements rapidly andsmoothly. § Deviations from normal: The patient cannot perform the movements rapidly and smoothly. o Finger to thumb: Have the patient touch each finger of his hand to the thumbof the same hand. § Normal: The patient is able to quickly touch each finger to the thumb on each hand. § Deviations from normal: The patient is not able to quickly touch each finger to the thumb on eachhand. o Fingers to fingers: Have the patient spread his arms at shoulder’s height and bring the fingers of opposing hands together at the midline. If the patient can do this with eyes open, repeat the test with eyes closed. § Normal: The patient is able to quickly and accurately touch the fingersof both hands at the midline. § Deviations from normal: The patient is not able to quickly and accurately touch the fingers of both hands at themidline. o Supination/pronation of hands: Have the patient sit with hands on the knees. Ask him to quickly pat his knees with his palms, alternating with the backs of his hands. § Normal: The patient is able to quickly supinate and pronate both hands. § Deviations from normal: The patient is not able to quickly supinate and pronate both hands, or performs the action clumsily. o Heel to shin: With the patient seated, have her place the heel of her foot onthe opposite shin below the knee and run the heel down the shin to the foot; repeat with the other foot. § Normal: The patient is able to run the heel down the shin bilaterally. § Deviations from normal: The patient is not able to run the heel down the shin in a coordinatedmanner. o Toe to nurse's finger: In a seated position, have the patient touch the nurse’s finger with the great toe of each foot. § Normal: The patient is able to touch the nurse's finger with his toe ina coordinated manner. § Deviations from normal: The patient is not able to touch the nurse's finger with his toe in a coordinatedmanner. o Assess the patient's touch sensation. Have the patient close his eyes. Using a wisp of cotton, touch the patient on the forehead, cheek, hand, forearm, abdomen, lower leg, and foot. In order to test symmetry of sensation, test both sides of the body (test both hands before testing another part of the body). Have the patient verbally indicate when a touch is felt. Ask the patient to point to the area touched. § Normal: The patient feels a light touch sensation on all parts of the body and on both sides of the body. § Deviations from normal: The patient does not feel a light touch sensation on all parts of the body, or feels the touch unequally on different sides of the body.

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