Assessment

Front 1

Allen Test

Back 1

asesses collateral circulation
occlude both the radial and ulnar arteries; then release only the ulnar; check for flushing
(+ if flushing)

Front 2

Skin Turgor

Back 2

Assesses fluid levels, but does not determine whether one is fluid deficit (daily weights is a better way to determine fluid volume deficit)
Expect skin turgor to be looser with the elderly

Front 3

Cullen's Sign

Back 3

ecchymosis around the umbilicus
sign of retro-peritoneal bleeding

Front 4

Turner's Sign

Back 4

ecchymosis on either flank
sign of retro-peritoneal bleeding

Front 5

Trousseau's Sign

Back 5

Occlude the brachial artery (usually with a BP cuff) and watch the fingers, hand, or forearm twitch.
sign of hypocalcemia

Front 6

Chvostek's Sign

Back 6

Tap at the angle of the jaw (to stimulate the facial nerve) and watch for twitching of that side of the face (usually the nose of lips).
Sign of Hypocalcemia

Front 7

Kernig's Sign

Back 7

Lie the patient flat and fully bend the leg in the hip and knee. Positive if pain is felt upon extension of the leg.
Indicates meningitis or subarachnoid hemorrhage.

Front 8

Brudzinski's Sign

Back 8

Positive if legs lift involuntarily upon lifting the patient's legs.
Sign of meningeal irritation

Front 9

Nuchal Rigidity

Back 9

INABILITY to flex the head forward due to rigidity of the neck muscles.
Most common sign among pts with meningitis.
(negative if full ROM of neck - even if severe pain upon flexion)

Front 10

Cushing's Triad

Back 10

1. widening pulse pressure (SBP and DBP are >30-40 mmHg apart)
2. decreased HR
3. Irregular Respirations (ex. Cheyne Stokes)

*LATE sign of increased ICP; r/t cerebral hemorrhage; indicates fatal herniation of the brain

Front 11

in an unconcsious client, when you turn the head the eyes move in the opposite direction

Back 11

normal (indicates brain stem activity) - doll's eyes

abnormal (absent) - moving in same direction or being fixed midline (needed for dx of brain death)