TNCC Physical Assessments

TNCC Physical Assessments
health history - ANSWER: subjective data from the individual; what the patient tells
the nurse; about 80% of health assessment data

physical assessment - ANSWER: objective measurement of health assessment; data
obtained by the nurse through direct physical examination; comprises about 20% of
the health assessment

inspection, palpation, percussion, and auscultation - ANSWER: order of assessment;
except in abdomen

inspection, auscultation, percussion, palpation - ANSWER: order of assessment in the
abdomen; different from normal order

inspection - ANSWER: the observable portion of the physical examination, first part
of an exam; view patient as a whole; regard posture, gait, anomalies, motor activity,
emotions, symmetry

palpation - ANSWER: "to feel"; second part of a physical exam where the nurse
extends her exam to touch; used to elicit tenderness, identify masses, detect
temperature change, and assess vibrations


superficial palpations - ANSWER: detect palpable findings on the skin surface or area
immediately below

deep palpation - ANSWER: used to confirm superficial findings, feel deep organs, and
elicit deep pain

percussion - ANSWER: used to detect air, fluid, or border of a solid mass in an
underlying area; 3rd step in physical assessment

resonant - ANSWER: sound heard when percussing over normal lung tissue

hyperresonance - ANSWER: sound heard when percussing over a child's lung,
abnormal in an adult; heard over areas of the lung where air amounts are
abnormally increased

flat - ANSWER: sound heard when percussing and no air is present; like over muscle,
bone, or a tumor

tympany - ANSWER: sounds heard when percussing over air filled areas like the
stomach or intestines

, auscultation - ANSWER: "to hear"; fourth step in the physical exam (second when
assessing the abdomen); uses both the bell and diaphragm of stethoscope

diaphragm - ANSWER: used to assess high-pitched sounds such as breath, bowel, and
normal hear sounds

bell - ANSWER: used to assess low-pitch sounds such as extra heart sounds or
murmurs

CN 1 Olfactory Nerve - ANSWER: responsible for sense of smell, frontal lobe into the
roof of the nose

CN 2 Optic Nerve - ANSWER: responsible for vision; reflected from the object
through the lens of the eye and focused on the retina (nerve cells on back of the
eye); this reflection/info is taken to the occipital lobe

CN 3 Occulomotor Nerve - ANSWER: responsible for moving the eye toward the
nose, up, down, and external rotation; also responsible for shrinking the pupil

CN 4 Trochlear Nerve - ANSWER: responsible for internal rotation of the eye;
problem might be noticed when walking down stairs

CN 6 Abducens Nerve - ANSWER: responsible for moving each eye temporarily or
away from the nose; a problem would result in double vision when looking at distant
objects

CN 5 Trigeminal Nerve - ANSWER: responsible for sensation from the face, forehead,
cheeks and the jaw (chewing)

CN 7 Facial Nerve - ANSWER: responsible for moving most of the muscles of the face;
close eyelid, smile, raise eyebrows, wrinkle forehead, puff cheek, straighten neck,
and wiggle ears; also taste from the front 2/3 of tongue and also aids in salivary
gland secretions

CN 8 Auditory Nerve - ANSWER: aka vestibulo-cochlear nerve bc it serves 2 purposes:
1) hearing/sound information transmitted back to brain through cochlear
2) balance is transmitted through vestibular portion

CN 9 & 10 Glossopharyngeal and Vagus Nerve - ANSWER: take info to and from the
brain regarding swallowing, taste, voice, organ function, heart rate, abdominal
function, etc.; vagus has even been found to help treat epilepsy

CN 11 Accessory Nerve - ANSWER: responsible for turning the head, nodding yes and
no, and shrugging the shoulders (sternocleidomastoid and trapezins)

CN 12 Hypoglossal Nerve - ANSWER: responsible for complex tongue movements