NCMB 316 - ORTHOPEDIC NURSING RETURN DEMONSTRATION

ASSISTIVE DEVICES FOR MOBILITY/ AMBULATION WITHOUT ASSISTIVE DEVICE

Commonly used Assistive Devices for Mobility:
● Cane
● Walkers
● Crutches
Rationale for this skill
1. To maintain & restore muscle tone, muscle strength & joint flexibility
2. To improve balance
3. Improves appetite
4. Improves respiratory and circulatory function
5. Stimulates bowel action
6. Enhances patient’s psychological well being
General procedures
1. Identify the patient, identify his capabilities, the activity ordered & previous level of
activity.
2. Determine whether assistive devices are needed
3. Take V/S:
● Pulse
● Respiration
● BP
● If pain reliever is indicated before ambulation, be sure to allow time to take
effect before the patient begins to ambulate
○ R! so the patient can tolerate the activity
● Set a tentative goal w/ the patient
○ R! So, the patient can cooperate & may know what to expect
● Check that the area should be litter-free and spill-free.
○ R! so that the patient does not fall or slip
● Obtain the patient’s robe and non-slip shoes or slippers
● Monitor the patient carefully for signs of fatigue & faintness. If this happens,
move him/her to a nearest bed or chair & let him sit w/ head down
○ R! so that the patient does not fall or slip
● If the patient loses balance, help him regain balance, but if falling is inevitable,
control the descent to the floor. Do not try to maintain the patient up.
○ R! this may cause injury to the nurse
1. CANES
● Is a hand held ambulation device made of wood or
aluminum
● Designed for those who are able to bear weight on both
legs but have one leg weaker than the other
Three Types
1. Standard Straight-Legged Cane
2. Tripod Cane
3. Quad Cane- has 4 feet and provides the most support

TINE, CHAEL, KEYSI, GRACIE, ALY 1

 ● The Standard cane should have rubber caps to improve tractions and prevent slipping.
● The Standard cane is 91 cm (36 in) long:
○ Some aluminum cane can be adjusted from 56 to 97 cm (22 to 38 in).
● The length should permit the elbow to be slightly flexed.
● Clients may use either one or two canes, depending on how much support they require.
USING OF CANES
1. Grasp the cane with one hand, opposite affected leg, for support
2. Slide the hips forward in the chair.
3. Grasp one arm of the chair with the free hand. If the patient cannot grasp at the same
time the armchair & the cane, only the cane is grasp
4. Push to a standing position
● Encourage this kind of independence
● Give only help that is needed
5. After standing, pause in place
● R! to gain balance and place the cane initially
6. Balance is best maintained if the cane is placed close to the foot

AMBULATE WITH CANE (COAL)

● The cane should be held by the hand on the unaffected side so that the cane & weaker leg
can work together w/ each step
○ Instruct the client to move the cane at the same time as
the affected leg

Cane

Opposite

Affected

Leg

1. The client’s elbow should be flexed at a 15 to 30˚ angle

2. Move the cane ahead about 4 to 6 inches to the side of the foot
3. Move the affected leg ahead opposite the cane
4. Place the weight on the cane and affected leg
5. Move the unaffected leg forward

2. WALKERS
● Assistive devices used by patients who have at least one weight-bearing leg & arms strong
enough to bear partial weight
● May be used by patients w/ generalized weakness & those w/ balance problems
● Gives greater support & balance than a cane

DIFFERENT TYPES O F WALKERS

1. STANDARD
● made of polished aluminum
● It has four legs with rubber tips and plastic
hand grips
● Many walkers have adjustable legs

KEYSI & GRACIE 2

 The standard walker needs to be picked up to be used
●
The client therefore requires partial strength in both hands and wrist, stronger elbow
●
extensors, and strong shoulder depressors
● The client also needs the ability to bear at least partial weight on both legs.
2. FOUR WHEELED WALKER
● These do not need to be picked up to be moved, but they are less stable than the
standard walking.
● They are used by clients who are too weak or unstable to pick up and move the
walker with each step.
● Some walkers have a seat at the back so that the client can sit down to rest when
desired.
3. TWO- WHEELED WALKER
● An adaptation of the standard and four-wheeled walker is one that has two tips and
two wheels.
● This type provides more stability than the four-wheeled model yet still permits the
client to keep the walker in contact with the ground all the time.
● The legs allow the client to easily push the walker forward, and the legs without
rollers prevent the walker from rolling away as the client steps forward

2 TYPES

1. Pick Up
● more stable, it does not slip when the patient lean on it
2. Rolling
● allows a smooth normal gait but is less steady
● Can be adjusted in height
● Ideally, they should reach slightly below waist level so that the handgrips can be grasped
w/ comfort & so that the arms are slightly flexed to give better support
● Teach the patient to stand up from a sitting position:
○ Place the walker in front (place gait belt if necessary
○ Place both hands of the client in the armchair and push to a standing position * Give
help and assistance if needed
○ Move the hand to the handgrips of the walker one at a time to maintain balance
● The nurse should walk closely behind the client

GAIT PATTERN:

1. Move the WALKER & AFFECTED LEG SIMULTANEOUSLY ahead about 4-6 inches
2. Place the weight on the arms for support; if able, place partial weight on the affected leg,
otherwise, place full weight on the arms
3. Move the unaffected leg forward

3. CRUTCH WALKING
● A crutch is a wooden or metal staff used to increase client mobility
● 2 TYPES
○ Axillary
■ most commonly used type, fits under the axilla w/ the weight being placed on
the hand grips
○ Forearm
■ has a handgrip and a metal cuff that fits around the arm, is more convenient
but provides less stability than the axillary crutch
● To prevent slipping, crutches have rubber tips, which must be kept dry
● If the tips are worn or loose, they must be replaced

KEYSI & GRACIE 3

 ● The crutch must be regularly inspected o if cracks or bends are present, the person’s
weight will not be properly supported
● Crutches are used by:
● Clients unable to bear any weight on one leg
● Clients who can bear partial weight on one leg o Clients who have full weight bearing on
both legs

Procedure:

1. Inform client that you will be assisting w/ ambulation using crutches

2. Assess client for strength, mobility, ROM, visual acuity, perceptual difficulties & balance
● R! Helps determine the capabilities of client & amount of assistance required
3. Adjust crutches to fit the client.
● With the client supine, measure from the heel to the axilla minus 2 inches.
● With the client standing, set the crutch position at a point 2 inches lateral to the
client and 4 to 6 in. in front of the client.
● The crutch pad should fit 1.5 to 2 in. below the axilla
● The hand grip should be adjusted to allow for the client to have elbows bent at 30°
flexion
● R! Provides a broad base of support for clients. Space between the crutch pad and
the axilla prevents pressure on radial nerves (crutch palsy). The elbow flexion allows
for space between the crutch pad and axilla
● Lower the height of the bed.
○ R! Allows client to sit with feet on floor for stability
● Dangle the client at the side of bed for several minutes
○ *Assess for vertigo R! Allows for stabilization of BP, thus preventing
orthostatic hypotension
● Instruct client to hold the crutches; that is, with elbows bent 30° and pad 1.5 to 2 in.
below the axilla
● Instruct client to position crutches lateral to and forward of feet *Demonstrate
correct positioning
○ R! Increase client comprehension & cooperation
● Apply the gait belt around the client’s waist if balance & stability are impaired
○ R! Provides support; promotes client safety

GAIT CRUTCH WALKING

1. Four-point gait for weight bearing w/ both legs

● Right crutch forward
● Left foot forward
● Left crutch forward, then
● Right foot forward
● The 4-point gait w/ crutches is very
stable but slow

2. Three-point gait for weight bearing w/ one leg

● Crutches & weak leg forward together, then
● Weight-bearing leg forward

KEYSI & GRACIE 4

 3. Two-point gait for weight bearing with both legs
● Right crutch and Left foot forward together, then
● Left crutch and Right foot forward together
● The 2-point gait requires more balance but is a faster
gait

4. Swing-through gait has the pattern of

● crutches forward, then
● Legs swing forward together.
● The swing-through gait has the advantage of
speed; however, it requires good balance

GOING UP THE STAIRS W/ RAILING

1. Hold both crutches under one arm.

2. Place the other hand on the railing in front of the body.
3. Raise the unaffected leg to the first step, and pull up with
your hand on the rail.
4. Pull up the affected leg and advance the crutches to the
level of the affected leg.
5. Repeat the process

DESCENDING FROM STAIRS

1. W/ weight on the unaffected leg, the crutches are placed on the next lower step, partial
weight is placed on the hands & crutches, & the affected leg is moved to the lower step
2. Put total weight on crutches & affected leg
3. Move unaffected leg to same step as crutches & affected leg
● If railing is present, hold both crutches w/ one arm, and use the other to grasp the
railing

GETTING INTO A CHAIR

1. Stand with the back of the unaffected leg

centered against the chair. The chair helps the
client during the next steps.
2. Transfer the crutches to the hand of the
affected side and hold the crutches by the
hand bars. The client grasps the arm of the
chair with the hand on the unaffected side.
This allows the client to support the body
weight on the arms and the unaffected leg.
3. Lean forward, flex the knees and hips, and lower into the chair.

KEYSI & GRACIE 5

GETTING UP THE CHAIR

1. Move forward to the edge of the chair and place

the unaffected leg slightly under the edge of the
chair.
● This position helps the client stand up from
the chair and achieve balance, because the
unaffected leg is supported against the
edge of the chair.
2. Grasp the crutches by the hand bars in the hand
on the affected side, and grasp the arm of the
chair by the hand on the unaffected side.
● The body weight is placed on the crutches and the hand on the armrest to support
the unaffected leg when the client rises to stand.
3. Push down on the crutches and the chair armrest while elevating the body of the chair

SIMPLE ASSISTED AMBULATION

1. Follow the General procedures
2. Assist the patient to ambulate
a. In most cases, walk on the patient’s weaker or affected side
● R! so that if the patient falters, you can give assistance & support
● S! BUT if the patient has poor balance & tends to lean toward the person assisting…
● N! Walk on the patient’s strong side, so that the patient’s weight is shifted to the strong leg,
rather than the weak leg, when he / she leans

B. Support the patient as you walk, but do not allow the patient to put an arm
around your shoulders

● R! If the patient starts to fall, the weight could place a twisting strain on your
back & cause you injury

C. Offer support by extending an arm bent at the elbow with the palm up; the patient can
then rest a hand on your arm

● R! The nurse can maintain firm support, & the patient can determine how much
support is need

ASSISTING TO AMBULATE WITH GAIT BELT

● also known as a transfer & ambulation belt
● this is a strong belt with a safety release buckle
● When using this belt, walk on the patient’s weaker side and slightly behind
○ with one hand grasping the belt in the center back
○ The other arm may be extended at the patient’s side for the patient to grasp
● Walk slowly & evenly, avoid speeding up/slowing down.
○ R! It would be difficult for the patient if your gait is uneven
● Try to make your step the same as the patient. Synchronize your steps w/ the patient
○ R! By using smooth & coordinated movements, you give the patient confidence in
you & diminishes fear of falling

KEYSI & GRACIE 6

 DAY 2
CAST
● a rigid external immobilizing device that is molded to the contours of the body
● Used to obtain immobilization, protection and correction of bone, tissue damage,
deformity and pain relief.
● Correct care is essential to prevent complications arising.
● Casting, which includes application, adaptation, & the removal of casts, requires skill,
knowledge & judgment to care for patients safely.
● PLASTER OF PARIS(gypsum sulfate) mixed with water (swells & forms into a hard
cement)
PURPOSE
● Permit mobilization of the pt while restricting movement of a body part
● Apply uniform pressure on encased soft tissue
● To immobilize a reduced fracture
● To correct a deformity
CASTING MATERIALS
● Plaster of Paris
● Synthetic materials
○ Polyester/ cotton knit
○ Fiberglass
○ Thermoplasts
PLASTER OF PARIS
● A high quality gypsum impregnated onto an open weave fabric material.
● It has been the most common choice for immobilization for many years.
● It is relatively inexpensive, pliable and easy to mold, smoothing to conform almost exactly
to the extremity
● It starts to set in 5-7 minutes however it may take up to 48 hrs for the plaster cast to dry
completely
● During this time, the wet cast should be supported by a pillow and handled with the palms
of the hands to prevent denting the cast. Walking on a cast before it is fully set will cause
the same problem

FIBERGLASS
● Is usually a knitted fabric impregnated with a polyurethane resin, which hardens on
exposure to water in a matter of minutes.
● It only takes a few seconds in water to initiate the chemical reaction
● It takes approximately 30 minutes to dry completely, making weight-bearing and use of
the casted limb possible much sooner.
● Fiberglass casting materials have water-resistant properties. However, the underlying
padding if not waterproof can pose a problem if exposed to water and may result in
excoriation of the skin or formation of a pressure sore
○ NOTE: Fiberglass is more expensive than Plaster of Paris, and for this reason is often
not the initial cast of choice following trauma or surgery, when removal may be
necessary because of swelling or wound inspection. Fiberglass casts can leave sharp
edges and may cause breakdown of the skin

KEYSI & GRACIE 7

SEMI RIGID MATERIALS
At first glance, this material looks like fiberglass. However, the composition is slightly different
and combines flexibility with resilience after the final curing stage.
● Is more commonly used in conjunction with fiberglass membrane (combination casting) to
add strength and stability to the finished product.
● It is versatile, lightweight, radiolucent, flexible, moldable and leaves a soft edge. The
application of this material is again quite specific. It can be removed using a serrated edge
scissor or by unwrapping it like a bandage
PRINCIPLES IN APPLYING PLASTER CAST
Generally speaking, the joints proximal and distal to the area to be immobilized are included in
the cast
1. Provide for maximal comfort & alleviation of complications
2. Application of padding is the first step in the procedure
● Padding materials include the following
○ wadding sheet
○ roll of cotton stockinette
3. Maintain desired position throughout cast application
4. Use caution in handling of the cast until it has set/ becomes hardened
● It can be applied as combination, like stockinette and sheet waddling
● Apply it to include the joint above & joint below the injured part
● Apply it in circular motion & mold it
● Support it with the palm
CONTRAINDICATIONS OF PLASTER CAST APPLICATION
1. Pregnancy
● growing size of abdomen
● may have edematous legs and feet
2. Skin disease
● lesions
● vesicles
● infection
● inflammation
APPLYING A PLASTER CAST (CIRCULAR CAST APPLICATION
1. Check the doctor's order
2. Inform & prepare the patient for the procedure
3. Explain to the patient & his relative the need for placing the affected part of the body in a
cast
4. Cleanse
● If possible, a good cleansing bath & shampoo is given to the pt
● The affected part is cleansed thoroughly w/ soap & water then dried
● If there is a wound, have it dressed accordingly
5. Prepare all things needed for the application
6. Position the extremity (by the doctor)
7. Apply padding including the joints above & below the fracture line w/ thicker pads on
bony prominences
8. Soak the plaster cast into a bucket w/ water
● Leave undisturbed until bubbles cease

KEYSI & GRACIE 8

 9. Grasp both ends of the cast towards the center without squeezing it
10. Free the end of the cast & hand it to the operator
11. Apply cast in circular motion o until the whole area is covered & molding it, during the
process of application, by the palm
12. Handle the cast w/ care

HANDLE THE CAST WITH CARE

1. Avoid moving patients or transferring w/ wet cast
● Avoid moving patients or transferring w/ wet cast
2. The excess plaster cast is trimmed by means of a trimming knife
● Cast spilled on the skin is easily removed by wiping it with a damp cloth
3. To hasten drying, several ways are used:
● exposure to open air / electric fan;
● exposure to a heat lamp; and
● placing the patient in warm room
4. Protect the pt from rapid drying of the cast (this will result to a dry outer layer while the
inner layer remains wet), preventing pneumonia to develop & preventing body fluid loss
from excessive sweating
5. Complaints of discomfort should be investigated
● appropriate measures be given to bring about comfort
6. Patients in body / spica cast is turned every 4-6 hrs
● to promote even drying of the cast
7. Edges that are extremely rough, should be trimmed or smoothed very slightly with a cast
knife
● Rough edges can be covered with adhesive petals, esp. if there is no stockinette
underneath the plaster & sheet wadding
8. The duration of keeping the body / part of it in cast is at least one month (may vary
among patients)
FACTORS THAT INFLUENCE THE DURATION ARE
● Age of the patient
● part of the body affected
● the degree of injury or affectation of the part
NURSING CARE ON PATIENT ON CAST
During the entire period that the patient is in cast, your responsibility is focused on ff :
1. Neuro-vascular checks
● The color, motion, temperature & sensation of toes / fingers should be observed
every 30 minutes for several hours (longer if there is much edema) and then
regularly every 3 hours
2. Circulatory impairment results in symptoms of coldness, edema cyanosis, pain, & finally
numbness in the toes / fingers
3. Pts in arm & leg cast should be able to move & feel each toe / finger, because the same
nerve does not innervate each one
● All toes & fingers should be checked
4. Preservation of the efficiency of the cast
5. Maintenance & promotion of the integrity of the system of the body
6. Maintenance of the cleanliness of the cast

KEYSI & GRACIE 9

 TURNING PATIENT IN CAST
1. Turning casted trunk & lower extremities must be done carefully
2. The patient must be lifted & not rolled / dumped.
3. Support should be provided to the encased part & the whole body
4. The first changing of the patient’s position depends on the condition of the case & the
body area involved
5. The first turning usually is to dry the posterior surface of the cast, provide comfort &
protect patients against respiratory complication

POINTS TO REMEMBER
1. After the cast removal, support the part w/ pillow, maintaining the same position that
existed in the cast
2. Move the extremity gently
3. Observe the skin for any abrasions & plaster sores o Wash skin w/ mild soap followed by
application of oil and lanolin as prescribed
TYPES OF CAST
SHORT ARM CAST
● Extends from below the elbow to the palmar
crease, secured around the base of the thumb.
● If the thumb is included, it is known as a thumb
spica or gauntlet cast

LONG ARM CAST

● Extends from the upper level of the axillary fold
to the proximal palmar crease.
● The elbow usually is immobilized at a right angle.

FUENSTER’S CAST
● Wrist and fingers with compound affection
● Radius/ ulna with callus formation

HANGING CAST
● shaft of the humerus

AIRPLANE
● Humerus & shoulder joint w/ compound affection

KEYSI & GRACIE 10

SHOULDER SPICA RIZZER JACKET
● Humerus and shoulder joint ● Scoliosis

FUNCTIONAL ARM CAST DOUBLE HIP SPICA

● Humerus (allows abduction and ● Hip And Femur
adduction)

COLLAR CAST DOUBLE HIP SPICA POSTERIOR MOLD

● Cervical affection ● Pelvic affection with Callus formation
plus 2
femur

MINERVA 1 ½ HIP SPICA

● Upper Dorsal cervical spine ● hip and femur

KEYSI & GRACIE 11

BODY CAST 1 ½ SPICA POSTERIOR MOLD
● Lower dorso-lumbar ● Hip And
spine Femur with
compound fracture

SINGLE HIP SPICA POSTERIOR MOLD

● Hip and ● Pelvic bone
Femur fracture with
Callus
Formation

PANTALON CAST LONG LEG POSTERIOR MOLD

● Pelvic bone fracture ● Tibia and fibula
compound affection

FROG CAST BASKET CAST

● Severe leg trauma
w/ open wound or
inflammation

LONG LEG CAST CYLINDRICAL LEG CAST

➼Tibia and fibula ➼Patella

KEYSI & GRACIE 12

QUADRILATERAL/ ISCHIAL BEARING CAST PTB (PATELLAR-TENDON BEARING)
● Shaft of the femur ➼Tibia and fibula w/ callus formation
w/ callus formation

CAST BRACE DELBIT CAST

➼Fracture of the femur distal ➼Tibia and fibula
3rd femur

SHORT LEG CAST SHORT LEG POSTERIOR MOLD

➼Ankle and foot ➼Ankle and foot w/
compound affection

INTERNAL ROTATOR SPLINT NIGHT SPLINT

➼Post hip operation ➼Hip And Femoral
fracture

NIGHT SPLINT
➼Post polio

KEYSI & GRACIE 13

 DAY 3
BALANCE SKELETAL TRACTION
● It is the act of pulling & drawing which is associated w/ counter traction.
Purpose of traction
1. To reduce fracture
2. To reduce pain & muscle spasm
3. To provide immobilization
4. To maintain good body alignment
5. For support
6. To prevent further deformity / correct deformity
3 BASIC TYPES OF TRACTION
1. Manual Traction
● The hands are used to exert a pulling force on the bone w/c
is to be realigned.
● Generally, this is reserved only for very stable fractures or
dislocations prior to splinting or immobilization in a cast
● It also may be used prior to the application of skin or
skeletal traction or surgical reduction
● The pulling force is applied by the hands of the operator.
● It is a temporary measure sometimes employed in handling neck injury when a cervical
spine is fractured.
● It is also used to apply the necessary pull to an extremity when cast is being applied
2. Skin Traction
● strips of tape, mole-skin, or other type of commercial skin traction strips are applied
directly to the skin
● Traction boots for leg traction & pelvic belts for spinal disorders are included in ST
● INDICATION:
○ Treatment of children’s fractures & adult fractures
○ Dislocations that require only a moderate
amt of pulling force for a relatively short
period

a. BRYANT SKIN TRACTION (BST)

● used for femoral fractures, hip
fractures among kids below 3y/o

b. OVERHEAD TRACTION
● Supracondylar fracture of the
humerus
c. HEAD HALTER TRACTION
● cervical spine affection
d. PELVIC GIRDLE TRACTION
● Lumbo-sacral affection,
herniated nucleus pulposus
e. COTREL TRACTION
● indicated for scoliosis

KEYSI & GRACIE 14

 f. HAMMOCK SUSPENSION TRACTION
● Pelvic affection
g. HALO PELVIC TRAC TION
● Scoliosis
h. HALO FEMORAL TRACTION
● Severe scoliosis
i. 90 DEGREE TRACTION
● fracture of the femur
j. STOVE IN CHEST TRACTION
● severe chest injury with multiple rib fractures
3. Special type tractions
a. Russell Traction
● affection of the femur
b. Boot leg Cast Traction
● hip and Femoral affection
4. Skeletal traction
● Apply skeletal traction by placing a metal pin
through the metaphyseal portion of the bone &
apply weight to the pin
● The pulling force is applied directly to the bone
using pins & wires such as Kirshner's wire,
Steinman's pin, Vinki's skull retractor & crutch field
tongs o
● It is important to place the pin correctly to avoid
injury to vessels, nerves, joints & growth plates

PRINCIPLES
1. POSITION
● Pt. should be in Dorsal Recumbent or supine position (o his/her back)
○ Proper position includes keeping the entire body in good alignment.
○ Also, either a solid bottom bed or bed boards must be used for all orthopedic
patients
2. COUNTERTRACTION
● For any traction to be effective, there must be countertraction
● Traction & countertraction represent forces in balance; for this reason, the patient
should not have his back raised more than 20 degrees
● No sitting up
3. FRICTION
● Any type of friction will reduce the efficiency of traction & hinder the pull.
Implications for nsg care include checking to see that:
○ The spreader/footplate is not touching the end of the bed
○ The weights are positioned at a reasonable level from the floor; a
considerable distance below the pulley; hanging free of bed; & away for the
patient
○ All knots are clear of the pulleys

KEYSI & GRACIE 15

 There is no impingement on the traction cord from bed clothes or any other
○
apparatus
○ The patient’s heels are not digging into the mattress
■ if any of these conditions are not being met, immediate corrective
action is indicated
4. CONTINUOUS
● In general, for traction to be effective, it should be continuous
● NEVER remove it without a doctor’s order
5. LINE OF PULL
● Once established correctly, the line of pull should be maintained

PROTECTION OF CARDIOVASCULAR SYSTEM

The nsg goals are
1. To monitor orthostatic tolerance & prevent venous stasis
● Instructing the patient in hourly ankle rotation, flexion & extension exercises
● Avoiding / minimizing positions that causes external pressure on venous walls such
as knee gatching / crossing legs
● Using (on physician order) anti-embolism stockings or pneumatic sleeves

MAINTENANCE OF NEUROVASCULAR STATUS

1. Regularly assessing neurovascular status with particular attention to traction apparatus
and pressure areas
2. Changing the pt’s position w/in the limitations of the traction every 2 - 4 hours
3. Report any signs & symptoms of neurovascular compromise to the attending physician

SKIN CARE
1. Static positioning in traction cause pressure that impairs capillary flow to the skin (may
lead to tissue necrosis & pressure sores)
2. Assessing skin integrity over bony prominences and any areas of the body which are
covered by / attached to traction apparatus
3. Massaging potential pressure areas every 2 - 4 hrs.
4. Using pressure relief devices or pressure relief bed
● ***If skin breakdown occurs, massage should be discontinued to prevent further
tissue damage

MAINTENANCE OF MUSCULOSKELETAL SYSTEM

1. Have the pt perform regular isometric and/or isotonic exercises of uninvolved extremities
& the involved extremities as prescribed by a physician
2. Pulling his/her toes toward his/her nose while pushing his/her knee into the bed
3. Sitting up in bed and pushing his/her palms against the bed to raise his/her buttocks off
the bed
4. Allowing to perform as many daily activities as possible
● Immobility decreases muscle strength, impairs skeletal strength, and limits joint
mobility
NOTE: NEVER IGNORE A PX’s COMPLAINTS!!!!!!! - This rule should be followed above
everything else. Traction systems can vary depends on the doctor

KEYSI & GRACIE 16

 PREPARATION PHASE
Preparation phase
1. Check the physician's order
2. Inform & explain the purpose & procedure to the patient - for easy installation &
cooperation during the procedure
3. Assemble all equipment

PREPARE TRACTION EQUIPMENTS

1. Orthopedic Bed
2. Thomas Splint with Pearson attachment.
3. Rest splint
4. Slings of variable sizes
5. Paper clips or safety pins
6. Ropes - different length
● Short - for the thigh
● Long - for the traction
● longest - for the suspension
7. Weights and Bags
● Suspension weight – is 1/2 lighter than the
weight of the traction.
● Traction weight – approximately 10% to of
the patient’s body weight
8. Foot rest - to prevent foot drop

PROCEDURE PHASE
1. Attach the rest splint to the Thomas splint with Pearson attachment.
● Upper part is the Thomas splint, which will support the thigh
● Lower part is the Pearson attachment w/c will support the leg
2. Measure the length of the thigh rope to the thigh of the pt.
● Adjust the Pearson attachment according to the length of the thigh of the pt.
● Tie the short (thigh) rope to the medial upright portion of the Thomas splint with slip
knot o to provide privacy to the patient
3. Attach slings to the Thomas splint and Pearson attachment

PRINCIPLE IN ATTACHING THE SLINGS

● Start from the longest (at least 2) to the Thomas splint and 3 to the Pearson
○ Smooth side should be touching the patient's skin
● Provide at least one to two inches apart between the slings for ventilation
● It must not be too loose nor too tight enough to support and follow the contour of the leg
● Provide space at the popliteal area to prevent irritation and provide ventilation

KEYSI & GRACIE 17

 4. Insert the apparatus to the affected leg
● Apply manual traction on the affected leg. Manual traction should be released after
the completion of the traction weight.
● With the help of assistants
○ one applying the manual traction
○ one lifting the affected leg
○ one removing the Braun Bohler, coordinate your movement.
○ At the count of three, insert the ready made Thomas splint to the affected
leg. Synchronize the procedure for the patient's comfort.
● Instruct the patient to flex the unaffected leg and hold on to the overhead trapeze.
● There should be continuous traction, so don't remove the manual traction until the
longer rope has been tied to the Steinman pin or Kirchner's wire holder then to the
traction weight
5. Tie the longer rope on the Steinman’s pin holder with the use of slip knot then insert the
other end of the rope to the third pulley, then -tie the traction weight.
● Check the groin (inguinal area) if resting on the half ring
○ to prevent irritation
6. Tie the other end of the short rope to the lateral aspect of the Thomas splint
7. Tie the longest rope to the middle of the short rope with slip knot. Insert it to the first pulley
then hang the suspension weight, which is half the weight of the traction weight. Anchor
suspension weight, then insert the rope to the second pulley
8. After the second pulley, tie it to the Thomas splint using the clove hitch knot then to the
Pearson Attachment.
● Before tying the rope to the Thomas splint & Pearson, be sure the rope is inside the
traction rope for support & prevent the affected leg from swaying sideways
9. Release suspension weight
10. Apply foot support - using ribbon knot
11. Remove the rest splint
12. To check the efficiency of the traction:
13. Instruct the patient to flex his unaffected leg and hold on the Overhead Trapeze and swing
affected leg with balanced skeletal traction.

REMOVAL OF TRACTION
1. Attach the rest splint.
2. Anchor the suspension weight.
3. Remove suspension rope.
4. Apply manual traction.
5. Remove traction weight, then tie the rope to the rest splint, Thomas and Pearson using the
clove hitch. Patient is ready for transfer to the stretcher.
6. Instruct the patient to flex his unaffected leg while holding on the trapeze. Help him slowly
to the stretcher.

KEYSI & GRACIE 18

 NURSING CARE OF PATIENT WITH TRACTION
1. ASSESSMENT
● Assess the patient as to level of understanding, and consciousness

2. Provision of general comfort

a. Skin care
● head to toe, focus on the sponging of affected extremity
b. Changing of linen
c. provide bedpans as needed. Serve bedpan on unaffected side, procide pillow at the
back and provide privacy
d. perineal care
3. COMPLICATIONS (Potential)
a. Upper respiratory - PNEUMONIA
● bronchial trapping
● deep breathing
b. bed sore
● good perineal care
● proper skin care
● turning left buttocks once in a while
c. Urinary & Kidney problem
● good perineal care
● increase fluid intake
d. Bowel complication
● fear of apparatus
● no privacy
● lack of fluids
● perineal care
e. Pin site infection
● observe s/sx of infection
● loosening of pin tract
● pus coming out
● foul smelling
● fever
f. Deformity
● contracted knee
● atrophy of the muscle
● foot drop
● joint contractures
4. Provision of exercise
a. ROM exercises with use of trapeze
b. deep breathing exercise
c. static quadriceps [Link] contractions and relaxation of quadriceps muscles
d. Toes pedal exercises
5. Nutritional Status
● depending on the status of the patient
6. Psychological Aspect

KEYSI & GRACIE 19

 ● fear of unknown
● fear of death
● fear of the apparatus
● fear of losing jobe
● financial fear
7. Provision of supportive therapy
● offer book to read
● something to listen radio or TV
● discover interest

8. Spiritual Aspects
● know his/her religion
● encourage relatives to give spiritual
● communication
● visiting chaplain

BRACES
● An orthosis or orthopedic appliance that supports or holds in correct position any movable
part of the body and that allows motion of the part, in contrast to a splint, which prevents
motion of the part

KEYSI & GRACIE 20

 DAY 4
NEUROLOGICAL ASSESSMENT

No. Cranial Nerve Type of Function

Impulse

I Olfactory Sensory Carries smell impulses from nasal mucous membrane

to the brain.

Olfaction or Smell

II Optic Sensory Carries visual impulses from eye to the brain.

Vision and Visual Fields

III Oculomotor Motor Contracts eye muscles to control eye movements

namely:
a. Interior Lateral
b. Medial
c. Superior
It constricts pupils and elevates the eyelids.

EOM (Extraocular Eye Movement), Movement of

Sphincter of Pupil, and Movement of Ciliary Muscles
of Lens

IV Trochlear Motor Contracts One (1) eye muscle to control the

Inferomedial Eye Movement EOM
- EOM
- Moves eyeball downward and Laterally

V Trigeminal Sensory/ Carries sensory impulses of Pain, Touch, and

Motor Temperature from the face to the brain.

Influences Clenching and Lateral Jaw Movements

(Biting and Chewing)

Sensory: Light Touch, superficial pain, and

temperature to face, corneal reflex.

Motor: Strength of Temporalis and Masseter Muscles

3 Branches
1. Opthalmic Branch (Sensory)
● Sensation of Cornea, skin of face, and
nasal mucosa.
2. Maxillary Branch (Sensory)
● Sensation of cornea, skin of face, and
nasal mucosa.
3. Mandibular Branch (Sensory and Motor
● Muscles of mastication and sensation of
skin of face.

KEYSI & GRACIE 21

 VI Abducens Motor Controls lateral eye movements/ moves eyes laterally.

EOM

VII Facial Sensory/ Sensory

Motor 1. Taste on the anterior ⅔ of the tongue.
2. Stimulates secretion from the salivary glands
(submaxillary and sublingual).
3. Stimulates tears from lacrimal glands.
Motor
1. Facial Movement
2. Facial Expressions (smiling, frowning, closing
eyes).

VIII Acoustic/ Sensoty Contains sensory fibers for hearing and balance.
Vestibulocochlear Branches
1. Cochlear (Acoustic) - gross hearing
2. Vestibular - For equilibrium (balance)

IX Glossopharyngeal Sensory/ Sensory

Motor 1. Taste on the posterior ⅔ of the tongue.
2. Sensory fibers on the pharynx that result in
Gag Reflex when stimulated.

Motor
1. Provides secretory fibers to the Parotid
Salivary Glands.
2. Promotes Swallowing movements.
3. Tongue movement

X Vagus Sensory/ Carries sensation from the throat, larynx, heart, lungs,
Motor bronchi, GIT, and abdominal viscera.

Promotes swallowing, talking, and production of

digestive juices.

Sensation of pharynx and larynx, swallowing, and

vocal cord movement.

XI Spinal Accessor Motor Innervates neck muscles (Sternocleidomastoid and

or Accessory Trapezius) that promotes the movement of shoulders
and head rotation.

Promotes some movement of the larynx.

Head movement and shrugging of shoulders.

XII Hypoglossal Motor Innervates tongue muscles that promote movement

of food and talking.

Protrusion of tongue, movement of tongue upward,

downward, and side to side.

KEYSI & GRACIE 22

 ASSESSMENT
CN I - OLFACTORY NERVE

PROCEDURE
1. Have the Client sit in a comfortable position at your eye level.
2. Ask them to clear their nose
● To remove any mucus.
3. Assess ability to smell:
a. Close their eyes and occlude one nostril to identify a scented object that you are
holding (soap, coffee, vanilla, peanut butter, orange, lemon, or chocolate).
b. Repeat the procedure for the other nostril.

FINDINGS
a. Normal
● Client correctly identifies the scent presented to each nostril.
● Some older client’s sense of smell may be decreased.
b. Abnormal
● Neurogenic Anosmia - inability to smell or correctly identify scent.
○ May indicate:
■ Olfactory Lesion
■ Frontal Lobe Tumor
■ Congenital, nasal, or sinus problems
■ Nerve Tissue Injury
■ Smoking and use of Cocaine

CN II - OPTIC NERVE

A. Snellen Chart - Used to assess vision in each eye.

1. Make the client stand 20 feet from the chart and make them cover one eye with an opaque
card.
● Opaque card prevents client from peeking through fingers.
2. Ask the client to read each line of letters until they can no longer distinguish them.

How to Interpret
● At the end of each line of the chart are standardized numbers (fractions).
● The top line is 20/200.
○ The numerator is always 20 (top number) - this is the distance the client
stands from the chart.
○ The denominator (bottom number) - is the distance from which the normal
eye can read the chart.
● Example: A client who has 20/40 vision.
○ It means that they can see in 20 feet what a normal-sighted client can see at
40 feet from the chart.
● Visual Acuity
○ Recorded as “sc” (without correction) or “cc” (with correction.
○ You can also indicate how many letters were misread in the line.
■ E.g., visual acuity 20/40 - 2 cc

KEYSI & GRACIE 23

 ● This indicates that two letters were misread in the 20/40 line by
a client wearing corrective lenses.

FINDINGS
a. Normal
● Client has 20/20 vision OD (right eye) and OS (left eye) - distance vision.
b. Abnormal
● Difficulty reading letters in Snellen Chart.
● Missing Letters
● Squinting

B. Near Vision
1. Ask the client to read a newspaper or magazine paragraph.
2. Have them place the reading material 14 inches away from them.

FINDINGS
a. Normal
● Reads print at 14 inches without difficulty.
● Until the patient is in the late 30s to late 40s, reading is generally possible at a
distance of 14 inches.
b. Abnormal
● Reads print by holding closer than 14 inches or holds print farther away as in
presbyopia (far sighted) which occurs with aging.

C. Visual Fields - assess peripheral vision.

1. Have the client sit directly facing you at a distance of 2-3 feet.
2. Ask them to cover their right eye with a card and look directly at your nose.
3. Cover or close your eye directly opposite to the client’s covered eye (left eye), and look
directly at the client’s nose.
4. Hold an object (e.g., penlight or pencil) with you fingers, extend your arm, and move the
object into the visual field from various points in the periphery (6 Visual Fields).
● The object should be at an equal distance from the client and yourself.
● Ask the client to tell you when the moving object is first spotted.
5. Visual fields or Peripheries
a. Temporal field of OS (left eye)
● Extend and move your right arm from the outside right periphery.
b. Upward field of client’s OS
● Extend and move right arm down from the upward periphery.
c. Downward field of OS
● Extend and move right arm from the lower periphery.
d. Nasal Field of OS
● Extend and move left arm in from the periphery.
6. Repeat the steps for the righ eye, reversing the process.

KEYSI & GRACIE 24

 FINDINGS
a. Normal
● Client can see full visual fields -
normal peripheral vision.
b. Abnormal
● Loss of visual fields, may be seen in:
○ Retinal damage or
Detachment
○ Lesions of the optic nerve
○ Lesions of the parietal cortex

CN III - OCULOMOTOR, CN IV - TROCHLEAR, CN VI - ABDUCENS NERVE

A. EOM (Extraocular Movement) Test - assess EOM

1. Stand directly in front of the client and hold the penlight at a comfortable distance (1 feet)
in front of the client’s eyes.
2. Ask the client to hold their head in a fixed position facing you and to follow the movements
of the penlight with only their eyes.
3. Move the penlight in a slow, orderly manner through the six cardinal fields of gaze.
● Move from the center and outward and back again to the center (follow arrows on
the picture).
4. Stop the movement of the penlight periodically for nystagmus to be detected.

FINDINGS
a. Normal
● Eyes move in a smooth and coordinated motion in all six directions (six cardinal
fields).
b. Abnormal
● Nystagmus - rhythmic oscillations or repetitive uncontrolled movement of the eyes.
○ Found in cerebral disorders.
● Limited eye movement through the six cardinal gaze due to increased ICP.
● Paralytic Strabismus - paralysis of the oculomotor, trochlear, and abducens nerve.
○ Inability of ocular muscles to move the eye due to muscular paralysis.

B. Hirschberg Test or Corneal Light Reflex

● Assess for location light reflex by shining penlight on the corneal surface.
● Check for ocular alignment.

1. Use a light source, such as a penlight or finhoff transilluminator.

2. Instruct the patient to focus their gaze on your light source.
3. From a distance of 2 feet, shine your light source equally into the patient’s eyes at midline.
4. Observe the reflection of light off the cornea, which should appear as a pin-point white
light near the center of the pupil in each eye

KEYSI & GRACIE 25

 FINDINGS
a. Normal
● Normal Alignment - reflection will
appear in the same position in each
pupil.
b. Abnormal
● Misalignment - location of the corneal
reflex will appear asymmetric and
“off center” of the pupil in the
deviating eye.

C. Pupillary Light Reflex - assess each pupil’s direct and consensual reaction to light to
determine function of the oculomotor and trochlear cranial nerves.

1. Partially darken the room.

2. Ask the client to look straight ahead.
3. Using a penlight, and approaching from the side, shine a light on the pupil.
4. Observe the response of the illuminated pupil.
● It should constrict (direct response).
5. Shine the light on the pupil gain and observe the response of the other pupil.
● It should also constrict (consensual response).

FINDINGS
a. Normal
● Illuminated pupil constricts (direct response)
● Nonilluminated pupil constricts (consensual response)
● Response is brisk.
b. Abnormal
● Unilaterally dilated pupil and Unresponsive to light - damage to oculomotor nerve.
● Neither pupil constricts
● Unequal responses
● Constricted pupil, pupil unresponsive to light - lesions in sympathetic nervous
system.
● Constricted fixed pupils - narcotic abuse or damage to the pons.
● Response is sluggish
● Absent response

D. Pupil Accommodation - assess reaction to accommodation.

1. Hold an object (penlight or pencil) about 4 inches from the bridge of the client’s nose.
2. Ask the client to look first at the top of the object and then at a distant object (e.g., far
wall) behind the penlight.
● Alternate gaze from near to far object.
● Observe pupil response.
3. Ask the client to then look at the near object and move the penlight or pencil towards the
nose.

KEYSI & GRACIE 26

 FINDINGS
a. Normal
● Pupils constrict when looking at near object and dilate when looking at far object.
● Pupils converge when near object is moved towards the nose.
● To record normal assessment of the pupils, use the abbreviation PERRLA (Pupils
Equally Round and React to Light Accommodation).
b. Abnormal
● One or both pupils fail to constrict, dilate, or converge.
● Unresponsive to accommodation - damage to oculomotor nerve.

E. Cover Test - determine the presence, type, and magnitude of misalignment (strabismus).
1. Have clients focus on a near or far object.
2. Cover one eye.
3. Observe for movement in the uncovered eye.
4. Repeat process for the other eye.

FINDINGS
a. Normal
● Uncovered eye Does not move.
b. Abnormal
● If misalignment is present, when dominant eye is covered, the uncovered eye will
move to focus on the object.

F. Eye Structure - Inspect margins of the eyelids of each eye.

1. Inspect the eyelids for surface characteristics, position in relation to the cornea, ability to
blink, and frequency of blinking.

FINDINGS
a. Normal
● Bilateral blinking
● 15 to 20 involuntary blinks/min
● Lids close symmetrically.
● Eyelids cover about 2 mm of the iris.
b. Abnormal
● Lids close asymmetrically, incompletely, or painful.
● Rapid, monocular, absent, or infrequent blinking.
● Ptosis, ectropion, or entropion.
○ Ptosis - drooping of the eyelids, seen with weak eye muscles.
○ Rim of sclera visible between lid and iris.

CN V - TRIGEMINAL NERVE

A. Corneal Reflex Test

1. Ask the client to look away and lightly touch the cornea with a fine wisp of cotton.
2. Repeat on the other side.

KEYSI & GRACIE 27

 FINDINGS
a. Normal
● Eyelids blink bilaterally

b. Abnormal
● Absent corneal reflex. Indicates:
○ Lesions of the trigeminal nerve.
○ Lesions of the motor part of CN VII (Facial Nerve)

B. Clench Test
1. Ask the client to clench their teeth while you palpate the temporal and masseter muscles
for contraction.

FINDINGS
a. Normal
● No tenderness noted.
● Bilaterally symmetrical contour of the jaw.
● Temporal and masseter muscles contract bilaterally.
b. Abnormal
● Decreased contraction in one or both sides.
● Asymmetric strength in moving the jaw may be seen.
○ Indicates lesion or injury of the CN V (Trigeminal).
● Pain occurs with clenching of the teeth.

C. Paper Clip Test - assess light and deep sensation.

1. Inform the client “I am going to touch your forehead, cheeks, and chin with the sharp or
dull side of the paper clip. Please close your eyes and tell me if and where you feel the
sharp or dull sensation.”
2. Vary the sharp and dull stimulus in the facial areas and compare sides.
3. Test for light touch with a wisp of cotton.

FINDINGS
a. Normal
● Correctly identifies sharp and dull stimuli as well as light touch to the forehead,
cheeks, and chin.
b. Abnormal
● Inability to feel and correctly identify facial stimuli. Indicates:
○ Lesions of the Trigeminal nerve
○ Lesions in the spinothalamic tract or posterior columns.

CN VII - FACIAL NERVE

A. Facial Expression Test

1. Ask the client to do the following:
a. Smile e. Purse Lips
b. Frown f. Show Teeth
c. Wrinkle Forehead g. Puff Out Cheeks
d. Raise Eyebrow h. Close Eyes Tightly

KEYSI & GRACIE 28

 FINDINGS
a. Normal
● Movements are Symmetrical and Smooth.
● Can do every movement.
b. Abnormal
● Inability to do the movements along with the paralysis of the lower part of the face
on the affected side.
○ Seen with Bell’s Palsy - a peripheral injury to CN VII (Facial Nerve).
● Paralysis of the lower part of the face on the opposite side affected.
○ Seen with a central lesion that affects the upper motor neurons.

B. Taste Test ⅔ of the Tongue

Not routinely tested, if testing is indicated however, the following are done:
1. Touch the anterior ⅔ of the tongue with a moistened applicator dipped in salt, sugar, or
lemon juice.
2. Ask the client to identify the flavor.
● If the client is unsuccessful, repeat the test using the remaining solution.

FINDINGS
a. Normal
● Client correctly identifies the flavor.
b. Abnormal
● Inability to identify correct flavor on the anterior ⅔ of the tongue.
○ Suggess impairment of the CN VII (Facial Nerve).

CN VIII - ACOUSTIC/ VESTIBULOCOCHLEAR NERVE

A. Romberg’s Test - assess equilibrium (balance)

1. Ask the client to stand with their feet together and arms resting at the sides. First with their
eyes open and then closed.
2. Stand close during this test.
● To prevent client from falling.

FINDINGS
a. Normal
● Negative Romberg
○ Patient may sway slightly but is able to maintain upright posture.
b. Abnormal
● Positive Romberg
○ Cannot maintain foot stance.
○ Moves the feet apart to maintain stance.
● If client cannot maintain balance with their eyes shut. They may have Sensory
Ataxia.
○ Lack of coordination of the voluntary muscles.

KEYSI & GRACIE 29

 ● If balance cannot be maintained whether eyes are open or shut, client may have
cerebellar ataxia.

B. Whisper Test - assess hearing.

1. Ask the client to gently occlude the ear not being tested and rub their tragus with a finger
in a circular motion.
2. With your head 2 feet behind the client (for client not to see your lips move), whisper a
two-syllable word such as “popcorn” or “football”.
3. Ask the client to repeat it back to you.
● If the response was incorrect the first time, whisper the word one more time.
● Identifying three out of six words is considered passing the test.

FINDINGS
a. Normal
● Able to correctly repeat the two-syllable word as whispered.
b. Abnormal
● Unable to repeat the two-syllable word after two tries.
○ Indicates hearing loss.
○ Requires follow-up testing by an audiologist.

C. Weber’s Test - done if client reports diminished or lost hearing in one ear.
The test helps to evaluate the conduction of soundwaves through bone to help distinguish
between conductive hearing (sound waves transmitted by the external and middle ear) and
sensorineural hearing (sound waves transmitted by the inner ear).
1. Strike a tuning fork softly with the back of your hand and place it at the center of the
client’s head or forehead.
● Centering is the important part.
2. Ask whether the client hears the sound better in one ear or the same in both ears.

FINDINGS
a. Normal
● Vibration heard equally well in both ears.
● No lateralization of sound to either ears.
b. Abnormal
● Conductive Hearing Loss
○ The client resorts lateralization of sound to the poor ear (client hears sounds
in the poor ear).
○ The good ear is distracted by background noise and conducted air, which the
poor ear has trouble hearing.
○ Poor ear receives most of the sound conducted by bone vibration.
● Sensorineural Hearing Loss
○ The client reports lateralization of sound to the good ear.
■ Due to the limited perception of sound due to the nerve damage in the
bad ear, making sound seem louder in the unaffected ear.

KEYSI & GRACIE 30

D. Rinne’s Test - compares air and bone conduction sounds.
1. Strike a tuning fork and place the base of the fork on the client’s mastoid process.
2. Ask the client to tell you when the sound is no longer heard.
3. Move the prongs of the tuning fork to the front of the external auditory canal.
4. Ask the client to tell you if the sound is heard after the fork is moved.

FINDINGS
a. Normal
● Air conduction sound is normally heard longer than bone conduction sound (AC >
BC).
b. Abnormal
● Conductive Hearing Loss
○ BC > AC - Bone Conduction (BC) sound is heard longer or equally as long as
Air Conduction (AC).
○ Indicates:
■ Fluid in the middle ■ Perforated
ear septum
■ Middle-ear ■ Benign tumors
infection (otitis ■ impacted
media) cerumen
■ Allergies (serous ■ Infection in the
otitis media) ear canal
■ Eustachian tube (external otitis
dysfunction media)
■ Presence of a
foreign body.
● Sensorineural Hearing Loss
○ Air conduction is heard longer than bone conduction sound (AC > BC) if
anything is heard at all.
○ Caused by:
■ Ototoxic Drugs ■ Head Trauma
■ Genetic Hearing ■ Malformation of
Loss the Inner Ear
■ Aging ■ Loud Noise
Exposure

CN IX - GLOSSOPHARYNGEAL, CN X - VAGUS NERVE

Both are assessed at the same time.

A. Taste Test
Same process with the taste tast in CN VII (Facial Nerve), you may use other reagents.
1. Touch the tongue with a moistened applicator dipped in salt, sugar, or lemon juice.
2. Ask the client to identify the flavor.
● If the client is unsuccessful, repeat the test using the remaining solution.

KEYSI & GRACIE 31

 FINDINGS
a. Normal
● Client correctly identifies the flavor.
b. Abnormal
● Inability to identify correct flavor on.

B. Swallowing Test
1. Give the client a drink of water.
2. Take not of the client’s voice quality.

FINDINGS
a. Normal
● Client swallows without difficulty.
● No hoarseness noted.
b. Abnormal
● Dysphagia or hoarseness may indicate:
○ Lesion of CN IX or X or other neurologic disorder.

C. Tongue Motor Test

1. Ask the client to open their mouth and say “ah” while you use a tongue depressor on the
client’s tongue.
2. Ask the client to move tongue from side to side and up and down.

FINDINGS
a. Normal
● Uvula and soft palate rise bilaterally and symmetrically upon phonation (“ah”).
b. Abnormal
● Soft palate does not rise.
○ Seen with bilateral lesions of CN X.
● Unilateral rising of soft palate and deviation of the uvula to the side.
○ Seen with a unilateral lesion of CN X.

D. Gag Reflex
1. Touch the posterior pharynx with the tongue depressor.

FINDINGS
a. Normal
● Gag reflex intact.
● Some normal clients may have a reduced or absent gag reflex.
b. Abnormal
● An absent gag reflex may be seen with lesions of CN IX or X.

KEYSI & GRACIE 32

 CN XI - ACCESSORY OR SPINAL ACCESSORY

A. Shoulder Shrug Test

1. Ask the client to shrug their shoulders against resistance towards your hand to assess the
trapezius muscles.
● Repeat on the other side.

FINDINGS
a. Normal
● Symmetric, strong contraction of the trapezius muscles.
b. Abnormal
● Asymmetric muscle contraction or drooping of the shoulder.
○ May be seen with paralysis or muscle weakness due to neck injury or
torticollis.

B. Sternocleidomastoid Strength Test

1. Ask the client to turn their head against resistance towards your hand.
● First to the right then to the left.
2. Assess the sternocleidomastoid muscle.

FINDINGS
a. Normal
● There is strong contraction of sternocleidomastoid muscle on the opposite side of
the turned face.
b. Abnormal
● Atrophy with fasciculations.
○ May be seen with peripheral nerve disease.

CN XII - HYPOGLOSSAL NERVE

Tongue Strength Test - assess strength and mobility of the tongue.

1. Ask the client to protrude their tongue.
2. Using the tongue depressor, ask the client to move it to each side against the resistance of
the depressor and then put it back in the mouth.

FINDINGS
a. Normal
● Tongue movement is symmetric and smooth.
● Bilateral strength is apparent.
b. Abnormal
● Fasciculations and atrophy of the tongue.
○ Seen with peripheral nerve disease.
● Deviation to the affected side.
○ Seen with a unilateral lesion.

KEYSI & GRACIE 33