Assessments Flashcards
Neurological
Neurological
AVPU/GCS
Level of Consciousness (AAOx?)
Stroke Assessment
Raise arms, close eyes, hold for 10 seconds with palms up
Smile
“Can’t teach an old dog new tricks”
PERRL
Check head for signs of head trauma
VITALS: Blood Glucose, Pulse Oximetry
Essential Questions:
Time of onset?
Baseline Mental/Neuro Status?
History of Stroke/Neuro Problems?
Recent Trauma (falls, car wrecks)?
Takes blood thinners?
IF TIME:
Check sensation of forehead, cheekbones,
Cognition (Spell the word DOG backwards? Birds fly in the sky or swim in the ocean? What color is the sky?)
Have PT clench teeth
Have PT puff their cheeks out
Have the PT stick their tongue out and say “ah-a-ah”
Have PT shrug their shoulders against resistance
Have PT turn head to both sides
Check sensation in face, hands, feet
Assess grip strength
Have PT touch their nose, then your finger
Have PT read something
Have PT run their heel along their shin of each leg
Follow/Track Movement of Finger with Eyes
Respiratory
Respiratory: AAOx4? Patent Airway? Positioning? Work of breathing? How many word sentences can PT speak in? Skin Color, Temp and Condition Pulse Rate and Quality Pulse Oximetry and ETCO2 ASAP Temperature if pneumonia suspected Apply O2 ASAP if a need is identified with the appropriate device (Check vitals and alertness check before considering CPAP) Physical Exam: Lung Sounds (LISTEN TO THE BACK TO GET LOWER LOBES!!! Check extremities for edema Check face and abdomen for rash, urticaria, edema from possible allergic reaction
Important Questions: Was the onset gradual or sudden? Improved with rest? Have you taken any medications? Recently Chest pain? Pain on inspiration/expiration? History of clotting disorders? Recent long periods of inactivity or bedrest? Any recent weight gain? Medical history? Medications? Sleeping with extra pillows? Any recent sickness?
Patient Competency/Abuse/Safety
Can this Patient be left on their own? Does something need to be reported?
