Guidelines for Exam and Eval of People w/ Neuro Deficits Flashcards
informal observation
level of awareness
posture in seated
gait
wheelchair propulsion
devices
level of awareness
interaction w/ environment
eyes open
looking around
posture in seated
slouch
tilt
where is UE?
gait will be observed
if appropriate
gait
assistive device
stability
pattern
assistance
w/c propulsion checked
if appropriate
w/c propulsion
pattern
if in the w/c, then
any devices are noted
any devices
lap board
communication board
IV pole
what does the subjective exam establish
level of communication with patient
what should we get from the subjective exam
communication level
common questions
what happened to you? when?
what was your tx before you came here?
what activities do you do on your own?
what activities do you need help with?
do you have any pain?
where are you?
what date is it?
subjective exam includes
pt interview/family interview/ chart review
pt interview/family interview/ chart review
PMH
PSH
social history
vocation
recreation
what shouldnt we do with our cues –> subjective
lead patient w/ verbal and non-verbal cues
some questions should –> subjective
challenge short and long term memory
what does the subjective exam help with
better understand the pt’s mentation, cognition and emotional state
objective exam includes
formal observation
formal observation includes
systems review
sensation
communication
CN screening
vision
balance
gait
cerebellar tests
w/c eval
fxnal tests
berg balance
special tests
formal observation
posturing of extremities and trunk in sitting
posturing of extremities and trunk in standing (if appropriate)
systems review
cardiopulmonary
integument
MSK
NM
cardiopulmonary
heart sounds
vital signs
breathing patterns
sitting posture
integument
decubiti present
potential decubiti
areas of redness
prevention via communication w/ family/caregiver(s), nursing staff
MSK
posture
AROM of extremities and trunk
PROM of extremities
pain