Health Assessment- Exam 3 Flashcards
Level of consciousness
- single most important neuro assessment component
- often first clue of deteriorating condition
Testing level of consciousness (LOC)
ALERT
Attentive, follows commands, if asleep - wakes promptly and remains attentive
Testing level of consciousness (LOC)
LETHARGIC
drowsy but awakens, slow to respond
Testing level of consciousness (LOC)
OBTUNDED
difficult to arouse, needs constant stimulation
Testing level of consciousness (LOC)
STUPOROUS/ SEMI COMATOSE
arouses only to vigorous/noxious stimuli, may only withdraw from pain
Testing level of consciousness (LOC)
COMATOSE
No response to verbal or noxious stimuli, no movement except deep tendon reflex
Testing level of consciousness (LOC)
What to look for?
ALOSC
Alert
Lethargic
obtunded
Stuporous/ semi-comatose
Comatose
Cognitive awareness also known as mentation
Is the patient oriented to person, place, and time?
Also know as mentation
Testing cognitive awareness
What is your name and date of birth?
> oriented to person
Where are you right now?
> orientated to place
What year/day is it?
> oriented to time
Cranial nerves
- 12 pairs
- sensory, motor, or both
- not all cranial nerves are always tested
- listed in order of testing
Olfactory
What number?
I
Optic
II
Oculomotor
III
Trochlear
IV
Trigeminal
V
Abducens
VI
Facial
VII
Vestibulocochlear
VIII
Glossopharyngeal
IX
Vagus
X
Accessory
XI
Hypoglossal
XII
Testing cranial nerves III, IV, and VI
Oculomotor, trochlear, abducens
Pupil response and cardinal gaze
Pupil response
-Examine size and shape of pupils and compare to scale
- start at ear with penlight and move in toward nose
- note change in size and speed of reaction
- with penlight, move penlight close to and away from pupils
PERRLA
P Pupils
E equal
R round
R react to
L light and
A accommodations
Cardinal gaze
-Use top of unlit penlight
- have pt follow with eyes only
- about 9-12” from face move the end of penlight in an “H” motion
Testing cranial nerve VII
Facial
-Ask patient to smile and show teeth
- Ask patient to wrinkle forehead or raise eyebrows
Testing cranial nerve XII
Hypoglossal
Ask patient to touch the roof of the mouth with tongue
Protrude tongue out of mouth
Move tongue from side to side
Testing cranial nerve XI
Accessory
Place hands lightly on patient shoulders
Ask patient to shrug shoulders
Testing motor function
Will complete as part of neuro and musculoskeletal assessments
- hand grasp and toe wiggle ( HGTW)
- flexion and extension with resistance
- all done bilaterally on BUE and BLE
Neuro components of assessment
LOC and orientation
Pupil response and cardinal gaze
Smile and show teeth, raise eyebrows
Tongue to roof of mouth, out, side to side
Shoulder strength with resistance
HGTW
Flexion/ extension BUE and BLE
Auscultation of the lungs - normal sounds
Vesicular - periphery of the lungs
Bronchovesticular- closer to the sternum
Bronchial - over trachea
Vestibular lung sounds
Periphery of the lungs
Bronchovesticular of the lungs
Closer to the sternum
Bronchial of the lungs
Over trachea
Abnormal or adventitious sounds
Crackles or rales - can be fine or course
rhonchi
Wheezes
Pleural friction rub
Abnormal respiratory patterns
Bradypnea
Tachypnea
Apnea
Hyperpnea
Kussmauls
Cheyne-Stokes
Nail shape
What to examine
Examine BUE nail shape
Clubbing
Respiratory components of assessment
Anterior and posterior lung sounds
Clubbing
LUB - heart sounds
Systole or S1 and is the sound associated with the closing of the mitral/ tricuspid valves
DUB - heart sounds
Diastole or S2 and is the sound associated with the closing of the aortic/pulmonic valves
Aortic location
Right base; second intercoastal space to the right of the sternal border
Pulmonic heart sounds
Left base; second intercostal space to the left of the sternal border
Tricuspid heart sounds
Left lateral sternal border; fifth intercostal space to the left of the sternal border
Mitral heart sound
Apex, midclavicular line at the fifth intercostal space
Pulses
Carotid
Brachial
Radial
Ulnar
Apical
Femoral
Popliteal
Dorsalis pedis
Assessment of pulses - Carotid
One at a time, bilaterally
Assessment of pulses - Radial
Bilaterally at the same time
Assessment of pulses - apical
With stethoscope for 2 beats
Assessment of pulses - dorsalis Pedis pulses
Bilaterally at the same time
Pulse points - 0
Absent, non-palpable
Pulse points- 1+
Diminished, palpable
Pulse points- 2+
Strong, normal
Pulse points - 3+
Full, increased
Pulse points- 4+
Bounding
Assessment via Doppler
Hand held device
Most often used for pedal places