Neurological Assessment Cheat Sheet

Neurological Assessment HEALTH QUESTIONS PRESENT (answered yes) Dizziness? Problems w/ ears State VITALS Blood pressure Pulse Weakness? BilaterSigns of stroke Resp. Rate Headaches Temperature Inc. cranial pressure or tumour Trouble Swallowing Problems w functions of cranial n. Head Injury? CRANIAL N. CN. II Confrontation Test CN. III, IV, VI: Pupil size and equality CN. III, IV, VI: Direct and Consensual Light Reflex CN V: Sensory Function CN VII: Motor function MOTOR SYSTEM Oxygen resounding signs & symp ie. dizziness and Pain: OPQRSTU+AAA hearing PROCEDURE patient at eye level & 2ft apart: -flick finger: bottom up to top, down from top, across the nose, behind the ear (then other eye) NORMAL FIND Normal Findings 120/80 60-100 bpm 10-20 35.8-37.3 oral >95 plus aggravting, associated, attributions. ABNORMAL measures peripheral visions in comparison to testers peripheral vision is worse than testers 3-5mm range, both equal not equal (smaller on one side) = trauma/ head injury. if both are dialated/constricted = drugs equal and simultaneous constriction unequal = tumour, head injury, trauma ask patient to close eyes, use cotton tip and touch opthalmatic, maxillary, and mandibular divisions (6 pnts alternating) all yes to touch = good nerve function silent or no feeling to tocuh = investigte damge to the nerve Raise eyebrows (contract fronalis), shut eyes (obicularis oculi), smiling (orbicularis oris), assess symmetry all symmetrical and functioning asymmetry or drooping = bell's palsy or stroke use pen light and measure size of pupils Shine light into one eye: Look at constriction of eye, look at other eye (while light is shining on direct eye PROCEDURE NORMAL FIND ABNORMAL Romberg Test lower bed, have patient stand, feet together, arms at side with eyes closed, be close incase they fall, 30 seconds, loss of balance can be slight swaying is okay due to past concussions Muscle Strength Raise bed, have patient squeeze hands tight symmetrical strength weakness on one side = stroke or brain issue, Rapid Alt. Movement Slap knees with the palms and then backhand and then increase speed alternating palms and back. Finger-Finger test touch finger to nose, moving my finger looks at coordination into her peripheral vision after a few not speed times back and forth Lesions in brain, tumour, head injury = lack of coordination Finger - Nose test have patient close their eyes and have arms out ^^^ ^^^ NORMAL FIND ABNORMAL lack of sensation = innervation problems, identify where sensation is felt again SENSORY SYSTEM PROCEDURE eyes closed, sharp and dull sensation. touch forearms with sharp/dulls Do random pattern, leave time to prevent symmation Spinothalamic tract - Pain strike the legs in the same spot while increasing speed distinguishes sharp with dull, good nerve function Lack of coordination = lesion in brain or intoxication Posterior Column tract Kinesthesia eyes closed, Have hands out and moving fingers up or down, have finers to the side distinguish direction of their fingers to prevent preindications Tactile Discrimination Graphesthesia eyes closed, draw bottom line on the palm distinguish letters/numbers, good problem with nerve and draw letters or numbers function of hand nerve endings in hand endings REFLEX PROCEDURE NORMAL FIND ABNORMAL have legs dangling, strike hammer below patella, have patient pull arms for distractions body maintain balance and appropriate muscle tone, normal score of 2+, 3+ reflec absent, reflex enhanced State VITALS Normal Findings Quadriceps Reflex Respiratory Assessment HEALTH QUESTIONS PRESENT (answered yes) Cough? acute (2-3w) or chronic (2m or more) Pulse SOB? a cardiac case, COPD, heart failure, asthma Resp. Rate Blood pressure Personal history of resp disease recurring patterms of patterns of resp illnessTemperature lesions, tumours pressing on area 120/80 60-100 bpm 10-20 35.8-37.3 oral Family history genetic component to respiratory illness >95 PPE and exporsure to chemicals that can Environmental exp lead to diseas Oxygen Pain: OPQRSTU+AAA plus aggravting, associated, attributions. ANTERIOR ASS. NORMAL FIND ABNORMAL PROCEDURE Inspection Level of Consciousness Shape and Configuration of Chest wall Ask the patient for their name, today’s date and where they are right now Check skin condition (uniform?), any lesions, insepct shape of ribs Thoracic Check the anteroposterior diameter to Diameter (AP:T) transverse diameter Respiratory and rate and pattern Measure pulse while watching respiration for 30 seconds x 2 Answers correctly sign of confusion which can be caused by not enough oxygen getting to the brain unifrom skin, no masses, sloping downward ribs and symmetrical interspaces. Costal angel within 90 degrees cyanosis= lack of O2, Masses/lumps = tumour?. Patients who have COPD = barrel chest, ribs are horizontal and costal angle > 90 degress 1:2 COPD cause the ratio to be 1:! (barrel chest) due to air trapping in the lungs Normal relaxed breathing, produces no noise, no accessory musc, normal resp rate Accessory musc. needed in acute airway obstruction. Tachypnea and bradypnea Palpation Palpate entire chest wall All lung fields Using tips of fingers, palpate down the chest wall and then side middle lobe using a circular motion to feel for and lumps or masses or tenderness Percussion Percuss the apices in the supraclavicular areas then the interspaces. Comparing one side with the other, moving down. borders of cardiac dullness normally found on the anterior chest no lumps felt sounds are normal Lumps = tumours and pain can indicate a pulled muscle or damage to the ribs. hear hyper-resosnance (where you would expect to hear cardiac dullness) = lungs are hyperinflated. dullness: tumour or mass w/in lung field Auscultation Auscultate over the anterior chest from the apices in the supraclavicular areas All lung fields down to the sixth rib. Progress from side (min 5x per side) to side as you move downward and listen to one full respiration in each location. Identify location of normal breath sound (3) POSTERIOR A. lung sounds hear hear bronchal (exp more) over trachea, bronch= trachea, BV bronchiovesicular over sternum, vesicular = sternum, vesicular = (insp more) in the lateral lateral PROCEDURE NORMAL FIND cannot hear lung sounds over one area that can be sign of a collapsed lung advetitious sounds, crackles, wheeze, atelectic crackles ABNORMAL Inspection Shape and Configuration of Chest wall Check skin condition (uniform?), any lesions, insepct spinous process, unifrom skin, no masses, straight spinous process cyanosis= lack of O2, Masses/lumps = tumour? scoliosis= limit thoracic cage excursion no lumps Lumps can indicate tumours underneath the skin and pain can indicate a pulled muscle or damage to the ribs. Palpation Palpate entire chest wall tips of fingers: palpate down the chest wall in a circular motion to feel for and lumps or masses or tenderness. Work your way down the side of the chest wall for the right middle lobe ulnar edge hand and touch the patient’s back while patient repeats "blue moon" or “ninety- nine” (it is a resonant phrase that Tactile Fremitus fremitus present generates strong vibrations) sound generated from the larynx, transmitted through lung parenchyma hands on the posterolateral chest wall with your thumbs at the level of T9 or T10. Symmetrical hands should move Chest Expansion Slide hands to pinch up a fold of skin btwn symmetriclaly thumbs. Then ask them to inhale and exhale Percussion decreased fremitus = anything obstructing the transmissions of vibrations such as obstructed bronchus unsymmetry = collapsed lung or pnemonia All lung fields Diaphragmatic excursion (one side) percuss the apices in the supraclavicular areas. Then, percussing the interspaces and comparing one side with the other, move down the anterior chest. hear hyper-resosnance (where you would expect to hear cardiac dullness) Hear resonance over = lungs are air filled spaces hyperinflated. dullness: tumour or mass w/in lung field Measures expansion of lung: state you High: Pregnancy, would do both sides have them take a expect range 3-5 cm, ascites, increased intradeep breath OUT & HOLD --> precuss athletes <7 cm is abdominal pressure. down and note change from resonance in norm Low/fixed diaphragm: lung field to spleen. mark line and vice Emphysema. versa Auscultation Have patient breath in and out each time All lung fields stethoscope moves, in a zig zag pattern, (min 5x per side) listen down then lateral Identify location of normal breath sound (2) normal breath sounds advetitious sounds, crackles, wheeze, atelectic crackles Scapula area: bronchial vesicular sound, Lateral: vesicular sounds Cardiac Assessment State VITALS HEALTH QUESTIONS PRESENT (answered yes) Chest Pain? prescene indicate angina, symptom of coro Pulse Cough? Hemoptysis occur with mitral stenosis Do you tire easily? Fatigue due to decreased Cardiac Output Blood pressure Resp. Rate Temperature Normal Findings 120/80 60-100 bpm 10-20 35.8-37.3 oral Swelling? Edema dependent when caused by heart failure Oxygen Do you smoke? Smoking can cause vasoconstriction and hypertension Pain: OPQRSTU+AAA plus aggravting, associated, attributions. NORMAL FIND ABNORMAL NECK (bilateral) PROCEDURE >95 Auscultate the Carotid Artery Palpate the Carotid Artery Inspect and Identify Jugular Venous Pulse PRECORDIUM I am ausculating before palpating to indivate plaque build up or clots to avoid dislodging. using the bell to listen to bruits One at a time to avoid blocking O2 to the brain. Feeling for shape, pulsation, force and regualtion. PROCEDURE inspect skin for uniform, note findings of discolouration. Inspect for Pulsations (Apex) inspect apex for visible pulsatons ie. apical impulse . Look at eye level for pulsations deep breath in and hold: Use the pad of one finger to palpate. should lie in 5th intercostal space mid-clavicular line. If no feel of impulse i would move the patient onto their left side as the apec becomes more superficial this way. Palpate Precordium for Thrills Bruits (turbulent blood flow) = build up/obstruction in artery Level 2 force pulsation. Normal 2<= absent/ non-palpable, Contour is smooth w 2>= increased pulse, rapid bounding. If bruits heard do upstroke/downstroke not palpate and moderate amplitude. lying in a 30 degree angle. Have head turn away from vein assessed. look for findings are within 3 the top point of the pulsation. place cm. higher pressure one ruler parallel to the floor at the more on the right top of the pulsation and the other on side. detects venous the sternal notch perpendicular to the pressure floor. indicates pressure in heart sys Inspect for Heaves/Lifts Palpate Apical impulse No sound NORMAL FIND moisture is normal indicating hydration, colour normal to ethnic background normal for impulse to not be noticable usually can’t feel with larger patients palpate across precordium in 5 points to feel any other pulsations: aortic no thrills were felt area, pulmonic area, erbs, point, tricuspid, mitral ABNORMAL Heaves/lifts = indicate excessive force within the heart. Happens in ventricular hypertrophy (overdevelopment of muscle) small flickering/soft knocks of visble pulsations heavy pulse feels Vibrations occur in the precordium if there is turbulent blood flow where it is not smoothly flowing through AUSCULTATE PRECORDIUM ฀ R.sternal border 2nd intercostal space → aortic area ฀ L.sternal border 2nd intercostal Correctly state space → pulmonic area landmarkings for ฀ L. sternal border 3rd intercostal all five sites space → erbs point when ฀ L. sternal border 5th intercostal auscultating space→ tricuspid area ฀ L. midclavicular line 5th intercostal space→ mitral area Aortic v. = S2 louder than S1, Pulmonic v. = S2 louder , Erbs point = S1 and S2 equal, Tricuspid v = S1 louder than S2, Mitral v = S1 louder S1 indicates systole and is louder at the apex closer to atrial valves, and S2 Define S1 and S2 indicates filling diastole and is louder at the base closer to semi lunar valves Aortic v. = S2 louder than S1, Pulmonic v. = S2 louder , Erbs point = S1 and S2 equal, Tricuspid v = S1 louder than S2, Mitral v = S1 louder Auscultation of 5 areas opposite of diaphragm for any abnormal blood flow, murmurs of valves (S3 S4 or murmurs) no murmers, S3 or 4: indication of closing valves appropriately and in-sync Ausc. w/ Bell Ausc. w/ Diaphragm ^^^ Count Apical Heart Rate COUNT FOR A MINUTE Peripheral Vascular System PROCEDURE (Bilateral) Inspect peripheral Checking for swelling, or edema extremities Palpate radial pulses Assess and grade edema Palpate each wrist and compare side to side, feel for regularity, force (level 2normal) and rhythm symmetry NORMAL FIND regular, force 2+, symmetrical Using both hands at the same time DEPRESSING over bones of the foot for 5 no indentations seconds and work up the shin, feeling for fluid Murmurs = *** ABNORMAL Abdominal Assessment HEALTH QUESTIONS PRESENT (answered yes) Adominal Pain? if so where is the location? referred pain? State VITALS Blood pressure Pulse Unplanned weight gain or loss diseases or condition Resp. Rate Food intolerances proper diet Temperature Personal History Bowel patterns INSPECTION Contour Skin colour and condition finds repeats or flares Oxygen what is the normal at home and is it same Pain: OPQRSTU+AAA at the hospital PROCEDURE contour: look at eye level , contour should be flat Lower bed flat, looking at colour and condition NORMAL FIND contour should be flat uniform colour (pink undertone) Normal Findings 120/80 60-100 bpm 10-20 35.8-37.3 oral >95 plus aggravting, associated, attributions. ABNORMAL Lesions, Visibile masses, cyanois, pallor, jaundice (jaundice = liver failure) Pulsations and movements eye level: Normal peristalisis (bowel movements), no BIG pulsations over abdominal aorta over midline in smaller patients small pulsations or no pulsation big pulsations Hernias have patient do one sit up assesing for hernias and bulges weakings on muscle wall often post surgery hernias not post op, bulge = risk for strangulation AUSCULTATION Four quadrants ausc. before palpation and percussing to hear "normal" sounds before disruptions Listen w diaphragm for bowel sounds, bowel sounds = then bell for vascular sounds---- starting normal 5-30 noises at the RLQ, 3x per quadrant in zig zag. Diapragm: over 30: hyperactive bowel, less than 5: hypoactive. absent: listen for 5 minutes Abdominal vessels (state only femoral arteries) starting at the Aortic area (top of abdominal area below xiphoid process), compare renal artery (blood flow to no bruits kidneys), illiac arteries inferior to umbilicus (arteries split and move to lefs) -Bell: bruits and turbulent bf DO NOT PALPATE, bruits can form from abnormal aneurysms PERCUSSION Four quadrants listening for general sounds and identifying normal structures, strating at RLQ, percuss 3x zig zag tympany noted all fieldes: fluid build and drum like dullness: masses, resonance: air pockets Liver Borders percussing down from lung fields to find top of liver border in midclavicular 5th intercostal space, changing from resonance to dull--------2. scratch test: scratch patient abdomen listening for sound to amplify normal distance: 612 cm depending on height/gender over 12 cm: cirrhosis over liver/damage occuring/enlargement Costovertebral Angle tenderness have patient sit up, legs dangling, place hands over costovertebral angle (12th rib), hit hand w thump pain/tenderness: inflam. of kidney Light Palpation (4 quad.) Deep Palp (4 quad) using fingertips pusing 1cm. in circular movement for superficial tissure pushing down 5-8cm in small circles, rasing and pushing each spot feel pain, lumps, masses or tenderness Liver Borders palpate only if no pain. on the Right side: backhand behind and front hand pushing down and up, having patient breath in & out feel bottom border if liver bumps fingers, feel smooth on palpation Kidneys below liver: backhand behind, front hand infront duckbill motion may or may not slide cirrhois, rigid feel: disease in and out of my hand process PALPATION Rebound assessing for inflammation and infection tenderness at over appendix on; push down on Mcburney's point mcburneys point and release quickly abnormal in organs enlargement of liver or cirrhois, rigid feel: disease process enlargement of liver or tenderness or pain indicates inflammation