NUR 101 Basic Physical Assessment Workshop Neurological and Skin Assessment

Mental Status and Level of Consciousness Observe level of consciousness, state of wakefulness (Glasgow Coma Scale) Level of orientation to surroundings Observe posture and body movements Observe dress, grooming , hygiene Observe facial expressions Assess speech (tone, clarity, pacing) Glasgow coma scale is a reliable objective way of recording the conscious state of a person Published in 1974 by 2 professors of neurosurgery at the university of Glasgow 3 deep unconsciousness, coma or death and 15 highest and fully awake Orientation X1 to person X2 to place X3 to time X4 to situation Posture and body movements= upright straight and appropriate OR slumped or tremors Is dress appropriate for age. Intense makeup. Sometimes schizophrenics or mental illness Are they restless overactive, overly nervous Speech: Clear and appropriate Confused Inappropriate Garbled aphasia expressive receptive

Degrees of wakefullness Alert= awake Awake, confused, disoriented Lethargic= easily aroused with speech or touch Obtunded= mild to moderate loss of arousability. Falls asleep unless verbally or tactile stimulation Stupor= deep sleep or unresponsive. Responds to deep painfull stimulation Coma= no verbal response, motor responses may be to deep painful stimulation

Best eye response (E) There are 4 grades starting with the most severe: 1.No eye opening 2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.) 3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.) 4. Eyes opening spontaneously Best verbal response (V) There are 5 grades starting with the most severe: 1.No verbal response 2.Incomprehensible sounds. (Moaning but no words.) 3.Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange) 4.Confused. (The patient responds to questions coherently but there is some disorientation and confusion.) 5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.) Best motor response (M) There are 6 grades starting with the most severe: 1.No motor response 2.Extension to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response) 3.Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response) 4.Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched) 5.Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.) 6.Obeys commands. (The patient does simple things as asked.) Intubation and severe facial/eye swelling or damage, make it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached

Mental Status and Level of Consciousness Observe cognitive abilities (orientation, concentration, remote and recent memory) Observe mood, feelings, and expressions Overly excited or depressed and withdrawn

Pupillary Changes Oculomotor response (Cranial nerve III) Size, equality, and roundness of pupils assessed Size measured in millimeters Evaluated for symmetry in size and response to light stimulus Brisk, sluggish, non-reactive Consensual reaction of opposite pupil at same time What is the pupil of the eye? Pupillary changes= guide to brain stem functioning Pupil is usually round, black, regular and equal in size (usually 3-7 mm in diameter) Your cranial nerve 3 is oculomotor nerve. Check size, equality, and roundness of pupils assessed Cloudy pupils= cataracts Dilated pupils- glaucoma, trauma, neuro disorders (eyes meds which have atropine in them) Constricted pupils= inflammations of iris, drug use (morphine, cocaine) Pinpoint= opiod intoxication

Pupillary Changes to Light Remember it is measured in MM opthalmoscope

Pupillary Changes Assess accommodation by holding finger 4-6 inches from client’s nose and then pull out to 18 inches. As finger moves away pupil will accommodate by dilating, as finger moves closer, constricting PEARLA- Pupils equal and reactive to light and accommodation We also assess accommodation= by holding finer 4-6 inches from patients nose and then follow to 18 inches AS finger moves away pupil will accommodate by dilating. As finger moves closer pupil constricts We say perla= pupils equal and reactive to light and accommodation

Cranial Nerves Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Auditory Glossopharyngeal Vagus Spinal Accessory Hypoglossal nerve function assess method Olfactory smell different aromas Optic visual acuity read eye chart (snellins) Oculomotor eye movement response to light pupil constric Trochlear eye movement up and down Trigeminal sensory nerve to skin and face corneal reflex Abducens lateral movement of eye Fascial fascial expressions fascial symmetry Auditory hearing Glassopharyngeal taste, swallowing gag reflex Vagus sensation of pharynx say “ah” movement of vocal cords Spinal accessory movement of head /shoulders shrug shoulders Hypoglossal position of tongue is tongue midline

Motor Function Ability to follow commands Muscle tone Muscle strength Coordination Balance (Romberg test) Posturing (Decorticate, Decerebrate) it’s in the back The cerebellum coordinates muscular activity. The brain sends messages to the muscles to move. Sensory impulses from the vestibular portion of the inner ear travel to the cerebellum, where impulses are relayed to proper motor nerves to maintain body equilibrium. Muscle tone= normal, flaccid, spastic, rigid Muscle strength= bilateral equal hand grasp and symmetry Coordination= perform repetitious movement after nurse does to avoid confusion (for example touch nose with finger or touch each finger with thumb ) This tests upper body Lower body have patient lye supine and place hand at the ball of patients foot and have them tap your hand Balance= romberg test sometimes seen in DUIs Feet together and arms at the sides eyes open and eyes closed. Protect patient’s safety Slight swaying is normal Stand on one foot for 5 seconds and then the other Or one foot in front of the other Decorticate= abnormal flexor posturing Decerebrate= abnormal extensor posturing this one is worse because it is indicative of brain stem involvement. You can go from decroticate to decerebrate

Decorticate/Decerebrate Decorticate looks like a mummy Usually they will do this with a stimulus

Sensory Function Tactile sensation Pain Temperature Vibratory sensation Tactile discrimination The sensory pathways of the central nervous system conduct sensation of pain, temperature, position, vibration, and crude and finely localized touch This can be done rather quickly Have patient close their eyes and touch different parts of body with cotton ball Pain broken tongue blade (ask when sharp and when dull alternating sides) Touch with alcohol swab this could be cold The book says that you can use two test tubes one filled with hot water and one with cold use wash clothes as well Vibration done with a tunning fork and have them state where they feel it over what joint Tactile discrimination is when a patient can tell that there are two broken tongue blades or broken q tips touching them

Reflexes Superficial Deep tendon Biceps Triceps Patellar Achilles Plantar (Babinski Response) Superficial = touch to area Deep tendon =graded 0-4 0= absent 1= hypoactive 2= normal 3= hyperactive 4= hyperactive with clonus (which is muscle contraction) Deep tendon reflexes with reflex hammer by taping the tendon it sends message to brain and the muscle causing the reflex response. Achilles Patellar knee Biceps Triceps Plantar (babinski response) Run the top of your pen along the outer lateral aspect of foot form heel to little toe and across to the big toe Toes fan on paralyzed side and bilateral in spinal cord injury If toes point down its normal If toes point up and toes fan out this is a babinski

Assess Speech and Hearing Clear and appropriate Confused Inappropriate Garbled Aphasia (Expressive, Receptive) Limited hearing Use of hearing aids

Skin Assessment Epidermis Dermis Subcutaneous tissue Hair follicle Nails Skin has two layers: Epidermis and the dermis epidermis= top layer this has several layers Dermis= inner layer of the skin= protects underlying muscles, bones and organs Subcutaneous tissue made up of fat cells. Provides insulation, and protection because soft and cushiony effects and stores fat for energy Hair follicles= due they have ingrown hair that’s causing ulceration in skin integrity Nails= check for fungus or any type of dark line (in dark skin people that may be normal, but in lighter skin people that could mean a melenoma Check to see if clubbing of the fingernails sign of hypoxia in patients with emphsema, chronic bronchitis

Skin Inspection General skin coloration (pallor, cyanosis, jaundice) Inspect skin integrity Inspect for lesions Assess texture Assess moisture Assess temperature Assess turgor Assess for edema Skin integrity= thoroughly inspect on admission and with every assessment. Check pressure areas, behind ears of nasal cannula, if arm bands too tight If there is some kind of break in skin integrity…. We call it a bedsore, pressure ulcer, pressure sore, decubitus ulcer In addition… check for tattoos and body jewelry texture= normal skin feels smooth and firm with an even surface rough or course, or onion skin in elderly especially on sterriods. Especially heals. We say boggy like and rotten orange or is it firm Moisture= perspiration appears normally on face, hands, axilla and skin folds in response to activity, warmth or anxiety from you inspecting But diaphoresis or profuse perspiration is not good. Look for dehydration by looking at the mucous membranes Normal to be moist and smooth Temperature= warm suggests normal circulation. Don’t use hand… use back of hand. Hands and feet may be slightly cooler in a cold environment but sometimes could be to poor circulation especially if there is a difference in maybe one foot as oppose to the other Turgor= refers to the ability for the skin to return to place promptly when released. Reflects elasticity of skin and this normally decreases with age. check on anterior of chest under the clavicle or back of forearm Severe dehyration or weight loss can cause skin to tent . Don’t do back of hand because skin is normally loose and thin there. Edema= it is fluid accumulating in the intercellular spaces Push thumbs firmly on the tibia. Normal skin stays smooth, but edema will leave an imprint of thumb Its graded on a scale from +1 edema to +4 (somewhat subjective)

Color Variations Know your patient’s normal baseline skin coloring. If this is the first time your meeting patient ask them about their usual skin color. Observe skin. Dark skinned people normally have areas of lighter pigmentation on the palms, nail beds, and lips (but not always) get a base line incase something does happen See different pictures

Skin Variations Freckles Moles (Nevus) Cutaneous tags Striae (stretch marks) Scars Rashes Discolorations Freckles= small, flat macules of brown melanin pigment that occur on sun-exposed skin Mole= these are growths of cells or proliferation of melanocytes. Can be tan to brown flat or raised When checking… check symmetry, (small size 6mm or less) smooth borders and one color Cutaneous tags= A skin tag is a common but harmless skin growth. Skin tags are frequently found on the eyelids, neck, chest, armpits, and groin. Treatments include freezing, tying off with a thread or suture, or cutting off. Stretch marks what stage of healing. Usually shiny when old Scars= they may have forgotten a surgery they had. Assess healing process. Don’t give injection in scars Rashes= what are they caused by????? Certain medication, moisture folds, scabies Discolorizations= circulation or PVD

Cutting off blood supply

Primary Skin Lesions Macule Papule Nodule Vesicle Wheal Pustule Cyst See next slide with pictures

Macule= a color change. Flat and less then 1cm (freckle, ptetichiae, flat mole) Papule= something you can feel because it’s a solid, elevated and less then .5cm (mole, wart) Nodule= solid, elevated and larger then .5cm and may extend deeper into dermis (fibroma, intradermal mole) Vesicle= elevated cavity containing free fluid up to .5cm (herpes zoster “shingles”, contact dermatitis, chickenpox when in that stage) Wheal= raised, and irregular shaped due to edema (mosquito bite, allergic reaction, hives) Pustule= pus in the cavity (impetigo or acne) Cyst= encapuslated fluid-filled cavity in the dermis or subcutaneous layer elevating skin

Looks like vesicle because looks like fluid filled Looks like vesicle because looks like fluid filled. Herpes or chicken pox One may be a Pustule Hard to tell size. We don’t even know what part of the body it is

Wheal Irregular shape

Cyst Encapsulated fluid-filled cavity

Vascular Skin Lesions Petechia Ecchymosis Hematoma Angioma (spider, telangiectasis) Petechia= look like tiny pinpoint hemorrhages <2mm round, dark red, purple or brown in color Won’t blanch, Cappillaries bleeding, Abnormal clotting factors Ecchymosis= bruise.. A large patch of cappilaries bleeding into tissues different colors means different levels of healing. Hematoma= a bruise you can feel. Seen as swelling angioma = blood vessels Telangiectases=== due to vascular dilation. They show as permanently enlarged and dilated blood vessels that are visasble on the skin surface Spider is example. Developes on face, neck, or chest. Red marking with . Sometimes looks like a star. Solid circular center with extended legs.. associated with pregnancy chronic liver disease or estrogen therapy. OR IT MAY BE NORMAL

ecchymosis

Spider angioma

hematoma

Pressure Ulcers Stages 1-4 Unstageable Braden scale Pressure ulcers rated Stage 1 – 4 Unstagable when eschar or necrotic tissue is present Braden scale some hospitals use a predictor of who is at risk for a pressure ulcer. Ask questions like are they mobile, incontinent, how is their nutrition level. This all factor into the patient getting a bedsore.                                                                          When Braden Scale Score 16 or less, implement Pressure Ulcer Prevention Protocols         These patient’s are at high risk

Progression of Tissue Destruction Stage 1 = pink, no open areas, may appear red, purple or blue in darker skin tones Pain or itching Stage 2= open area loss of skin involving the epidermis or dermis, appears clinically as abrasion, blister, or shallow crater Stage 3 = full thinkness skin loss involving damage or necrosis of subcutaneous tissue Pesent clinically as a deep crater Stage 4= full thinkness skin loss with extensive distruction, tissue necrosis or damage to muscle, bone or supporting structure. Probably require surgery. THESE ARE VERY SERIOUS. PATIENT’S CAN DIE FROM PRESSURE ULCERS

Stage 1 Pressure Ulcer

Stage II Pressure Ulcer

Stage III Pressure Ulcer

Stage IV Pressure Ulcer

Deep Tissue Injury

Eschar Must be removed by debridment before staging can be done. Why????? Eschar is the same as necrotic tissue Wound bleed it is a good sign This wound has no blood supply