Focused Assessments Flashcards
(28 cards)
What are the four general areas of neuro assessment
LOC
Sensory & Motor function
Pupillary changes & extraocular movements
VS & RR
What should we be concerned about with a head injury
severe headache (worst ever)
LOC
problems w/ balance & coordination
What should we ask when a pt has a headache
ask when it started
ask history of HA
any meds that improve HA
any N/V
blurred vision/changes
What are S/S of nervous sys disorders
persistent/sudden onset HA
HA that changes/feels different
Loss of feeling/tingling
weakness or loss of muscle strength
loss of sight/double vision
memory loss
impaired mental ability
problems w/ balance or coordination
what should we ask when pt experiences in LOC
what is the date
who is the president
what is going on w/ the news
where are you
How should we examine sensory perception for pt
use of qtip - cotton vs. sharp
how should we assess motor function
HG; TW - gait
What is the normal size for pupils
2-4mm in diameter in bright light
4-8mm in dark
What are we listening for in the heart valves
quality of rt & rhythm
any abnormal sounds
apical pulse
what should a cardiac assessment be done for
chest pain
peripheral edema
SOB
irreg pulse
dizziness
unexplained wt gain
What side should we use for high pitched sounds
use diaphragm
what side should we use for low pitched sounds
bell
What should we look for during a respiratory assessment
any signs of injury
check symmetry of chest expansion
rate & quality of breathing
look for color changes (cyanosis)
are they able to speak in complete sentences
what should we note during respiratory assessment
any difficulty breathing or use of axially muscles
when should we palpate during respiratory assessment
only if injury has occurred or any visible signs of irregularity in symmetry
What are the 6 P’s that should be assessed for Peripheral Neurovascular nerve damage
pain
pallor
paralysis
paresthesia
pulselessness
poikilothermia
what does pain mean
can have compartment syndrome if unrelieved by pain meds
what does pallor mean
dusky pale, compare unaffected extremity
what does paralysis mean
movement impaired
what does paresthisia mean
tingling, numb
what does pulselessness mean
late sign in effective extremity
what does poiklothermia
compare temp; cool may mean compartment syndrom
what should we assess for on the abdomen
pain, nausea, vomiting, injury
changes in appetite or bowel habits
any treatmern
what should we listen for in abdomen
listen for bs
listen for any bruits
