Comprehensive Patient Assessment Techniques

1. RSPT 1085 MODULE F Lesson #4a - Initial Impression, Neurological, HEENT & Neck Assessment

2. ASSIGNMENTS • Read Egan’s Fundamentals: • Chapter 15, pages: • 325 – 326 • 330 – 331 • 341 - 342 • Egan’s Workbook • Chapter 15 • Review Lesson objectives

3. OBJECTIVES • At the end of this module, the student should be able to… • Define the words used in this module. • List the main categories of physical assessment done by the RCP. • State the purpose of the initial impression. • List and explain the three areas of neurological assessment.

4. OBJECTIVES • At the end of this module, the student should be able to… • List the six levels of consciousness. • Explain how to evaluate orientation. • List the terms used to describe emotional state. • Describe two different postures and their causes.

5. OBJECTIVES • At the end of this module, the student should be able to… • During HEENT inspection, what can be some abnormal findings. • Explain the significance of jugular vein distension. • Compare the different forms of tracheal deviation.

6. Against the Wind

7. KAHOOT IT! https://play.kahoot.it/#/k/4089edf6-87e0-44cd-b838-00575ac86612

8. MAJOR TOPICS • Initial Impression • Neurological Assessment • HEENT Assessment • Neck Assessment

9. RCP Patient Assessment(Secondary Survey) • Initial Impression • Neurological • HEENT • Neck • Vital Signs • Thorax • Respiratory • Cardiac • Abdominal & Renal • Extremities

10. Initial Impression • Appropriate looking for: • Age • Height and weight • Position • Sitting up • Lying down • Side lying • Tripod

12. Initial Impression • General Appearance – “The patient looks…” • Healthy vs. sick, run down looking, weak, diaphoretic (General Malaise) • Well nourished vs. malnourished (Nutritional status) • Well taken care of vs. abused (see handout) • Neat & clean vs. homeless (Personal hygiene) • Calm vs. anxious or in pain (Facial expression) • Ability to perform activities of daily living (ADL’s) vs. confined to bed

13. Neurological Assessment A. Level of Consciousness B. Orientation (sensorium) C. Emotional State *Three different things with different terminology.

14. Level of Consciousness Involves two areas: 1. Ability to awaken 2. Awareness when awake

15. Level of Consciousness • Alert and responsive – normal. • Lethargic, somnolence - sleepy but arouses easily. • Obtunded - difficult to awaken but responds appropriately, may have decreased cough or gag. • Stuporous, confused – does not awaken completely & responds slowly, decreased mental & physical activity. • Semicomatose - responds only to painful stimuli, reflex response only. • Comatose - does not respond to painful stimuli, no reflexes, no voluntary movement.

16. What’s my level of consciousness?

17. Glasgow Coma Scale • Accurate assessment of Level Of Consciousness (LOC) based on: • Eye opening (1 – 4) • Motor (verbal & pain) response (1 – 6) • Verbal response (1 – 5) • Good for monitoring neurologic trends • Range of scores are 3 – 15

19. Glasgow Coma Scale • The larger number the better • 15 is closest to normal • Lower number – more ill or deeper coma • Can get score of 3 and not be alive

20. Posturing • Decortication – abnormal flexion of arms and extension of legs due to cortex dysfunction. • Decerebration – abnormal extension of arms & legs due to brain stem dysfunction.

21. Posturing Cortex Brain stem

22. Neurological Assessment A. Level of Consciousness B. Orientation (sensorium) C. Emotional State

23. Orientation • Orientation x3 • Person • Question – What is your name? • Place • Question – Can you tell me where you are? • Time • Question – Do you know what time it is or what day it is?

24. Orientation (Based on answers to questions) • Well oriented - cooperative, knows who people are • Disoriented - confused, slow, incoherent • Confused – slow response, dulled perception, incoherent thoughts • Delirious – easily agitated, irritable, hallucinations • Able to cooperate - ask to perform simple tasks, ask to repeat instructions • Unable to cooperate & may be due to: • language difficulties • Influence of medication • Hearing loss • Fear, apprehension, depression, etc.

25. Neurological Assessment A. Level of Consciousness B. Orientation (sensorium) C. Emotional State

26. Emotional State Facial expressions

27. Emotional State • Anxious, nervous - watching every movement (asthmatic) • Distressed (hypoxemia) • Depressed - quiet or denial • Angry, combative, irritable (electrolyte imbalance) • Euphoric – (drug overdose) • Sedated – (medicated to relieve anxiety or induce sleep) • Panicky – (hypoxia, tension pneumothorax, status asthmaticus, pulmonary embolism)

29. HEENT Assessment • General & Head • Eyes • Ears • Nose • Mouth • Throat

30. HEENT Assessment • Head • What can be observed when doing an assessment of the head? • Cuts & bruises • Burns • Change from normal skin temperature • Sweating (diaphoresis) • What does the finding mean?

31. The photo is of Kolby - 24 hours after being burned by a Magic Eraser sponge. It was much worse the day before.

32. HEENT Assessment • Eyes • What can be observed when doing an assessment of the eyes? • (PERRLA) - Pupils should be equal in size, round, reactive to light and accommodation (distance) • Dilation (mydrasis) with brain death, catecholamines, atropine • Constriction (miosis) with parasympathetics, opiates • Eyelid drooping (ptosis) with cranial nerve damage, tumors, myasthenia gravis… • What does the finding mean?

33. Eyes – Pupils

34. HEENT Assessment • Ears & Nose • What can be observed when doing an assessment of the ears & nose? • Inspect nose & ears for fluid • Itching or burning sensations of the nose and throat • Newborns with nasal flaring - a sign of respiratory distress • What does the finding mean?

35. HEENT Assessment • Mouth: • What can be observed when doing an assessment of the mouth? • Grunting in newborns • Pursed-lip breathing • Blood in mouth • Broken or loose teeth • Color of mucous membranes • Pink, Red, Blue • Breath odor • ETOH, Diabetic = sweet or acetone • What does the finding mean?

37. HEENT Assessment • Throat • What can be observed when doing an assessment of the throat? • Difficulty swallowing or drooling (dysphagia) • Noisy breathing (stridor & wheezing) • Hoarseness or voice change • Speech difficulty (dysphasia) • Can they complete a sentence with one breath? • Can they hold their breath? • Is it clear and understandable ? • Cough & production • What does the finding mean?

39. MAJOR TOPICS • Initial Impression • Neurological Assessment • HEENT Assessment • Neck Assessment

40. Neck Assessment • Supra sternal retractions • Masses • Medic Alert tags • Subcutaneous emphysema • Accessory muscle use • Transtracheal oxygen catheter or other invasive catheters • Stoma • Jugular Vein Distension • Tracheal Deviation

41. Estimation of jugular venous pressure.

42. Neck Assessment • Jugular vein distention - defined • When the bed is elevated 45 degrees, the blood should fill the neck veins no more than a few cm above the clavicles. • Venous distention greater than 4 cm above the sternal angle, at end exhalation, is abnormal. • See Egan page 342

43. Jugular vein distension (JVD)

44. Neck Assessment • Jugular vein distention - causes • Congestive right heart failure • COPD with Cor Pulmonale or RHF • Obliteration of the pulmonary capillary bed by pulmonary disease such as emphysema • Chronic hypoxemia • Pulmonary hypertension (vasoconstriction) • Polycythemia • Also possibly caused by severe LHF, hypervolemia, right atrial tumors

45. EMPHYSEMA

46. Cor Pulmonale *Begins with Lung disease JVD Right heart failure Liver enlargement Pedal edema

47. Neck Assessment • Tracheal deviation • To determine proper position, place the index finger through the supra sternal notch. • Compare the space between the clavicles and the borders of the trachea.

49. Thyroid Deviation This is a picture of a thyroid cartilage shift (possibly from a neck mass) Center Right Left

50. Tracheal Deviation Atelectasis of the right lower lobe Trachea deviated toward the affected side Pull