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Clinical Assessment

Basic Head to Toe Assessment

Use your headlet your senses be your guide
As you enter the room What do you see? What do you hear? What do you smell? When you touch, what do you feel?

Neuro-level of consciousness
LOCthe most sensitive clinical indicator of a change in neurological status and oxygenation status Consciousnesslevel of awareness: self; environment; responses to environment Evaluate the amount stimulus needed to get a response
Verbal Tactile Painful

Neuro-level of consciousness
Glasgow Coma Scale Developed as a method to standardize observation of responsiveness in patients with traumatic brain injury Parameters

Minimum 3 Maximum (normal) 15 Clinically significant if there is a change of 2 points or more

Normal : 2-6 mm Abnormal: Significant change is more than 1 mm Pinpoint & non-reactivecould be a lesion or medication response (morphine or pilocarpine) Midsize (2-6mm) & non-reactivemidbrain lesion Unilateral large (>6mm) & non-reactivepressure on the occulomotor nerve on the same side Bilateral large (>6mm) & non-reactivebrainstem lesion or medication response (atropine, epi)

Abnormal: 50% of population are unequal >1mm or Change from baseline Call neurosurgeon or neurologist Shape Oval may precede dilated pupil indicating oculomotor pressure Irregular may be from cataracts or implants Position Abnormal : may deviate to the side of injury

Reactivity to light Normalbrisk, bilateral Abnormal

Sluggish or absentcranial nerve damage, hypothermia, barbiturate intoxication

Cranial Nerve



1. Olfactory
2. Optic 3. Oculomotor

Sensory Motor

Visual acuity / visual fields Extraocular movements pupilary reaction to light & accommodation Extraocular movements Sensation in forehead, jaw, cheeks & chin, mastication Extraocular movements Taste / movement of facial muscles Hearing acuity & balance Taste / movement of pharynx, gag reflex

4. Trochlear 5. Trigeminal 6. Abducens 7. Facial 8. Acoustic 9. Glossopharyngeal

Motor Mixed Motor Mixed Sensory Mixed

10. Vagus


Swallowing / movement of pharynx, gag reflex

Assess grips, shoulder movement Assess leg movement Have pt push foot against your hand (like you are

stepping on the gas) Look for symmetry, equal strength, equal movement, sensation Evaluate for weakness, sensation loss, inability to follow commands

Neurological Assessment
Compare baseline information to current assessment Changes in personality are a BIG hint something is going on
Neuro Respiratory Cardiac

Cardiovascular Assessment
Heart Sounds S1 (first heart sound) closing of the valves [mitral before tricuspid] the lubb sound S2 (second heart sound) closing of aortic & pulmonic valves, the dubb sound Extra heart soundscan be before the lubb/dubb or after

Cardiovascular Assessment
Murmur, rubs, clicks
Murmurflow across either an incompetent or stiff valve Rubsscratchy, scraping soundpericarditis Clicksartifical valves

Cardiovascular Assessment
Evaluate central and peripheral perfusion
Peripheral cyanosiscoldseen in fingertips, toes;

associated with hypoperfusion or vasoconstriction Central cyanosiswarmcyanosis seen in lips, tongue, mucous membranesis associated with a drop in oxygenated hemoglobin

Assess vital signs Skincolor, temperature; peripheral pulses

Pay attention to lips, mucous membranes, distal extremities Nail color and capillary refill Edemameans an increase in interstitial fluid of 30% above


CardiovascularEdema Scale
0 = no depression in tissue +1 = small depression in

tissue, disappears in less than one second +2 = depression in tissue, disappears in less than 1-2 seconds +3 = depression in tissue, disappears in less than 2-3 seconds +4 = depression in tissue, disappears in greater than 4 seconds

Note the location of edema Facialseen in allergies (anaphylaxis), steroids, renal disease Dependentright ventricular failure Generalized edema (anasarca)end stage heart failure, end stage renal failure, severe hyperproteinemia

Cardiovascular Assessment
Peripheral pulses Assess radial Assess Dorsalis pedis & posterior tibialis Check for equality, quality, rate & regularity Use a doppler if you cannot palpate pulsesDO NOT chart unable to palpate pulses unless you have assessed using a doppler and other findings correlate with lack of pulse

CardiovascularPulse Amplitude
0 = not palpable
1+ = weak and thready, easily obliterated 2+ = normal, not easily obliterated

3+ = full and bounding, cannot be obliterated

Assess distal pulses and work inwardsassess for

equality in pulses Use a doppler for difficult to palpate pulses

Arterial vs Peripheral Vascular Disease

Excruciating in acute occlusion; intermittent claudication in chronic Absent or diminished Pale Cool or cold Absent Thickened toenails

Crampy pain Homens sign in thrombophlebitis Normal (may be difficult to palpate due to edema) Normal or ruddy Warm Present; may be severe

Pulses Color Temp Edema

Skin changes Tiny shiny atrophic, loss of hair

At toes or points of trauma

Brown pigmentation at ankles

At sides of ankles

Cardiovascular Assessment
IV sites and IV fluids Note where sites are and what they look like

Assess for infiltration and infection, patency Note date, time of venipuncture and size of the catheter Are the IV fluids what was ordered and are they running at the rate ordered? If a titrated medication or running at a calculated dosecheck to make sure infusion is correct Check date on tubingno datechange it!

Cardiovascular Assessment
Monitor? Telemetry / hard wire?

What is the rhythm? Rate? Regular? What are the alarm parameterschecked and audible? When were the electrodes changed? Heart rate versus pulse rate

Respiratory Assessment
Oxygenation and ventilationthe focus of respiratory assessment
Rate, rhythm of respirations and symmetry of chest wall movement

Normal adult chest versus barrel chest

Respiratory Assessment
Note LOCrestlessness or confusion usually first sign

of hypoxia What is the work of breathing? Should be an unconscious eventis the patient having to think and work at breathinglaboring?
Pursed lip breathingseen in dyspneamay be

instinctive or patient may have been taught

Respiratory Assessment
Rhythm Description Eupnea
Rate 12-20 minute and normal depth of ventilation; regular with an occasional sigh Slow less than 10 per minute NORMAL

Possible Causes

Depression of resp center with opium (narcotics), alcohol or tumor Sleep Increased intracranial pressure CO2 narcosis Metabolic alkalosis


Rapid greater than 30 minute; depth may be normal or decreased

Restrictive lung disease Pneumonia Pleurisy Chest pain Fear, anxiety Respiratory insufficiency


Shallow ventilations, normal rate

Deep sleep Heart failure Shock Meningitis Central nervous system depression Coma


Deep ventilation; rate may be normal or increased

Exercise Hypoxia Fever Hepatic coma Midbrain or pons lesion Acid-base imbalance Salicylate overdose


Increasing and decreasing rate and depth

Intracranial hypertension Heart failure Renal failure Meningitis Cerebral hemisphere damage Drug overdose


Deep gasping rapid using greater than 35 minute ventilations

Prolonged gasping inspiration followed by short inefficient expiration

Metabolic acidosis (DKA, renal failure) Peritonitis


Lesion in the pons


Periods of apnea alternating with a series of breaths of equal depth; breathing may be slow and deep or rapid and shallow
Lack of any pattern to ventilation

Meningitis Encephalitis Lesion of the lower pons, upper medulla Intracranial hypertension


Brainstem lesion


I:E ratio of 1:4 or greater

expiration takes longer than inspiration

Asthma Emphysema Chronic bronchitis


Cessation of ventilation for longer than 15 seconds

Central nervous system damage Sleep

Lung Sounds
Adventitious sounds


Possible etiology

Fine crackles

Series of short explosive high pitched sounds heard just before the end of inspiration; result of rapid equalization of gas pressure when collapsed alveoli or small terminal bronchioles suddenly snap open; similar sound to that made by rolling hair between fingers just behind ear
Series of low pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa; evident on inspiration and at times expiration; similar to blowing through straw under water; increase in bubbling quality with more fluid

Interstitial fibrosis (asbestosis), interstitial edema (early pulmonary edema), alveolar filling (pneumonia), loss of lung volume (atelectasis)

Coarse crackles

Congestive heart failure, pulmonary edema, pneumonia with severe congestion, chronic obstructive pulmonary disease (COPD)


Continuous rumbling, snoring or rattling sounds resulting from obstruction of large airways with secretions; most prominent on expiration; change often evident after coughing or suctioning

COPD, cystic fibrosis, pneumonia


Continuous high pitched squeaking sound caused by rapid vibration of bronchial walls; evident on expiration but possibly evident on inspiration as obstruction of airway increases; possibly audible without stethoscope

Bronchospasm (caused by asthma), airway obstruction (caused by foreign body or tumor)


Continuous musical sound of constant pitch; result of partial obstruction of larynx or trachea

Croup, epiglottitis, vocal cord edema after extubation, foreign body

Absent breath sounds

No sound evident over entire lung or area of lung

Pleural effusion, mainstem bronchi obstruction, large atelectasis

Pleural friction rub

Creaking or grating sound caused by roughened, inflamed surfaces of the pleura rubbing together; evident during inspiration and expiration and no change with coughing; usually uncomfortable, especially on deep inspiration

Pleurisy, pneumonia, pulmonary infarct

Respiratory Assessment
Assess nailbeds Colorcyanosis? Clubbingindicates chronic decrease in O2 supply to body tissues

Normal angle between nailbed and nail = less than 180 degrees Early clubbingangle = to 180 degrees Late clubbingangle greater than 180 degrees


Early clubbing
Late clubbing

Clinical Indications of Respiratory Distress

Pursed lip breathing
Tripod positioning Speaking only one or two words between breaths

Use of accessory muscles Intercostal retractions

Oxygen Therapy
Nasal Cannula 24 to 40% at 1-6 L/min

Oxygen Therapy
Simple face mask 40-60% at 5-8 L/min

Oxygen Therapy
Partial re-breather mask 60-75% at 6-11 L/min (maintain liter flow to keep reservoir bag 2/3 full during inspiration)

Oxygen Therapy
Non-rebreather mask 80-95% (maintain liter flow to keep reservoir bag 2/3 full during inspiration)

Oxygen Therapy
Venturi Mask 24 to 55% (usually 4-10 L/min; provides high humidity)

Oxygen Therapy
Aerosol Mask, Face Tent, Trach Collar 24-100% with flow rates of at least 10 L/min; provides high humidity

Oxygen Therapy
T-Piece 24-100% with flow rates of at least 10 L/min; provides high humidity

GI Assessment
History Pain? Nausea and vomiting? Change in bowel pattern? Change in appetite?

Weight gain / loss Difficulty swallowing

GI Assessment
Cullens Sign Bruising around the umbilicusindicates intraabdominal bleeding Grey-Turners Sign Bruising of the lower abdomen and flank area indicates retro-peritoneal bleeding

GI Assessment
Inspection first
Auscultation secondlisten all four quads (best

Bowel sounds are not the sole indicator of bowel

functionpassage of flatus or stool provides better assessment information

Percussiontympany over stomach and intestines;

dullness over fluid or dense masses

GI Assessment
Palpationlast Light palpation is one handed and superficial Deep palpation is bimanual; used to palpate liver, aorta, parts of the colon Rebound tendernesssudden removal of palpating hand after deep palpation. Presence of pain = peritoneal irritation

GU Assessment
Historypain, problems with urination, changes in

pattern Up to void versus indwelling catheter

Size of catheter (look at balloon port)

Catheter care every eight hours minimally

Urine Color Sediment? Odor?

Wounds / Tubes / Drains

Where? What does it look like? Dressing? Drainage

what does that look like, how much? Any smell? Staples or sutures?

NG tubessingle or double lumen? Suction? What draining? Placement checked? Chest tubewhere? Suction? Draining? Check volume

in water seal and in suction (if not dry suction) T-tubedraining?

Wounds / Tubes / Drains

Drains JP? Wound vac? Hemovac?

What draining? Color, amount Where is it?