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An_Easy_Guide_to_Head_to_Toe_Assessment_Vrtis_12_2008_Website

An_Easy_Guide_to_Head_to_Toe_Assessment_Vrtis_12_2008_Website

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An Easy Guide to Head to Toe Assessment © Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com Neurological Assessment Oriented to: Person Place Time Communication/ Speech: WNL Non-verbal Dysarthria Aphasia: Expressive Receptive Global Pupils: PERRLA OR Equal: Yes No R larger L larger Round: Yes No R abnormal shape L abnormal shape Reactive to Light: Yes N Reaction: Brisk Sluggish R no reaction L no reaction Accommodation: R L (hold finger 4” above nose, bring closer to face, do both eyes maintain focus?) Glasgow Coma Scale (Score range 0 to 15, Coma =< 7) Eye opening to: Spontaneous = 4 Verbal command = 3 Pain = 2 No response = 1 Verbal response to: Oriented, converses = 5 Disoriented, converses = 4 Uses inappropriate words = 3 Incomprehensible sounds = 2 No response = 1 Motor response to: Verbal command = 6 Localized pain = 5 Flexes and withdraws = 4 Flexes abnormally (decorticate) = 3 Extends abnormally (decerebrate) = 2 No response = 1 Location Muscle Tone Muscle Strength Sensation Tremor Head/ Neck WNL Flaccid Spastic WNL To pain No response to pain No Present R hand WNL Flaccid Spastic L hand WNL Flaccid Spastic RUE WNL Flaccid Spastic LUE WNL Flaccid Spastic RLE WNL Flaccid Spastic LLE WNL Flaccid Spastic Muscle Strength: 5 = WNL 4 = 75% normal 3 = 50% normal 2 = 25% normal 1 = 10% normal 0 = complete paralysis Respiratory Assessment Pulse ox: WNL (95-100%) WNL for this patient at _____ Cough: None Non-productive, dry Productive Productive sounding, no sputum Sputum: None Consistency: Thick Thin Foamy Color: White Other, __________________ Oxygen: N/A Room air ____ liters/ nasal cannula ____ % per face mask Mechanical ventilator Respiratory rate: WNL Tachypnea/ hyperventilation (too fast) Bradypneic/ hypoventilation (too slow/ shallow) Respiratory effort: Relaxed and regular Pursed lip breathing Painful respiration Labored Dyspnea at rest Dyspnea with minimal effort, talking, eating, repositioning in bed, etc. Dyspnea with moderate exertion, dressing, walking =< 20 feet, etc. Dyspnea when walking ____ feet or with exercise Recovery time following dyspneic episode: _____ minutes Respiratory rhythm: WNL Regular, tachypneic Regular, bradypneic Regular with periods of apnea Regular pattern of increasing rate and depth, followed by decreasing rate and depth, followed by apnea (Cheyne-Stokes) Regular, abnormal, rapid and deep respiration (central neurogenic hyperventilation) Regular, abnormal, prolonged inspiration with a pause or sigh with periods of apnea (apneustic) Irregularly irregular pattern/ depth (ataxic) Irregular with periods of apnea (cluster breathing) Breath sounds (auscultate anterior & posterior, R & L upper, mid, lower chest) : Clear (vesicular) throughout Decreased (atelectasis?) Crackles:
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