1. NUR 101 Basic Physical Assessment Workshop
Neurological and Skin Assessment

2. 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

3. 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

4. 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

5. 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

6. 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

7. Pupillary Changes to Light
Remember it is measured in MM
opthalmoscope

8. 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

9. 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

10. 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

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

12. 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

13. 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

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

16. 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

17. 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)

18. 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

19. 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

20. Cutting off blood supply

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

22. 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

23. 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

24. Wheal
Irregular shape

25. Cyst
Encapsulated fluid-filled cavity

26. 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

27. ecchymosis

28. Spider angioma

29. hematoma

30. 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

31. 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

32. Stage 1 Pressure Ulcer

33. Stage II Pressure Ulcer

34. Stage III Pressure Ulcer

35. Stage IV Pressure Ulcer

36. Deep Tissue Injury

37. 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