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

2. ASSIGNMENTS Chapter 15 Read Egan’s Fundamentals: Egan’s Workbook
Chapter 15, pages:
325 – 326
330 – 331
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. https://play.kahoot.it/#/k/4089edf6-87e0-44cd-b838-00575ac86612
KAHOOT IT!

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: Position 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

18. TEST PARAMETER
RESPONSE
SCORE
Eyes - Open
Spontaneously
To verbal Command
To Pain
No response 4 3 2 1
Best Motor Response
To Verbal Command
Moves arms to painful stimuli
of knuckles against sternum
Obeys command
Localizes pain
Withdrawal
Decorticate
Decerebrate 6 5
Best Verbal Response
Oriented & converses
Disoriented & converses
Inappropriate words
Incomprehensible sounds

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 Place Time
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 What does the finding mean? 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 Jugular Vein Distension Tracheal Deviation
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. *Begins with Lung disease
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

51. Tracheal Deviation Large Pleural Effusion on right
Trachea deviated away from affected side
Push

52. Tracheal Deviation Tension pneumothorax
Tracheal deviation away from the affected side
Push

53. Pneumothorax View DVD showing: Tension pneumothorax
Respiratory distress
Relief of pressure

54. Tracheal Deviation Pulled to the abnormal side Pushed to the
(toward pathology)
Pushed to the
normal side
(away from pathology)
Spontaneous pneumothorax
(non-tension or open)
Pulmonary alveolar collapse (atelectasis)
Pneumonectomy
Diaphragmatic paralysis
Massive pleural effusion
Tension pneumothorax
Neck or thyroid tumors
Large mediastinal mass
Upper lung tumors

56. Shows inspection of head & neck

58. A clinician who, during the patient encounter, stands with his arms crossed and avoids eye contact is conveying a lack of concern for the patient.
True
False
Countdown 15

59. Asking for permission to use an article within the patient’s room acknowledges the patient’s territorial rights while conveying respect for the patient.
True
False
Countdown 15

60. We should use as much medical terminology as we can because it shows the patient how educated we are.
True
False
Countdown 15

61. Before we leave a patient’s room we should ask…
Is there anything else you need?
Do you have any questions?
Did I do a good job?
Would you like to go home?
1 & 2
Countdown 15