Test out #4

BEGIN

Gather equipment 

Wash hands 

Provide for privacy 

Greet patient and introduce self 

Correct patient 

“Today we are going to do a neuro and abdomen assessment”

Safety survey 

• “What's your name?”

• “where are we?”

• “What time is it?”

“patient is alert and oriented times 3”

• “can you tell me our appointment time?”

“patient can tell me appointment time, representing recent memory” 

• “what year did you graduate high school”

“patient can tell me graduation date representing remote memory” 

• “what would you do if you failed a nursing exam?”

“patient has reasonable judgment to her own physical and cognitive condition“

“The patient shows thoughts expressed through the interview with speech. she is logical, relevant, organized and coherent” 

• “can you stand up and hold your arms out with your palms up and eyes closed”

“patients pronator drift is negative, if positive, arms would drift down and palms go towards the floor” 

• I CROSS ARMS WITH TWO FINGERS

 “can you grip my fingers as hard as you can?”

“patients grip strength is 5/5 bilaterally”

• PATIENTS ARMS UP HOLD AGAINST/PULL “stand up and don’t let me push/pull” 

“patients elbow flexion/extension is 5/5 bilaterally”

• SITTING HOLD THIGH ONE AT A TIME AND ASK TO LIFT KNEE

“patients hip flexion is 5/5 bilaterally” 

• HOLD ANKLES, PUSH AGAINST AND HOLD BEHIND AND PULL 

“patients knee flexion and extension is 5/5 bilaterally”

• HOLD DOWN TELL TO PUSH AND GO UNDER AND PUSH ON FEET

 “patients foot plantar and dorsi-flexion is 5/5 bilaterally” 

“can you raise your eyebrows, frown, smile, show teeth” 

“patients cranial nerve 7 facial nerve is intact with no facial droop” 

“Can you stick your tongue out?”

“patients cranial nerve 12 hypoglossal is intact” 

“Is your abdomen in any pain today? if she was i would palapate that area last”

• INSPECT ABDOMEN

inspect abdomen

“skin color is congruent with the rest of the body, warm, dry, without rash; abdomen is symmetrical, contour flat, umbilicus is midline, no hernia”

• AUSCULTATE ABDOMEN (diaphragm) 4 QUADRENTS 

“bowel sounds x4, normo-active” 

• AUSCULATE ABDOMEN FOR VASCULAR BRUITS (use bell firm pressure)

AORTA (middle top)

RENAL ARTERY (R&L upper)

ILIAC ARTERY (R&L lower)

“no abdominal bruits present” 

• PALPATION 

GENTLE ROTATIONS/CIRCLES

“In RLQ, I'm palpating the appendix. In RUQ, I’m palpating the liver, gallbladder and the head of the pancreas. In LUQ, I’m palpating the spleen and the tail of the pancreas then LLQ, with no tenderness, masses, or rigidity”