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196 PHYSICAL EXAMINATION
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UNIT 2
Objective data is:
> collected during the physical examination of the consumer
> usually collected after subjective data
> information that is measured or observed by the clinician as opposed to being
reported by the consumer
> vital to the overall health assessment, to enable you to make clinical decisions
that are representative of the whole consumer picture.
Evaluating subjective data to focus physical examination
Before commencing the physical examination of the person’s mental health and
neurological status, consider what information the health history has provided.
Critical consideration, linked to knowledge of anatomy and physiology, should focus
the physical assessment so your examination will be more effective and efcient.
Environment
Assessment of the consumer’s mental health and neurological status needs to be
done in a suitable environment. This means controlling the level of light, and
somewhere for the consumer to feel secure that condentiality can be maintained,
as well as a safe environment for staff if the person is agitated, restless or
experiencing changes in mood. Staff should position themselves where they are able
to clearly exit and obtain assistance with consumers who may be unpredictable or
unstable. As you are likely to require several different pieces of equipment for this
assessment, enough bench space for you to lay out your equipment will allow you
to work methodically through the assessment.
Equipment
> Cotton wisp
> Cotton-tipped applicators
> Penlight (torch)
> Tongue blade
> Vials containing odorous materials (coffee, orange extract, vinegar)
> Vials with solutions for tasting: quinine (bitter), glucose solution (sweet),
lemonor vinegar (sour), saline (salty)
> Snellen chart or Rosenbaum pocket screener
IMPLEMENTATION: CONDUCTING THE
PHYSICAL EXAMINATION
Implementation of the physical examination requires you to consider your scope of
practice as well. In this section, depending on your context, you may be performing
a foundation examination with aspects of advanced examination if you are
practising in a specialised area.
EXAMINATION IN BRIEF: MENTAL STATUS AND NEUROLOGICAL ASSESSMENT
Examination of mental status
Level of consciousness (LOC)
Physical appearance and behaviour
> Posture and movements
> Facial expression
> Dress, self-care, grooming and personal hygiene
> Mood and affect
Speech and communication
Cognitive abilities and mentation
> Attention
> Memory
> Judgement
> Insight
> Spatial perception
>>
MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 197
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>>
> Calculation
> Abstract reasoning
> Thought process and content
> Suicidal ideation
Mental health
Sensory examination
Exteroceptive sensation
> Light touch
Proprioceptive sensation
> Motion and position
Examination of cranial nerves
Olfactory nerve (CN I)
Optic nerve (CN II)
> Visual acuity
> Visual elds
> Fundoscopic examination
Oculomotor nerve (CN III)
> Cardinal elds of gaze
> Eyelid elevation
> Pupil reactions
Trochlear nerve (CN IV)
> Cardinal elds of gaze
Trigeminal nerve (CN V)
> Motor component
> Sensory component
Abducens nerve (CN VI)
> Cardinal elds of gaze
Facial nerve (CN VII)
> Motor component
> Sensory component
Acoustic nerve (CN VIII)
> Cochlear division
> Vestibular division
Glossopharyngeal and vagus nerves (CN IX and CN X)
Spinal accessory nerve (CN XI)
Hypoglossal nerve (CN XII)
Examination of motor system
Pronator drift
Examination of cerebellar function
Coordination
Gait
CHAPTER 7
General approach to neurological assessment
1. Greet the consumer and explain the assessment techniques you will be using.
2. Maintain a quiet, unhurried, self-condent demeanour to help relieve any
feelings of anxiety or discomfort, and to help the consumer relax during
theassessment.
3. Provide a warm, quiet and well-lit environment.
4. After the mental status examination (if required), ask the consumer to
remove all street clothes, and provide an examination gown for the
consumer to put on.
5. Begin the assessment with the consumer in a comfortable (where appropriate),
upright sitting position or, for the consumer on bed rest, position the
consumer comfortably, preferably with the head of the bed elevated, or at,
whichever is tolerated best or is within activity orders for the consumer.
HEALTH EDUCATION
Risk factors for stroke
Consider the following risk factors for stroke and where appropriate provide individualised
education to increase awareness.
Signicant risk factors for stroke include:
> hypertension
> physical inactivity (increases risks of hypertension, type 2 diabetes mellitus and obesity)
> diabetes mellitus
> cocaine and methamphetamine use
> marijuana use
> cigarette smoking
>>
198 PHYSICAL EXAMINATION
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>>
> hyperlipidaemia
> migraines
> atrial brillation and utter
UNIT 2
> history of cerebral aneurysm
> sickle cell disease
> alcohol abuse
> kidney dysfunction
> obesity
> oral contraceptive use, especially in women over age 35 who smoke and have hypertension
> environmental factors (such as lead exposure, pollution, temperature).
Sources include Healthdirect (2022), Parekh, Pemmasani & Desi (2020); Madsen et al. (2018);
Stark et al. (2021).
A complete examination includes an assessment of mental status, sensation, cranial
nerves, motor function, cerebellar function and reexes. For consumers with minor
or intermittent symptoms, a rapid screening examination may be used, as outlined
Table 7.5.
in
TABLE 7.5 Neurological screening assessment
ASSESSMENT
PARAMETER ASSESSMENT SKILL COMMENTS
Mental status Perform
Sensation Assess pain and vibration in the hands and feet, light touch on
Cranial nerves Assess CN II, III, IV, VI: visual acuity, gross visual elds, fundoscopic
Motor system Muscle tone, strength and posture
Cerebellar
function
Glasgow Coma Scale (GCS) with motor assessment
component and pupil assessment.
Note general appearance, personal hygiene and dress (level of
self-care and appropriate to season), affect (facial expression),
speech content, memory, logic, mood, and manner, judgement
and speech patterns during the history.
the limbs.
examination, pupillary reactions and extraocular movements.
Assess CN VII, VIII, IX, X, XII: facial expression, gross hearing,
voice, and tongue.
Abnormal movements
Hand grasp
Observe the consumer’s:
gait on arrival
1
2 ability to:
• walk heel-to-toe
• walk on toes
• walk on heels
• hop in place
• perform shallow knee bends.
Check
3 Romberg’s test
4 Finger-to-nose test
5 Fine repetitive movements with hands
If GCS < 15, perform full assessment of mental status and
consciousness. If motor assessment is abnormal or asymmetrical,
perform complete motor and sensory assessment.
URGENT FINDING: if GCS score drops by 2 or more, activate a
medical emergency response.
If any abnormalities or inconsistencies are evident, perform full
mental status assessment.
If decits are identied, perform a complete sensory assessment.
If any abnormalities exist, perform complete assessment of all
12 cranial nerves.
If any abnormalities exist, perform complete assessment of all
12 cranial nerves.
If decits are noted, perform a complete motor system assessment.
If any abnormalities exist, perform complete cerebellar assessment.
Reexes Assess the deep tendon reexes and the plantar reex. If an abnormal response is elicited, perform a complete
reex assessment.
MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 199
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Examination of mental status
Much of the mental status assessment should be done during the interview, with
the consumer comfortably positioned facing you. Mental status may also continue
to be assessed throughout the neurological assessment. Assess level of consciousness,
physical appearance and behaviour, speech and communication, cognitive abilities
and mentation while conversing with the consumer. Assess suicidal ideation and
mood by asking specic questions.
Note: Mental status and neurological examination may also be performed
independently of each other, but they are usually undertaken together to ensure a
comprehensive initial assessment. If a consumer is displaying signs of irritability
and paranoia or aggression, aspects of the neurological examination may be delayed
or be more appropriately undertaken at another time when a more focused mental
status and neurological examination is undertaken.
CLINICAL REASONING
Practice tip: Commence mental status assessment when you rst meet
the consumer
1. Begin your assessment as the consumer approaches you. Observe gait, posture, mode of
dress, involuntary movements, speech, and other features that will help guide and rene
your assessment priorities.
2. The history should be holistic because neurological disorders can affect all body systems.
3. The history should be age-sensitive:
• Utilise other family members when appropriate.
• Acknowledge adolescents’ ability to speak for themselves.
• Do not make assumptions regarding elderly or young consumers’ ability to describe
their own health histories.
4. Allow the consumer to remain clothed during the history and mental status assessment.
5. Consider language and cultural norms when obtaining the history and performing the
mental status assessment.
CHAPTER 7
Level of consciousness (LOC)
Consciousness is the level of awareness of the self and the environment. Conscious
behaviour requires arousal, or wakefulness, and awareness, or cognition and affect.
Arousal is controlled by the reticular activating system (RAS). The RAS activates
the cortex after receiving stimuli from the somatic and special sensory pathways.
Awareness is a higher-level function of the cerebral cortex, which interprets
incoming sensory stimuli. Aspects of awareness at a higher level include judgement
and thinking, which are generally assessed as part of the cognitive assessment.
Orientation is awareness of self and environment.
E
1. Observe the consumer’s eyes when you enter the room (environmental stimuli).
Note whether the consumer’s eyes are open or whether they open when you
enter the room (prior to any verbalisation). Note the consumer’s response to
any general environmental stimuli, such as noises or lights.
2. If the consumer’s eyes are closed, introduce yourself (verbal stimuli). Observe
whether the consumer’s eyes open, whether he or she responds verbally and
appropriately, and whether he or she follows verbal commands.
3. If the consumer does not respond to verbal stimuli, lightly touch or squeeze
the consumer’s hand or gently shake the consumer awake.
4. If the consumer is not responding to environmental or verbal stimuli,
proceed to the application of a painful stimulus.
a. Apply pressure with a pen to the nail bed of each extremity, or
b. Firmly pinch the trapezius muscle, or
c. Apply pressure to the supraorbital ridge or the manubrium.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
200 PHYSICAL EXAMINATION
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UNIT 2
5. Observe the consumer’s reaction to the painful stimulus. Note whether the
E
consumer’s eyes open.
6. Observe whether the consumer can localise the painful stimulus by reaching
for the area being stimulated. Strength of the consumer’s extremities can
be assessed by the strength and distance of movement during his or her
attempt to reach the painful stimulus. Note any abnormal motor responses.
7. Compare the motor responses and strength of the responses of right versus
left sides of the consumer.
8. Note whether the consumer responds verbally to the painful stimulus.
9. Assess orientation by asking questions related to person, place and time:
a. Person: name of the consumer, name of spouse or signicant other
b. Place: where the consumer is now (what town, what state), where the
consumer lives
c. Time: the time of day, month, year, season.
10. Determine the Glasgow Coma Scale (GCS) (see Figure 7.9) score, an
international method for grading neurological responses of the injured
orseverely ill consumer. It is monitored in consumers who have the
potential for rapid deterioration in level of consciousness. The GCS
assessesthree parameters of consciousness: eye opening, verbal response
andmotor response.
C
O
M
A
S
C
A
L
E
L
I
M
B
M
O
V
E
M
E
N
T
S
PUPILS
Eyes
open
Best
verbal
response
Best
motor
response
TIME
Size
R
reaction
Size
L
reaction
PUPIL
GAUGE
(mm)
Spontaneously
To speech
To pain
None
Oriented
Confused
Inappropriate
Incomprehensible
None
Obey commands
Localise pain
Withdrawal
Flexion abnormal
Extension to pain
None
COMA SCORE TOTAL
Normal power
Mild weakness
A
R
Severe weakness
M
Flexion
S
Extension
No response
Normal power
Weakness
L
E
Flexion
G
Extension
S
No response
B = Brisk
S = Sluggish
NR = No reaction
C = Eye closed
2 3 4 5 6 7 8 9
4
3
C = Eyes closed
2
1
5
4
T = Intubated
3
or tracheostomy
2
1
6
Record best
5
response
4
V = Voice
3
S = Shaking
2
P = Pain
1
= Same
behaviour
bilaterally
R = right
L = left
If
different
in
response
between
2 sides
FIGURE 7.9 Neurological ow sheet, including Glasgow Coma Scale
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 201
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CLINICAL REASONING
Glasgow Coma Scale
Most often, the GCS is included in neurological assessment documentation. This includes:
> vital signs
> motor movement and strength
> pupillary size and reactions.
This provides a more in-depth evaluation of the neurological status of the consumer.
However, using the GCS does not replace undertaking a full mental status assessment.
The consumer’s best response to each of these categories is what is recorded.
N
Thesum of the three categories is the total GCS score. The highest score of
responsiveness is 15 and the lowest is 3. A score of 15 would indicate a fully
alert, oriented individual.
Table 7.6.
See
A P
TABLE 7.6 Levels of consciousness: Abnormalities and pathophysiology
RESPONSE
LOC GCS
TO STIMULI PUPIL RESPONSE PATHOPHYSIOLOGY PROGNOSIS
CHAPTER 7
Confusion 14 Spontaneous but may
be inappropriate
Memory faulty
Reexes intact
Lethargy 13–14
Stupor 12–13
Unresponsive
wakefulness syndrome
OR Unaware and
unresponsive state
Locked-in syndrome 6 Awake and aware Normal Lesion in ventral pons
Coma 3–6 Abnormal
8–10
Requires stimulus to
respond (verbal, touch)
Reexes intact
Requires vigorous,
continuous stimuli
to respond
Reexes intact
Responds to pain
No cognitive response
Reexes abnormal
Varied response to pain
Reexes abnormal
or absent
Normal Metabolic derangements
Diffuse brain dysfunction
Normal to unequal Metabolic derangements
Medications
Increased ICP
Normal, unequal,
or sluggish
Normal Anoxic ischaemic insults Irreversible
Abnormal
Dilated or pinpoint
Metabolic derangements
Medications
Increased ICP
All four extremities
andlower cranial
nervesparalysed
Myasthenia gravis
Acute polyneuritis
Anoxia
Traumatic injury
Space-occupying lesion
Cerebral oedema
Good chance of recovery
Must treat primary cause
Good chance of recovery
Must treat primary cause
Good chance of recovery
Must treat primary cause
Poor prognosis
Prognosis dependent on
length of time in coma
Brain death 3 No response
LOC – level of consciousness; GCS – Glasgow Coma Scale; ICP – intracranial pressure
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Reexes abnormal
or absent
Abnormal
Dilated or pinpoint
Anoxia
Structural damage
Irreversible
202 PHYSICAL EXAMINATION
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UNIT 2
CLINICAL REASONING
Practice tip: Application of painful stimuli
1. Application of painful stimuli is extremely upsetting to signicant others and therefore
should not be performed without a comprehensive explanation.
2. Apply only the amount of pressure needed to elicit a response.
3. Alternate sites when possible.
4. Pain applied centrally (e.g. trapezius muscle squeeze) that results in a response always
indicates involvement of the cerebrum. Pain applied to an extremity (e.g. pen pressure
ona nail bed) may elicit a reex response or cerebral response, or both.
Great care is needed when interpreting the signicance of response to pain with
consumers in profound coma.
Note: Care needs to be taken in choosing when and where painful stimuli should be
applied. If always applied to the same soft tissue, injury and tissue breakdown will occur
and may need treatment for pressure injury.
Physical appearance and behaviour
Posture and movements
1. Observe the person’s ability to wait patiently (dependent also on
E
environmental factors).
2. Note if consumer’s posture is relaxed, slumped or stiff.
3. Observe the consumer’s movements for control and symmetry.
4. Observe the consumer’s gait (see Chapter 16).
The consumer should appear relaxed with the appropriate amount of concern
N
for the examination. The consumer should exhibit erect posture, a smooth gait,
and symmetrical body movements.
Restlessness, tenseness and pacing can be abnormal.
A
These may be signs of anxiety or metabolic disorders, which should alert you to
P
further investigate these problems.
At times you may need to just undertake a mental status assessment
Note:
or an abbreviated neurological assessment separately due to the consumer’s
condition. The neurological assessment described in this text is comprehensive
rather than focused or abbreviated.
A
Slumped posture, slow gait, poor eye contact and slow responses can be
abnormal ndings. (However, consider that lack of eye contact may be a cultural
difference – see Chapter 4.)
P
These may be signs of depression.
Stooped, exed or rigid posture; drooping neck; deformities of the spine; and tics
A
are abnormal ndings.
Consumers with kyphosis, scoliosis, Parkinson’s disease, cerebral palsy, osteoporosis,
P
schizophrenia, muscular atrophy, myasthenia gravis or stroke may exhibit these signs.
REFLECTION IN PRACTICE
Inuences on dress, self-care, grooming and personal hygiene
Dress and self-care are inuenced by the consumer’s economic status, age, home situation and
ethnic background. Information obtained during the health history will assist you in determining
appropriate dress and grooming for each consumer. It is helpful to directly ask the consumer
about self-care routines and clothing choices when there is a question as to appropriateness.
How would you phrase this type of questioning so that it does not sound judgemental?
Practise with your colleagues, friends or family members.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 203
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Facial expression
Observe for appropriateness of, variations in, and symmetry of facial expressions.
E
Facial expressions should be appropriate to the content of the conversation and
N
should be symmetrical.
Extreme, inappropriate or unchanging facial expressions, or asymmetrical facial
A
movements, are abnormal.
Abnormal facial expressions demonstrate anxiety, depression, or the unchanging
P
facial expression of a consumer with Parkinson’s disease. They may also indicate
a lesion in the facial nerve (CN VII).
Dress, self-care, grooming and personal hygiene
1. Note the appearance of the consumer’s clothing, specically:
E
• cleanliness
• condition
• age appropriateness
• weather appropriateness
• appropriateness for the consumer’s socioeconomic group or
cultural afliations.
2. Observe the consumer’s personal grooming (hair, skin, nails, teeth) for:
• adequacy
• symmetry
• odour.
The consumer should be clean and should wear appropriate clothing for age,
N
weather and socioeconomic status.
Poor personal hygiene such as uncombed hair, body odour or unkempt clothing
A
is usually abnormal.
P
These signs may be indications of depression, schizophrenia or dementia.
Excessive, meticulous care and attention to clothing and grooming are
A
abnormalbehaviours.
P
These signs may indicate obsessive-compulsive behaviour.
Obvious one-sided differences in grooming and dressing or the use of only one
A
side of the body is abnormal.
Stroke in the parietal lobe may cause the consumer to be aware of only one side
P
of the body, which is termed ‘one-sided neglect’.
CHAPTER 7
Mood and affect
1. Observe the consumer’s interaction with you and others where possible
E
(e.g.in waiting room or with other staff), paying particular attention to
bothverbal and nonverbal behaviours.
2. Note if the consumer’s affect appears labile, blunted or at. Note if their
choice of words also denotes mood.
3. Note the variations in the consumer’s affect with a variety of topics.
4. Note any extreme emotional responses during the interview.
The appropriateness and degree of affect should vary with the topics and the
N
consumer’s cultural norms, and be reasonable, or eurhythmic (normal).
Blunted affect, manifested by the consumer shufing into the examination room,
A
slumping into a chair, moving slowly and not making eye contact, is abnormal.
A blunted affect may indicate psychotic disorders. It may also indicate frontal
P
lobe dysfunction associated with traumatic brain injury or brain tumour.
Unresponsive, inappropriate affect is abnormal.
A
P
A at, unresponsive affect may indicate depression or schizophrenia.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
204 PHYSICAL EXAMINATION
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UNIT 2
Anger, hostility and paranoia are abnormal responses in most clinical situations.
A
P
These may be the responses of an individual experiencing paranoia.
Euphoric, dramatic, disruptive, irrational or elated behaviours are abnormal in
A
most clinical situations. Signicant changes in mood, not necessarily related to
context, are abnormal.
A consumer with bipolar disorder might display these responses during the
P
manic phase, or experience signicant changes in mood.
Speech and communication
Speech and communication skills should be assessed throughout the entire
interview and physical assessment.
1. Note voice quality, which includes voice volume and pitch.
E
2. Assess articulation, uency and rate of speech by engaging the consumer in
normal conversation. Ask the consumer to repeat words and sentences after
you, or to name objects you point out.
3. Assess for quantity of information in conversation. In conversation, is the
consumer able to answer the questions asked in a coherent manner. Observe
for pressured, loud, slurred, mumbled, poverty of speech, or word salad.
Word salad is a confused or unintelligible mixture of seemingly
random words and phrases. A person may attempt to communicate an
idea, butwords and phrases may appear to be random and unrelated and
come out inan incoherent sequence. This can be present in people with
schizophrenia or dementia.
4. Note the consumer’s ability to carry out requests during the assessment,
such as pointing to objects within the room as requested. Ask questions that
require ‘yes’ or ‘no’ responses.
5. Write simple commands for the consumer to read and perform: for example,
‘point to your nose’ or ‘tap your right foot’. Reading ability may be
inuenced by the consumer’s educational level or visual impairment.
6. Ask the consumer to write his or her name, birthday, a sentence the
consumer composes, or a sentence that you dictate. Note the consumer’s
spelling, grammatical accuracy and logical thought process (be aware that
theconsumer’s level of schooling may affect this as well).
The consumer should be able to produce spontaneous, coherent speech.
N
Thespeech should have an effortless ow with normal inections, volume,
pitch, articulation, rate and rhythm. Content of the message should make sense.
Comprehension of language should be intact. The consumer’s ability to read and
write should match the consumer’s educational level. Non-native speakers may
exhibit some hesitancy or inaccuracy in written and spoken language.
Aphasia is an impairment (often complete absence) of language functioning.
A
Aphasias are classied by involved anatomy, behavioural speech manifestations,
P
uency of speech (uent: rhythm, grammar and articulation are normal;
nonuent: speech production is limited and speech is poorly articulated), and
comprehension (receptive) versus expression (expressive) decits. Other
categories include amnesic (the inability to recall specic types of words) and
central (a decit in the coordination among the speech areas). Table 7.7 has a
summary of the characteristics and pathophysiology of specic aphasias. Most
consumers with an aphasia will have some components of several aphasia
classications (e.g. a consumer with transcortical motor aphasia will usually
have some degree of transcortical sensory aphasia).
E
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MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 205
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URGENT FINDING
The confused consumer – missed diagnosis
The confused consumer should be thoroughly assessed for aphasia, especially after a
fall or a brain injury. A missed diagnosis because of ‘confusion’ can be fatal if aphasia is
present and due to a subdural haematoma (SDH). Check for other signs associated with
anSDH, including headache, slow cerebration (functioning of the brain), decreasing level
of consciousness, and ipsilateral pupil dilatation with a sluggish response to light. An SDH
canhave an acute onset (within hours to days after moderate to severe injury) or chronic
(days to weeks after minor injury). Any person with this history should be referred to a
medical ofcer or emergency department for urgent brain imaging.
Dysphasia, an impairment of language functioning, which may be complete
A
orpartial, is abnormal. May include loss or impairment to understand language,
speak, read or write.
Causes include stroke or TBI to left side (usually) of brain, causing damage on
P
this side of the brain.
URGENT FINDING
CHAPTER 7
Acting on signs of stroke
According to the Stroke Foundation (2018), the most common signs of stroke are facial
weakness, arm weakness and difculty with speech.
Other signs include:
> weakness, numbness or paralysis of the face, arm or leg on either or both sides of the body
> difculty speaking or understanding
> dizziness, loss of balance or an unexplained fall
> loss of vision, sudden blurring or decreased vision in one or both eyes
> headache, usually severe and abrupt onset or unexplained change in the pattern
ofheadaches
> difculty swallowing.
In Australia, the following poster is used to raise awareness of seeking help as soon as
possible. New Zealand uses the same acronym, but 111 is the emergency number to call.
FIGURE 7.10 Stroke symptoms recognition
A stroke is a medical emergency and just like a ‘heart attack’ where time means more heart
cell death, a stroke is a ‘brain attack’ and time is related to more brain cell injury/death. Any
person who experiences these symptoms should be assisted to seek emergency care urgently.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
STROKE FOUNDATION, STROKEFOUNDATION.ORG .AU
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