Assessing the Neurologic, Musculoskeletal, and Peripheral Vascular Systems

Goal: The assessments are completed without causing the patient to experience anxiety or discomfort, the findings are documented, and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation.

1. Perform hand hygiene and put on PPE, if indicated.

2. Identify the patient.

3. Close curtains around bed and close the door to the room, if possible. Explain the purpose of the neurologic, musculoskeletal, and peripheral vascular examinations and what you are going to do. Answer any questions.

4. Help the patient undress, if needed, and provide a patient gown. Assist the patient to a supine position. Use the bath blanket to cover any exposed area other than the one being assessed.

5. Begin with a survey of the patient’s overall hygiene and physical appearance.

6. Assess the patient’s mental status.
a. Evaluate the patient’s orientation to person, place, and time.
b. Evaluate level of consciousness.
c. Assess memory (immediate recall and past memory).
d. Assess abstract reasoning by asking the patient to explain a proverb, such as “The early bird catches the worm.”
e. Evaluate the patient’s ability to understand spoken and written word.

7. Test cranial nerve (CN) function.
a. Ask the patient to close the eyes, occlude one nostril, and then identify the smell of different substances, such as coffee, chocolate, or alcohol. Repeat with other nostril.
b. Test visual acuity and pupillary constriction.
c. Move the patient’s eyes through the six cardinal positions of gaze.
d. Ask the patient to smile, frown, wrinkle forehead, and puff out cheeks.
e. Test hearing.
f. Test the gag reflex by touching the posterior pharynx with the tongue depressor. Explain to patient that this may be uncomfortable.
g. Place your hands on the patient’s shoulders while he or she shrugs against resistance. Then place your hand on the patient’s left cheek, then the right cheek, and have the patient push against it.

8. Inspect the ability of the patient to move his or her neck. Ask the patient to touch his or her chin to chest and to each shoulder, each ear to the corresponding shoulder, and then tip head back as far as possible.

9. Inspect the upper extremities. Observe for skin color, presence of lesions, rashes, and muscle mass. Palpate for skin temperature, texture, and presence of masses.

10. Ask patient to extend arms forward and then rapidly turn palms up and down.

11. Ask patient to flex upper arm and to resist examiner’s opposing force.

12. Inspect and palpate the hands, fingers, wrists, and elbow joints.

13. Palpate the radial and brachial pulses.

14. Have the patient squeeze two of your fingers.

15. Ask the patient to close his or her eyes. Using your finger or applicator, trace a one-digit number on the patient’s palm and ask him or her to identify the number. Repeat on the other hand with a different number.

16. Ask the patient to close his or her eyes. Place a familiar object, such as a key, in the patient’s hand and ask him or her to identify the object. Repeat using another object for the other hand.

17. Assist the patient to a supine position. Examine the lower extremities. Inspect the legs and feet for color, lesions, varicosities, hair growth, nail growth, edema, and muscle mass.

18. Test for pitting edema in the pretibial area by pressing fingers into the skin of the pretibial area. If an indentation remains in the skin after the fingers have been lifted, pitting edema is present.

19. Palpate for pulses and skin temperature at the posterior tibial, dorsalis pedis, and popliteal areas.

20. Have the patient perform the straight leg test with one leg at a time.

21. Ask the patient to move one leg laterally with the knee straight to test abduction and medially to test adduction of the hips.

22. Ask the patient to raise the thigh against the resistance of your hand; next have the patient push outward against the resistance of your hand; then have the patient pull backward against the resistance of your hand. Repeat on the opposite side.

23. Assess the patient’s deep tendon reflexes (DTR).
a. Place your fingers above the patient’s wrist and tap with a reflex hammer; repeat on the other arm.
b. Place your fingers at the elbow area with the thumb over the antecubital area and tap with a reflex hammer; repeat on the other side.
c. Place your fingers over the triceps tendon area and tap with a reflex hammer; repeat on the other side.
d. Tap just below the patella with a reflex hammer; repeat on the other side.
e. Tap over the Achilles’ tendon area with reflex hammer; repeat on the other side.

24. Stroke the sole of the patient’s foot with the end of a reflex hammer handle or other hard object such as a key; repeat on the other side.

25. Ask patient to dorsiflex and then plantarflex both feet against opposing resistance.

26. As needed, assist the patient to a standing position. Observe the patient as he or she walks with a regular gait, on the toes, on the heels, and then heel to toe.

27. Perform the Romberg’s test; ask the patient to stand straight with feet together, both eyes closed with arms at side. Wait

20 seconds and observe for patient swaying and ability to maintain balance. Be alert to prevent patient fall or injury related to losing balance during this assessment.

28. Assist the patient to a comfortable position.

29. Remove PPE, if used. Perform hand hygiene. Continue with assessments of specific body systems, as appropriate, or indicated. Initiate appropriate referral to other healthcare practitioners for further evaluation, as indicated.