PEROS

(PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM)

Areas Assessed Objective Findings Problem Identified

General Assessment

1. Ask when, where, how the

injury occurred.

2. Does patient lose

consciousness; if so, for how
long?

3. Has been there a change in level

of consciousness. If trauma is
relate to alcohol or drug
consumption.

4. If the patient experience seizure

after the injury.
HEAD

 Inspection.  Scalp bruising (ecchymosis)

 Laceration scalp, skull and
exposure of dura of the brain. o Pain
 Hematoma o Risk for infection
 Impacted area of bone bends
inward and the area around it bends
outward.
 Bone is pressed inward into the
brain tissue
 CSF leakage from the nose and
ears.
 Abnormal head tilt

 Palpate the head. Note

 Tenderness in the scalp
consistency
EYES
1. Check for pupil size and reaction
to light (penlight).
2. Check gross vision.
If patient’s condition permits.
Have patient read any printed
materials
NEUROLOGIC
1. Assess LOC using GCS
2. Assess for signs and symptoms
ICP elevation
RESPIRATORY
Assess patients ABC (airway,
breathing, clearance).
1. Note the respiratory pattern
(chest wall movement)
2. Note the respiratory rate.
3. Auscultate chest for breath
sound.
o Risk for injury
 Pinpoint and noresponsive pupils
 Pupils that fixed (nonreactive) and
dilated pupils (poor prognostic
sign)
 Ovoid pupil- midstage between
normal and dilated pupil size
 Uneven pupils
 Loss of light reaction
 Temporary cortical blindness
 Loss of consciousness o Deficient fluid volume
 Mild TBI: 15minutes w/ GCS o Ineffective cerebral
score 13-15 tissue perfusion
 Moderate TBI: 6hrs w/ GCS o Imbalanced body
score 9-12 temperature related to
 Severe TBI: longer than 6 hrs damaged temperature-
w/ GCS of 3-8. regulating mechanisms
 Disorientation or confusion in the brain
 Amnesia o Risk for injury
 Restlessness or Irritability
 Persistent Headache
 Decrease in arousal or deep
sleepiness
 Seizures (w/in 24 hrs)
 changes in temperature
 Hyperventilation o Ineffective airway
 Bradypnea clearance
 Short period of Apnea o Impaired gas exchange.
 Cheyne-stoke respirations o Decreased cerebral and
 Pulmonary edema tissue perfusion.
MUSCULOSKELETAL
1. Assess of range of motion of
joints and development of
deformities and spasticity
2. Assess for bilateral motor
responses.
CARDIOVASCULAR
1. Check BP, HR,PR
GASTROINTESTINAL
1. Inspect the abdomen for
distention
2. Auscultate bowel sounds
INTEGUMENTARY
1. Inspect the skin integrity
and character.
GENITOURINARY
1. Record Intake and output
o Self-care deficit
 Decerebrate or decorticate o Impaired physical
posturing or flaccidity mobility
 Hemiparesis
 Immobility
 Ataxia
 Hypotension or severe
hypertension o Deficient fluid volume
 Bradycardia
 Thread, irregular and rapid pulse.
 Tachycardia
 Cardiac dysrhythmias
o Constipation
 Projectile vomiting o Imbalance nutrition
 Constipation less than body
 Bowel incontinence requirements
 Paralytic ileus
 Pressure ulcers o risk for impaired skin
integrity
 Urinary incontinence