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307 Health Assessment > HEAD TO TOE > Flashcards

HEAD TO TOE Flashcards

1
Q

FIRST

OVERVIEW

A
  1. gather supplies
  2. protect privacy
  3. introduce yourself
  4. id patient
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2
Q

second

overview

A

determine orientation
fall risk band?
ask about fall

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3
Q

fourth-head/eyes/mouth

overview

A

inspect head
check pupils reaction to light (d and c)
check pupil accomodation
inspect mouth with penlight

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4
Q

third- vitals

A

pain
bp
temp
pulse
rr

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5
Q

fifth- heart

overview

A

auscultate
“all people eat too much”
with diaphragm then with bell

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6
Q

sixth-lungs

overview

A

auscultate
posterior, axillary, anterior
side to side comparison
full respiration at each location

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7
Q

7th- neck/chest

overview

A

assess skin turgor unde clavicles

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8
Q

8th- upper extremeties

overview

A

test hand strength bilaterally
check capillary refill
color
temp
palpate radial pulses bilaterally

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9
Q

9th- abdomen

overview

A

inspect shape
auscultate four quadrants for bowel sounds
palpage lightly
last bowel movement? normal?

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10
Q

10th- urinary

overview

A

ask about urination. normal?

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11
Q

11th- lower extremeties

overview

A

inspect/palpate legs and feet
capillary refill
palpate dorsalid pedis and posterior tibial bilaterally
test foot strength bilaterally

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12
Q

supplies for head to toe

A

stethoscope
penlight
gloves
bp cuff
thermometer
watch w/ second hand
etc

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13
Q

general principles to remember

shift assessment

A

ntroduce yourself, identify patient (2 identifiers),make sure you have supplies (gloves,stethoscope, pen light, etc.), hand hygiene,provide privacy

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14
Q

physiologic parameters

shift assessment

A

vs
pain

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15
Q

general appearance

shift assessment

A

Hygiene/grooming, positioning, comfort

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16
Q

neuro/musculoskeletal

shift assessment

A

LOC, orientation, PERRLA,ROM/strength/sensation (BUE/BLE)

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17
Q

heent

shift assessment

A

Inspect head shape, symmetry of facial features,mucous membranes

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18
Q

respiratory

shift assessment

A

Work of breathing/effort, rate, rhythm,auscultate lung sounds, check for clubbing

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19
Q

cardiac

shift assessment

A

Auscultate heart sounds, check for murmurs, lifts,thrills. Check cap refill and skin temp. Bilateralradial and bilateral pedal pulses. Inspect forperipheral edema

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20
Q

gi

shift assessment

A

Inspect abdomen, auscultate bowel sounds,palpate for tenderness, ask about last BM anddiet

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21
Q

gu

shift assessment

A

Inspect (or ask) about urine color, characteristics,burning, hesitancy, pain, etc

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22
Q

skin

shift assessment

A

inspect color, wounds, lesions, skin turgor,palpate temperature

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23
Q

other

shift assessment

A

check IV sites, wounds, drains, tubes,environment, etc

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24
Q

organizing the shift assessment part 1

A
  1. Physiologic parameters and general appearance
  2. LOC, orientation, PERRLA
  3. HEENT inspection
  4. Auscultate heart, lung, and bowel sounds
  5. Inspect for work of breathing, respiratory rate/rhythm, inspect chest for heaves/lift
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25
Q

organizing the shift assessment part 2

A
  1. Palpate for any thrill in the chest, palpate abdomen for pain/tenderness (ask for last BM,diet, urine)
  2. Assess upper extremities (bilateral radial pulses, skin condition, turgor, cap refill, clubbing,edema, ROM/strength, and sensation)
  3. Assess lower extremities (bilateral pedal pulses, skin condition, turgor, cap refill, clubbing,edema, ROM/strength, and sensation)
  4. Assess any other areas of the skin, looking at color, temperature, wounds, lesions, etc.
  5. Check environment for safety, assess lines/drains/tubes, etc
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26
Q

physiologic parameters

normals of physical assessment

A

vs including pain

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27
Q

general appearance

normals of physical assessment

A

Clean appearing, resting comfortably in bed watching TV, NAD

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28
Q

neurological

normals of physical assessment

A

A&O x3 (or x4), PERRLA intact, sensation intact x4

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29
Q

musculoskeletal

normals of physical assessment

A

full rom x4
strength intact

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30
Q

heent

normals of a physical assessment

A

normocephalic, facial features symmetrical, mucous membranes pink and moist, no irritation ordrainage present, denies any problems

31
Q

respiratory

normals of a physical assessment

A

Respiratory: respirations even and unlabored, Lungs CTA bil., O2 sat 98% RA, no clubbing present

32
Q

cardiovascular

normals of physical assessment

A

normal S1&S2, no murmurs, lifts, or thrills, cap refill <2secs, radial and pedal pulses 2+,skin warm to touch, no peripheral edema

33
Q

gi

normals of physical assessment

A

active bowel sounds x4, abdomen soft, non-tender, non-distended, denies any pain, last bm wasyesterday (was soft and easy to pass), consuming 75% of meals, on regular diet

34
Q

gu

normals of physical assessment

A

GU: voiding clear yellow urine, denies any burning, hesitancy, or pain with urination

35
Q

skin

normals of physical assessment

A

Skin: warm, color normal for ethnicity, no abrasions or wounds, no tenting

36
Q

other

normals of physical assessment

A

Other: IV sites, equipment, anything that you feel like did not fit in one of the other categories

37
Q

inspect

THORAX & LUNG Physical AssessmentCheck-off

A

thoracic cage symmetry
Respirations (rate, rhythm, depth, effort)
Accessory muscle useSkin color & condition
Person’s position (COPD tripod ?)
Facial expression
Level of consciousness
Transverse diameter versus anterior/posteriordiameter ratio

38
Q

palpate

THORAX & LUNG Physical AssessmentCheck-off

A

Symmetric expansion
Tactile fremitus
Lumps, masses, tenderness, crepitus

39
Q

percuss

THORAX & LUNG Physical AssessmentCheck-off

A

percuss over lung fields

40
Q

auscultate

THORAX & LUNG Physical AssessmentCheck-off

A

Assess anterior and posterior chest fornormal breath sounds
Note any abnormal/adventitious breathsounds

41
Q

neck

HEART & NECK VESSELS Physical Assessment Check-off

A

blood Vessels
Inspect & palpate carotid pulse
JVD (jugular vein distention) present

42
Q

precordium

HEART & NECK VESSELS Physical Assessment Check-off

A

Inspect & palpate apical pulse (note location)
Inspect & palpate any heave (lift) or thrill

43
Q

auscultate

HEART & NECK VESSELS Physical Assessment Check-off

A

Identify anatomic areas for heart sounds
Note rate & rhythm of heartbeat
Identify S1 & S2, note any variation
Listen for any extra heart sounds in S1 & S2
Listen for any murmurs in S1 & S2
Repeat sequence with bell
Listen at apex with pt. in left lateral position
Listen at the base with pt. in sitting position
carotid arteries for bruits

44
Q

upper extremities

PERIPHERAL VASCULAR SYSTEM &LYMPHATICS Physical Assessment Check-off

A

Inspect & palpate the arms for:
Symmetry
Color
any lesions
Temperature
texture
turgor
Capillary refill
Nailbeds

45
Q

upper extremities
part 2

PERIPHERAL VASCULAR SYSTEM &LYMPHATICS Physical Assessment Check-off

A

Pulses:
Radial
Ulner
Brachial

Epitrochlear lymph node
Modified Allen test
Dialysis Access? Patent?

46
Q

lower extremities part 1

PERIPHERAL VASCULAR SYSTEM &LYMPHATICS Physical Assessment Check-off

A

Inspect & palpate the legs for:
Symmetry
Color
Temperature
Size
swelling or atrophy
Lesions/ulcers
Hair distribution
Varicose veins

47
Q

lower extremities part 2

PERIPHERAL VASCULAR SYSTEM &LYMPHATICS Physical Assessment Check-off

A

Pulses:
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

Inguinal lymph nodes
Pretibial edema

48
Q

inspection

abdomen physical assessment check off

A

Contour
Symmetry
Umbilicus
Skin characteristics
Pulsations or movement
Person’s demeanor

49
Q

ausculatation and percussion

absomen physical assessment check off

A

bowel sounds
gastric tympany (bell all 4 quadrants
costovertebral angle tenderness

50
Q

palpation

absomen physical assessment check off

A

Light palpation in all fourquadrants
Deep palpation in all fourquadrants
Rebound Tenderness

51
Q

inspect/palpate the skull

HEAD & NECK Physical Assessment Check-off

A

scalp
hair
size/shape/symmetry
temporal artery
tmj area

52
Q

inspect the face

HEAD & NECK Physical Assessment Check-off

A

Facial expression
Eye contact
Symmetry of movement (CN VII)
Involuntary movements
Edema or lesions

53
Q

inspect/palpate the neck

HEAD & NECK Physical Assessment Check-off

A

Symmetry
Skin
Thyroid
Lymph nodes
auscultate the theyroid (if enlarged for bruits)
ROM

54
Q

lymph nodes to inspect/palpate

HEAD & NECK Physical Assessment Check-off

A

Pre-auricular
Post auricular
Occipital
Superficial cervical
Jugulodigastric (Tonsillar)
Submandibular
Submental
Posterior cervical
Supraclavicular
Deep cervical chain

55
Q

eyes Physical Assessment Check-off

A

Test visual acuity:
Snellen chart
Near vision if age 40 & older, if reading difficulty

Test visual fields:
Confrontation test

Inspect extraocular muscle function:
Corneal light reflex (Hirschberg test)
Cover test
Diagnostic position test (6 cardinal positions)

56
Q

Inspect external ocular structures:

eyes Physical Assessment Check-off

A

General symmetry
Eyebrows
Eyelids & lashes
Eyeball alignment
Conjunctiva & sclera
Lacrimal apparatus

57
Q

Inspect anterior eyeball structures:

eyes Physical Assessment Check-off

A

Cornea & lens

Iris & pupil:
Size, shape, equality
Pupillary light reflex
Accommodation

58
Q

Inspect the ocular fundi (with opthalmoscope):

eyes Physical Assessment Check-off

A

Red reflex
Optic disc (color, shape, margins)
Retinal vessels
Macula

59
Q

inspect external ear

EAR Physical Assessment Check-off

A

Size & shape of auricle
Position & alignment on head
Skin condition (color, lumps, lesions)
External meatus for size, swelling, redness, discharge, cerumen, lesions, foreign bodies
Palpate auricle & tragus for tenderness

60
Q

Otoscopic exam: inspect

EAR Physical Assessment Check-off

A

External canal (color, redness, discharge, swelling, lesions, foreign object)

Tympanic membrane:
Color & characteristics
Position (flat, bulging, or retracted)
Integrity of membrane
Cone of Light (presence & direction)

61
Q

Test for hearing:

EAR Physical Assessment Check-off

A

Note response to conversational speech
Voice test
Weber test
Rinne test

62
Q

nose

NOSE/MOUTH/THROAT PhysicalAssessment Check-off

A

Inspect: external nose for symmetry, deformity, lesions

Palpate: test for patency of each nostril
Using nasal speculum, inspect:
Nasal mucosa: color & integrity
Septum: any deviation, perforation, bleeding
Turbinates: color, swelling, exudates, polypsP

alpate the sinuses (frontal & maxillary) for tenderness

63
Q

mouth and throat

NOSE/MOUTH/THROAT PhysicalAssessment Check-off

A

inspect (using a penlight) for color, integrity of structures, any lesions:
Lips
Teeth
Gums
Tongue
Buccal mucosa
Palate & uvula: integrity & mobility
Tonsils: Grade
Pharyngeal wall

64
Q

Motor System

Musculoskeletal SYSTEM Physical ExamCheck-off

A

Muscles: Size, strength, tone
Any involuntary movements

Cerebellar function (Balance):
Gait
Tandem walking
Romberg test
Shallow knee bend or hop in place

65
Q

motor system part 2

Musculoskeletal SYSTEM Physical ExamCheck-off

A

Cerebellar function (Coordination):
Rapid alternating movements(RAM)
Finger-to-thumb test
Finger-to-finger test
Finger-to-nose test
Heel-to-shin test

66
Q

sensory system

Musculoskeletal SYSTEM Physical ExamCheck-off

A

Spinothalamic tract:
Pain (sharp vs. dull)
Temperature
Light touch

67
Q

sensory system part 2

Musculoskeletal SYSTEM Physical ExamCheck-off

A

Posterior tract:
Vibration
Position (kinesthesia)

Tactile discrimination:
Stereognosis
Graphesthesia
Distinction
Point location

68
Q

reflexes

Musculoskeletal SYSTEM Physical ExamCheck-off

A

Deep Tendon
Biceps
Triceps
Brachioradialis
Patella
Achilles

Superficial
Plantar

69
Q

CN I AND CN 2

NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off

A

CN I Olfactory: Smell (each nare at a time)

CN II Optic:
Visual acuity (distant & near vision)
Visual fields by confrontation
Ophthalmoscopic exam of fundI

70
Q

CN III AND CN IV

NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off

A

CN III Oculomotor:
EOM by six cardinal positions
Raise eyebrows & eyelids symmetrically
Pupillary size, direct & consensual response to light & accommodation

CN IV Trochlear:
Eye movement down & inward

71
Q

CN V AND CN VI

NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off

A

CN V Trigeminal:
Assess muscle movement & strength with clenching of teeth
Superficial touch – three divisions
Corneal reflex

CN VI Abducens:
Lateral movement of eye

72
Q

CN VII AND CN VIII

NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off

A

CN VII Facial:
Symmetry of facial features with expressions (smile, frown, puffed cheeks, wrinkled forehead, squint eyes tightly)
Identify sweet & salty tastes on each side of tongue

CN VIII Acoustic:
Whisper test
Weber test
Rinne test

73
Q

CN IX AND CN X

NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off

A

CN IX Glossopharyngeal :
Gag reflex

CN X Vagus:
Phonates “ahh”
Gag reflex
Note swallowing
Note voice quality

74
Q

CN XI AND CN XII

NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off

A

CN XI Spinal accessory:
Turn head against resistance
Shrug shoulders against resistance

CN XII Hypoglossal:
Protrude tongue
Wiggle tongue from side to side
Say “light, tight, dynamite” (evaluate quality of sounds l,t,d,n)

307 Health Assessment (6 decks)

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