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Health Assessment > Final Head to Toe > Flashcards

Final Head to Toe Flashcards

1
Q

1

A

Introduce self to client and check ID band

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2
Q

2

A

Explain what you’re going to be doing, ask about allergies, ask if now is a good time

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3
Q

3

A

Hand hygiene (verbalize)

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4
Q

4

A

Ask them to tell you where they are, why they’re there, and ask what month and year it is.

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5
Q

5

A

Pull curtain for privacy, adjust bed, clean stethoscope.

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6
Q
  1. Head and Neck
A

Inspect face, and head for shape
(Say normalcephalic and symmetrical)

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7
Q
  1. Head and Neck
A

Inspect external nose and lips
(Say nose is midline, symmetrical, ask to smile and say symmetrical, color, intact skin)

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8
Q
  1. Head and Neck
A

Check for patency of nostrils (Use penlight)
(Ask to occlude each nostril and sniff, say patency in each nostril. Say no deviations or obstructions)

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9
Q
  1. Head and Neck
A

Inspect and palpate scalp
(Check for dents, shape, skin intact, clean, hair color, even distribution, no infestations)

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10
Q
  1. Head and Neck
A

Palpate maxillary and frontal sinuses
(Say they will feel pressure, ask if any pain)

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11
Q
  1. Head and neck
A

Palpate temporal artery bilaterally
(Grade pulse or say unable to palpate)

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12
Q
  1. Head and Neck
A

Inspect neck and trachea
(Say skin intact, consistent w/ ethnic background, muscles symmetric, trachea midline)

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13
Q

Lymph Nodes

A

Inspect all 10
(name each one)

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14
Q

1.

A

Preauricular

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15
Q

2.

A

Posterior auricular

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16
Q

3.

A

Occipital

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17
Q

4.

A

Submental

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18
Q

5.

A

Submandibular

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19
Q

6.

A

Jugulodigastric

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20
Q

7.

A

Superficial cervical

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21
Q

8.

A

Deep cervical chain

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22
Q

9.

A

Posterior cervical

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23
Q

10.

A

Supraclavicular

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24
Q

Ears

A

Palpate external ears
(Name pinna, tragus and mastoid process. Ask for tenderness)

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25
Q

Eyes

A

Test pupillary reflexes
(State pupil size, Direct and consensual, state cranial nerve 3 is intact)

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26
Q

Upper extremities

A

Inspect skin and palpate for temperature
(Say symmetrical, skin color, use dorsal hand and start from shoulders and move down. Say skin is warm, consistent w/ ethnic background, intact)

27
Q

Upper extremities pt.2

A

Assess nails
(State color, capillary refill [brisk], no clubbing)

28
Q

Upper extremities pt.3

A

Check radial pulses bilaterally
(Say grade of pulse, regular)

29
Q

Thorax

A

Preform on right side of patient

30
Q

Thorax pt.2

A

Inspect for JVD
(Have patient turn head to right and left, say negative for JVD)

31
Q

Thorax pt.3

A

Palpate carotid arteries
(One at a time, 2+)

32
Q

Thorax pt. 4

A

Auscultate carotid arteries for bruits
(Use bell, each side, have patient exhale and hold breath, say no bruits heard)

33
Q

Thorax pt.5

A

Listen to trachea
(Use diaphragm, have patient breath in and out, say bronchial sounds heard)

34
Q

Thorax pt.6

A

Inspect anterior thorax
(Say skin intact, consistent w/ ethnic background, even and unlabored breaths)

35
Q

Thorax pt.7

A

Assess skin turgor
(Pinch lightly under clavicle, say no tenting)

36
Q

Thorax pt.8

A

Auscultate anterior chest
(Identify from side to side, top to bottom, have patient breathe in and out at each spot, say Broncho vesicular or vesicular say no adventitious sounds heard)

37
Q

Thorax pt.9

A

Auscultate posterior chest
(Identify from side to side, top to bottom, have patient breathe in and out at each spot, say Broncho vesicular or vesicular say no adventitious sounds heard)

38
Q

Thorax pt.10

A

Auscultate with diaphragm S1 and S2
(Verbalize you’re going to listen for 1 full minute, state heart rate and rhythm, in 5th space [mitral])

39
Q

Thorax pt.11

A

Auscultate with diaphragm 5 areas on precordium

40
Q

1.

A

Aortic

41
Q

2.

A

Pulmonic

42
Q

3.

A

Erb’s point

43
Q

4.

A

Tricuspid

44
Q

5.

A

Mitral

45
Q

Thorax pt.12

A

Auscultate with bell 5 areas again
(Say no vascular sounds heard)

46
Q

Thorax pt.13

A

Auscultate with bell for S3 and S4
(Have patient lie slightly on their left side and listen at mitral space, say no S3 or S4 heard)

47
Q

Abdomen

A

Inspect abdomen for contour, symmetry, pulsations and peristalsis
(Say flat or rounded, symmetrical, no lesions, no pulsations, no peristalsis, skin consistent w/ ethnic background)

48
Q

Abdomen pt.2

A

Auscultate with diaphragm each quadrant
(Start in RLQ, move clockwise, say bowel sounds heard in each quadrant)

49
Q

Abdomen pt.3

A

Auscultate with bell for vascular sounds
(State name and location, no vascular sounds heard)

50
Q

1.

A

Aortic- Below xiphoid process in line w/ umbilicus

51
Q

2.

A

Renal- left and right above umbilicus

52
Q

3.

A

Iliac- Left and right below umbilicus

53
Q

Abdomen pt.4

A

Percuss abdomen
(Use zig zag pattern, state tymphany heard)

54
Q

Abdomen pt.5

A

Palpate abdomen
(Lightly, use zigzag pattern, ask for any tenderness, say no masses, pain or tenderness, muscle wall is smooth, no guarding)

55
Q

Lower Extremities

A

Inspect skin and palpate for temperature bilaterally
(Dorsal hand, top to bottom, say skin is warm, consistent w/ ethnic background, no lesions)

56
Q

Lower extremities pt.2

A

Palpate femoral artery bilaterally
(Over patient shorts, grade pulse, 2+)

57
Q

Lower extremities pt.3

A

Palpate for edema
(Push on tibia, say no edema)

58
Q

Lower extremities pt.4

A

Palpate popliteal pulse separately
( say unable to palpate or grade pulse)

59
Q

Lower extremities pt.5

A

Palpate posterior tibial pulse bilaterally
(Grade pulse, at the same time)

60
Q

Lower extremities pt.6

A

Palpate dorsalis pedis pulses bilaterally
(Grade pulse, at the same time)

61
Q

Lower extremities pt.7

A

Passive ROM for hip
(Do for them, state each one, flexion, extension, abduction and adduction, bilateral state full ROM of hip)

62
Q

Lower extremities pt.8

A

Passive ROM for ankle
(State each one, planter flexion and dorsiflexion state full ROM of ankle)

63
Q

Close Exam

A

Thank patient for time

Health Assessment (2 decks)

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