FINAL Shift Assessment Flashcards
(Subjective Data) Abbreviated Health History
1. Identifies pt (name & DOB): Pt name, A.A. DOB: 1/1/71 AGE: 42 2. Ask about hx of diseases, trauma, surgeries: Pt denies history of trauma, surgery
3. Medications and allergies: Pt denies taking meds, denies allergies to food, medication, contrast dye, or environmental
4. Personal habits: Pt denies the use of tabacco, alcohol, or street drugs
5. Nutritional Status: Patient provided 24-hour diet recall. Patient states “i have poor dietary habits due to the demands of nursing school”
6. Exercise and activity status: pt denies routine exercise; reports sedentary lifestyle
(Objective Data) Abbreviated General Survey
1. Age: pt appears stated aged
2. Level of consciousness & orientation: A&O to person, place, and time (x4)
3. Skin color: Tone is even. Skin color is pink. Pigmentation is consistent with ethnical background and **darker in sun exposed areas**
4. Symmetry of facial features: Facial features symmetrical bilateral
5. Nutrition: fat distribution even
6. Position and posture: sitting errect with hands resting in lap; position relaxed
7. Facial expression, mood, & affect: Pt maintains eye contact; facial expressions, mood, and affect are appropriate for situation; willing to copperate with examiner.
8. Speech: clear, effortless, understandable
Head and Face
Abnormal: lesions on scalp, tenderness on frontal sinus
1. Inspect skin characteristics: Tone is even. Skin color is pink, intact with no obvious lesions. Pigmentation consistent with ethnic background and rest of the body.
2. Inspect symmetry and external characteristics of eyes and ears: Facial features symmetrical bilaterally including eyebrows, ears symmetric (tip of ear lines up with corner of eye), no thickening of cartilage on ears symmetrically bilaterally
3. Inspect and palpate scalp and hair for texture, distribution, and quality: Scalp/skull symmetric and smooth; no lesions or pest inhabitants noted. Hair brown, curly, and fine in texture
4. Palpate sinus region: No tenderness or visible swelling noted to frontal or maxillary sinuses
5. Palpate temporomandibular joint: Smooth movement with no limitation noted.
6. Ask client to clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile, stick out tongue puff out cheeks (CN VII): CN VII (facial) intact as evidenced by pt’s ability to clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile, stick out tongue, and puff out cheeks.
7. Test light sensation of forehead, cheecks, chin (CN V):
CN V (Trigeminal nerve) intact as evidenced by pt’s ability to detact light sensation of forehead, cheecks, and chin bilaterally
Eyes
Abnormals: Discharge, red conjunctiva
1. Inspect external structures of eyes, orbit, any periorbital edema, lashes, brows, conjunctive, sclera: Facial expression relaxed. No squinting noted. Eye balls aligned. Able to navigate obstacles within the sourroundings without difficulty. Eye orbits symmetric bilaterally. No periorbtial edema noted. Upper lids overlap the superior part of the iris and appropriate completely when closed. Skin is intact with no redness, swelling, discharge, or lesions. Eyelashes are evenly distributed along lid margins and curve outward. Conjunctiva clear; able to see pink over the lower lids and white over the sclera. Sclera china white with no foregin body, discharge or lesions present.
2. Inspect cornea, iris, pupil: Cornea= transparent, smooth, clear with no opacities. Iris is round, regular shape with even coloration. Pupil size is 2mm bilaterally.
3. Palpate lacrimal apparatus (gland and duct): Lacrimal glands without swelling, bulging, or excessive tearing. Puncta without redness of swelling.
–Make room dark, open curtain a little and remeber to close again after—
4. Test pupillary response to light and accommodation: Pupillary light reflex intact both direct and consenual response. Accommodation intact aeb pupillary constriction and convergence of the axes of the eyes. PERRLA.
5. Test corneal light reflect (Hirschberg test): Light reflected symmetrically in both eyes.
6. Inspect for presense of the red reflex using the ophthalmoscope: Positive red reflex bilaterally
—-TURN LIGHT BACK ON,CLOSE CURTAIN—-
7. Test visual acuity using Snellen chart (CN II): Left Eye 20/20, Right eye 20/20 with/without correction
8. Test extraocular eye movements (CN III, IV, VI) using cardinal positions of gaze: Parallel tracking of the object with both eyes; no nystagmus noted.
9. Perform cover-uncover test: Steady, fixed gaze noted bilaterally
10. Confrontation test (peripheral vision/cover eye): Peripheral vision intact
L eye coveredR eye covered
Overhead: 50 Overhead: 50
Underhead: 70 Underhead: 70
Right Side: 90 Right Side: 60
Left Side: 60 Left Side: 90
Ears
Abnormals: Red bulging tympancy membrane, drainage
1. Inspect enternal structures of the ear, alignment, configuration, and abnormalities: Ears equal size bilaterally with no swelling or thickening noted. Skin intact. Darwin’s tubercle present bilaterally. External auditory meatus without swelling, redness, or discharge bilterally.
2. Inspect and describe each ear canal, note abnormalities: External cancal without redness, swelling, lesions, foreign bodies, or discharge. Cerumen present bilaterally.
3. Inspect and describe tympanic membrane: Make forcrum (use left hand to hold scope and pull pinna up and back with right hand=for left ear & use right hand scope and pull pinna back w/ left hand=for right ear). Tympanic membrane shiny and translucent with a pearly gray color bilaterally.
4. Perform whisper test and describe findings (CN VIII): Stand behind pt. CN VIII intact aeb pt’s ability to repeat 3 words whispered bilterally.
peanutbutter, boogers, tastey
garage, chocolate, bandage
Nose
Abnormals: Discharge, nares not patent,
1. Inspect skin characteristics, midline: Nares symmetric, nose midline and in proportion to other facial features. No inflammation, deformity, or skin lesions noted.
2. Determine patency of each nostril: Nares patent bilaterally
3. Inspect muscosa, septum, turbinates: Nasal muscosa red, smooth, moist surface; no discharge or foreign body noted. No septal deviation, perforation or bleeding noted. Turbinate’s light red in color with no polyps, or growth noted.
4 Assess olfactory function, test sense of smell (CN I): CN I intact aeb pt’s ability to identify appropriately an aroma bilaterally. (Grab 2 smells to distinguish each nostril)
Communication Skills & Professionalism
- Introduces self as BSN student
- Performs hand hygiene
- Privacy provided througout assessment
- Communicates interactively & explains procedures
- Exhibits professional behaviors
- Examiner is prepared, & exam flows in organized manner following a head-to-toe sequence
- Caring behaviors
Mouth and Pharynx
Abnormals: Tonsils 4+, Tonsils with exudate
1. Inspect condition of lips, gums, teeth: Lips pink, moist, and intact. Gums pink with stippled surface. Gum margins are tight with no swelling, bleeding, or discolored gums noted. Teeth are white, straight, evenly spaced and free of decris or decay.
2. Inspect condition of buccal mucosa, tongue, hard and soft palates, floor of mouth, ducts: Buccal mucosa pink, smooth, moist, and intact. Stenson’s duct and Warten’s duct visible. Tongue pink and moist with no exudate or lesions. Hard palate white with irregular transverse rugue. Soft palate is pink and smooth.
3. Inspect oropharynx, grade tonsils: Pharyngeal wall pink without exudate or lesions. Tonsils pink and no exudate noted. Grade 1+ bilaterally.
4. Inspect tongue, symmetry, movement (CN XII): CN XII intact aeb tongue protrudes midline without tremor, loss of movement or deviation to either side.
5. Assess TMJ and range of motion of jaw: Smooth movement with no limiations.
6. Note if uvula elevates in midline when patient says “ahh” and test gag reflex: Deffered no gag reflex, pt can swallow. CN X intact aeb uvula rises midline with phonation.
Neck
Abnormals: Limited ROM, Submental lympth node present and tender
1. Inspect for synnetry of neck structures/muscles: Head position centered midline. Accessory neck muscles symmetric.
2. Inspect jugular vein distention: External jugular veins appear collapsed with supine. No evidence of jugular venous distention.
3. Inspect range of motion: Full ROM aeb ability to touch chin to chest, turn head to right and left, touch right ear to right shoulder, left ear to left shoulder, extend head backwards. Motions are smooth and controlled.
4. Test shoulder shrug & head resistance againist examiner’s hand (CN XI): CN XI intact aeb able to shrug shoulders against resistance and able to turn head side to side against resistance
5. Palpate tracheal position: Trachea midline
6. Palpate thyroid: Unable to palpate thyroid. No nodules present.
7. Palpate lympth nodes: No lymphadenopathy noted upon palpation of the pre auricular, post auricular, occipital, jugulodigastric (tonsillar), submandibular, submental, superficial cervical, posterior cervical, deep cervical chains, and supraclavicular lympth nodes.
8. Auscultate carotid arteries: No bruits noted to carotid artery bilaterally
Chest/Lung
Abnormals: Labored breathing, use of accessory muscles
1. Inspect for symmetry, contour (AP/transverse ratio) note deformities: Thorax is symmetric, scapulae are symmetric, AP/transverse ratio 1:2, no deformities noted
2. Assess breathing rate, pattern, depth, effort: Respiratory rate (stated number of breaths) automatic and effortless, regular and even, silent. Chest expands symmetrically on inspiration and expiration.
3. Palpate for symmetry of chest expansion (posterior only): Posterior chest expansion equal biaterally
**This happens at T9 and T10
4. Percuss posterior lung field only, note predominate sound and symmetry: Posterior lung field percussed with a predominate note of resonance; symmetric bilaterally
5. Auscultate anterior/posterior/lateral lung fields, note findings in terms of breathing sounds heard, presence or absence of adventitious sounds: Lungs are clear to auscultate, bilaterally. No adventitious breath sounds. Respirations are regular, silent, even, and unlabored.
Remember, Bronial (top) sounds are harsh and high-pitched. Bronial Vesicular (middle) sounds are regular. Vesicular (bottom) sounds are soft and dull. Also the right lung has 3 lobes while the left lung as 2 lobes. At the 4th intercostal space on the right is when you hear the right middle lobe while on the left you can hear the upper left lobe
Cardiovascular
Abnormals: Murmur, S3 & S4 sounds heard
1. Inspect anterior chest. Note any chest wall pulsations, heaves or lifts: Anterior chest-skin tone even, color consitent with ethnic background. Unable to visualize the apical pulse. No visible heave or lift.
2. Auscultate the apical heart rate. Note rate and rhythmn: apical heart rate ___, regular rhythm
3. Ausculatate systematically using disphragm and bell (aortic, pulmonic, erbs, tricuspid, mitral). Identify S1 &S2, note where you hear each loudest:
Aortic sounds: 2nd intercostal space, right sternal boarder, S2 loudest.
Pulmonic sounds: 2nd intercostal space, left sternal boarder, S2 loudest.
Erb’s Point: 3rd intercostal space, left sternal boarder, S1 and S2 sounds are equal.
Tricuspid sounds: 4th intercostal space, left sternal boarder, S1 loudest.
Mital (apical) sounds: 5th intercostal space, left mid-clavicular line, S1 loudest. We would listen here for a full minute. NOW LISTEN WITH BELL BACKWARDS for 15 seconds at each spot.
Regular rate and rhythm, S1 and S2 noted, no murmurs or extra sounds.
4. Note the presence or absence of abnormal sounds (murmur, extra sounds): Regular rate and rhythm, S1 and S2 noted, no murmurs or extra sounds.
5. Inspect color and pigmentation of extremities: Upper and lower extremities skin tone is even and color is consistent with ethnic background, could be darker in sun-exposed areas
6. Palpate extremities for edema and temperature: No edema present in upper and lower extremities. Temperature is warm equal bilaterally upper and lower extremities.
7. Palpate peripheral pulses bilaterally, note quality and symmetry (radial, dorsails, pedis, posterior tibial):
Peripheral pulses equal bilaterally:
Radial pulse: strong, 2+, equal, bilaterally
Brachial pulse: strong, 2+, equal, bilaterally
Posterior tibial pulse: strong, 2+, equal, bilaterally
Dorsalis pedis: strong, 2+, equal, bilaterally
Abdomen
Abnormals: Absent bowel sounds
1. Inspect abdomen for contour, symmetry, pulsations: Abdomen flat, symmetric bilaterally. No herniations noted. No aortic pulpation visible.
2. Inspect for skin color, lesions, scars, and striae: Skin is consistant with eithnic background, skin tone even, no lesions, no scars, no striae noted.
3. Auscultate all quadrants for bowel sounds: Bowel sounds present in all 4 quadrants. Normoactive bowel sounds.
**Listen to each quadrant for 1 minute, cant call it absent until listened for 5 whole minutes.
Hypoactive: <5
Normoactive: 5-30 sounds
Hyperactive: 30>
4. Percuss all quadrants and describe prodominant sound: Tympany predominant upon percussion of all 4 qudrants
5. Percuss liver boarders and estimate liver span: Liver span 7cm (range 6-12cm) in right midclavicular line
6. Perform light and deep palpation over four quadrants to determine the presence of enlarged organs, tenderness, or masses: No masses, no nodules, no organomegaly, no tenderness noted with light palpation and deep palpations
1-2 inches=light palpation
3-5 inches= deep palpation
7. Percuss for CVA tenderness: No CVA tenderness noted
Neuromuscular
Abnormals: unsteady gait, right bicep reflex 3+
1. Test deep tendon reflexes (biceps, triceps, patellar, achilles)
Biceps: Right 2+ Left 2+
Triceps: Right 2+ Left 2+
Patellar: Right 2+ Left 2+
Achilles: Right 2+ Left 2+
2. Test plantar/babinski reflexes: Positive plantar flexion; negative babinski (dorsiflexion)
3. Test bilateral response to light and sharp touch on distal portion of extremities:
***Pt must have their eyes closed for this
CN V intact aeb bilateral response to light and sharp stimuli upper and lower, distal postion of extremities
4. Test motor strength for upper extremities against resistance: Upper extremity strength strong against resistance equal bilaterally
5. Ask pt to squeeze hands for (grip) strength: Hand grasp strong, strength equal bilaterally
6. Test for range of motion in upper extremities: Full ROM upper extremities bilaterally
7. Ask client to touch nose with alternating fingers:
***After a few times have pt close their eyes and do it
Accurate and smooth movement noted
8. Ask pt to run heel down tibia of each leg: Pt able to move heel in a straight line down shin bilaterally
9. Ask client to stand. Perform Romberg test:
**Have pt start with eyes open and after a few seconds ask them to close their eyes
Pt maintains balance and posture
10. Ask pt to bend over and touch toes while standing behind pt and inspecting spine: Spine straight; Double-S shape noted; horizontal position of shoulders equal; knees and feet aligned with trunk
11. Stabilize the pelvis and perform ROM of the spine, note findings: Full ROM lateral bend, hyperextension, and rotation bilaterally
12. Ask pt to walk, note gait: Steady, smooth, effortless with opposing arm swing
13. Have client walk heel-to-toe (tandem walking): Pt able to walk straight line and maintain balance
