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Physical Assessment Flashcards
Physical assessment grading points
114
Health Care
Graduate
09/12/2016

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Cards

Term
A. General assessment strategies
Definition
1. Gather supplies before beginning
Term
2. Adequately explain what is being done, while limiting small talk
Definition
3. Consider client's anxiety and fears.
Term
4. consider own facial expression and comments
Definition
5. Demonstrate confidence, empathy, and gentle manner
Term
Demonstrate confidence, empathy and gentle manner
Definition
6. Acknowledge and apologize for any discomfort caused
Term
7. Provide for privacy and warmth at all times
Definition
8. Determine comfort level, pausing if patient becomes tired
Term
9. Coordinate procedures to limit position changes for examiner and client
Definition
*10. Wash hands at appropriate times
Term
11. Briefly summarize findings to client, and thank client for his/her time.
Definition
12. Use appropriate terminology and correctly pronounces medical terminology with client
Term
13. Demonstrate skills of inspection, percussion, palpation and auscultation in the correct order for each system with the correct technique
Definition
14. Demonstrate correct use of instruments, including assembly and manipulation of component parts.
Term
15, Complete assessment in scheduled time
Definition
16. Refer to notes minimally.
Term
B. General survey of Client
Definition
1. gather name, age, sex and occupation
Term
2. Level of consciousness (arousal, wakefulness)
Definition
3. Obvious physical deformities
Term
4. Facial expression: Note distress
Definition
a. Note anxiety
Term
b. observe for cyanosis
Definition
short and long term memory assessed
Term
c. Standing in front of the client, client is sitting.
Definition
1. skin
Term
a. inspect hands
Definition
*inspect fingernails, note nail bed color
Term
*c. assess for clubbing
Definition
d. palpate nails for capillary filling: fingernails
Term
e. inspect skin color and pigmentation. notes cyanosis
Definition
f. palpates skin temperature
Term
g. palpate skin moisture
Definition
h. palpate skin texture
Term
*note color of lesion. (must have some type of lesion for students to eval)
Definition
*note pattern or shaw of lesion.
Term
*note any lesions: use ABCDE
Definition
Term
*Note length, width, and elevation of lesion in centemeters
Definition
*Note location and distribution of lesion
Term
Note any exudate
Definition
note exudate color
Term
note exudate odor
Definition
*Palpate radial pulses bilaterally. Scale 0-+4 noted
Term
*Palpate brachial pulsees bilaterally
Definition
Palpate arms to shoulders
Term
J. Assess range of motion (ROM)
Definition
*hands
Term
*wrists
Definition
*elbow
Term
*Shoulders
Definition
L. Assess muscle strength of upper extremities
Term
*hands
Definition
wrist
Term
*elbow
Definition
*shoulders
Term
m. assess relfexes
Definition
*biceps
Term
*triceps
Definition
*brachialradialis
Term
*n. rapid alternating movements
Definition
*o. finger to nose
Term
p. stereographics
Definition
q. assess epitrochlear nodes
Term
*r. assess axillary nodes
Definition
2. head and face
Term
a. Inspect and palpate scalp, hair and cranium
Definition
b. face, (CN VII)
Term
*Frown
Definition
*Puff cheeks
Term
C. Palpate and percuss maxillary sinuses, frontal sinuses
Definition
d. auscultate temporal artery for bruits
Term
*e FaceL lightly touch either one or both sides of each of the three divisions of the trigeminal (CN V)
Definition
3. eyes
Term
a. Hirschberg (corneal light reflex)
Definition
*b. six cardinal fields of gaze (CN III, IV and VI (visual acuity CNII)
Term
c. PERRLA (CN III)
Definition
*Verbalize equal and round
Term
VERBALIZE and demonstrate direct response
Definition
VERBALIZE and demonstrate consensual response
Term
*Accomodation and convergence
Definition
d. cover and uncover
Term
e. Inspect and palpate
Definition
*external structures
Term
f. inspect
Definition
*conjunctivae
Term
*sclerae, cornea, iris
Definition
*g. Fundocopic (verbalize red reflex, retina, vessels, optic disk)
Term
*4. Ears
Definition
*Inspect and palpate external ears
Term
b. gross hearing/whisper test (CN VIII)
Definition
*C. otoscopic ear canals.
Term
know what to note in ear canals
Definition
*e. Weber test (check for lateralization)
Term
*F. Rinne test. (Compares air and bone conduction)
Definition
5. Nose
Term
a. inspect and palpate external nose.
Definition
b. Patency of nostrils (CN I)
Term
*c. Inspects nasal mucosa
Definition
6. Mouth and throat
Term
*a. Inspect lips and buccal mucosa with light and tongue blade.
Definition
b. teeth and gums
Term
c. Tongue, CN XII (hypoglossal)
Definition
*Observe tongue at rest in the floor of the mouth
Term
*Observe tongue protruding. (CN IX and X)
Definition
*Palpate Oral cavity
Term
*Palpate tongue for strength against cheek
Definition
*palpate TMJ.
Term
d. hard and soft palate
Definition
*e. tonsils
Term
*f. observes swallow
Definition
*G. Ask client to say "ah" and observe uvula movement (CN X-vagus)
Term
7. Neck
Definition
a. Assess skin characteristics
Term
b. Inspect for symmetry, plus palpate for lumps and pulsations.
Definition
c. palpate and verbalize nodes
Term
*preauricular nodes
Definition
*postauricular nodes
Term
*submandibular nodes.
Definition
*submental nodes.
Term
*superficial cervical nodes
Definition
*tonsilar nodes
Term
*deep cervical nodes
Definition
*Posterior cervical nodes
Term
*supraclavicular nodes
Definition
Occipital nodes.
Term
*Auscultate and palpate carotic pulse.
Definition
*d. trachea
Term
*e. palpate thyroid (front or back approach)
Definition
*f. ROM of neck
Term
*g. shrug shoulders against resistance (CN XI)
Definition
*h. Push chin against examiner's hand bilateral.
Term
D. Move to BACK of CLIENT, SITTING
Definition
CHEST AND LUNGS, POSTERIOR
Term
a. Inspect and VERBALIZE observations:
Definition
Thoracic cage configuration (AP and transverse diameter)
Term
skin characteristics
Definition
use of accessory muscles
Term
*Retractions, heaves, or dyspnea
Definition
*symmetry
Term
The following criteria will be evaluated according to the competency map
Definition
*b. palpate expansion
Term
*c. palpate tactile fremitus
Definition
*d. percussion over lung fields
Term
*e. egophony
Definition
f. auscultate breath sounds with diaphragm of stethoscope in:
Term
Organized sequence, side to side. Posterior (6 minimum sites)
Definition
*and verbalize findings
Term
*g. Lateral breath sounds (5 sites)
Definition
h. describe breath sounds heard.
Term
*j. Assess for CVA tenderness
Definition
E. MOVE TO FRONT OF CLIENT.
Term
1. CHEST AND LUNGS, Anterior.
Definition
a. inspect and VERBALIZE observations
Term
*Respirations
Definition
*skin characteristics.
Term
b. Palpate for lumps or tenderness (4 places, upper/lower)
Definition
c. Palpate skin turgor
Term
d. osculate breath sounds with diaphragm of stethoscope in organized sequence, side-to-side (4 minimum sites) VERBALIZE FINDINGS
Definition
F. CLIENT SUPINE, STAND AT CLIENT'S RIGHT.
Term
1. Heart (Pulls out table extension)
Definition
a. Inspect precordium for pulsations and heaves.
Term
b. Palpate precordium with palm.
Definition
*c. Locate, inspect, palpate, and auscultate PMI/apical impulse.
Term
*d. Auscultate apical rate and rhythm. Verbalize findings
Definition
e. Locates landmarks
Term
f. auscultates heart sounds in 5 areas with diphragm
Definition
*aortic area
Term
*pulmonic area
Definition
*erb's point
Term
*tricuspid area
Definition
*mitral area
Term
g. Auscultate heart sounds in 5 areas with bellL
Definition
*Aortic area
Term
*Pulmonic area
Definition
*erb's point
Term
*tricuspid area
Definition
*mitral area
Term
*abdomen
Definition
a. Ensures out/pulls out table extension
Term
b. observe abdomen at eye level from client's right
Definition
c. inspect skin characteristics
Term
d. inspect contour, symmetry
Definition
e. inspect umbilicus and pulsations
Term
f. ask client to raise head.
Definition
g. observe face while client has head raised.
Term
h. observe abdomen while client has head raised.
Definition
*auscultate bowel sounds with diaphragm in all four quadrants
Term
*auscultate bowel sounds with diaphragm in all four quadrants
Definition
*auscultate vascular sounds with bell (5 sites)
Term
*j Percuss in all four quadrants.
Definition
*k. light palpation in all 4 quadrants
Term
*l. Deep palpation in all 4 quadrants.
Definition
*m. Palpate liver
Term
*n. Palpate spleen
Definition
4. lower extremities
Term
a. inspect symmetry
Definition
b. inspect skin characteristics, hair distribution
Term
*palpate and auscultate femoral pulse
Definition
*e. Pretibial edema
Term
*f. Posterior tibial pulses VERBALIZE findings on 0- +4 scale
Definition
*g. Dorsalis pedis pulses. VERBALIZE findings on 0-+4 scale
Term
*h. inguinal nodes
Definition
i. toes-nails
Term
*j. Range of motion, hips
Definition
*k. range of motion, knees
Term
*l. muscle strength, hips
Definition
*m. muscle strength, knees
Term
n. heel down shin bilateral
Definition
G. CLIENT SITTING UP
Term
*a. Patella reflex
Definition
*b. achilles reflex
Term
c. Babinski reflex
Definition
H. Client stands up
Term
1. musculoskeletal
Definition
a. walks across room (gait)
Term
b. walk heel to toe
Definition
c. walk on tiptoes, then walk on heels
Term
*d. Romberg sign
Definition
e. shallow knee bend
Term
f. Assess spine
Definition
*posture
Term
*curvatures (cervical, thoracic, and lumbar)
Definition
*from behind for lateral curvatures, inequality of scapula, iliac crests and gluteal folds
Term
*g. ROM of spine
Definition
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