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Health Assessment > Adult Complete Health Assessment (Final) > Flashcards

Adult Complete Health Assessment (Final) Flashcards

1
Q

Sequence of Examination

A
  1. obtain health history
  2. observe general appearance
  3. obtain measurements
  4. examine skin
  5. vitals
  6. inspect, palpate and auscultate
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2
Q

Inspect and Palpate

A
  1. head and face
  2. eyes and ears
  3. nose, mouth, throat and neck
  4. chest
  5. heart
  6. UE
  7. breasts and neck vessels
  8. abdomen and inguinal area
  9. LE
  10. MSK
  11. neurologic
  12. genitalia and rectum
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3
Q

Biographic Data

A

source
reason for seeking care
history of present illness

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4
Q

Past Health

A

illnesses
accidents
last exam
allergies
meds

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5
Q

Family History

A

genogram

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6
Q

Review of Symptoms

A

general health
all body systems

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7
Q

Functional Assessment

A

activity
exercise
sleep
nutrition
alcohol
smoking
support
coping and stress

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8
Q

Perception of Health

A

own feelings about health
generally interest in health status

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9
Q

Measurements

A

height/weight/weight circumference/BMI
vital signs
vision (snellen eye chart, CN II)

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10
Q

Head and Face

A

inspect and palpate scalp, hair, cranium
inspect facial symmetry, expression, CN VII
palpate temporal artery then temporomandibular joint as person opens and closes mouth
palpate maxillary and frontal sinuses

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11
Q

Inspecting External Eye Structures

A

conjunctiva
sclera
corneas
irises

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12
Q

Ears

A

inspect external ear for position and alignment, skin condition, auditory meatus; move auricle and push tragus for tenderness
test hearing (whispered voice test)
otoscope (inspect canal, then tympanic membrane for color, position, landmarks and integrity)

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13
Q

Inspecting nares with…

A

a speculum

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14
Q

Mouth and Throat

A

inspect mouth with light (buccal mucosa, teeth and gums, tongue, floor of mouth, palate, uvula) GRADE TONSILS IF PRESENT
test gag reflex, CN IX AND X, XII
bimanually palpate mouth if indicated with glove

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15
Q

Neck

A

inspect neck
palpate cervical lymph nodes
palpate carotid
palpate trachea
test ROM and strength, CN XI
palpate thyroid

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16
Q

Anterior Chest

A

inspect respirations and skin
palpate for tactile fremitus, lumps, tenderness
percuss anterior lung fields
auscultate

17
Q

Posterior and Lateral Chest

A

inspect configuration of thoracic cage, skin, and symmetry of shoulder and muscles
palpate for symmetric expansion, etc. and length of spinous processes
percuss all lung fields, costovertebral angle noting tenderness
auscultate

18
Q

Heart

A

ask person to lean forward and exhale briefly, ascultate for murmurs
inspect precordium for pulsations and heaves
palpate apical pulse, precordium for thrill
auscultate apical rate and rhythm
turn person to left to auscultate with bell

19
Q

UE

A

test ROM and strength
palpate epitrochlear nodes
palpate temp and cap refill
compare radial and brachial pulses bilaterally

20
Q

Breasts

A

inspect symmetry, mobility, and dimpling as she lifts arms/leans forward and pushes hands on hips; supra and infraclavicular areas
palpate each breast including tail of spence and areola, nipple for discharge
palpate axilla and lymphs
self exam

21
Q

Male Breasts

A

inspect and palpate anterior chest wall
palpate axilla and lymph

22
Q

Neck Vessels

A

inspect each side for jugular venous pulse, turning persons head slightly to the side
estimate jugular venous pulse if indicated

23
Q

LE

A

inspect legs for varicose veins

24
Q

MSK

A

ask person to walk normally away and towards you, heel-to-toe
ask person to walk on toes for few steps, then heels for few steps
check for romberg
ask person to hold edge of bed and perform shallow knee bend for each leg
stabilize pelvis and test ROM of spine as person hyperextends, rotates and laterally bends

25
Q

Neurological

A

test sensation (superficial pain, light touch, vibration)
position sense of finger, one hand
stereognosis
cerebellar function of UE using finger to nose test or rapid alternating movements
cerebellar function of LE by asking person to run each heel down opposite shin
deep tendon reflexes
babinski

26
Q

Inguinal Area

A

palpate each groin for femoral pulse and inguinal nodes; lift drape to expose legs

27
Q

LE

A

palpate popliteal, posterior tibial and dorsalis pedis pulses
separate toes and inspect
test ROM and strength (ask person to sit on edge of bed and dangle legs)

28
Q

Genitalia and Rectum

A

male (inspect, palpate scrotal contents; transilluminate if mass exists, check for inguinal hernia, teach TSE)
female (inspect perineum and perineal areas)
rectum (inspect perianal area, save stool specimen for occult test)

Health Assessment (19 decks)

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