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Assessment > CPE Assessment > Flashcards

CPE Assessment Flashcards

1
Q

Order of Assessment

A
  • VS/Intro
  • General survey
  • Skin Nails
  • Head
  • Eyes
  • Ears
  • Nose/Sinuses
  • Mouth
  • Neck
  • Neuro/Msk
  • Chest
  • Breast
  • Abdomen
  • Legs
  • Spine/Ambulation
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2
Q

Included Vital Signs

A
  • height
  • weight
  • BP
  • Temp
  • Pulse
  • Resp
  • SNELLEN
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3
Q

Communication Techniques

A

introduction
eye contact
wash hands

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4
Q

General survey

A

observe clients behavior and appearance t/o exam;

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5
Q

Skin

A 
Inspect for:
-color
-lesions
-edema
-open wounds
-texture
-turgor
integrate t/o exam;
*skin assessment starting with nails;
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6
Q

Head

A

Inspect & palpate scalp and hair

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7
Q

Eye

A 
Inspect:
-position and alignment of eyes and lids
-sclera and conjunctiva
-pupil size
Check PERRLA
*Grab scope & turn off light
Perform fundoscopic exam (CNII)
Test Oculomotor Fields (III, IV, VI)
Convergence
Accommodation
*Test Facial Nerve (VII): raise eyebrows, open eyelids against resistance, smile, puff cheeks
*****FINISH CNs?********
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8
Q

Ears

A

Inspect: tympanic membrane for landmarks, deformities, and inflammation
Assess: hearing with rubbing fingers (VIII)
Assess: Weber & Rinne Tests

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9
Q

Nose/Sinuses

A

Inspect: external nose, nasal mucosa,septum, turbinates
Palpate: frontal and maxillary sinuses

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10
Q

Mouth and Oropharnyx

A

(using tongue blade and penlight)
Inspect: lips, buccal mucosa, gums, teeth, roof of mouth, pharynx
*say you would test gag reflex and “ah” reflex (CN 9/10)
*Stick tongue out (CNXII)
*CN V –> TMJ/clench

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11
Q

Neck

A 
Inspect & Palpate Lymph Nodes
-occipital
-preauricular
-postauricular
-submaxillary
-posterior cervical chain
-anterior cervical chain
-Supraclavicular
-Infraclavicular
Auscultate Carotids for bruits using bell
Test Shoulder shrug CN XI **CN II-XII intact**
*note masses or unusual pulsations
palpate trachea & thyroid (swallow) noting any pain, nodules, or masses
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12
Q

Neuro/Msk

A

Assess ROM
-Neck: flex, extend, rotate
-Shoulders: flex, extend, internal & external
I already tested strength with CN XI
-Elbows: flex, extend, pronation & supination
-wrists: flex, extend, radial & ulnar
-Hands: finger adduction/abduction
Test: Deep Tendon Reflexes (DTRs)
-brachioradial
-biceps
-triceps
*assess upper extremity & neck muscle strengths

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13
Q

Chest: Cardiac

A

Inspect:

  • msk development
  • symmetry of chest and shoulders and scapulae
  • note posture
  • Auscultate Heart Sounds sitting up with diaphragm
  • Auscultate again while lying down using both sides (S3/S4? is it RRR?)
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14
Q

Chest: Pulmonary

A

Inspect:

  • resp rate and effort
  • depth
  • Rhythm
  • Pattern
  • *Percuss post lung fields!!
  • Auscultate post and sup anterior (including RML)
  • instruct to breath through mouth
  • *No adventitious breath sounds
  • *Check CVA tenderness
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15
Q

Axillary Nodes, etc

A 
Inspect breasts with:
-arms relaxed
-arms elevated
-positioned on hips
Inspect nipples: for symmetry, enlargement
*Inspect and palpate axillary nodes
*Palpate epitrochlear nodes
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16
Q

Breasts

A

Palpate systematically: palpate midaxillary line to sternum and clavicle to inframammary fold

  • Complete vertical stripping with three levels of pressure, light, medium, and deep in all 4 quads including tail of spence
  • *If patient report nipple discharge, palpate areola and nipple for discharge
17
Q

Abdomen

A

Inspect: skin characteristics, contour, pulsations, movement
Auscultate: 4 quads for active bowel sounds & presence of bruits in aorta, renal and iliac arteries
Percuss: liver (estimate span), spleen on L MAL and costal margin for dullness
Palpation: light 4 quads; deep 4 quads
Palpation: liver, spleen, kidneys, aorta

18
Q

Feet & Legs (vascular and msk)

A 
Inspect:
-skin characteristics, hair distribution, muscle mass, temperature, open wounds
Palpate:
-pulses: fem, pop, tib, pedal
-DTRs: patella, achilles, clonus
**palpate for edema**
Assess ROM: (while still laying)
-hips: flex (with and without knee flex), abduction, adduction, internal & external rotation
-knees: flex, extend (IN BED!)
*****have patient sit up****
-assess leg strength
-ankle/feet: dorsi, plantar, inversion, eversion, adduction, abduction
-assess feet strength
19
Q

Gait/Spine

A

CLIENT STANDING
-Hyperextend hip
Spine:
-ROM: flex (bend), hyperextend, lateral bending, rotation
-Gait
-Tandem walk
-Romberg

Assessment (6 decks)

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