Final PAPSE

Question 1

Introduction 1. - 7.

Answer 1

1. Provide privacy - close curtain
2. Introduce self - Robyn, nursing student at NSC
3. Hand hygiene
4. 2 patient identifiers (name, DOB - bracelet)
5. Gender identification
6. Explain procedure. Head to Toe assessment
7. 4 caring behaviors

Question 2

Health History 1. - 11.

Answer 2

1. What is the reason for your visit (chief complaint)?
2. Do you have any new or acute symptoms?
3. How is your overall health?
4. Do you have a history of major illness or surgery?
5. Have you ever had any spinal or head injuries or trauma?z
6. Can you tell me about your medications and your allergies?
7. What is your occupation?
8. Lifestyle (smoking, drinking, illicit drugs).
9. Exercise and diet
10. Vaccinations?
11. When was last bowel movement and describe.

Question 3

General Survey 1. - 7.

Answer 3

1. Assess Orientation. Where are you, and what time is it?
2. Assess physical development: “Patient appears stated age and build is appropriate”.
3. Posture: “sitting erect w/ hands in lap”.
4. Affect: “Patient’s behavior is appropriate to situation”.
5. Speech: “Patient’s speech is clear”.
6. Vitals: “BP, HR, RR, T, SpO2”.
7. Pain: “Patient doesn’t have pain, but I’d use COLDSPA if she did”.

Question 4

Head and Face 1. - 5.

Answer 4

1. Inspect and palpate hair and head: “Hair is brown, evenly distributed and head is round, free of lesions, lumps, and masses.
2. Inspect facial features: “Nose is midline, and eyes, ears, and mouth are symmetrical bilaterally”.
3. Have client smile, frown, show teeth, blow out cheeks, raise eyes and tightly close eyes (CN VII): “Cranial Nerve 7 is intact bilaterally”
4. Test sensation of forehead, cheeks and chin w/ swab (CN V): “Cranial Nerve 5 is intact bilaterally”.
5. Test Sensation in arms and hands w/ same swab: “Sensation in the upper extremities is intact bilaterally”

Question 5

Eyes, Ears, Nose, and Mouth 1. - 7.

Answer 5

1. Inspect eyes: “Brown eyes, white sclera, no discharge nor abnormalities, patient uses corrective lenses”
2. Test pupillary reaction, to light accommodation, and visual fields: “PERRLA, peripheral vision intact bilaterally”
3. Inspect external nose and check patency of nares: “Breathe in/out of each nostril. Nares patent bilaterally. No drainage”
4. Occlude each nostril and ask client to smell (coffee, mint, etc). “Cranial Nerve I intact bilaterally”
5. Inspect lips, gums, buccal mucosa and teeth: “Lips and gums are pink, moist and intact. Teeth are white, straight, evenly spaced and free of decay”.
6. Inspect hard and soft palate, uvula, tonsils and assess for gag reflex (CN X): “Hard and soft palate pink, moist and intact. “say ‘ahhhh’” CN IX intact, tonsils are present and 2+, “assess for gag reflex” CN X intact.
7. Inspect Ears: “Ear are pink, dry and intact; free of discharge, lesions and erythema. Patient denies using a hearing device”

Question 6

Neck 1. - 5.

Answer 6

1. Test ROM of neck (rotation, flexion, extension, lateral bend): “ROM intact”
2. Assess spinal curvature: “There is no abnormal spinal curvature”.
3. Palpate Trachea and thyroid gland: “Trachea is midline. Unable to palpate thyroid, no nodules noted”.
4. Palpate and auscultate carotid arteries: “+2 elastic, no bruit or thrills bilaterally
5. Test shoulder shrug and ability to turn head against resistance (CN XI): “Cranial nerve XI Intact”

Question 7

Anterior and Posterior Chest 1. - 4.

Answer 7

1. Inspect chest (note quality and pattern of respirations): “Rise and fall symmetric bilaterally, RR 16 even, non-labored”
2. Assess chest expansion posteriorly: “Chest expansion is equal bilaterally posteriorly”
3. Auscultate lung sounds anteriorly and posteriorly: “Listening for 10 sec in each area. Breath sounds clear, no adventitious breath sounds noted”.
4. “Auscultating heart sounds w/ diaphragm (15 seconds at each site - Aortic, Pulmonic, Erbs point, Tricuspid, and Apex and state return using bell: HR 62 bpm, and regular. S1 S2, no abnormal heart sounds”

Question 8

Abdominal 1. - 5.

Answer 8

1. Supine position , cover chest with gown and expose abdomen
2. Inspect abdomen: “Abdomen is flat and symmetrical, umbilicus is midline, no scars, lesions or distention”
3. Auscultate all 4 quadrants: “Normoactive x4”
4. Percuss all 4 quadrants: “Tympanny x4”
5. Palpate all 4 quadrants light, and deep: “No tenderness, masses, organomegaly or distention noted x4 quadrants”

Question 9

Skin 1. - 3.

Answer 9

1. Assess skin for color, temp, turgor, and lesions: “Skin is warm, dry and intact, no tenting. Color appropriate for ethnicity. No lesions”
2. Inspect high risk areas for pressure ulcers: “No skin breakdown at bony prominances bilaterally”.
3. Assess for edema on lower extremities: “no edema noted”

Question 10

Upper and Lower extremities 1. - 10.

Answer 10

1. Palpate muscles of upper and lower extremities: “muscle bulk is equal bilaterally in upper/lower extremities.
2. Palpate radial and dorsalis pedis pulses bilaterally: “Peripheral pulses equal bilaterally 2+”
3. Test for capillary refill in fingers and toes: “Cap refill is less than 3 sec”
4. Test ROM and strength for upper extremities (squeeze fingers): “5/5 strength bilaterally with full ROM.
5. Test alternating hands: “Alternating hand movement is intact bilaterally”
6. Palpate knees and ankles: “No swelling, crepitus, nor deformities”
7. Test ROM and strength of knees and ankles: “5/5 strength bilaterally with full ROM.”
8. Heel to Shin Test: “Smooth and even movement bilaterally”

Question 11

Neurological 1. - 4.

Answer 11

1. Assess gait: “Steady and even w/o use of assistive devices”
2. Assess tandem walk: “Balanced and steady”
3. Perform Romberg: “Romberg negative”
4. Perform finger to nose: “Accurate and smooth movement”

Question 12

Disengagement 1. - 4.

Answer 12

1. Informs client assessment is complete.
2. Ask if there are any questions or needs.
3. dispose of PPE
4. Hand hygiene