H2T Flashcards
Proper order
Critical Elements
General appearance/mental status
HEENT
Respiratory
Cardiovascular
GI
GU
Musculoskeletal
Neuro
Integumentary
Completion
Critical elements
Gather equipment, wash hands, apply gloves
Identify client, introduce self, explain exam
Provide privacy and ensure environmental safety
General appearance/mental status
Physical appearance (signs of distress)
Body structure (nourishment)
Mobility (ease of movement)
Behavior (mood or affect)
HEENT
2 questions (headaches and nodules on throat)
Head is normocephalic and the neck is an appropriate size and shape
Eyes are aligned normally and are within their sockets
Ears are of equal size bilaterally with no swelling or thickening
Nose is symetric, along the midline, and proportional
Use tongue blade to assess mouth - say ah- uvula should rise and tonsils should go in. Poke the back and make sure they can feel it (9 and 10)
Have them stick out tongue for cranial nerve XII
Clench teeth and palpate masseter muscle ( 5)
Have them frown, smile, puff cheeks, purse lips, and lift eyebrows (7)
Pupils are equal, round, reactive to light (direct and consensually) and parallely follow finger as it moves clockwise (3,4,6)
Whisper test (8)
Shrug shoulders (11)
Respiratory
2 questions (persistent cough and do you smoke)
Ant/Post inspection - spinous processes are medially aligned, thorax is elliptical, and symmetric with downward sloping ribs. Costal angle is within 90 degrees
Nail beds are appropriate color for skin tone. Skin is not cyanotic
No use of accessory muscles while breathing - breathing is non strenuous without wheezing or crackles
Percuss 9 places on the back and state that it is resonant
Auscultate 8 on back (2nd is BV), and 6 on front (B, B, BV, BV, V, V)
Cardio
2 questions: chest pain and fam hist of CAD
Inspect precordium - symetric. No indication of injury. no heave or lift
Assess apical pulse and palpate - left lateral position
Auscultate: Aortic valve in 2R IC, Pulmonic valve in 2L IC, Tricuspid 5L IC, Mitral 5L mid clav (S2 A/P; S1 T/M) use bell and diaphragm - note rate and rhythm
Assess for thrill
Capillary refill: appropriate color - no evidence on cyanosis, warm temperature, no edema –> refill takes about 2 s which is normal
Palpate carotid, radial, brachial, popliteal, dorsalis pedis, and posterior tibialis. 2+ pulse
GI assessment
2 questions: any constipation? Any diarrhea?
Abdomen is flat, symmetric, and warm. There are scars just around the belly button
Auscultate 4 regions - count # of bowel sounds –> should be 5-30 per min
Percuss –> general tympany
Palpate –> warm, no masses, light pulsations from abdominal aorta, (any pain?) no tenderness. No rigidity or muscle guarding
GU
2 questions: any trouble producing a stream? Any discomfort/burning when you urinate?
The area is an appropriate color for the skin tone. There is no foley to inspect
Palpate for distension –> bladder is not distended
Musculoskeletal
2 questions: any joint pain? any muscle cramping?
Inspect knees, elbows, wrists, ankles for swelling, redness, deformities
2 motions for neck, shoulders, elbows, hips, knees
Assess strength of elbows and knees –> grade 5 for full strength
Neuro exam
2 questions: any headaches? any history of seizures?
Rapid Alternating movement: equal turning and quick rhythmic pace
Finger to nose test: coordination is normal
Gait assessment: smooth, rhythmic, effortless
Romberg test: minimal swaying
Integumentary
2 questions: any change in skin pigmentation? any excessive dryness?
Throughout the exam the skin has been dry, warm, even toned, and an appropriate color for the patient’s skin tone
Completion
I will cover and reposition the patient
I will lower the bed and place the call light and personal items within reach
I will open the privacy curtain
I will wash my hands and stethoscope
I will record my findings
