HEAD TO TOE Flashcards
FIRST
OVERVIEW
- gather supplies
- protect privacy
- introduce yourself
- id patient
second
overview
determine orientation
fall risk band?
ask about fall
fourth-head/eyes/mouth
overview
inspect head
check pupils reaction to light (d and c)
check pupil accomodation
inspect mouth with penlight
third- vitals
pain
bp
temp
pulse
rr
fifth- heart
overview
auscultate
“all people eat too much”
with diaphragm then with bell
sixth-lungs
overview
auscultate
posterior, axillary, anterior
side to side comparison
full respiration at each location
7th- neck/chest
overview
assess skin turgor unde clavicles
8th- upper extremeties
overview
test hand strength bilaterally
check capillary refill
color
temp
palpate radial pulses bilaterally
9th- abdomen
overview
inspect shape
auscultate four quadrants for bowel sounds
palpage lightly
last bowel movement? normal?
10th- urinary
overview
ask about urination. normal?
11th- lower extremeties
overview
inspect/palpate legs and feet
capillary refill
palpate dorsalid pedis and posterior tibial bilaterally
test foot strength bilaterally
supplies for head to toe
stethoscope
penlight
gloves
bp cuff
thermometer
watch w/ second hand
etc
general principles to remember
shift assessment
ntroduce yourself, identify patient (2 identifiers),make sure you have supplies (gloves,stethoscope, pen light, etc.), hand hygiene,provide privacy
physiologic parameters
shift assessment
vs
pain
general appearance
shift assessment
Hygiene/grooming, positioning, comfort
neuro/musculoskeletal
shift assessment
LOC, orientation, PERRLA,ROM/strength/sensation (BUE/BLE)
heent
shift assessment
Inspect head shape, symmetry of facial features,mucous membranes
respiratory
shift assessment
Work of breathing/effort, rate, rhythm,auscultate lung sounds, check for clubbing
cardiac
shift assessment
Auscultate heart sounds, check for murmurs, lifts,thrills. Check cap refill and skin temp. Bilateralradial and bilateral pedal pulses. Inspect forperipheral edema
gi
shift assessment
Inspect abdomen, auscultate bowel sounds,palpate for tenderness, ask about last BM anddiet
gu
shift assessment
Inspect (or ask) about urine color, characteristics,burning, hesitancy, pain, etc
skin
shift assessment
inspect color, wounds, lesions, skin turgor,palpate temperature
other
shift assessment
check IV sites, wounds, drains, tubes,environment, etc
organizing the shift assessment part 1
- Physiologic parameters and general appearance
- LOC, orientation, PERRLA
- HEENT inspection
- Auscultate heart, lung, and bowel sounds
- Inspect for work of breathing, respiratory rate/rhythm, inspect chest for heaves/lift
organizing the shift assessment part 2
- Palpate for any thrill in the chest, palpate abdomen for pain/tenderness (ask for last BM,diet, urine)
- Assess upper extremities (bilateral radial pulses, skin condition, turgor, cap refill, clubbing,edema, ROM/strength, and sensation)
- Assess lower extremities (bilateral pedal pulses, skin condition, turgor, cap refill, clubbing,edema, ROM/strength, and sensation)
- Assess any other areas of the skin, looking at color, temperature, wounds, lesions, etc.
- Check environment for safety, assess lines/drains/tubes, etc
physiologic parameters
normals of physical assessment
vs including pain
general appearance
normals of physical assessment
Clean appearing, resting comfortably in bed watching TV, NAD
neurological
normals of physical assessment
A&O x3 (or x4), PERRLA intact, sensation intact x4
musculoskeletal
normals of physical assessment
full rom x4
strength intact
heent
normals of a physical assessment
normocephalic, facial features symmetrical, mucous membranes pink and moist, no irritation ordrainage present, denies any problems
respiratory
normals of a physical assessment
Respiratory: respirations even and unlabored, Lungs CTA bil., O2 sat 98% RA, no clubbing present
cardiovascular
normals of physical assessment
normal S1&S2, no murmurs, lifts, or thrills, cap refill <2secs, radial and pedal pulses 2+,skin warm to touch, no peripheral edema
gi
normals of physical assessment
active bowel sounds x4, abdomen soft, non-tender, non-distended, denies any pain, last bm wasyesterday (was soft and easy to pass), consuming 75% of meals, on regular diet
gu
normals of physical assessment
GU: voiding clear yellow urine, denies any burning, hesitancy, or pain with urination
skin
normals of physical assessment
Skin: warm, color normal for ethnicity, no abrasions or wounds, no tenting
other
normals of physical assessment
Other: IV sites, equipment, anything that you feel like did not fit in one of the other categories
inspect
THORAX & LUNG Physical AssessmentCheck-off
thoracic cage symmetry
Respirations (rate, rhythm, depth, effort)
Accessory muscle useSkin color & condition
Person’s position (COPD tripod ?)
Facial expression
Level of consciousness
Transverse diameter versus anterior/posteriordiameter ratio
palpate
THORAX & LUNG Physical AssessmentCheck-off
Symmetric expansion
Tactile fremitus
Lumps, masses, tenderness, crepitus
percuss
THORAX & LUNG Physical AssessmentCheck-off
percuss over lung fields
auscultate
THORAX & LUNG Physical AssessmentCheck-off
Assess anterior and posterior chest fornormal breath sounds
Note any abnormal/adventitious breathsounds
neck
HEART & NECK VESSELS Physical Assessment Check-off
blood Vessels
Inspect & palpate carotid pulse
JVD (jugular vein distention) present
precordium
HEART & NECK VESSELS Physical Assessment Check-off
Inspect & palpate apical pulse (note location)
Inspect & palpate any heave (lift) or thrill
auscultate
HEART & NECK VESSELS Physical Assessment Check-off
Identify anatomic areas for heart sounds
Note rate & rhythm of heartbeat
Identify S1 & S2, note any variation
Listen for any extra heart sounds in S1 & S2
Listen for any murmurs in S1 & S2
Repeat sequence with bell
Listen at apex with pt. in left lateral position
Listen at the base with pt. in sitting position
carotid arteries for bruits
upper extremities
PERIPHERAL VASCULAR SYSTEM &LYMPHATICS Physical Assessment Check-off
Inspect & palpate the arms for:
Symmetry
Color
any lesions
Temperature
texture
turgor
Capillary refill
Nailbeds
upper extremities
part 2
PERIPHERAL VASCULAR SYSTEM &LYMPHATICS Physical Assessment Check-off
Pulses:
Radial
Ulner
Brachial
Epitrochlear lymph node
Modified Allen test
Dialysis Access? Patent?
lower extremities part 1
PERIPHERAL VASCULAR SYSTEM &LYMPHATICS Physical Assessment Check-off
Inspect & palpate the legs for:
Symmetry
Color
Temperature
Size
swelling or atrophy
Lesions/ulcers
Hair distribution
Varicose veins
lower extremities part 2
PERIPHERAL VASCULAR SYSTEM &LYMPHATICS Physical Assessment Check-off
Pulses:
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Inguinal lymph nodes
Pretibial edema
inspection
abdomen physical assessment check off
Contour
Symmetry
Umbilicus
Skin characteristics
Pulsations or movement
Person’s demeanor
ausculatation and percussion
absomen physical assessment check off
bowel sounds
gastric tympany (bell all 4 quadrants
costovertebral angle tenderness
palpation
absomen physical assessment check off
Light palpation in all fourquadrants
Deep palpation in all fourquadrants
Rebound Tenderness
inspect/palpate the skull
HEAD & NECK Physical Assessment Check-off
scalp
hair
size/shape/symmetry
temporal artery
tmj area
inspect the face
HEAD & NECK Physical Assessment Check-off
Facial expression
Eye contact
Symmetry of movement (CN VII)
Involuntary movements
Edema or lesions
inspect/palpate the neck
HEAD & NECK Physical Assessment Check-off
Symmetry
Skin
Thyroid
Lymph nodes
auscultate the theyroid (if enlarged for bruits)
ROM
lymph nodes to inspect/palpate
HEAD & NECK Physical Assessment Check-off
Pre-auricular
Post auricular
Occipital
Superficial cervical
Jugulodigastric (Tonsillar)
Submandibular
Submental
Posterior cervical
Supraclavicular
Deep cervical chain
eyes Physical Assessment Check-off
Test visual acuity:
Snellen chart
Near vision if age 40 & older, if reading difficulty
Test visual fields:
Confrontation test
Inspect extraocular muscle function:
Corneal light reflex (Hirschberg test)
Cover test
Diagnostic position test (6 cardinal positions)
Inspect external ocular structures:
eyes Physical Assessment Check-off
General symmetry
Eyebrows
Eyelids & lashes
Eyeball alignment
Conjunctiva & sclera
Lacrimal apparatus
Inspect anterior eyeball structures:
eyes Physical Assessment Check-off
Cornea & lens
Iris & pupil:
Size, shape, equality
Pupillary light reflex
Accommodation
Inspect the ocular fundi (with opthalmoscope):
eyes Physical Assessment Check-off
Red reflex
Optic disc (color, shape, margins)
Retinal vessels
Macula
inspect external ear
EAR Physical Assessment Check-off
Size & shape of auricle
Position & alignment on head
Skin condition (color, lumps, lesions)
External meatus for size, swelling, redness, discharge, cerumen, lesions, foreign bodies
Palpate auricle & tragus for tenderness
Otoscopic exam: inspect
EAR Physical Assessment Check-off
External canal (color, redness, discharge, swelling, lesions, foreign object)
Tympanic membrane:
Color & characteristics
Position (flat, bulging, or retracted)
Integrity of membrane
Cone of Light (presence & direction)
Test for hearing:
EAR Physical Assessment Check-off
Note response to conversational speech
Voice test
Weber test
Rinne test
nose
NOSE/MOUTH/THROAT PhysicalAssessment Check-off
Inspect: external nose for symmetry, deformity, lesions
Palpate: test for patency of each nostril
Using nasal speculum, inspect:
Nasal mucosa: color & integrity
Septum: any deviation, perforation, bleeding
Turbinates: color, swelling, exudates, polypsP
alpate the sinuses (frontal & maxillary) for tenderness
mouth and throat
NOSE/MOUTH/THROAT PhysicalAssessment Check-off
inspect (using a penlight) for color, integrity of structures, any lesions:
Lips
Teeth
Gums
Tongue
Buccal mucosa
Palate & uvula: integrity & mobility
Tonsils: Grade
Pharyngeal wall
Motor System
Musculoskeletal SYSTEM Physical ExamCheck-off
Muscles: Size, strength, tone
Any involuntary movements
Cerebellar function (Balance):
Gait
Tandem walking
Romberg test
Shallow knee bend or hop in place
motor system part 2
Musculoskeletal SYSTEM Physical ExamCheck-off
Cerebellar function (Coordination):
Rapid alternating movements(RAM)
Finger-to-thumb test
Finger-to-finger test
Finger-to-nose test
Heel-to-shin test
sensory system
Musculoskeletal SYSTEM Physical ExamCheck-off
Spinothalamic tract:
Pain (sharp vs. dull)
Temperature
Light touch
sensory system part 2
Musculoskeletal SYSTEM Physical ExamCheck-off
Posterior tract:
Vibration
Position (kinesthesia)
Tactile discrimination:
Stereognosis
Graphesthesia
Distinction
Point location
reflexes
Musculoskeletal SYSTEM Physical ExamCheck-off
Deep Tendon
Biceps
Triceps
Brachioradialis
Patella
Achilles
Superficial
Plantar
CN I AND CN 2
NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off
CN I Olfactory: Smell (each nare at a time)
CN II Optic:
Visual acuity (distant & near vision)
Visual fields by confrontation
Ophthalmoscopic exam of fundI
CN III AND CN IV
NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off
CN III Oculomotor:
EOM by six cardinal positions
Raise eyebrows & eyelids symmetrically
Pupillary size, direct & consensual response to light & accommodation
CN IV Trochlear:
Eye movement down & inward
CN V AND CN VI
NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off
CN V Trigeminal:
Assess muscle movement & strength with clenching of teeth
Superficial touch – three divisions
Corneal reflex
CN VI Abducens:
Lateral movement of eye
CN VII AND CN VIII
NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off
CN VII Facial:
Symmetry of facial features with expressions (smile, frown, puffed cheeks, wrinkled forehead, squint eyes tightly)
Identify sweet & salty tastes on each side of tongue
CN VIII Acoustic:
Whisper test
Weber test
Rinne test
CN IX AND CN X
NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off
CN IX Glossopharyngeal :
Gag reflex
CN X Vagus:
Phonates “ahh”
Gag reflex
Note swallowing
Note voice quality
CN XI AND CN XII
NEUROLOGICAL: CRANIAL NERVES PhysicalAssessment Check-off
CN XI Spinal accessory:
Turn head against resistance
Shrug shoulders against resistance
CN XII Hypoglossal:
Protrude tongue
Wiggle tongue from side to side
Say “light, tight, dynamite” (evaluate quality of sounds l,t,d,n)
