Physical Assessment/Head to Toe Flashcards
Step 1
perform hand hygiene
Step 2
introduce myself to the patient and identify the patient.
Step 3
state my purpose, “today I am going to be doing a physical assessment.” and Ensure the patient’s privacy by securing a screen to cover them.
Step 4:
assess the patient’s general physical appearance and hygiene.
“my patient is sitting up straight, they look clean and put together”
Step 5:
assess the patient’s consciousness and mental status
“do you know what month we’re in?” “do you know what day it is?”
Step 6:
assess my patient’s pain status
“Are you in any pain?”
if they say yes, “on a scale from 1 to 10, 1 being the weak and 10 being strong, what is your pain?”
Step 7:
check IV lines-IV site, tubing dates, IV solutions, IV infusion rates, etc
Step 8:
inspects head and face for color, and symmetry. lesions, and distribution of facial hair. Note facial expressions. Note drainage or discharge from orifices.
Step 9:
inspects external eye structures (eyelids, eyelashes. eyeball, and eyebrows, and cornea, conjuntiva and sclera. Note color, edema, symmetry, alignment. Ask my patient about their vision, do they use glasses.
Step 10:
examines the pupils for quality of size, shape, and reaction to light by darkening the room. Shine a light on the eyes. The pupil should constrict in the light and return to normal size.
Step 11:
Tests for pupillary accommodation & convergence as patient focuses on an object brought close to the nose
Step 12:
Inspects the external nose, checks for patency, any drainage, and notes any abnormalities
Step 13:
Inspects the lips, oral mucosa & tongue using a penlight.
Step 14:
Inspects the neck for jugular vein distention (HOB at 30-45 °).
Step 15:
Inspects & palpates the trachea, assess if is midline
Step 16:
Assesses ROM of head & neck by asking patient to touch chin to chest & to each shoulder, & then tip head back as far as possible. Note any pain or limitations.
Step 17:
Inspects anterior and posterior thorax. Assesses skin color, symmetry, use of accessory muscles during respirations.
Step 18:
Palpate for temperature, tenderness, and masses using the palmer surface of the hand.
Step 19:
Auscultates the lungs both anterior and posterior thorax from apex to bases as the patient breathes slowly and deeply through the mouth (avoids breast tissue anteriorly & scapula posteriorly).
Step 20:
Positions the patient supine position with the HOB elevated 30 to 45 degrees.
Step 21:
Inspects the anterior chest for pulsations and heaves.
Step 22:
Land-marks to locate the apical pulse at the 4th to 5th intercostal spaces and left mid-clavicular region. Identifies locations to best auscultate S1 and S2
Step 23:
Palpate the apical impulse at the mitral area.
Step 24:
Counts apical pulse for 1 minute and notes rate and rhythm