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SUM '20 - Health Assessment > System Return 3 > Flashcards

System Return 3 Flashcards

1
Q

Initial

A
  1. Appearance, dress, and behavior
  2. Orientation to time, place, and person
  3. Recent and remote memory
  4. Speech
  5. Gait. Posture getting in/out of chair or on the table
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2
Q

Appearance, dress and behavior

A
  1. Note appearance, dress, and patient behavior as they enter exam room.
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3
Q

Orientation to time place and person

A
  1. Ask patient to state name.
  2. Ask person to state the date.
  3. Ask person to state the place.
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4
Q

Recent and remote memory

A
  1. Recent memory: Ask what patient ate for breakfast.

2. Remote memory: Ask date of birth.

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5
Q

Speech

A
  1. Observed when patient answered previous questions.
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6
Q

Gait. Posture, getting in/out of chair or on the table

A
  1. Observe patient walking into room.
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7
Q

Back and Extremities

A
  1. Neck ROM-CN XI
  2. Shoulder ROM-CN XI
  3. Wrist ROM and grip
  4. Hip ROM
  5. Spine ROM and level of Iliac crests
  6. Romberg tests
  7. One fine motor test
  8. One gross motor coordination
  9. Assess radial pulses
  10. Assess brachial pulses
  11. Palpate tenderness of hands and fingers
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8
Q

Neck ROM - CN XI

A
  1. Test accessory nerve.
  2. Place hand on side of face and have patient move neck against your hand.
  3. Repeat on the opposite side.

Neck ROM

  1. Tuck chin to chest (Flexion).
  2. Look upwards to ceiling (Extension).
  3. Rotate to right and left (Cervical rotation).
  4. Place ear on shoulder (Lateral bending).
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9
Q

Shoulder ROM - CN XI

A
  1. Place hands on top of shoulders and have patient shrug shoulders against your hands.

Shoulder ROM:

  1. Shoulder flexion (raise arms above head).
  2. Shoulder extension (bring arm behind body).
  3. Abduction: arm out to side.
  4. Adduction: cross arm in front of body like you are stretching.
  5. Internal Rotation: ask patient to scratch back of neck.
  6. External Rotation: ask patient to reach back and scratch opposite scappula.
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10
Q

Wrist ROM and grip

A
  1. Place arms out with palms down.
  2. Extend (raise to ceiling).
  3. Flexion (pull wrist down).
  4. Abduction (away from body).
  5. Adduction (towards body).
  6. Wrist grip: Ask patient to squeeze fingers.

INSERT IMAGE

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11
Q

Hip ROM

A
  1. Have patient lie down.
  2. Bring each leg up (flexion).
  3. Lie on stomach and lift leg to sky (extension).
  4. Place patient on side.
  5. Abduct up away from body.
  6. Adduct leg.
  7. Place patient back on back.
  8. Flex knee to check internal rotation.
  9. Move leg in towards body (adduction).
  10. Move leg outward (abduction).

INSERT IMAGE

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12
Q

Spine ROM and Level of Iliac Crests

A
  1. Forward flexion to try to touch toes. NOte allignment of spine.
  2. While patient is still bent over, place hands on iliac crests to make sure they are even (this is to check for even limb length).
  3. Bend backwards slightly.
  4. Twist to each side.
  5. Lateral bending.
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13
Q

One fine motor test

A
  1. Find motor test: Have patient grab something.
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14
Q

One gross motor coordination

A
  1. Gross motor test: Heel to toe walking
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15
Q

Assess Radial pulses

A
  1. Palpate radial pulse bilaterally.
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16
Q

Assess brachial pulses

A
  1. Palpate brachial pulse bilaterally.
17
Q

Palpate tenderness of hands and fingers

A
  1. Palpate fingers and joints. Could indicate arthritis if they experience tenderness.
18
Q

Skin and Nails

A
  1. Personal hygiene
  2. Skin color, temperature, turgor, moisture
  3. Lesions, masses, edema, pigmentation
  4. Color of nail beds, shape and contour
  5. Assess capillary refill
19
Q

Personal Hygiene

A

Hopefully, the patient showered

20
Q

Skin Color, Temperature, Turgor, Moisture

A
  1. Skin warm and dry.
21
Q

Lesions, Masses, Edema, Pigmentation

A
  1. Observe for any noticeable masses or edema.
22
Q

Color of Nail-Beds, Shape, and Contour

A
  1. Look at nail-beds to ensure they are pink in coloring. No clubbing.
23
Q

Assess Capillary Refill

A
  1. Should be less than 3 seconds.
24
Q

Deep Tendon Reflexes

A
  1. Biceps
  2. Triceps
  3. Brachiordialis
  4. Knee
  5. Ankle
25
Q

Biceps

A
  1. Place thumb in bend of elbow.
  2. Strike thumb.

INSERT IMAGE

26
Q

Triceps

A
  1. Lift arm up and have patient relax arm.
  2. Strike behind the elbow.

INSERT IMAGE

27
Q

Brachioradialis

A
  1. Relax arm.
  2. Place thumb on arm and strike with hammer.

INSERT IMAGE

28
Q

Knee

A
  1. Strike right below patella.
29
Q

Ankle

A
  1. Aim hammer so that it hits Achilles.
  2. Strike on outside part of ankle.

INSERT IMAGE

SUM '20 - Health Assessment (17 decks)

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