1014 lab exam study guide

skin, hair and nails health history questions

• Previous history of skin disease (allergies, hives, eczema)?

• Change in pigmentation - any change in skin color or pigmentation?

• Any change in the feel of your skin - temperature, moisture, or texture?

skin assessment (9)

1. Observe general pigmentation 

2. Observe temperature of skin using backs of hands to palpate the person, and check bilaterally. 

3. Check for moisture on face, hands, skin, and axilla. 

4. Check texture of skin. 

5. Check thickness of skin. 

6. Check for edema by imprinting thumbs firmly against ankle or tibia - use edema grading scale. 

7. Check mobility and turgor by pinching a large fold of skin on the anterior aspect of the chest under the clavicle. 

8. Check for vascularity or bruising. 

9. Check for lesions - palpate any visible lesions.

hair assessment

1. color

2. texture

3. distribution

4. lesions (make sure to palpate)

nails assessment (4)

1. Check nail shape and contour. 

2. Check nail consistency. 

3. Check nail color. 

4. Check capillary refill.

head and neck health history questions

1. Have you had any unusually frequent or severe headaches?

   1. Onset, Location, Character

2. Any head injury or blow to the head?

3. Experienced any dizziness?

head assessment (2)

1. Inspect and palpate the skull

   1. Size and shape

   2. Palpate temporal artery

2. Inspect the face

   1. Facial structures

   2. Edema

   3. Masses or lesions

   4. Color and texture of skin

neck assessment (6)

1. Inspect and palpate the neck

   1. Symmetry

   2. Note any obvious pulsations (ex. Carotid artery)

2. Range of motion for neck (6)

   1. Ask patient to touch chin to the chest, turn head to right and left, try to touch each ear to the shoulder, and extend the neck backward

3. Palpate lymph nodes (10)

4. Palpate trachea

5. Palpate thyroid gland

6. Auscultate thyroid gland

nose, mouth and throat health history questions

1. Any nasal discharge or runny nose?

2. Any sinus pain or sinusitis?

3. Any nosebleeds? How often?

4. Any sore throat?

5. Any difficulty swallowing?

nose assessment

1. Inspect and palpate the nose

   1. Symmetry

   2. Deformity, asymmetry, inflammation

   3. Test patency of each nostril - push each nostril shut with finger while asking the person o sniff inward

2. Inspect nasal cavity

   1. Insert speculum into nostril, gently lifting up the top of the nose with finger before inserting

   2. View each nostril with patient’s head tilted back, inspecting the nasal mucosa

   3. Note color of nasal mucosa, discharge, septum deviation

   4. Inspect turbinates

3. palpate sinus area

   1. frontal (below eyebrows)

   2. maxillary (cheekbone)

mouth assessment

1. Lips

   1. color, moisture, cracking, and lesions

   2. Retract lips and notice inner surface

2. Teeth and gums

   1. Note anything abnormal

   2. Ask patient to bite down and note alignment

   3. Check color of gums

3. Tongue

   1. Check tongue for color, surface characteristics, and moisture

   2. Ask patient to touch tongue to roof of the mouth

4. buccal mucosa (inside of cheek)

5. Palate 

   1. Observe uvula, ask patient to say “ahhhh” and note the soft palate and uvula rise

   2. Notice any breath odor

throat assessment

using penlight and tongue depressor:

1. tonsils (grade 1-4+)

2. posterior wall

3. gag reflex

4. tongue protrusion

eyes health history questions

1. Any vision difficulty (blurring, blind spots)?

2. Any eye pain?

3. Any redness or swelling? 

   1. One eye or both? Gradual or sudden?

eye assessment: vision

1. Snellen eye chart

   1. Have patient cover one eye at a time

   2. Shorten distance until patient can see clearly

2. Handheld vision screener for near vision

   1. For those who report increasing difficulty reading

3. Confrontation test

   1. Direct patient to cover one eye and look straight in your ryes

   2. Cover your own eye opposite to the patient’s covered one

   3. Hold flicking finger and slowly advance it from perpiphery in multiple directions

   4. Ask patient to say “now” when they see the finger

4. Corneal light reflex

   1. Shine a light toward the patient’s eyes, as them to stare straight ahead

   2. Note the reflection of the light on the cornea

5. Cover-uncover test

   1. Cover one eye (normal response is steady gaze with other eye)

   2. Uncover then repeat

6. Diagnostic positions test

   1. Ask patient to hold head steady and follow movement of your finger as you move it around

eye assessment: inspection

1. Inspect external ocular structures

   1. Facial expression

   2. Eyebrows - symmetrical movement

   3. Eyelids and lashes

   4. Eyeballs

   5. Conjunctiva and sclera

   6. eversion of upper eyelid (state)

   7. Lacrimal apparatus

2. Inspect anterior eyeball structures

   1. Cornea and lens

   2. Iris and pupil

      1. Pupillary light reflex

      2. accommodation

3. Inspect ocular fundus

   1. Optic disc

   2. Vessels

   3. Background of fundus

   4. Macula 

   5. red reflex

ear health history questions

1. Any earache or other pain in ears?

2. Any infections?

3. Any discharge?

4. Any hearing loss?

ear assessment

1. Inspect and palpate external ear

   1. Size and shape

   2. Skin condition

   3. Tenderness

      1. Move pinna and push on tragus - should feel firm, no pain with movement

   4. External auditory meatus

      1. Look with otoscope

2. Inspect using otoscope

   1. External canal

      1. Hold otoscope upside down and have back of hand along patient’s cheek

      2. redness or swelling

      3. lesions

      4. foreign bodies

      5. discharge

   2. Tympanic membrane

      1. Color and characteristics

      2. Position

      3. Integrity of membrane

3. Test hearing acuity

   1. Whispered voice test

      1. Stand 2 feet behind person, test one ear at a time while masking hearing in the other ear - place one finger on tragus and push in and out of the auditory meatus

      2. Whisper a set of words and ask them to repeat it

      3. Repeat on other side

   2. Romberg test

      1. Ask patient to stand with eyes closed and feet together

heart and neck health history questions

1. Any chest pain or tightness?

2. Any shortness of breath?

3. Any swelling of feet and legs (edema)?

heart and neck vessels assessment

1. Auscultate carotid artery (3 points)

   1. use bell to auscultate - check for bruits

2. Palpate carotid artery

   1. Only one artery at a time - contour and amplitude

3. Inspect jugular venous pulse

   1. Position patient supine at 30-45 degree angle

4. Precordium

   1. Inspect anterior chest - skin color and condition, chest wall pulsations, heaves and lifts, apical impulse

   2. Palpate apical impulse (using one finger pad)

   3. Palpate across precordium - use palmar aspect of four fingers

      1. over apex

      2. left sternal border

      3. base

5. Auscultation (use diaphragm) and verbalize main auscultation areas

   1. Second right interspace: aortic valve area

   2. Second left interspace: pulmonic valve area

   3. Fifth intercostal space at left lower sternal border: tricuspid valve area

   4. Fifth interspace at around left midclavicular line: mitral valve area

   5. Identify S1 and S2

      1. state S1 louder at apex and S2 louder at base

6. assess heart rate and rhythm

7. listen for murmurs or extra heart sounds (use bell)

8. verbalize purpose of changing client’s position for auscultation

peripheral vascular system health history questions

1. Any leg pain or cramps?

2. Any skin changes in arms or legs?

3. Any swelling in arms or legs?

peripheral vascular system arms assessment

1. Inspect and palpate both sides of hands for color, temperature, texture, skin turgor, lesions, edema

2. Assess profile sign and capillary refill of nails

3. Inspect arms for symmetry and scars

4. Locate and palpate the radial pulse bilaterally noting rate, rhythm, elasticity and force (fourpoint scale)

5. Locate and palpate the brachial pulse bilaterally noting rate, rhythm, elasticity and force (fourpoint scale)

6. Assess epitrochlear lymph node by “shaking hands” and palpating groove between biceps and triceps muscles

peripheral vascular system legs assessment

1. Inspect legs for color, hair distribution, venous pattern, size, lesions, ulcers

2. State would measure calf circumference if asymmetrical in size

3. Palpate along legs down to feet for temperature bilaterally

4. Flex knee and compress calf muscle against tibia to assess for tenderness

5. State would palpate inguinal lymph nodes

6. Locate and palpate the following pulses bilaterally noting the force (four-point scale):

   1. femoral (may state)

   2. popliteal

   3. posterior tibial

   4. dorsalis pedis

7. Assess for pretibial edema and state would grade on scale (1+ to 4+) if pitting edema

8. Assess venous system in standing position for visible, dilated, varicose veins

9. With client lying, raise legs 30cm for 30 seconds and note color of feet (if arterial deficit suspected)

10. Ask client to sit with legs over side of bed, compare color of feet, length of time it takes for color to return to feet, and for superficial veins in feet to fill

11. State would test lower leg strength and sensation

respiratory system health history questions

1. Do you have a cough?

2. Have you ever had any shortness of breath?

3. Any chest pain with breathing?

respiratory system assessment: posterior chest

1. Inspect posterior chest

   1. Shape and configuration of chest wall

   2. AP diameter - state 2:1 ratio

   3. neck and trapezius muscles

   4. breathing position

   5. Assess skin color and condition

2. Palpate posterior chest

   1. Symmetrical chest expansion - place hands on posterolateral chest wall, slide hands up medially to pinch up a small fold of skin between thumbs

   2. Assess tactile/vocal fremitus - ask patient to say ninety-nine while placing base of hands on different locations

   3. Palpate the entire chest wall

      1. note tenderness, temperature, moisture, lumps or masses, lesions

3. Percuss posterior chest

   1. Lung fields (for resonance) 18 locations (9 per side)

4. Auscultate posterior chest 18 locations (9 per side)

respiratory system assessment: anterior chest

1. Inspect anterior chest

   1. Shape and configuration of chest wall

   2. Facial expression

   3. Level of consciousness

   4. Skin color and condition, clubbing

   5. Quality of respirations

   6. retractions or bulging

   7. accessory muscle use

   8. respiratory rate

2. Palpate anterior chest

   1. Symmetrical chest expansion - place hands under breasts and watch thumbs move apart

   2. tactile/vocal fremitus - palpate over lung apices (ask patient to say 99)

   3. Palpate anterior chest wall 

      1. Tenderness

      2. Superficial lumps or masses

      3. Skin mobility and turgor

      4. Skin temp and moisture

3. Percuss anterior chest

   1. 10 locations (5 per side)

4. Auscultate anterior chest

   1. diaphragm of stethoscope

   2. 10 locations (5 per side)

respiratory system assessment: lateral chest

1. inspection - state and demonstrate inspection

2. palpation - state and demonstrate

3. percussion - state and demonstrate

4. auscultation - state and demonstrate

musculoskeletal system health history questions

1. any problems with joints? any pain or stiffness of limitation of movement?

2. any problems with muscles, such as pain or cramping?

3. any bone pain? is the pain affected by movement?

musculoskeletal system assessment - upper half of body

1. Temporomandibular Joint

   1. Inspect

   2. Palpate

   3. ROM:

      1. Vertical Motion

      2. Lateral Motion

      3. Protrusion

   4. Strength

      1. Vertical Motion

      2. Lateral Motion

      3. Protrusion

2. Cervical Spine

   1. Inspect

   2. Palpate

      1. spinous processes

      2. sternomastoid

      3. trapezius

      4. paravertebral muscles

   3. ROM:

      1. Flexion/Extension

      2. Lateral Bending

      3. Rotation

   4. Strength:

      1. Flexion/Extension

      2. Lateral Bending

      3. Rotation

3. Shoulders

   1. Inspect

   2. Palpate

   3. ROM:

      1. Forward Flexion/Hyperextension

      2. Internal/External Rotation

      3. Abduction/Adduction

   4. Strength:

      1. Shoulder Shrug

      2. Forward Flexion

      3. Abduction

4. Elbows

   1. Inspect

   2. Palpate

   3. ROM:

      1. Flexion/Extension

      2. Pronation/Supination

   4. Strength:

      1. Flexion/Extension

5. Wrists and Hands

   1. Inspect

   2. Palpate

   3. ROM:

      1. Hyperextension/Palmar Flexion (Wrists)

      2. Hyperextension/Flexion (Fingers)

      3. Ulnar/Radial Deviation

      4. Abduction of Fingers/Tight Fist

      5. Touch Thumb to Each Finger

   4. Strength:

      1. Wrist flexion

musculoskeletal assessment: lower body

1. Hips

   1. Inspect

   2. Palpate

   3. ROM:

      1. Flexion

      2. Internal/external rotation

      3. Abduction/Adduction

      4. Hyperextension (while standing)

   4. No strength assessment

2. Knees

   1. Inspect

   2. Palpate

   3. ROM:

      1. Flexion/Extension

      2. Ambulation

   4. Strength:

      1. Flexion

      2. Sit to Stand

3. Ankles and Feet

   1. Inspect

   2. Palpate

   3. ROM:

      1. Plantar/Dorsiflexion

      2. Eversion/Inversion

      3. Flexion/Extension of Toes

   4. Strength:

      1. Plantar/dorsiflexion

4. Spine

   1. Inspect

   2. Palpate

   3. ROM:

      1. Lateral Bending

      2. Flexion/Extension

      3. Rotation

      4. Walking on Toes/Heels

   4. No strength assessment

cranial nerves health history questions

1. any headaches?

2. any head injury?

3. any dizziness or vertigo?

cranial nerves: assessment

1. Cranial Nerve I- Olfactory Nerve  

   1. Assess patency of nares  

   2. Test sense of smell 

      1. ex. coffee vs. cinnamon

2. Cranial Nerve II- Optic Nerve  

   1. Test visual acuity with Snellen eye chart and Rosenbaum index card (may state)

   2. Test visual fields by confrontation 

   3. State would examine fundus with ophthalmoscope 

3. Cranial Nerve III, IV, VI- Oculomotor, Trochlear, Abducens Nerves 

   1.  Inspect eyelids for drooping  

   2. Check PERRLA  

   3. Assess extraocular eye movements with cardinal positions of gaze (6 sides)

4. Cranial Nerve V- Trigeminal Nerve 

   1. Palpate jaw muscles for strength with teeth clenched  

   2. Apply resistance to chin  

   3. Test light touch sensation with cotton to forehead, cheeks, chin  

   4. State will assess corneal reflex

5. Cranial Nerve VII- Facial Nerve  

   1. Inspect facial mobility and symmetry with expressions (smile, frown, close eyes tightly- against resistance, lift eyebrows, show teeth, puff cheeks- press to assess equal air escape)  

   2. State would test the sense of taste with sweet, salty or sour. 

6. Cranial Nerve VIII- Acoustic (Vestibulocochlear)  

   1. Assess ability to hear normal conversation  

   2. Complete whispered voice test 

7. Cranial Nerve IX, X- Glossopharyngeal and Vagus Nerves 

   1.  Inspect palate & uvula with “ahhh” sound for symmetry  

   2. Assess gag reflex 

8. Cranial Nerve XI- Spinal Accessory Nerve 

   1.  Assess sternomastoid and trapezius muscles for size  

   2. Check strength against resistance- side of chin with head rotation and shoulders with shoulder shrug 

9. Cranial Nerve XII- Hypoglossal Nerve  

   1. Inspect tongue for wasting or tremors  

   2. Inspect tongue movement (patient sticks out tongue) 

   3. Note quality of lingual speech (sounds of letters l, t, d, n clear and distinct when states “light, tight, dynamite”

sensorimotor health history questions

1. any seizures?

2. any significant past history?

3. any weakness?

sensorimotor assessment

Motor System

1. Inspection and Palpation  

   1. Inspect and palpate muscle groups size, strength and tone (may state)  

      1. remember to do this bilaterally

   2. Assesses for involuntary movements 

2. Cerebellar Function  

   1. Balance Tests

      1. Inspect gait 

      2. Heel-to-toe walking (Tandem walking) 

      3. Romberg Test

      4. Shallow knee bend or Hopping  

   2. Coordination and Skilled Movements

      1. Rapid alternating movements

         1. pat knees with both hands, lift up and turn hands, and pat knees with back of hands (faster and faster)

         2. touch thumb to each finger as fast as possible

      2. Finger-to-finger test 

         1. ask patient to touch your finger then their nose

      3. Finger-to-nose test 

         1. patient closes eyes and touches their nose with each index finger, alternating hands and increasing speed

      4. Heel-to-shin test 

         1. patient in supine position, place heel on opposite knee, run it down the shin from the knee to the ankle

Sensory System 

1. Spinothalamic Tract  

   1. Pain  

      1. sharp vs. dull with tongue blade

   2. Temperature  

   3. Light touch 

      1. cotton ball

2. Posterior Column Tract  

   1. Vibration  

      1. tuning fork, ask patient to say when vibration starts and stops

   2. Position (Kinaesthesia)  

      1. move a finger or big toe up and down and ask them which direction it moved

   3. Tactile Discrimination (Fine Touch) 

      1. Stereognosis 

         1. ability to recognize objects by feeling them with their eyes closed

      2. Graphesthesia 

         1. ability to read a number by having it written on the skin

      3. Two-point discrimination 

         1. ability to distinguish between two separate pinpricks on skin

      4. Extinction 

         1. touch both sides of the body at the same point, ask how many are felt and where

      5. Point Location 

         1. touch skin and ask patient to touch where you touched them

3. Reflexes  

   1. Assess deep tendon reflexes and rates on scale (0-4+): 

      1. Biceps Reflex 

      2. Triceps Reflex 

      3. Brachioradialis Reflex 

      4. Quadriceps or patellar Reflex 

      5. Achilles Reflex 

      6. Clonus

   2. Assess superficial reflexes and rates on scale (0-4+): 

      1. Abdominal Reflex 

      2. Cremasteric Reflex (if appropriate- may state) 

      3. Plantar reflex 

abdomen health history questions

1. any changes in appetite?

2. any difficulty swallowing?

3. any foods you can’t eat (food intolerance)?

abdomen assessment

1. Inspection 

   1. Contour  

      1. 4 contours: flat, scaphoid, rounded, protuberant (state)

   2. Symmetry  

      1. shine light

      2. ask patient to take a deep breath

   3. Umbilicus  

   4. Skin  

   5. Presence of any tubes or drains  

   6. Pulsations/movement  

   7. Hair distribution  

   8. Demeanor 

2. Auscultation  

   1. Use diaphragm to assess bowel sounds in all four quadrants starting in RLQ and moving clockwise  

   2. Note character/frequency of bowel sounds  

   3. Use bell to listen for vascular sounds in all seven areas 

3. Percussion  

   1. Percuss the four quadrants moving clockwise in a zig zag pattern  

   2. Listen for tympany and dullness 

4. Palpation  

   1. Lightly palpate four quadrants