Physical Assessment Lecture Notes

Vocabulary flashcards based on physical assessment lecture notes covering patient intake, vitals, head-to-toe examination, organ auscultation, and health history screening.

GPSP and $11$ Rights

Initial safety guidelines and rights of care followed at the start of a physical assessment routine.

Baseline Vital Signs Findings

Recorded vital signs showing BP $120/60$, HR $80$, RR $18$, $O_2$ 98\text{\normalfont{\%}} on room air, and Temp $97.5$.

Whispered/Spoken Hearing Test Results

Whispered ear hearing test where the patient repeats back letters: $EBL$ for the left ear and $RFG$ for the right ear.

Facial Inspection and Palpation Findings

Physical findings showing pink, warm, and symmetrical skin with no lesions or facial hair, assessed for temperature using the back of the hand on the forehead.

Jaw and Cranial Nerve Motor Assessment

Motor testing performed by having the patient open, close, and clench the jaw, push face against hands, push shoulders against hands, stick tongue out, push tongue against cheeks, smile, and say "ahh".

Oral Mucosa Assessment Findings

Inspection of the inside and outside of the mouth showing pink, moist, and smooth oral mucosa with no lesions or abnormalities.

Nasal Patency and Sinus Examination

Palpation above the eyebrows and under the eyes, and closing one side of the nose at a time while breathing; normal findings show no pain, no drainage, and moist red mucosa.

Pupillary Assessment (PERRLA)

Pupil evaluation conducted with lights off then on, revealing pupils that appear equal, round, and reactive to light.

Cardinal Motions Test

Extraocular movement test performed using a pen light held $12\text{\textnormal{ in}}$ back from the eyes to check cardinal fields of vision.

Olfactory and Facial Tactile Tests

Sensory tests where the patient closes their eyes to identify a smell (coffee) and indicates where touch is felt on the face.

Upper Extremity Pulse and Circulatory Checks

Bilateral pulse checks at the carotids, brachial bend of arms, and radial wrists, along with checks for edema, skin temperature, capillary refill, and bilateral hand squeeze strength.

Lower Extremity Assessment Sequence

Evaluation performed with the head of the bed lowered: inspecting knees, testing knee ROM, feeling posterior tibial and dorsalis pedis pulses, temperature, toe capillary refill, edema, and foot push/pull strength.

Skin Turgor Inspection

Assessment of skin hydration status performed by sitting the head of the bed up, pulling the gown down, and inspecting turgor.

Cardiac Auscultation Protocol

Listening to heart sounds using the stethoscope diaphragm under the collar bone, sternum, and under left/right breast, and using the bell at the far left side of breast for $1\text{\textnormal{ min}}$; normal findings show regular $S_1$ and $S_2$ sounds.

Anterior Lung Sound Auscultation Pattern

Listening to breath sounds as the patient takes deep breaths, starting at top edges under the collar bone (both sides), middle, and even with nipples around the sternum.

Posterior Lung Sound Auscultation Pattern

Listening to posterior breath sounds while the patient leans forward and takes $20$ breaths, checking below the neck and $14$ times in a ladder pattern moving up the sides of the back.

Abdominal Auscultation Order

Listening with the stethoscope diaphragm for $1\text{\textnormal{ min}}$ in each quadrant sequentially: Right Lower Quadrant (RLQ), Right Upper Quadrant (RUQ), Left Upper Quadrant (LUQ), and Left Lower Quadrant (LLQ).

Vascular Auscultation for Bruits

Using the stethoscope bell at the middle top of the stomach (aorta) and over both carotid arteries while the patient holds their breath to verify no bruits are present.

Abdominal Palpation and Percussion Routine

Manual palpation and percussion of the stomach performed in a sequential loop pattern starting in the Right Lower Quadrant (RLQ).

Health History and Psychosocial Questions

Assessment interview covering surgeries, allergies, pain, medications/supplements/herbs, vaccines, income, living situation, personal safety, transportation, medication access, mental health, and self-harm thoughts.

Post-Assessment Routine

Final care sequence consisting of handing the patient the call light, performing hand hygiene, reporting findings, and recording/documenting the assessment.