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10 Cards in this Set

  • Front
  • Back
Step 1: Gather Equipment (Verbalize the list)
Thermometer, BP cuff, penlight, DTR hammer, stethoscope & watch.
Step 2: Introduction (Remember WIIEP)
Wash hands, Introduce yourself, Identify client by name/ID band, Explain the procedure, Provide privacy
Step 3: General Survey (Remember SBAG VS MOP

Subjective info is important in all steps!
Safety, Build of client, Appearance, Gait, Vital signs, Mood of client, Orientation, Pain
Step 4: Head & Face
Subjective: Ask about hearing, vision, headaches, dizziness
Objective: inspect facial features for symmetry, eyes PERRLA, tongue/mucous membranes for color/lesions, movement of soft palate & uvula, Palpate lymph nodes (call them out)
Step 5: Neck
Subjective: ask about stiffness/tenderness in upper back & neck
Objective: inspect lower neck for fullness, swallowing, trachea position. Palpate anterior/posterior/supraclavicular lymph nodes.
Step 6: Upper Extremities
Subjective: Ask about changes in skin & problems w/ movement
Objective: Inspect ROM, skin for color/lesions, nails: color-brittleness- cap refill. Palpate skin temp/moisture, Radial pulse bilat (rhythm/volume), strength of hand grip
Step 7: Thorax
Subjective: Ask bout cough, dyspnea, palpitations, chest pain
Objective: Inspect skin color/lesions A&P. Palpate skin turgor < 3 sec, Auscultate A-P & lateral breath sounds. Auscultate heart sounds (state location & sound heard). Compare apical/radial pulses rate/rhythm
Step 8: Abdomen
Subjective: Inquire about N/V, diarrhea, constipation, pain, & changes in bowel bladder function.
Objective: Inspect Skin color/lesions/scars/bulges/distention/pulsations. Auscultate for bowel sounds all 4 quads. Percusss systematically all 4 quads (state percussion note(s) heard) Palpate all 4 quads for consistency/tenderness
Step 9: Lower Extremities
Subjective: Ask about changes in skin & problems w/movement
Objective: Inspect- ROM, Skin- color/lesions. Palpate: skin temp/moisture, toenails cap refill < 3 sec, Posterior tibial & dorsalis pedis pulses bilat. Palpate presence of pitting edema Percuss patellar DTR bilat.
Step 10: Finished!
Thank your client for their cooperation with the assessment.