Heent, Neuro, Hsn

Front 1

8 pre exam behaviors

Back 1

verify policy, introduce self to pt, provide for privacy, state purpose for interaction, assessment equipment, ID pt w/ 3 identifiers, wash hands, drape pt

Front 2

HAIR:
inspect hair for distribution and color

Back 2

even distribution, say color

Front 3

separate hair w/ tongue blade and inspect for dandruff, lesions, or pest inhabitants

Back 3

No dandruff, lesions or pest inhabitants

Front 4

palpate hair and scalp for lesions and hair texture (wear gloves, and wash hands after)

Back 4

hair texture smooth, palpable no lesions

Front 5

SKIN AND NAILS:
inspect skin head to toe APL, ask pt to stand.

Back 5

Skin pale pink/flesh colored w/ even pigmentation, no visible edema, erythema, variscosity, body hair distribution even

Front 6

inspect all fingernails and toenails for color shape and contour bilaterally

Back 6

fingernails smooth rounded, cuticles intact, nail beds pink

Front 7

inspect at least one on each hand for clubbing

Back 7

no clubbing bilaterally

Front 8

palpate one fingernail on each hand for capillary refill

Back 8

capillary refill less than 3 sec bilterally

Front 9

check skin turgor/mobility on chest/neck in one location

Back 9

Turgor: instant recoil, no tenting

Front 10

palpate skin w/ back of hand for temp. (face, arms, legs bilaterally)

Back 10

temperature warm bilaterally

Front 11

Palpate skin with palms for moisture and texture (face, arms, legs bilaterally)

Back 11

Skin, dry, texture smooth bilaterally

Front 12

Palpate pretibial edema bilaterally, depress for 5 seconds

Back 12

No pretibial edema bilaterally

Front 13

Palpate feet bilaterally for temp., moisture, texture. Separate toes and note skin condition

Back 13

Temperature warm, dry bilaterally

Front 14

Palpate at least one toenail on each foot for capillary refill

Back 14

capillary refill <3 seconds bilaterally

Front 15

HEENT
8 pre-exam behaviors

Back 15

verify facility policy, assemble equipment, introduce self to client, state purpose, identify the pt by 3 factors (name, dob, and Medical #), provide privacy, wash hands, drape/gown appropriately

Front 16

HEAD AND FACE:
Inspect face for expression and symmetry

Back 16

face symmetrical

Front 17

instruct client to smile, frown, and close eyes tightly and resist your attempts to open them bilaterally. Observe for strength and symmetry

Back 17

face symmetrical with smile, frown. Eye muscle strength 5/5 bilaterally

Front 18

Instruct client to lift eyebrows, show teeth, puff out cheeks. Press on cheeks and note air escape equally on both sides. Observe for symmetry of movement

Back 18

Face symmetrical w/ lifting eyebrows, frown, smile, puff cheeks, show teeth. Air escapes equally bilaterally

Front 19

Palpate skull for size, shape, and symmetry

Back 19

head normocephalic

Front 20

Palpate temporal artery bilaterally

Back 20

Temporal artery pulses present and equal bilaterally

Front 21

Instruct client to clench teeth. Palpate temporal & masseter muscles bilaterally (TMJ). Attempt to separate jaw by pushing down on the chin

Back 21

TMJ muscle strength 5/5, equal bilaterally

Front 22

Palpate frontal & maxillary sinuses for pain and edema, bilaterally

Back 22

Frontal & maxilarry sinuses, non-tender, no edema bilaterally

Front 23

EYES:
Inspect external eye structures-eyebrows, eyelids, eyelashes bilaterally

Back 23

even distribution of eyebrows, eyelashes. No ptosis bilaterally

Front 24

Inspect conjunctiva, sclera, cornea, iris, bilaterally

Back 24

Conjunctiva pink, sclera white, cornea smooth, iris is (color) bilaterally

Front 25

Inspect extraocular muscle function: corneal light reflex bilaterally using penlight

Back 25

corneal light reflex symmetrical

Front 26

PERRLA

Back 26

pupils equal, round, react to light, accomodation

Front 27

Inspect 6 cardinal positions of gaze

Back 27

pupils move parallel in 6 cardinal fields of gaze

Front 28

Inspect extraocular muscle function: cover/uncover test bilaterally

Back 28

Cover/uncover reveals fixed, steady gaze

Front 29

Fundoscopic exam of red reflex bilaterally

Back 29

Red reflex present bilaterally

Front 30

EARS:
Inspect external ear for size,shape, and skin condition bilaterally

Back 30

External ear equal size, shape, height bilaterally

Front 31

Palpate pinna, tragus, and msatoid process for tenderness bilaterally

Back 31

Pinna, tragus, and mastoid process non-tender bilaterally

Front 32

otoscopic exam-inspect external, internal ear canal & tympanic membrane bilaterally

Back 32

External ear canal skin intact, tympanic membrane pearly grey, cone of light bright bilaterally

Front 33

Test hearing: whisper test bilaterally

Back 33

Able to repeat whispered words bilaterally

Front 34

NOSE:
Inspect external nose for symmetry

Back 34

Nose symmetrical, no deformities or lesions

Front 35

Inspect nasal mucosa, septum, turbinates bilaterally with penlight

Back 35

Mucosa & turbinates pink, moist, no exudates bilaterally. No septal deviation or perforations bilaterally

Front 36

Test patency of each nostril, occlude one nostril at a time

Back 36

Nares patent bilaterally

Front 37

MOUTH AND THROAT:
Inspect mouth using penlight and tongue blade. Note: buccal mucosa, teeth, gums, tongue, floor of mouth, grade tonsils if present

Back 37

buccal mucosa, floor of mouth and gums pink, moist, no masses or lesions, teeth present and in good repair, tongue smooth, tonsils (grade)

Front 38

Observe tongue position upon protrusion

Back 38

Tongue protrudes midline

Front 39

Note mobility of uvula with phonation

Back 39

Uvula rises with phonation

Front 40

NECK:
Inspect neck for lumps, pulsations, symmetry

Back 40

symmetrical, no lumps, or pulsations

Front 41

Palpate trachea midline by placing index finger in sternal notch and slip it off to each side

Back 41

Trachea midline

Front 42

Palpate all nodes bilaterally

Back 42

Preauricular, post auricular, occipital, jugulodigastric, superficial cervical, posterior cervical, supraclavicular, deep cervical chains, submandibular, submental nodes non-palpable bilaterally.

Front 43

NEURO Exam
8 pre exam behaviors

Back 43

verify facility policy, assemble equipment, introduce self to client, state purpose, provide privacy, ID pt using wrist band (name, DOB, medical #), wash hands, drape/gown pt

Front 44

Instruct client to close eyes for trigeminal nerve test. take cotton ball and test on forehead, cheeks, chin bilaterally. Ask patient if each sensation is felt equal on each side

Back 44

Trigeminal light touch able to be felt equally bilaterally

Front 45

Close eyes again. Take cotton ball and test randomly on upper arm, forearm, hand, thighs, leg, foot, bilaterally. Ask client "does this feel the same as this?"

Back 45

Light touch present and felt equally bilaterally on anterior upper arms, forearms, hands, thighs, lower legs, tops of feet

Front 46

Close eyes. Test sharp and dull pain on hands and feet (3 different places) bilaterally. Wait 2 seconds in between sensations. Tell client to say "sharp" or "dull" to stimulation

Back 46

Pain present and equal in C-6,7,8 on dorsal side of hands bilaterally and S1, 2 and L4, 5 on dorsal side of feet bilaterally

Front 47

Observe rapid alternating mvmts bilaterally. Hands on thighs "do what I am doing"

Back 47

Coordinated skilled smooth rhythemic turning

Front 48

Hand grips for strength bilaterally. Cross fingers and ask patient to squeeze fingers (both at same time)

Back 48

hand grips equal bilaterally

Front 49

Deep tendon reflexes:

Biceps (place thumb over tendon and tap thumb with point), both arms

Triceps (support arm and tell pt to let arm go limp, hit tendon with point) Both arms

Brachioradialis (grab thumb and make sure to shake loose, hit with point) both arms

Quadriceps (make sure feet are dangling, hit with flat edge) both legs

Achilles tendon (hit with flat) both ankles

Plantar (use handle to stroke across foot) both feet

Back 49

Deep tendon reflexes +2 bilaterally

Front 50

Ask client to stand up:
Walk across the room with normal stride (approx 10 ft), turn around and walk heel-toe

Back 50

Gait steady, smooth with appropriate arm swing, able to tandem walk

Front 51

Romberg test. Tell pt to stand with feet together, hands at sides and close eyes. "I will be behind you to make sure you are safe" Watch for sway, 30 seconds

Back 51

Romberg negative

Front 52

POST EXAM
6 behaviors

Back 52

Cleaned up after procedure, explained the results to pt, did in head to toe fashion, in the proper amount of time, maintained safe environment, adhered to infection control