Pt Assessment Exam 1-73

Front 1

General Survey

Back 1

1. Wash hands with sanitizer upon entering the rm
2. Introduce self to pt; first & last name. State reason for being there
Assesses pt's:
3. mental status- orientation to person/place/time
4. apparent state of health
5. level of consciousness & state of awareness
6. signs of distress
7. posture
8. dress, grooming, hygiene
9. affect, mood, manner, speech

Front 2

Vital signs
Blood Pressure

Back 2

Blood Pressure
10. places cuff properly
11. palpates brachial/radial artery
12. determines BP upper limit by palpation
13. places stethoscope properly
14. determines BP accurately with bell

Front 3

Vital signs
Pulses

Back 3

Pulses
15. determines rate & rhythm for 15 or 60"
16. compares radial pulses bilaterally (b/l)

Front 4

Vital signs
Respiration

Back 4

Respiration
17. counts respirations for 15 or 60"
18. interprets rate & pattern (reg, tachy, shallow, deep)

Front 5

Cerebellar funct.s
gait

Back 5

Gait
19. normal
20. heel-to-toe
21. toe
22. heel
23. romberg test (pt's arms to side, eyes open/closed, 20 to 30 sec)
24. pronator drift test (pt's arms extended, palms up, eyes closed, tap down on hands)

Front 6

Cerebellar funct.s
Rapid alternating movements b/l

Back 6

Rapid alternating movements b/l
25. arms rapid alternating movements (hands to thigh)
26. thumbs to fingers
27. finger-to-nose with eyes open & closed
28. legs- rapid alternating movements (foot tap b/l)
29. heel-to-shin b/l

Front 7

Spine

Back 7

30. inspects posture & curvature; properly drapes pt
31. palpates spine

Front 8

Determines ROM on ...

Back 8

32. flexion
33. extension
34. lateral bending
35. rotation

Front 9

Skin
inspect....

Back 9

36. inspects entirety of skin

Front 10

Skin
palpates entirety of skin noting....

Back 10

37. color & any lesions
38. temp & moisture
39. texture, turgor, & mobility
40. nail beds- b/l hands & feet
41. dons gloves for exam of lesions if present

Front 11

Upper Extremities (UEs)

Back 11

42. inspects b/l upper extremities

Front 12

UEs
palpates b/l UEs

Back 12

43. digit joints
44. wrists
45. elbows
46. shoulders
47. muscles

Front 13

UEs
determines ROM on b/l UEs fingers on ...

Back 13

48. flexion
49. extension
50. spreading

Front 14

UEs
determines ROM on b/l UEs wrists on ...

Back 14

51. flexion
52. extension
53. radial & ulnar deviation

Front 15

UEs
determines ROM on b/l UEs elbows on ...

Back 15

54. flexion
55. extension
56. pronation
57. supination

Front 16

UEs
determines ROM on b/l UEs shoulders on ...

Back 16

58. flexion
59. extension
60. abduction
61. adduction
62. internal rotation
63. external rotation

Front 17

UEs
determines muscles strength on b/l UEs (neuro)

Back 17

64. handgrip
65. wrist flexion
66. wrist extension
67. elbow flexion
68. elbow extension
69. shoulder flexion
70. shoulder extension
71. shoulder adduction
72. shoulder abduction
73. shoulder shrugging (CN XI)