Assessment

Look over health history, gather equipment, enure that the timing is appropriate to give assessment.

The whole person: biographic(age, race, gender, dob, address, insurance, primary care provider); Chief complain (quote patient directly); History of present illness (PQRST); Past history( allergies and any medical conditions that occurred through lifetime, medications); Family history/illness; Lifestyle(diet, alcohol/smoking/drug use, sleep/rest patterns(taking anything for sleep)); Activity of Daily Living(ADL): how well can they take care of themselves(mobility, hygiene, elimination, eating etc..), exercise/hobbies; Social data: family/friends, ethnic affiliation, education, occupation, economic, home conditions; Psychological Data: major stressors; how to cope with stress; communication; spiritual health.

• P=Palliative or Precipitating (what provokes pain and what makes it worse or better
• Q=Quality (describe what the pain is like)
• R= Radiation (does the pain move to other places)
• S=Severity (1-10 pain)is it getting worse or better
• T= Timing (when did it start and how long did it or does it last)
• T= Timing/onste

Stethoscope, pen light, otoscope, tongue depressor, cotton balls, orthoscope, opthalmascope, tuning forks, gloves, percussion hammer

• Our interview consists of open-ended and closed ended questions. 3 Id's. We need to build rapport and establish communication in order to establish what to expect from each other during the assessment and patients visit. We need to know how to approach the client in a professional manner ensuring patients needs are clarified and can be assessed.
• Empathy: build rapport (who is this person and why are they here) timing; review of evidence(look over health history and chart)
• Environment: good lighting, minimal distractions(noise), comfortable temperature, and privace
• Equipment: see equipment flashcard
• Emotional: Expectations, Explanations (Why are they here, what is there chief complaint)
• Everything Else: Anything we need to consider about developmental level, language barriers, hearing, age, limitations

• Skin: pink, (not cyanotic, jaundiced), smooth (not rough dry,) smooth hair
• Posture/Gait: balanced walk, no obvious structural anomolies (scoliosis or favoratism to one died, good posture)
• Hygiene: they look upkept and don't smell bad
• Mood: how do they feel
• Awareness: Do they seem alert and oriented, are they breathing regularly
• Speech: Do they have anything indicating they're confused or distracted, do they have any language barriers, developmental stage
• Body type: are they good weight
• Race/Ethnicity/Age

• Height: standing or supine in bed (heals to back of wall)
• Weight: consistency of clothing, elimination, intake, time etc.. every time we weigh.

• Skin: Normal= pink, warm, dry, smooth, elastic; Abnormal= lesions or rash: macule, papule, vesicle, ulcer, plaque (ABCDE of skin care) assymetrical, irreg border, color change/irreg; diameter > eraser; elevation and unevenness; Color: jaundice, cyanotic, pallor, erythema (red patchy gritty look/dilated capillaries), plethoric(swelling redish), pigmentations; Edema (1+ 2mm; 3+6 mm; tenting: dehydration vs aging skin; Diaphoresis (sweating, why are they hot?); Cold and
• clammy=Shock
• Hair: Normal= shiny, smooth, pliant, full and color; Abnormal= Alopecia (balding) vs male-pattern baldness, thinning; stringy, dull, dry, brittle; Hirsutism=abnormal excessive hair growth
• Nails: Normal= pink/brown, uniform, smooth, cap refill < 3 seconds, firm nail base, nail plate angle<160 degrees; Abnormal= Clubbing (hypoxia >180 degrees) Paronychia= infected "hang nail") Spooning=anemia (low rbc count) Beau's lines-sign of unjury

• HEENT=head, eyed, ears, nose, mouth, throat (thyroid gland, trachea, carotid arteries, lymph nodes, pharynx, neck)
• Health history= should they use a helmet (have they had concussion or are there hobbies conducive to head injuries?)

• clear lens and sclera, moist-no redness/drainage,
• PERLA: pupils are even, round, respond to light, and accomodate
• Visual acuity=CN 2 Snellen chart
• Extraocular movements (EOM) Abnormal= Nystagmus-oscillation
• Alignment= Strabismus (eyes look coordinated in looking at something and not crosseyed) and ptosis (drooping eyelid)
• Visual fields: CN 3, 4, 6)
• Lacrimal apparatus: fluid/tears draining
• Corneal reflex (cotton wisp) CN V: touch eye and observe blinking when touched
• Raise eyebrows= CN 7
• Conjunctivae and Sclera: look for redness (indicative of allergic or infectious conjunctivitis.
• Arcus Senilis: thin white ring along margin of iris (common in aging but shouldn't be seen if 40<.
• Retinal exam: opthalmoscope
• Constricting pupils: shine light and observe pupil constriction on opposite pupil on both sides.

• Well curved pinna, no pain, drainage, or deformity
• ear color is same as face, no moles, cysts, deformities, or nodules.
• No redness(inflamattion) or pallor (frostbite)
• Pearly gray shiny with light reflex
• Otoscope exam: up and back 3> down and back if 3<
• Cerumen: yellow waxy present in external canal (not foul smelling yellow or green discharge=infection/foreign body)
• Whisper test/tuning fork: bone should be half as long to stop hearing

• auricles for texture, tenderness, skin lesions
• normally smooth and w/out lesions

• Norm: symmetrical nares, no drainage, patent (open not obstructed)
• Inspect turbinates w/ light: no inflammation, redness, drainage, deviated or perforated septum, polyps (little bulbs in nares).
• slide notes:
• When inspecting the external nose, observe for shape, size, skin, color, and the presence of deformity or inflammation.
• If swelling or deformities exist, gently palpate the ridge and soft tissue of the nose by placing one finger on each side of the nasal arch and gently moving the fingers from the nasal bridge to the tip.

• [Ask students: How can the color of nasal discharge indicate patient condition? Discuss: Pale mucosa with clear discharge indicates allergy. A mucoid discharge indicates rhinitis. A sinus infection results in yellowish or greenish discharge.]
• For the patient with a nasogastric tube, routinely check for local skin breakdown (excoriation) of the naris, characterized by redness and skin sloughing.
• During the examination, note any polyps (tumorlike growths) or purulent drainage.•Examination of the sinuses involves palpation.

• Lips: moist mucous membran, pink, smooth
• Chielosis= Cracking at corners (aged, dehydration, B-vitamin deficiency)
• Buccal (gums/teeth): moist, no lesions, smooth, pink, intact teeth and gums, no caries
• Palate: intact
• Look/Inspect for: white/red patches (leukoplakia/ erythroplakea), blisters, ulcers, hyperplasia/retraction of gums (dylantin can cause hyperplasia or excess of tissue), caries, mobile pink tongue, centered uvula, firm palate, tonsils non-inflammed.
• Clench teeth: CN 5
• Speak and "say ah": CN X
• Smile, frown, puff cheeks: CN 7
• swallow and taste: CN 9
• Stick out tongue: CN 12
• Slide notes: Lip color in the dark-skinned patient varies from pink to plum.
• Anemia causes pallor of the lips, with cyanosis caused by respiratory or cardiovascular problems. Cherry-colored lips indicate carbon monoxide poisoning.
• Any lesions should be evaluated for the potential of being an infection, an irritation, or skin cancer.
• Ask the patient to clench the teeth and smile to observe tooth occlusion. The upper molars normally rest directly on the lower molars, and the upper incisors slightly override the lower incisors.
• Inspect the mucosa for color; hydration; texture; and lesions such as ulcers, abrasions, or cysts. Normally, the mucosa is glistening, pink, smooth, and moist. Some common small, yellow-white raised lesions on the buccal mucosa and lips are Fordyce spots, or ectopic sebaceous glands. If lesions are present, palpate them gently with a gloved hand for tenderness, size, and consistency.
• Inspect the gums (gingivae) for color, edema, retraction, bleeding, and lesions.
• Inspect the teeth to determine the quality of dental hygiene. Note the color of teeth and the presence of dental caries (cavities), tartar, and extraction sites.

• Using a penlight for illumination, examine the tongue for color, size, position, texture, and coatings or lesions. Inspect for color, swelling, and lesions such as nodules or cysts.
• Observe the palates for color, shape, texture, and extra bony prominences or defects.
• Perform an examination of pharyngeal structures to rule out infection, inflammation, or lesions.

• Normal: symmetric, trachea cener, full ROM, nontender
• Push cheek opposite direction and shrug shoulder: CN 11
• Palpate lymph node
• Thyroid: non-tender, non-enlarged (enlarged=goiter), no nodes
• Carotid arter
• Jugular vein: no distention
• Trachea: midline

• Occipital
• cervical
• clavical
• supraclivicular
• submandibular
• submental
• parotid