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Cards In This Set
| Front | Back |
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HEENT/Integumentary
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Skin (color, turgor, scars);
rashes, bruises, scaling_______________ Scalp______ Hair_______ Nails_________ Symmetry of face, head, neck Eyes/ears +findings______ Oral mucosa, tongue_________ Palpate the skin for temp and moisture, palpate neck for lumps, masses Visual acuity (snellen chart) 3 age related changes: alopecia, decreased elasticity, decreased vision |
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Respiratory assessment:
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Overall color______
Rate, rhythm, symmetry__________ Accessory muscle use/effort______ Shape of chest______ pulse ox_______ Coughing, sputum color________ Night sweats, Fatigue, weight loss ________ Palpate for crepitus, fremitus, chest symmetry____________ Auscultate Anterior, Lateral, and Posterior describe adventitious sounds and describe Bronchial, bronchialvesicular and Vesicular breath sounds 3 age related changes: Alveoli are less elastic, decline in lung function, kyphosis |
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Cardiac assessment:
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Overall skin color/appearance______
Cap refill_______ clubbing _______ JVD______ Edema________ Orthostatic vitals_______ Check EKG rhythm______ Palpate for rate, rhythm, amplitude, symmetry of pulses_______ Peripheral pulses (radial brachial popliteal dorsalis pedis posterior tibialis)________ Central pulses (Carotid and femoral) _______ Auscultate heart sounds for rhythm, S1 S2, quality___________ Auscultate for carotid bruits and apical pulse____ 3 age related changes: Decreased cardiac output, loss of contractility, syncope |
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Neuro assessment:
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Appearance____ Orientation____ GCS_____ Gag____ Speech_____
PERRL_____ Bell's Palsy exam_____ Gait ______ bowel/bladder_______ Palpate grips, pushes, pulls______ DRT/Patella______ Extremity strength/sensation______ Babinski______Romberg______ Fields of gaze______ Finger to nose movement______ 3 age related changes: dementia, decrease in the 5 senses, risk of falls |
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Abdominal GI/GU assessment:
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LOOK LISTEN FEEL
Overall appearance, distention______ Drainage_______ Scars_______ Wounds/stomas_____ pulsations_______ Bowel/bladder patterns/changes______ Paulate for distention, firm/soft____ Tenderness (rebound)______ Flank pain________ Lumps/masses________ Bladder_______ Auscultate for bowel sounds in all 4 quads Auscultate for vascular sounds_____ NOTE; urine color______ clarity_____ +findings_____ Female: LMP_____ Pregnancies/children_____ BSE_____ PAP_____ Male: TSE______ 3 age related changes: constipation, decreased bacterial flora, decreased taste sensation |
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Musculoskeletal assessment:
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Gait____ posture_____
ROM major joints______ crepitus______ Palpate joints for temp, deformity, crepitus_____ Palpate upper/lower muscle strength 8 characteristics of pain: Location____ Quality____ Quantity____ Chronology_____ Setting______ Associated Manifestations____ Alleviating factors-____ Aggravating factors_____ Note height and weight______ 3 age related changes: muscle weakness, osteoporosis, atrophy of muscles |
