Term
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Definition
Equipment (as needed):
- -scales
- -spygmomanometer
- -stethoscope
Assessment Parameters:
- observe general appearance, hygiene, posture, gait, thought processes, and speech patterns
- evaluate height and weight
- take vital signs
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Term
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Definition
Equipment (as needed):
Assessment Parameters:
- skin: inspect for color and lesions; palpate for temperature, texture, and moisture
- hair: inspect for texture, loss, unusual growth, and infestations
- nails: inspect for color and condition
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Term
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Definition
Equipment (as needed):
- gloves
- snellen chart
- ophthalmoscope
- otoscope
- tongue depressor
Assessment Parameters:
- skull and face: inspect for shape and symmetry
- neck: palpate trachea and thyroid gland
- lymph nodes: palpate for size, shape, consistency, and tenderness
- eyes: test visual acuity, extraocular movements, and peripheral vision; inspect for discharge, alignment, and internal structures
- ears: test hearing acuity; inspect position, external ear, tympanic membrane, and for cerumen
- nose, mouth, and throat: inspect for color, consistency, condition of teeth, exudate, and condition of tonsils; palpate for tenderness
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Term
Thorax and Lungs Assessment |
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Definition
Equipment (as needed):
- gloves
- stethoscope
- tape measure
Assessment Parameters:
- thorax: inspect posture and respiratory rate; palpate for crepitus and expansion; percuss for tones; auscultate breath sounds
- breasts: inspect size, shape, symmetry, color, areolas, nipple (discharge), retraction, and dimpling; palpate for masses or tenderness
- axillary lymph nodes: palpate for size, shape, consistency, and tenderness
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Term
Cardiovascular Assessment |
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Definition
Equipment (as needed):
- stethoscope
- watch with second hand
Assessment Parameters:
- carotid arteries: auscultate for bruit; palpate pulse strength
- jugular vein: inspect for pulsations and sitention
- precordium: inspect for pulsations; palpate apical impulse, pulsations, and heart rate and rhytm; auscultate heart sounds and murmurs
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Term
Peripheral Vascular Assessment |
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Definition
Equipment (as needed):
- stethoscope
- doppler (if needed)
Assessment Parameters:
- peripheral pulses: palpate for symmetry, character, strength, rate, and patency
- arms and legs: inspect for color, hair pattern, veins, lesions, and edema; palpate for temperature
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