Upgrade to remove ads
Only $35.99/year

PD practical 2

Terms in this set (47)

General, appearance, and vital signs steps
1) Introduce and establish reason for exam
2) Sanitize hands
3) Measure and verbalize vital signs
Integument/CV Integument steps
1) VERBAL Inspect ant/post/lat UE and LE skin for color changes, cyanosis, ulcers, lesions: Purposefully examine skin (pt standing, turn) including dorsum/soles of feet
2) VERBAL Inspect hair distribution of LE
3) Palpation of skin (VERBALIZE) for bilateral:
Texture (fingertips): ant bilat UE & LE only
Temperature (dorsum hands) proximal distal UE/LE
Pretibial edema & Pedal edema (thumbs, 2 sec)
4) VERBAL Inspect bilat fingernails and toenails for lesions, cyanosis, clubbing
5) VERBALIZED Capillary refill (1 fingernail and toenail BILAT)
6) Sanitize hands
VERBAL Inspect ant/post/lat UE and LE skin
I'm going to inspect the skin for any color changes, cyanosis, ulcers, and lesions bilaterally
Can you please hold onto the bed and show me the bottom of your feet?
VERBAL Inspect hair distribution of LE
I'm going to inspect the hair distribution of your lower extremities
Palpation of skin
Texture (fingertips)
Temperature (dorsum hands)
Pretibial edema & Pedal edema
I'm going to palpate the skin anteriorly on the UE and LE for texture using my fingertips.
run fingertips on ant bilat arms and ant bilat legs
Now, I'm going to check the temperature of your skin using the dorsum of my hands. proximal distal UE/LE
I'm going to check for pretibial edema & pedal edema using my thumbs 2 seconds
VERBAL Inspect bilat fingernails and toenails
I'm going to inspect fingernails and toenails for lesions, cyanosis, and clubbing.
VERBALIZED Capillary refill
(1 fingernail and toenail BILAT)
I'm going to check the capillary refill bilaterally.
SANITIZE HANDS
eyes steps
1) VERBAL Inspect upper/lower conjunctivae and sclera for color, injection, and edema
2) Direct/Consensual light reflex (CN II,III)
3) EOMs and lid movements (CN III, IV, VI)
4) Ophthalmoscopic exam (bilat):
(Lights dimmed in room, bed raised/lower to proper height, proper use/familiarity of equipment, lights resumed, Student/patient glasses off, patient pre-instructed)
Braces ophthalmoscope
(Light on pupil during exam & student slowly moves to examine entire retina. Scope is focused while examining if needed)
5) Bilateral VERBAL notation of:
Red reflex, blood vessels, retinal wall, optic disc, (for papilledema) Macula examined last
VERBAL Inspect upper/lower conjunctivae and sclera
I'm looking at the upper/lower conjunctivae and sclera for color, injection, and edema.
Can you pull upper eyelids up and look down? Can you pull your lower eyelids down and look up?
Direct/Consensual light reflex (CN II,III)
We'll do the direct/consensual light reflex. Can you place your hand like this (show pt)? Please look over my shoulder/at my nose.
Shine penlight obliquely in right eye and see pupil constrict. Repeat but look at left eye. Then, repeat starting with left eye.
EOMs and lid movements (CN III, IV, VI)
I'm going to be testing the movements of your eye muscles and lids and pupil convergence now. You will have to follow my finger with your eyes but keep your
head still.
Ophthalmoscopic exam (bilat)
DIM LIGHTS, Raise/lower bed to proper height. Ophthalmoscope at dimmest light setting. Gently pull up on eyebrow and start focusing on eye from further out and then going in closer to the eye. Make sure light is on pupil.
I'm going to take a look at your eyes with the ophthalmoscope. While I'm looking at
your eyes, I want you to look over my shoulder.
I see the red reflex, blood vessels, retinal wall, and optic disc. No papilledema and macula not seen. (Remember to do bilaterally!)
Make sure to turn on the lights back on.
ear exam steps
Otoscopic exam (bilat):
(Pulls auricle up and back; scope handle held horizontally while braces otoscope with ulnar aspect of hand/fingers on face before gentle insertion)
Otoscopic exam (bilat)
Pull auricle up and back; scope handle horizontal and brace with ulnar aspect of hand/fingers on face before inserting.
I'm going to be taking a look at your ears with the otoscope. It might feel a little uncomfortable but let me know if you feel any pain
nose exam steps
Instructs pt to tilt head back, places hand on forehead with thumb gently pushing nasal tip up; scope handle held horizontally while braces scope with ulnar aspect of hand/fingers on face before gentle insertion; clean speculum used
Sets with similar terms