Professional Documents
Culture Documents
Subjective Data: (Obtain all info under “General State of Health” from
Review of Systems page 5 of Jarvis)
Objective Data:
Appearance
Posture
Overall hygiene and grooming
Any apparent signs of distress
Dress
Behavior
Level of consciousness
Mood and affect/ Facial expressions (appropriate for situation)
Cognition
Orientation (person, place, time, and purpose-X4)
Speech (clear, garbled, slurred, incomprehensible)
Responsiveness (follows directions and responds appropriately)
Subjective Data: (Obtain all info under “Skin”, “Hair”, & “Nails” from
Review of Systems page 5 Jarvis)
Objective Data:
Inspection and palpation of the skin
Color(pink, cyanotic, jaundiced, erythematous),
Pigmentation (even, hyper/hypopigmentation)
Lesions (Describe 3)
Description – size & color
Structure - type of lesion (macule, papule, nodule etc.)
Anatomical Distribution
Hydration – skin turgor (immediate recoil, tenting)
Temperature & Moisture
Inspection and palpation of the hair
Color & condition
Quantity, distribution, & texture
Inspection and palpation of the fingernails
Color of nail bed
Firmness, texture, ridging, irregularities
Clubbing:
Palpate for firm nail matrix
Estimate nail angle
Subjective Data: (Obtain all info under “Head, Eyes, Ears, Nose, Mouth and
Neck” from Review of Systems page 5-6 Jarvis)
Objective Data:
Inspection and palpation of the head and face
Skull for symmetry & tenderness
Face (includes eyes, ears, nose, mouth, and neck)
Symmetry
Discoloration
Lesions
Drainage
Distention
Oral mucous membranes –color, hydration, lesions
Subjective Data: (Obtain all info under Respiratory from Review of Systems
in Jarvis page 6)
Objective Data
Inspect chest wall
Color, Configuration (symmetry) and Lesions
Movement
Respiratory rate, depth, and effort
Objective Data
HEART
Inspection
Pulsations, lifts, heaves
JVD with chest at 35-45 degree angle
Auscultation
Rhythm assessment of S1 and S2 (Regular/Irregular)
Assess all auscultatory sites: APETM
Count Apical Heart Rate
Objective Data
Inspection
Contour
Lesions
Scars
Distention
Pulsations
Hernia (while patient lifts head)
Auscultation (all quadrants)
Bowel sounds
Palpation
Light palpation
Tension of abdominal wall (soft, firm, hard)
Tenderness
Masses
Deep palpation
Tenderness
Masses
Enlarged organs
Percussion
CVA tenderness
Objective Data
Muscle strength
Check each muscle group against resistance
Compare right with left:
Upper extremities
Triceps
Biceps
Adduction arms
Abduction arms
Wrists – flexion, extension
Lower extremities
Quadriceps
Hamstrings
Abduction knees
Adduction knees
Plantar flexion feet
Dorsiflexion feet
Neurological Assessment
Objective Data
Mental Status Examination
Appearance (posture, body movement, dress appropriate
for setting, grooming/hygiene)
Behavior (level of consciousness, facial expression,
mood and affect)
Cognition (orientation x4, responsiveness, speech)
Thought Processes (thought content for consistency and logic, perceptions
consistency with reality, any suicidal thought)
Pupillary Reaction
(equality, size, shape, reaction to direct and consensual light)
Sensory system
Spinothalamic tract
Light touch
Pain and temperature (only if negative result to light touch)
Posterior column tract
Vibration
Kinesthesia (position sense)
Stereognosis
Graphesthesia
Two-point discrimination
Motor function
Hand grips
Foot pushes
Deep tendon reflexes (Grade)
Biceps C5-C6
Triceps C7-C8
Brachioradialis C5-C6
Quadriceps L2-L4
Achilles L5-S1
Cerebellar Functions
Balance
Gait
Gross motor coordination – heel to toe walking
Romberg
Rapid Alternating Movements (RAM)
**Starred ** items are critical elements and must be passed by the student.
Technique Organization Clear Description
(5) (5) Instructions(2) Accurate (4)
General Survey:
Appearance (posture, grooming, hygiene,
apparent signs of distress, dress)
Behavior (attitude, mood and affect, facial expressions)
Cognition (mental status, speech, level of orientation)
Skin
Color (pink, cyanotic, jaundice, dusky, pale)
Hydration – skin turgor
Temp. and Moisture (warm/cool, dry/clammy)
Lesions (describes morphology, size, color, pattern of
Arrangement, and distribution)
Peripheral Vascular
Palpates for pulses together:
Radial, Femoral, Posterior tibial, Pedal
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