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CSON > Head to Toe Assesment > Flashcards

Head to Toe Assesment Flashcards

1
Q

Level of Consciousness is

A

-the Single most important neuro assesment componet
-Often the first clue of deteriorating condition

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2
Q

Alert

A

-Attentive

-Follows commands

-If asleep – wakes promptly and remains attentive

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3
Q

Lethargic

A

-Drowsy but awakens

-Slow to respond

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4
Q

Obtunded

A

-Difficult to arouse

-Needs constant stimulation

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5
Q

Stuporous/Semi-Comatose

A

-Arouses only to vigorous/noxious stimuli

-May only withdraw from pain

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6
Q

Comatose

A

-No response to verbal or noxious stimuli

-No movement except deep tendon reflex

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7
Q

Cognitive Awareness

A

-Also known as mentation

-Is the patient oriented to person, place, and time?

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8
Q

Three Questions to test Cognitive Awareness

A

-Oriented to person: What is your name and date of birth?

-Oriented to place: Where are you right now?

-Oriented to time: What year/day is it?

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9
Q

Test Cranial Nerves III, IV, and VI (3,4,6)

A

-Pupil Response
-Dilation (Before and After)
-Focus (close too and away/light off)

-Cardinal Gaze
-H motion (9-12in away from face)

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10
Q

Test Cranial Nerve VII (7) - The Facial Nerve

A

-Smile and show teeth

-Wrinkle forehead or raise eyebrows

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11
Q

Test Cranial Nerve XII (12) - the hypoglossal nerve

A

-Tounge to roof of mouth

-Tounge out

-Tounge side to side

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12
Q

Test Cranial Nerve XI (11) - the accessory nerve

A

-Shoulder Shrug

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13
Q

Test Motor Function

A

-Hand grasp and toe wiggle (HGTW)

-BUE & BLE Flexion and extension (with resistance)

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14
Q

H2T Neuro Components of Assessment

A

-Level of consciousness and orientation

-Pupil response and Cardinal gaze

-Smile and show teeth, raise eyebrows

-Tongue to roof of mouth, out, side to side

-Shoulder strength with resistance

-HGTW

-Flexion/Extension BUE and BLE

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15
Q

3 Normal Lung Sounds

A
  1. Vesicular – heard periphery of the lungs
  2. Bronchovesicular – heard closer to the sternum
  3. Bronchial – heard over trachea
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16
Q

4 Abnormal or Adventitious Lung Sounds

A
  1. Crackles or rales (can be fine or course)
  2. Rhonchi
  3. Wheezes
  4. Pleural Friction Rub
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17
Q

6 Abnormal Respiratory Patterns

A
  1. Bradypnea
  2. Tachypnea
  3. Apnea
  4. Hyperpnea
  5. Kussmaul’s
  6. Cheyne-Stokes
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18
Q

How many Anterior Lung Auscultation locations are there

A

7

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19
Q

How many Posterior Lung Auscultation locations are there

A

-10
-Deep breaths on 7-10

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20
Q

What do you test for nails?

A

-Shape

-Clubbing: happens where there is consistant low O2 levels in the blood

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21
Q

H2T Respiratory Components of Assessment

A

-Anterior and posterior lung sounds

-Clubbing

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22
Q

2 Normal Heart Sounds

A
  1. Lub: Systole or S1
    -sound associated with the closing of the mirtal/tricuspid valves
  2. Dub: Diastole or S2
    -sound associated with the closing of the aortic/pulmonic valves

There should be a longer pause between S2 & S1

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23
Q

4 Location of Heart Sounds

A
  1. Aortic: Right base
    -Second intercostal space to the right of the sternal border
  2. Pulmonic: Left base
    -Second intercostal space to the left of the sternal border
  3. Tricuspid: Left lateral sternal border
    -Fifth intercostal space to the left of the sternal border
  4. Mitral: Apex
    -Midclavicular line at the fifth intercostal space
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24
Q

8 Pulse Points

A
  1. Carotid*** (neck)
  2. Brachial (elbow)
  3. Radial*** (wrist thumb side)
  4. Ulnar (wrist pinky side)
  5. Apical*** (chest)
  6. Femoral (inner hip)
  7. Popliteal (behind knee)
  8. Dorsalis pedis*** (top of foot or bw big/middle toe)
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25
Q

4 H2T Assesment Pulse Points

A
  1. Carotid – one at time, bilaterally
  2. Radial – bilaterally at the same time
  3. Apical – with stethoscope for 2 beats
  4. Dorsalis Pedis or Pedal pulses – bilaterally at the same time
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26
Q

Pulse Quality Scale

A

0 – Absent, Non-palpable

1+ – Diminished, palpable

2+ – Strong , normal

3+ – Full, Increased

4+ – Bounding

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27
Q

What is a Doppler?

A

-Hand-held device that amplifies pulse sounds
-Most often used for pedal pulses

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28
Q

2 Extremity Assessments

A
  1. Capillary refill: Press skin of nailbed to produce blanching, release pressure and observe time taken for color return, should be less than 2-3 seconds, BUE and BLE
  2. Edema: Swelling in the extremities
    Dependent edema: most often on feet and ankles, older adults.
    and standing
    Pitting edema: venous insufficiency or heart failure, fluid in tissues
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29
Q

H2T Cardiac Components of Assessment

A

-Heart sounds

-Carotid pulses

-Radial pulses

-Pedal pulses

-Capillary refill

-Assess for edema (swelling)

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30
Q

7 Locations to Assess Range of Motion (ROM)

A
  1. Neck
  2. Shoulders
  3. Upper arms & Elbows
  4. Wrists
  5. Hips
  6. Knees
  7. Ankles
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31
Q

How to Test Neck ROM

A

-Move neck side to side

-Chin to chest

-Extension back (look up)

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32
Q

How to Test Shoulders, Upper Arms & Elbows ROM

A

-Arms out to side

-Arms straight up

-Touchdown (goal post)

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33
Q

How to Test Wrists ROM

A

Wrist circles

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34
Q

How to Test Hips, Knees, and Ankles ROM

A

-Bilateral hip flexion out

-Bend knees

-Ankle circles

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35
Q

How to Test Strength

A

-Handgrip

-Toe wiggle

-Flexion and extension of BUE/BLE

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36
Q

H2T Musculoskeletal Components of Assessment

A

-Neck ROM

-BUE ROM

-BLE ROM

-HGTW

-Flexion/Extension BUE and BLE

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37
Q

7 Things to Assess the Skin for

A
  1. Hydration
  2. Temperature
  3. Color
  4. Texture
  5. Rashes
  6. Lesions
  7. Cracking
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38
Q

4 Skin Color Assessments

A
  1. Pallor – pale or ashen gray
  2. Erythema – redness r/t vasodilation
  3. Jaundice – yellow, impaired liver
  4. Cyanosis – bluish, decreased circulation or oxygenation of blood
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39
Q

How should healthy skin temperature feel?

A

Skin should be WARM and consistent with the room temperature

40
Q

How should skin moisture feel if dehydrated

A

DRY

41
Q

Impaired Peripheral Circulation Signs

A

Texture can be dry & course (elbows/knees) or shiny with no hair

42
Q

What does Turgor test for?

A

elasticity of the skin related to hydration

43
Q

Where do you assess skin turgor on a patient?

A

Under clavicle (pinch skin)

44
Q

7 Factors Effecting the Skin

A
  1. Dampness
  2. Dehydration
  3. Nutrition
  4. Circulation
  5. Disease
  6. Jaundice
  7. Lifestyle
45
Q

Normal Skin Changes in Older Adults

A

Epidermis
Subcutaneous tissue
Collagen & elastin fibers
Hormones
Vascularity
Hair follicles
Melanocytes
Nails
Skin growths

46
Q

Pitting Edema

A

-Caused by kidney or heart failure
-Leads to excess fluid collection in tissues

47
Q

How do you Assess Pitting Edema?

A
  • Poke the affected area and assess the pit for depth and response time
    -Measured on a 4 point scale
    1+ 2mm to trace Rapid Response
    2+ 4mm to mild 10-18 second Response
    3+ 6mm to moderate 1-2 minute Response
    4+ 8mm to severe 2-5 minute Response
48
Q

4 Bony Prominences to Assess

A
  1. Hips
  2. Heels
  3. Coccyx
  4. Shoulders
49
Q

What do you Assess the Bony Prominences for?

A
  • Skin Integrity
  • Blanching Red Spots
50
Q

4 Things to Asses the Nails for

A
  1. Shape
  2. Contour
  3. Cleanliness
  4. Neatly manicured/trimmed
51
Q

A Patients Nails should be

A

Transparent
Smooth
Rounded
Convex
Hygienic

52
Q

5 Things to Assess the Hair for

A
  1. Quantity (Alopecia, hirsutism-due to hormones)
  2. Distribution
  3. Texture
  4. Color
  5. Parasites
53
Q

2 Main Types of Body Hair

A
  1. Terminal Hair - Scalp, axillae, pubic, and beard
  2. Vellus Hair - Soft tiny hairs covering body except on palms and soles
54
Q

8 Things to Assess the Ears for

A
  1. Symmetry
  2. Drainage
  3. Shape
  4. Hearing defects
  5. Lesions
  6. Redness
  7. Tenderness
  8. Odor
55
Q

9 Things to Assess the Nose for

A
  1. Position
  2. Symmetry
  3. Color
  4. Swelling
  5. Deformities
  6. Discharge
  7. Flaring
  8. Patency
  9. Sinus tenderness
56
Q

5 Oral Cavity Assessments

A
  1. Lips
  2. Oral Mucosa
  3. Teeth (dentition)
  4. Gums / Toungue
  5. Breath Odor
57
Q

6 Throat inspections

A
  1. Lumps
  2. Ulcers
  3. Edema
  4. White spots
  5. Redness
  6. Swallowing
58
Q

Inspect the neck for

A

-Contour & symmetry

-Midline Trachea

-Jugular vein distention

59
Q

Palpate the neck for

A

Inflamed or enlarged Lymph Nodes

60
Q

H2T Integumentary Components of Assessment

A

-hair and scalp
-ears
-nose
-mouth and throat
-Inspect and palpate neck
-Assess skin turgor
-skin on back and bony prominences
-Inspect skin of BUE and BLE
-nails

61
Q

Elimination is the

A

excreation of waste products from kidneys and intestines

62
Q

Defecation is the

A

process of elimination of waste

63
Q

Feces is

A

a semisolid mass of fiber, undigested food, inorganic matter

64
Q

Incontinence is the

A

inability to control urine or feces

65
Q

Void means

A

to urinate

66
Q

Micturate means

A

to urinate

67
Q

Dysuria is when a patient has

A

painful or difficult urinations

68
Q

Hematuria is when there is

A

blood in the urine

69
Q

Nocturia is when a patient has

A

frequent night urinations

70
Q

Polyuria is

A

large amounts of urine

71
Q

Urinary frequency

A

voiding at frequent intervals

72
Q

Urinary urgency is

A

the need to void all at once

73
Q

Proteinuria is

A

the presence of large protein in urine

74
Q

Dribbling is

A

the leakage of urine despite voluntary control of urination

75
Q

Retention is

A

the accumulation of urine in bladder without the ability to completely empty

76
Q

Residual is

A

> 100mL of urine remaining post void

77
Q

4 Sructures of the Gastrointestinal Tract

A
  1. Upper gastrointestinal tract
  2. Small intestine
  3. Large Intestine
  4. Rectum and anus
78
Q

Chyme travels via

A

peristalsis

79
Q

Small Intestine

A
  • Folded, twisted, and coiled tube from stomach to large intestine
  • 1” in diameter and 20’ long
  • Most digestion and absorption happens here
80
Q

3 Segments of the Small Intestine

A
  1. Duodenum
  2. Jejunum
  3. ileum
81
Q

Large Intestine

A
  • AKA – colon
  • 2.5” diameter and 5-6’ long
82
Q

7 segments of the Large Intestine (Colon)

A
  1. Cecum
  2. Ascending colon
  3. Transverse colon
  4. Descending colon
  5. Sigmoid colon
  6. Rectum
  7. Anus
83
Q

4 Organs of Urinary Elimination

A
  1. Kidneys
  2. Ureters
  3. Bladder
  4. Urethra
84
Q

Kidney Functions

A

-Filter and regulate

-Remove waste from blood to form urine

85
Q

Ureter Function

A

Transport urine from kidneys to bladder

86
Q

Bladder Function

A

Reservoir for urine until the urge develops

87
Q

Urethra Function

A

Urine travels from bladder and exits through urethral meatus

88
Q

Kidneys

A
  • Bilateral, posterior flanks
  • Size of fists
  • Primary regulators of fluid and acid-base balance

Nephron – functional unit of the kidney
Glomerulus - cleaning process done here
Bowman’s Capsule
Proximal Convoluted Tubule - Absorbtion and reabsorption
Loop of Henle - Absorbtion and reabsorption
Distal Tubule - Absorbtion and reabsorption
Collecting Duct

89
Q

Ureters

A
  • Tubule structures that enter the bladder
  • Urine traveling through ureters is typically sterile
  • Ureters enter bladder obliquely and posteriorly to prevent reflux
  • Obstructions(kidney stones) cause peristaltic waves severe pain often referred to as renal colic
90
Q

Bladder

A
  • Hollow, distensible, muscular organ
  • In men – bladder lies against anterior wall of rectum
  • In women – bladder rest against anterior walls of uterus and vagina
  • When bladder is full, it extends above symphysis pubis
  • Normal bladder – 500ml
    -Can extend to 1000ml
91
Q

Urethra

A
  • Turbulent flow washes urethra free of bacteria
  • Descends through pelvic floor muscles
  • Contraction of pelvic floor muscles can prevent flow of urine
  • In women – urethra is short (1 ½ to 2 ½ in), leads to prevalence of infection
  • In men – urethra is long (8 in), serves in both GU and reproductive system, three sections: prostatic, membranous, and penile
92
Q

Abdomen Assessment Order (must go in this order)

A
  1. Inspection (look) – observe size, shape, contour, skin integrity
  2. Auscultation (listen) – bowel sounds, four quadrants
  3. Palpation (feel) – palpate for tenderness, pain, masses
93
Q

Abdomen Auscultation Order

A

Start at the Right Lower Quadrent and go clockwise

4 Spots of Auscultaion

94
Q

4 Questions to Ask During Abdomen Assessment

A
  1. Normal bowel and urine patterns
  2. Appearance
  3. Changes
  4. History of problems
95
Q

Assessment of Urethral Meatus and Perineal Area

A

-Inspect urethral orifice for erythema, discharge, swelling, or odor

-Signs of infection, inflammation, or trauma

-Perineal area: color, condition, presence of urine or stool

96
Q

H2T GI/GU Components of Assessment

A
  • Examination of abdomen – look, listen, feel
  • Ask questions about habits
  • Examination of urethral meatus and perineal area

CSON (4 decks)

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