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IM1 > Head-to-Toe Assessment > Flashcards

Head-to-Toe Assessment Flashcards

1
Q

what types of data do we gather from a pt?

A

subjective
objective
pain
bp, pulse ox, temp

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2
Q

Types of Physical Assessment: what is a comprehensive exam?

A

looking @ everything & asking lot’s of q’s

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3
Q

Types of Assessment: what is a focused exam?

A

checking a specific problem

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4
Q

Type of assessment: what is a system specific exam?

A

anything related to a certain body system

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5
Q

Type of assessment: what is an on-going exam?

A

do the same assessment every time

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6
Q

What are diagnostic tests we can run?

A

labs: abg’s, cbc, sputum
radiology: chest x-ray, ct, v/q scan, pet scan
skin test
pulmonary function test
endo exams

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7
Q

What are methods of data collection?

A

interview
nursing health history
physical exam
diagnostic & lab results

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8
Q

What are elements of an assessment?

A

history
baseline history
problem based history
Exam:
VS
inspection
Ausculation
Palpation

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9
Q

What does the assessment include?

A

interview & physical

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10
Q

What does the nursing diagnosis determine?

A

diagnosis nurse can make based on their judgement

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11
Q

What does planning include?

A

based on the data from the assessment

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12
Q

What does the evaluation include?

A

established nursing accountability

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13
Q

What are techniques used in the assessment?

A

inspection
palpation
percussion
auscultation
olfaction

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14
Q

Do we use or sense of taste during our assessment?

A

no!!

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15
Q

During our visual exam what should we do to make sure we do the exam properly?

A

good lighting
expose all parts to be examined & maintain privacy for other parts not being examined
use additional light for som areas of body; eyes, ears, throat

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16
Q

What do we observe for in the visual inspection?

A

color
shape/symmetry
movement
position

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17
Q

What techniques do we use for palpation?

A

bimanual/manual
dorsum of hand
palm or ulnar surface of hand
palmar surface of finger/pads

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18
Q

How far do we push for light palpation?

A

1cm or 1/2 depth

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19
Q

How far do we push for deep palpation?

A

4cm or 2 in depth

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20
Q

When we palpate what are we assessing?

A

texture
resistance
resilience
mobility
temp
thickness
shape
moisture

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21
Q

What is percussion?

A

tapping on the body w/ fingers or an instrument

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22
Q

What is direct percussion?

A

applied directly to body

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23
Q

What is indirect percussion?

A

applied through another surface

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24
Q

Characteristics of sound: what is frequency?

A

of osculations per sec generated by a vibrating object

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25
Q

Characteristics of sound: what is loudness?

A

amplitude of a sound wave

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26
Q

Characteristics of sound: what is quality?

A

descriptive

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27
Q

Characteristics of sound: what is duration?

A

length of time that sounds last

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28
Q

When using the stethoscope what should we always do?

A

always place directly on skin

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29
Q

What can the bell of the stethoscope best hear?

A

low sounds (heart/vascular)

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30
Q

What can the diaphragm of the stethoscope best hear?

A

high pitched sounds
(bowel & some abnormal lung sounds)

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31
Q

What can our olfactory sense be used for in the healthcare setting?

A

used to detect abnormal vs normal smells

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32
Q

How do we prepare for the assessment?

A

Gather all supplies
Into
Explain
Hand hygiene
use gloves (if needed)
clean stethoscope & bp cuffs b/w pt’s
make pt comfy & privacy

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33
Q

What are special considerations for the aged?

A

Recognize physical/sensory limitations
Recognize normal changes of aging vs abnormal

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34
Q

When do we take the health history?

A

before the exam

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35
Q

What should we ask/assess during the assessment?

A

race/gender
age
body
type
posture
signs of distress
substance abuse
speech
movement/gait
hygiene/grooming
dress
affect/mood
pt abuse

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36
Q

What are signs of abuse?

A

inconsistent statement & injury
bruises, lacerations, burns, bites
x-ray showing fractures in various stages of healing
behavior issues; insomnia, anxiety, iso

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37
Q

LOC: What does alert mean?

A

attentive, follows command, if asleep - wakes promptly & remains attentive

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38
Q

LOC: what does lethargic mean?

A

drowsy but awakens, slow to respond

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39
Q

LOC: what does obtunded mean?

A

difficult to arouse, need constant stimulation

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40
Q

LOC: what does stuporous/semi-comatose mean?

A

arouses only to vigorous/noxious stimuli, may only withdraw from pain

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41
Q

LOC: what does comatose mean?

A

no response to verbal or noxious stimuli, no movement except deep tendon reflex

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42
Q

What is checked for cognitive awareness?

A

pt oriented to person, place, time
known as mentation

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43
Q

How do we ask a patient about their cognitive awarness?

A

what is their name/dob
where are you right now
what day/year is it?

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44
Q

What are we testing when we examine cranial nerves III, IV, & VI?

A

Pupil response & cardinal gaze `

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45
Q

What do we assess with the acronym PERRLA?

A

Pupils
Equal
Round
React to
Light &
Accommodation

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46
Q

What is tested for Cranial Nerve VII

A

smiling with teeth & forehead wrinkle/eyebrow raise (for symmetry)

47
Q

What are we asking the pt to do to test cranial nerve XII?

A

Ask pt to touch mouth w/ roof of tongue
protrude tongue out of mouth
move tongue from side to side

48
Q

What do we ask the pt to do when we are testing cranial nerve XI?

A

place hands on shoulders & have them shrug

49
Q

What do we test for neuro muscular function?

A

hand grasp
toe wiggle
flexion & extension
all done bilaterally

50
Q

What three areas do we listen to when checking lungs?

A

vesicular - periphery of lungs
bronchovesicular - closer to sternum
bronchial - over trachea

51
Q

What are abnormal lung sounds?

A

crackles
rales
rhonchi
wheezes
pleural friction rub

52
Q

What are abnormal respiratory patterns?

A

bradypnea
tachypnea
apnea
hyperpnea
kussmaul’s
cheyne-stokes

53
Q

How many places do we check for lung sounds anteriorally?

A

7

54
Q

How many places do we check for lung sounds posterially?

A

10

55
Q

When do we ask pt to take deep breaths?

A

last 4 lungs sounds posterior

56
Q

What are we looking for in the nail shape?

A

clubbing

57
Q

What is the normal heart sound?

A

lub dub

58
Q

What does lub indicate in the heart?

A

systole or S1 & sound associated w/ mitral/tricuspid valve shutting

59
Q

What does dub indicate in the heart?

A

diastole or S2 & is the sound associated w/ aortic/pulmonic valve closing

60
Q

Where is the location of the aortic sound?

A

right base, 2nd intercostal space to right of sternal border

61
Q

Where is the location of the pulmonic sound?

A

left base; 2nd intercostal space to left of the sternal border

62
Q

Where is the location of the tricuspid sound?

A

left lateral sternal border; 5th intercostal space to the left of the sternal border

63
Q

Where is the location of the mitral sound?

A

apex, midclavicular line @ the 5th intercostal space

64
Q

What are the pulse sites we can take around the body?

A

carotid
brachial
radial
ulnar
aplical
femoral
popliteal
dorsalis pedis

65
Q

Which pulses do we assess & how do we assess them?

A

carotid- one @ a time
radial - bilaterally @ the same time
apical - w/ stethoscope for 2 beats
dorsalis pedis or pedal pulses - bilaterally @ the same time

66
Q

What does a 0 pulse quality mean?

A

absent, non-palpable

67
Q

What does 1+ pulse quality mean?

A

diminished, palpable

68
Q

What does 2+ pulse quality mean?

A

strong, normal

69
Q

What does 3+ pulse quality mean?

A

full, increased

70
Q

What does 4+ pulse quality mean?

A

bounding

71
Q

Which pulse do we assess w/ a doppler?

A

pedal pulse

72
Q

How do we assess capillary refill?

A

press skin of nail bed & observe time taken for color to return
should be less than 2-3 secs

73
Q

How do we assess for edema?

A

observe for swelling

74
Q

What is dependent edema?

A

most often on feet & ankles, older adults & standing

75
Q

What is pitting edema?

A

venous insufficiency or heart failure
fluid in tissues

76
Q

Where do we asses for ROM on the body?

A

neck
shoulders
upper arms/elbows
wrists
hips
knees
ankles

77
Q

What do we do assess for neck ROM?

A

move neck side to side
chin to chest
extension back

78
Q

What do we assess for shoulders, upper arms & elbows?

A

arms out to side
arms up
touchdown

79
Q

What do we ask pt’s to do for ROM in wrists?

A

wrist circles

80
Q

What do we assess for hip, knees, & ankles ROM?

A

bilateral hip flexion out
bend knees
ankle circles

81
Q

How do we assess a pt’s strength?

A

handgrip
toe wiggle
flexion & extension

82
Q

What do we inspect skin for?

A

hydration
temp
color
texture
rashes
lesions
cracking

83
Q

What is pallor color?

A

pale or ashen gray

84
Q

What is erythema color?

A

redness r/t vasodilation

85
Q

What is jaundice color?

A

yellow, impaired liver

86
Q

What is cyanosis color?

A

bluish, decreased circulation or oxygenation of blood

87
Q

What can skin characteristics offer clues about?

A

the health status of the pt

88
Q

What should temp be?

A

warm, consistent w/ room temp

89
Q

what should we look for moisture wise?

A

diaphoresis or dehydration

90
Q

what does turgor test?

A

elasticity of skin related to hydration

91
Q

What factors effect skin?

A

dampness
dehydration
nutrition
circulation
disease
jaundice
lifestyle

92
Q

What are normal skin changes in adults?

A

epidermis
subcutaneous tissue
collagen & elastin fibers
hormones
vascularity
hair follicles
melanocytes
nails
skin growths

93
Q

What causes pitting edema?

A

caused by kidney or heart failure
leads to excess fluid collection in tissues

94
Q

What does 1+ mean on the pitting edema four point scale?

A

2mm to trace
skin responds rapidly

95
Q

What does 2+ mean on the pitting edema four point scale?

A

4mm to mild
10-18 secs response time

96
Q

What does 3+ mean on the pitting edema four point scale?

A

6mm to moderate
1-2 min response time

97
Q

What does 4+ mean on the pitting edema four point scale?

A

8mm to severe
2-5 mins response time

98
Q

What do we assess on the hips, heels, coccyx, & shoulders?

A

asses for skin integrity
blanching red spots

99
Q

What do we observe for in nail health?

A

shape
contour
cleanliness
neatly manicured/trimmed

100
Q

What should healthy nails look like?

A

transparent
smooth
rounded
convex
hygienic

101
Q

Where is terminal hair?

A

scalp, axillae, pubic, & beard

102
Q

Where is vellus hair?

A

soft tiny hairs covering body except on palms & soles

103
Q

What else should we assess for in hair

A

quantity
distribution
texture
color
parasites

104
Q

What should we assess the ears?

A

symmetry, drainage, shape, hearing defects, lesions, redness, tenderness, odor

105
Q

What do we assess nose for?

A

position, symmetry, color, swelling, deformities, discharge, flaring, patency, sinus tenderness

106
Q

What do we inspect in the oral cavity?

A

lips
oral mucosa
teeth
gums/tongue
breath odor

107
Q

What do we inspect the throat for?

A

lumps
ulcers
edema
white spots
redness
swallowing

108
Q

What do we inspect the neck for?

A

contour & symmetry, midline trachea, jugular distension

109
Q

What do we palpate the neck for?

A

inflamed/enlarged lymph nodes

110
Q

Where does most food digest in the intestines?

A

small intestine
duodenum, jejunum, & ileum

111
Q

What is the large intestine called & what components make it up?

A

colon
cecum, ascending colon, transverse colon, decreased colon, sigmoid colon, rectum, anus

112
Q

How do we assess the abdomen

A

inspect
auscultate bowel sounds in four quads
palpate for tenderness, masses, pain

113
Q

What q’s should we ask during abdominal exam?

A

normal bowel & urinary patterns
appearance
changes
history of problems

114
Q

What should we assess peri area for?

A

for erythema, discharge, swelling, or odor
signs of infection
inflammation
trauma
color
condition
presence of urine or stool

IM1 (18 decks)

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