Cardiac Head-to-toe assessment

Question 1

Auscultate heart sounds: (2) check page 17 for pictures

Answer 1

1: are they regular or irregular
2: any murmurs, mufed, or whooshing heart sounds

Question 2

Aortic:

Answer 2

2nd intercostal space R sternal border

Question 3

Pulmonic:

Answer 3

2nd intercostal space L sternal border

Question 4

ERBs point:

Answer 4

3rd intercostal space L sternal border

Question 5

Tricuspid:

Answer 5

4th intercostal space L sternal border

Question 6

Mitra:

Answer 6

5th intercostal space L midclavicular line

Question 7

remember APETM: ( all, people, enjoy, time, magazine.

Answer 7

A: aortic
P: pulmonic
E: ERBs point
T: tricuspid
M: mitra

Question 8

Lower extremities: (4)

Answer 8

~ inspect color, hair distribution, any lesions or swelling
~ palpate for edema (pitting or non-pitting)
~ check cap refill
~ assess strength (have patient fex & press feet against hands

Question 9

Pulse check: (4)

Answer 9

1: dorsalis pedis (pedal)
2: posterior tibial
3: popliteal
4: femoral

Question 10

Pulse check steps (3)

Answer 10

1: start at pedal pulse
2: move UP to next landmarks
3: if unable to feel a pulse, check with a doppler

Question 11

Urinary: (3)

Answer 11

~ assess if patient has foley catheter, external catheter, or voids on their own
~ assess color and quantity
~ palpate bladder for any distention

Question 12

Urine color meanings: clear

Answer 12

overhydration

Question 13

Urine color meanings: Pale yellow

Answer 13

normal

Question 14

Urine color meanings: amber

Answer 14

dehydrated

Question 15

Urine color meanings: brown

Answer 15

liver disease or severe dehydration

Question 16

Urine color meanings: pink/red

Answer 16

possible blood, food dye, kidney disease

Question 17

Urine color meanings: green

Answer 17

possible effect form medication or bacterial infection

Question 18

Abdomen: (4)

Answer 18

~ inspect color, contours, scar, etc.
~ auscultate starting in ELQ & move clockwise
~ percuss for tympany or dullness
~ palpate lightly in all 4 quadrants

Question 19

Abdomen assessment order changes: (4)

Answer 19

1: inspect
2: auscultate
3: percuss
4: palpate ( palpating and percussing before auscultating may produce false bowel sounds

Question 20

Hyperactive:

Answer 20

> 30 sounds per minute (may be able to hear without stethoscope)

Question 21

Normoactive:

Answer 21

5-30 sounds per minute

Question 22

Hypoactive:

Answer 22

<5 sounds per minute

Question 23

Absent:

Answer 23

must listen for at least 5 minutes to confirm absent bowel sounds

Question 24

Skin:

Answer 24

~ throughout assessment, take note of any lesions, rashes, discoloration, or skin breakdown
~ make sure to check patients points of contact

Question 25

Skin (points of contact):

Answer 25

any bony prominences such as the sacrum and heels can start to break down FAST if the patient is malnourished with other risk factors

Question 26

Skin (points of contact) (7):

Answer 26

head shoulders elbows sacrum buttocks heels toes

Question 27

Upper extremities (3) plus note:

Answer 27

~ inspect for lesions, scars, swelling, tenderness, color, texture, etc. ~palpate radial pulses bilaterally ~ assess strength (have patient squeeze hands) + if no pulse found must check with doppler

Question 28

Capillary refill:

Answer 28

press finger for a seconds & count how long it takes to regain color normal <2-3 seconds

Question 29

Pulse scale (5):

Answer 29

4+ bounding 3+ increased 2+ normal 1+ weak 0 absent

Question 30

Musculoskeletal: during your assessment take note

Answer 30

~ is the patient easily moving or do they require assistant ~ are there any gait abnormalities ~ is one side weaker than the other