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CSON IM1 > EXAM 3- Head to Toe Assessment > Flashcards

EXAM 3- Head to Toe Assessment Flashcards

1
Q

what should you do before beginning a head to toe assessment?

A
  • consider age group
  • organizeation of the assessment
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2
Q

what is the most important neuro assessment component?

A

level of conciousness

(LOC) often the 1st clue of deteriorating condition

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3
Q

what levels are you testing for when assessing a pt’s LOC?

5

A
  • alert- attentive, follows commands or wakes promptly & remains attentive
  • lethargic- drowsy but awakens, slow to respond
  • obtunded- difficult to arouse, needs constant stimulation
  • stuporous/semi-comatose- arouses only to vigorous/noxious stimuli, may only withdraw from pain
  • comatose- no response to verbal/ noxious stimuli, no movement except deep tendon reflex
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4
Q

examples of a vigorous/noxious stimuli to test alterness

A

pinching, sternal rub, pressure points

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5
Q

cognitive awareness

A

is the pt oriented to person, place, event, & time?

AxOx4

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6
Q

what does mentation assess?

A

cognitive awareness

AxOx4

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7
Q

what should you ask your pt when assessing cognitive awareness?

4

A
  • person- name? DOB?
  • place- where are you?
  • time- what month/year is it?
  • event- what brought you in today? why are you in the hospital?
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8
Q

how many cranial nerves are there?

A

12

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9
Q

cranial nerves I, II, III

not on test

A
  • CN I- olfactory
  • CN II- optic
  • CN III- oculomotor
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10
Q

cranial nerves IV, V, VI

not test

A
  • CN IV- trochlear
  • CN V- trigeminal
  • CN VI- abducens
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11
Q

cranial nerves VII, VIII, IX

not on test

A
  • CN VII- facial
  • CN VIII- vesibulocochlear
  • CN IX- glossopharyngeal
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12
Q

cranial nerves X, XI, XII

not on test

A
  • CN X- vagus
  • CN XI- accessory
  • CN XII- hypoglossal
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13
Q

what doi CN III, IV, and VI test for?

A
  • pupil response
  • cardinal gaze
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14
Q

assessing pupil response

A

examine the size & shape of pupils
* move light from ear toward nose
* note change in size & speed
* with light off, move pen close & far away

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15
Q

assessing cardinal gaze

A
  • have pt follow the pen as you move the pen in an “H” motion
  • 9-12 inches away from pt
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16
Q

testing cranial nerve VII

A
  • ask pt to smile with teeth
  • ask pt to raise eyebrows/ wrinkle forehead
  • assess for inability or one sided drooping
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17
Q

testing cranial nerve XII

A
  • ask pt to touch roof of mouth with rongue
  • stick out tongue
  • move tongue side to side
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18
Q

testing cranial nerve XI

A
  • place hands lightly on pt shoulders
  • ask pt to shrug shoulders
  • test resistance/ strength
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19
Q

testing motor function

A

part of neuro & musculoskeletal aseessments
* hand grasp & toe wiggle (HGTW)
* flexion/extension with resistance

all should be assessed bilaterally on BUE BLE

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19
Q

testing motor function

A

part of neuro & musculoskeletal aseessments
* hand grasp & toe wiggle (HGTW)
* flexion/extension with resistance

all should be assessed bilaterally on BUE BLE

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20
Q

neuro components of assessment

A
  • LOC & orientation (AxOx4)
  • pupil response & cardinal gaze
  • smile with teeth, raise eyebrows
  • tongue to roof of mouth, out, side to side
  • shoulder strength with resistance
  • HGTW
  • flexion/extension BUE & BLE
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21
Q

vesicular lung sounds

A

normal
periphery of the lungs

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22
Q

bronchovesicular lung sounds

A

normal
closer to the sternum

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23
Q

crackles (rales) lung sounds

A

abnormal
* can be fine or coarse
* caused by fluid excretions
* high pitch
* heard at the base of lungs

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24
Q

rhonchi lung sounds

A

abnormal
* coarse sounds
* caused by mucus in airway, usualy clears with cough
* heard over trachea

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25
Q

wheezing lung sounds

A

abnormal
* high pitch
* heard over all lung areas on exhalation
* caused by ** narrowing of airways** (asthma, COPD)

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26
Q

pleural friction rub lung sounds

A

abnormal
* main reason why we listen with stethoscope on skin
* sounds like clothes rubbing
* occurs when there is no fluid between lungs & pleural tissue
* very painful

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27
Q

abnormal respiratory patterns

6

A
  • bradypnea
  • tachypnea
  • apnea
  • hypernea
  • kussmaul’s
  • cheyne - stokes
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28
Q

pattern of auscultation of the respiratory system

A
  • **start on left side **(Lungs on Left)
  • move to right side to compare L & R sides of the same lung region
  • listen to an **inhalation & exhalation **to compate
  • ask pt to breathe deeply on posterior 7-10
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29
Q

why would you assess the nails as part of the respiratory assessment?

A
  • examine for clubbing- results from chronically low O2 levels
  • examine BUE nail shape
  • ask pt to put finger nails together (normal should touch)
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30
Q

respiratory components of assessment

2

A
  • anterior & posterior lung sounds
  • clubbing
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31
Q

know the pathophysiology of blood flow through the heart & lungs

A
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32
Q

LUB

A

systole or S1
the sound associated with the closing of the mitral/tricuspid valves

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33
Q

DUB

A

diastole or S2
the sound associated with the closing of the aortic/pulmonic valves

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34
Q

where are the pauses in the lub/dub sounds?

A

natural pauses:
* between S1 and S2

longer pause:
* between S2 and S1

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35
Q

where is the aortic heart sound?

A
  • right base
  • 2nd ICS to the right of sternal border
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36
Q

where is the pulmonic heart sound?

A
  • left base
  • 2nd ICS to the left of sternal border
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37
Q

where is the tricuspid heart sound?

A
  • left lateral sternal border
  • 5th ICS to the left of sternal border
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38
Q

where is the mitral/ apical heart sound?

A
  • apex
  • midclavicular line at 5th ICS
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39
Q

All Party Til Midnight

A
  • aortic
  • pulmonic
  • tricuspid
  • mitral
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40
Q

know the basic conduction of the heart

A
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41
Q

which pulses do we assess in a head to toe assessment?

A
  • carotid
  • radial
  • apical
  • dorsalis pedis
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42
Q

how do you assess the carotid pulse?

A

one at a time, bilaterally

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43
Q

how do you assess the radial pulse?

A

bilaterally at the same time

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44
Q

how do you assess the apical pulse?

A

with a stethoscope for 2 beats

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45
Q

how do you assess the dorsalis pedis or pedal pulses?

A

bilaterally at the same time

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46
Q

pulse points

A
  • 4+ bounding
  • 3+ full, increased
  • 2+ strong/ normal
  • 1+ diminished, palpable
  • 0 absent, non palpable
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47
Q

if you cannot find a pedal pulse, what would you do?

A

use a doppler

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48
Q

cardiac components of assessment

A
  • heart sounds
  • carotid pulses
  • radial pulses
  • pedal pulses
  • capillary refill
  • assess for edema
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49
Q

what areas do you assess ROM for?

A
  • neck
  • shoulders, upper arms & elbows
  • wrists
  • hips
  • knees
  • ankles
50
Q

neck ROM

A
  • side to side
  • chin to chest
  • extension backward
51
Q

shoulders, upper arms, & elbow

A
  • arms out to side
  • arms straight up
  • touchtown
52
Q

wrists ROM

A

wrist circles

53
Q

hips, knees, & ankles ROM

A
  • bilateral hip flexion out (bend knee, move outward)
  • bend knees
  • ankle circles
54
Q

strength ROM

A
  • handgrip
  • toe wiggle
  • flexion & extension of BUE/BLE
55
Q

musculoskeletal components of assessment

A
  • neck ROM
  • BUE ROM
  • BLE ROM
  • HGTW
  • flexion/extension BUE and BLE
56
Q

skin assessment

A
  • temperature- should be warm, consistent with room temp
  • moisture from diaphoresis or dry from dehydration
  • texture - dry/course or shiny with no hair (impaired peripheral circulation)
  • turgor tests elasticity of the skin (hydration)
57
Q

why would a patient’s skin be shiny with no hair?

A

impaired peripheral circulation

58
Q

what does turgor test for?

A

hydration

gentle pinch on the clavicle

59
Q

factors effecting the skin

A
  • dampness
  • dehydration
  • nutrition
  • circulation (low circulation = tissue death)
  • disease (eczema, psoriasis)
  • jaundice
  • lifestyle (moisture, barriers)
60
Q

how do the epidermis & subcutaneous tissue change in older adults?

A

as age increases, the skin is:
* thinner
* paler
* more translucent
* bruises easier & heals slower
* cold

61
Q

how does the collagen & elastin fibers change in older adults?

A

lower collagen = more wrinkles

62
Q

how do hormones change in older adults?

A

lower hormones = dry/thinning of hair

63
Q

how do hair collicles, nails, & skin growths in order adults?

A
  • lower number of hair follicles & activity
  • thicker or softer nails
  • more warts, liver/age spots on skin
64
Q

how do melanocytes change in older adults?

A

skin pigmentation decreases = causes abnormal pigmentation & grey hair

65
Q

how does vascularity change in older adults?

A

cooler extremities over time

66
Q

pitting edema

A
  • caused by kidney or heart failure
  • leads to excess fluid in tissues
67
Q

pitting edema scale

A
  • 1+: 2mm, rapid response
  • 2+: 4mm, 10-18 second response
  • 3+: 6mm, 1-2 minute response
  • 4+: 8mm, 2-5 minute repsponse
68
Q

what areas of the body are prone to skin breakdown? (bony preminences)

A
  • hips
  • heels
  • coccyx
  • shoulders

low tissue/muscle between the bone & skin

69
Q

how do you assess body prominences for skin breakdown?

A

non-blanching red spots are a problem

70
Q

how do you assess the nails?

A
  • nail shape, countor, cleanliness
  • transparent, smooth, round, convex, hygienic
71
Q

how do you assess the hair?

A
  • terminal hair
  • vellus hair
  • quality (alopecia, hirsutism)
  • distribution
  • texture
  • color
  • parasites
72
Q

terminal hair

A

scalp, axillae, pubic, & beard

73
Q

vellus hair

A

soft tiny hairs covering the body except on palms & soles

this is what makes us mammals

74
Q

alopecia

A

baldness, excessive/unusual hair loss

75
Q

hirsutism

A

excess hair where not generally expected

76
Q

how do you assess the ears?

A
  • use penlight
  • assess neck ROM at the same time
  • inspect for symmetry, drainage, shape, hearing defects, lesions, redness, tenderness, & odor
77
Q

how do you assess the nose?

A
  • assess neck ROM at the same time
  • inspect for position, color, symmetry, swelling, deformities, discharge, flaring, patency, sinus tenderness
78
Q

how do you assess the oral cavity?

A

inspect:
* lips
* oral mucosa
* teeth
* gums/tongue
* breath odor

79
Q

how do you assess the throat?

A

inspect for:
* lumps
* ulcers
* edema
* white spots
* redness
* swallowing

80
Q

how do you assess the neck?

A

inspect for:
* contour & symmetry, midline trachea, jugular vein distention

palpapte for:
* inflamed/enlarged lymph nodes (circular motion)

81
Q

components of integument assessment

A
  • hair & scalp
  • ears, nose, mouth/throat
  • inspect & palpate neck
  • skin turgor
  • skin on back & bony prominences
  • skin of BUE & BLE
  • nails
82
Q

elimination

A

excretion of waste products from kidneys & intestines

83
Q

defacation

A

process of elimination of waste

84
Q

feces

A

semisolid mass of fiber, undigested good, inorganic matter

85
Q

incontinence

A

inability to control urine or feces

86
Q

void/ micturate

A

to urinate

87
Q

dysuria

A

painful or difficult urination

88
Q

hematuria

A

blood in the urine

hemat (blod) + uria (urine)

89
Q

nocturia

A

frequent night urination

kidneys should be functioning slower at night

noct (night) + uria (urine)

90
Q

polyuria

A

large amounts of urine

poly (many) + uria (urine)

91
Q

urinary frequency

A

voiding at frequent intervals

92
Q

urinary urgency

A

the need to void all at once

cannot wait/hold it at all

93
Q

proteinuria

A

presence of large protein in urine

kidney disfunction

94
Q

dribbling

A

leakage of urine despite coluntary control of urination

95
Q

retention

A

accumulation of urine in bladder without the ability to completely empty

96
Q

residual

A

urine remaining post void > 100mL

97
Q

structures of GI tract

A
  • upper GI tract (mouth, pharynx, esophagus, stomach: begins mastication)
  • small intestine
  • large instestine
  • rectum & anus
98
Q

where dost mastication begin?

A

upper GI tract (mouth, pharynx, esophagus, stomach)

99
Q

structure of the small intestine

A
  • folded, twisted, & coiled tube from stomach to large intestine
  • 1” in diameter, 20’ long
100
Q

function of the small intestine

A
  • most digestion & absorption
  • chyme (partially digested food) travels via peristalsis (moves, sits, absorbs)
101
Q

3 segments of the small intestine

A
  • duodenum
  • jejunum
  • ileum
102
Q

structure of the large intestine

A

2.5” in diameter, 5-6’ long

103
Q

7 segments of the large intestine

A
  • cecum
  • ascending colon
  • transverse colon
  • descending colon
  • sigmoid colon
  • rectum
  • anus
104
Q

structure of the rectum

A
  • 6” long
  • lots of blood flow
  • should be free of stool until defacation
105
Q

another term for large intestine

A

colon

106
Q

organs involved in urinary elimination

A
  • kidneys- filter/regulate, remove waste from blood to form urine
  • ureters- transport urine from kidneys to bladder
  • bladder- reservoir for urine until the urge develops
  • urethra- urine travels from bladder & exits through urethral meatus
107
Q

know the structure of the urinary tract

A
108
Q

kidney structure & function

A
  • location: bilateral, posterior flanks
  • size of a fist
  • primary regulators of fluid & acid-base balance
109
Q

components of the nephron

A
  • glomerulus
  • bowman’s capsule
  • proximal convoluted tubule (PCT)
  • loop of Henle (absorption & reabsorption)
  • distal covoluted tubule (DCT)
  • collecting duct
110
Q

what is the functioning unit of the kidney

A

nephron

111
Q

function of the ureters

A
  • tubule structures that enter the bladder
  • typically sterile urine
  • urine enters bladder obliquely & posteriorly to prevent reflux
112
Q

renal colic

A

obstructions cause peristalitic waves of severe pain

kidney stones

113
Q

why do the ureters enter the bladder obliquely & posteriorly?

A

to prevent reflux

114
Q

structure of the bladder

A
  • hollow, distensible (grows & contracts), muscular organ
  • in men- lies aggainst anterior wall of rectum
  • in women- rests against anterior walls of uterus & vagina
  • when the bladder is full, it extends above the symphysis pubis
115
Q

how much can the bladder hold normally? extended?

A
  • normal- 500mL
  • can extend to- 1000mL
116
Q

structure of the urethra

A
  • decends through pelvic floor muscles
  • in men- 8” long, part of GU & reproductive system, 3 sections (prostatic, membranous, & penile)
  • in women- 1.5-2.5” long, prone to infection
117
Q

function of the urethra

A
  • turbulent (powerful/fast) flow washes urethra free of bacteria
  • contraction of pelvic floor muscles can prevent flow of urine
118
Q

why are women more likely to obtain a UTI?

A

shorter urethra
(less area for bacteria to have to travel to infect the person)

1.5-2.5” urethra

119
Q

which assessment MUST you do in a particular order?

A

abdominal

120
Q

how do you assess the abdomen?

A
  1. inspection- observe size, shape, contour, skin integrity
  2. auscultation- bowel sounds, 4 quadrants (hypoactive, active, hyperactive) (RLQ, RUQ, LUQ, LLQ)
  3. palpation- palpate for tenderness, pain, masses, distension
  4. ask- normal bowel/urine patterns & frequency, appearance, changes, hx of problems
121
Q

in what order to you auscultate & palpate the quadrants of the abdomen?

A
  1. RLQ
  2. RUQ
  3. LUQ
  4. LLQ
122
Q

how do you assess the urethra meatus & perineal area?

A
  • inspect for erythema, discharge, swelling, or odor
  • inspect for signs of infection, inflammation, or traums
  • peri area: color, condition, presence of urine or stool (abnormal)
123
Q

GI/ GU components of assessment

A
  • abdomen- look, listen, feel
  • ask about bowel/urinary habits
  • examin urethral meatus & perineal area

CSON IM1 (15 decks)

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