HEAD TO TOE Flashcards

Question

organizing the shift assessment part 2

Answer 1

6. Palpate for any thrill in the chest, palpate abdomen for pain/tenderness (ask for last BM,diet, urine) 7. Assess upper extremities (bilateral radial pulses, skin condition, turgor, cap refill, clubbing,edema, ROM/strength, and sensation) 8. Assess lower extremities (bilateral pedal pulses, skin condition, turgor, cap refill, clubbing,edema, ROM/strength, and sensation) 9. Assess any other areas of the skin, looking at color, temperature, wounds, lesions, etc. 10. Check environment for safety, assess lines/drains/tubes, etc

Answer 2

vs including pain

Answer 3

Clean appearing, resting comfortably in bed watching TV, NAD

Answer 4

A&O x3 (or x4), PERRLA intact, sensation intact x4

Answer 5

full rom x4 strength intact

Answer 6

normocephalic, facial features symmetrical, mucous membranes pink and moist, no irritation ordrainage present, denies any problems

Answer 7

Respiratory: respirations even and unlabored, Lungs CTA bil., O2 sat 98% RA, no clubbing present

Answer 8

normal S1&S2, no murmurs, lifts, or thrills, cap refill <2secs, radial and pedal pulses 2+,skin warm to touch, no peripheral edema

Answer 9

active bowel sounds x4, abdomen soft, non-tender, non-distended, denies any pain, last bm wasyesterday (was soft and easy to pass), consuming 75% of meals, on regular diet

Answer 10

GU: voiding clear yellow urine, denies any burning, hesitancy, or pain with urination

Answer 11

Skin: warm, color normal for ethnicity, no abrasions or wounds, no tenting

Answer 12

Other: IV sites, equipment, anything that you feel like did not fit in one of the other categories

Answer 13

thoracic cage symmetry Respirations (rate, rhythm, depth, effort) Accessory muscle useSkin color & condition Person’s position (COPD tripod ?) Facial expression Level of consciousness Transverse diameter versus anterior/posteriordiameter ratio

Answer 14

Symmetric expansion Tactile fremitus Lumps, masses, tenderness, crepitus

Answer 15

percuss over lung fields

Answer 16

Assess anterior and posterior chest fornormal breath sounds Note any abnormal/adventitious breathsounds

Answer 17

blood Vessels Inspect & palpate carotid pulse JVD (jugular vein distention) present

Answer 18

Inspect & palpate apical pulse (note location) Inspect & palpate any heave (lift) or thrill

Answer 19

Identify anatomic areas for heart sounds Note rate & rhythm of heartbeat Identify S1 & S2, note any variation Listen for any extra heart sounds in S1 & S2 Listen for any murmurs in S1 & S2 Repeat sequence with bell Listen at apex with pt. in left lateral position Listen at the base with pt. in sitting position carotid arteries for bruits

Answer 20

Inspect & palpate the arms for: Symmetry Color any lesions Temperature texture turgor Capillary refill Nailbeds

Answer 21

Pulses: Radial Ulner Brachial Epitrochlear lymph node Modified Allen test Dialysis Access? Patent?

Answer 22

Inspect & palpate the legs for: Symmetry Color Temperature Size swelling or atrophy Lesions/ulcers Hair distribution Varicose veins

Answer 23

Pulses: Femoral Popliteal Posterior tibial Dorsalis pedis Inguinal lymph nodes Pretibial edema

Answer 24

Contour Symmetry Umbilicus Skin characteristics Pulsations or movement Person’s demeanor

Answer 25

bowel sounds gastric tympany (bell all 4 quadrants costovertebral angle tenderness

Answer 26

Light palpation in all fourquadrants Deep palpation in all fourquadrants Rebound Tenderness

Answer 27

scalp hair size/shape/symmetry temporal artery tmj area

Answer 28

Facial expression Eye contact Symmetry of movement (CN VII) Involuntary movements Edema or lesions

Answer 29

Symmetry Skin Thyroid Lymph nodes auscultate the theyroid (if enlarged for bruits) ROM

Answer 30

Pre-auricular Post auricular Occipital Superficial cervical Jugulodigastric (Tonsillar) Submandibular Submental Posterior cervical Supraclavicular Deep cervical chain

Answer 31

Test visual acuity: Snellen chart Near vision if age 40 & older, if reading difficulty Test visual fields: Confrontation test Inspect extraocular muscle function: Corneal light reflex (Hirschberg test) Cover test Diagnostic position test (6 cardinal positions)

Answer 32

General symmetry Eyebrows Eyelids & lashes Eyeball alignment Conjunctiva & sclera Lacrimal apparatus

Answer 33

Cornea & lens Iris & pupil: Size, shape, equality Pupillary light reflex Accommodation

Answer 34

Red reflex Optic disc (color, shape, margins) Retinal vessels Macula

Answer 35

Size & shape of auricle Position & alignment on head Skin condition (color, lumps, lesions) External meatus for size, swelling, redness, discharge, cerumen, lesions, foreign bodies Palpate auricle & tragus for tenderness

Answer 36

External canal (color, redness, discharge, swelling, lesions, foreign object) Tympanic membrane: Color & characteristics Position (flat, bulging, or retracted) Integrity of membrane Cone of Light (presence & direction)

Answer 37

Note response to conversational speech Voice test Weber test Rinne test

Answer 38

Inspect: external nose for symmetry, deformity, lesions Palpate: test for patency of each nostril Using nasal speculum, inspect: Nasal mucosa: color & integrity Septum: any deviation, perforation, bleeding Turbinates: color, swelling, exudates, polypsP alpate the sinuses (frontal & maxillary) for tenderness

Answer 39

inspect (using a penlight) for color, integrity of structures, any lesions: Lips Teeth Gums Tongue Buccal mucosa Palate & uvula: integrity & mobility Tonsils: Grade Pharyngeal wall

Answer 40

Muscles: Size, strength, tone Any involuntary movements Cerebellar function (Balance): Gait Tandem walking Romberg test Shallow knee bend or hop in place

Answer 41

Cerebellar function (Coordination): Rapid alternating movements(RAM) Finger-to-thumb test Finger-to-finger test Finger-to-nose test Heel-to-shin test

Answer 42

Spinothalamic tract: Pain (sharp vs. dull) Temperature Light touch

Answer 43

Posterior tract: Vibration Position (kinesthesia) Tactile discrimination: Stereognosis Graphesthesia Distinction Point location

Answer 44

Deep Tendon Biceps Triceps Brachioradialis Patella Achilles Superficial Plantar

Answer 45

CN I Olfactory: Smell (each nare at a time) CN II Optic: Visual acuity (distant & near vision) Visual fields by confrontation Ophthalmoscopic exam of fundI

Answer 46

CN III Oculomotor: EOM by six cardinal positions Raise eyebrows & eyelids symmetrically Pupillary size, direct & consensual response to light & accommodation CN IV Trochlear: Eye movement down & inward

Answer 47

CN V Trigeminal: Assess muscle movement & strength with clenching of teeth Superficial touch – three divisions Corneal reflex CN VI Abducens: Lateral movement of eye

Answer 48

CN VII Facial: Symmetry of facial features with expressions (smile, frown, puffed cheeks, wrinkled forehead, squint eyes tightly) Identify sweet & salty tastes on each side of tongue CN VIII Acoustic: Whisper test Weber test Rinne test

Answer 49

CN IX Glossopharyngeal : Gag reflex CN X Vagus: Phonates “ahh” Gag reflex Note swallowing Note voice quality

Answer 50

CN XI Spinal accessory: Turn head against resistance Shrug shoulders against resistance CN XII Hypoglossal: Protrude tongue Wiggle tongue from side to side Say “light, tight, dynamite” (evaluate quality of sounds l,t,d,n)