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Module 1 > Head to Toe Assessment > Flashcards

Head to Toe Assessment Flashcards

1
Q

before starting head to toe, think about…

A

-age group
-organization of assessment (clean to dirty)

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2
Q

testing level of consciousness (LOC) - 5

A

-alert
-lethargic
-obtunded
-stuporous/semi-comatose
-comatose

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3
Q

alert LOC

A

attentive, follows commands, if asleep – wakes promptly and remains attentive

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4
Q

lethargic LOC

A

Drowsy but awakens, slow to respond

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5
Q

obtunded LOC

A

Difficult to arouse, needs constant stimulation

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6
Q

stuporous/semi-comatose LOC

A

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

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7
Q

vigorous

A

loud, hard

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8
Q

noxious

A

unpleasant, knuckle rub to sternum, soft spot behind ear (pressure points), nail bud pressure

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9
Q

comatose LOC

A

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

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10
Q

cognitive awareness
-what do we orient patient to? (4)
-also known as…

A

-orient person to person, place, time, event
-mentation

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11
Q

how do we test cranial nerves III, IV, and VI?

A

-pupil response
3-oculomotor
4-trochlear
6-abducens

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12
Q

pupil response (PERRLA)

A

Pupils Equal Round Reactive Light and Accommodation

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13
Q

how do we test pupil response

A

place hand on bridge of nose, start at ear, move light into pupil (should constrict) – document size of pupil constriction
-same thing for other side

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14
Q

testing cardinal gaze

A

9-12 in. from face, move penlight in shape of an H, can pt eyes track movement

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15
Q

how do we test cranial nerve VII?

A

7-facial nerve
ask pt to smile, wrinkle forehead/raise eyebrows
-is it all even?

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16
Q

how do we test cranial nerve XII?

A

12 - hypoglossal
ask pt. to touch roof of mouth with tongue, stick tongue out, move tongue side to side

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17
Q

how do we test cranial nerve XI?

A

11-accessory
ask pt. to shrug shoulders, place hands on pt. shoulders with light resistance

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18
Q

how do we test motor function? what is included in this?

A

-neuro and musculoskeletal
-have patient grasp hands
-flexion and extension (push against hands and pull back)
-put hands on sole of foot, ask pt to push against, hand on top of foot, ask to push up

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19
Q

neuro components of assessment

A

-Level of consciousness and orientation x4
-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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20
Q

vesicular lung sounds

A

heard in all of lobes
soft, blowing sound

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21
Q

bronchovesicular lung sounds

A

closer to sternum
hollow quality sound

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22
Q

bronchial lung sounds

A

over trachea
loud, blowing sound

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23
Q

wheeze lung sounds

A

-high pitched musical sounds
-“strider” : struggling to breathe

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24
Q

crackle/rales lung sounds (fine or coarse)

A

-Rice Krispies
-crackling (mostly heard in lung bases)
-lower lobes
-fluid collection

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25
Q

rhonchi lunch sound

A

-rumbling
-mucus
-bigger airways
-normally cleared when they cough

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26
Q

pleural friction rub lung sound

A

-sounds like stethescope to clothing
-pleural cavity loses fluid, no lubrication

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27
Q

bradypnea respiratory pattern

A

slow breathing

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28
Q

tachypnea

A

fast breathing

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29
Q

apnea

A

abscence of breathing

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30
Q

hyperpnea

A

patient is struggling and rapid breathing

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31
Q

Kussmaul’s

A

respirations are becoming slow and low

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32
Q

Cheyne-stokes

A

increase in rr/depth, decrease in rr/depth, absence (apnea)

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33
Q

pattern of auscultation-lungs

A

7 on front
10 on back, follow scapula
start on left!

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34
Q

when do we have patient take deep breaths? why?

A

on back , 7-10
farther away from trachea, quieter lung sounds & lower lobes are where we normally have disease and fluid collection

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35
Q

examining nail shape

A

have patient put nails together, cuticles touching, a little space between
-clubbing (low o2)

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36
Q

respiratory assessment components

A

-anterior and posterior lung sounds
-clubbing

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37
Q

LUB heart sound

A

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

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38
Q

LUB DUB

A

1 cardiac cycle

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39
Q

DUB

A

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

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40
Q

there should be a longer pause between ___

A

S2 and S1

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41
Q

aortic

A

right base, second intercostal space to right of sternal border
2 heart cycles

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42
Q

pulmonic

A

left side, second intercostal space to left of sternal border
lub dub/ 2 cycles

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43
Q

tricuspid

A

left lateral sternal border, 5th intercostal space to left of sternal border

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44
Q

mitral

A

apical pulse/apex ; midclavicular line at the 5th intercostal space

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45
Q

pulses assessed in assessment

A

carotid (feeling bilaterally, not together)
radial (at same time, 2 cycles)
apical (cardiac, 2 beats)
dorsalis pedis (at same time, 2 cycles)

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46
Q

0 quality pulse point

A

absent, non-palpable

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47
Q

1+ pulse

A

diminished, palpable

48
Q

2+ pulse

A

strong, normal

49
Q

3+ pulse

A

full, increased

50
Q

4+ pulse

A

bounding

51
Q

if unable to locate pulse by palpation, _____

A

use doppler

52
Q

capillary refill

A

applying pressure to nail bed and observe time it takes to return color (2-3 seconds)
-bilateral upper extremities and lower (finger nails and toenails)

53
Q

edema

A

swelling in extremities

54
Q

dependent edema

A

most often on feet or ankles, older adults and standing

55
Q

pitting edema

A

venous insufficiency or heart failure, fluid in tissues

56
Q

cardiac components of assessment

A

Heart sounds
Carotid pulses
Radial pulses
Pedal pulses
Capillary refill
Assess for edema

57
Q

range of motion tests (7)

A

Neck
Shoulders, upper arms, & elbows
Upper arms & Elbows
Wrists
Hips
Knees
Ankles

58
Q

neck ROM

A

-move neck side to side
-chin to chest
-extension back

59
Q

shoulders,, upper arms and elbows

A

arms out to side, arms straight up, touchdown

60
Q

wrists ROM

A

circles

61
Q

hips, knees, and ankles ROM

A

-bilateral hip flexion out
-bend knees
-ankle circles

62
Q

musculoskeletal components

A

-neck ROM
-BUE ROM
-BLE ROM
-HGTW
-flexion/extension of BUE and BLE

63
Q

inspect skin for (7)

A

Hydration
Temperature
Color
Texture
Rashes
Lesions
Cracking

64
Q

pallor

A

pale or ashen gray

65
Q

erythema

A

redness related to vasodilation

66
Q

jaundice

A

yellow, impaired liver
skin or sclera of eyes

67
Q

cyanosis

A

bluish, decreased circulation or oxygenation of blood
around mouth, nail beds

68
Q

turgor test

A

pinch to skin under clavicle related to hydration, will tent if dehydrated

69
Q

texture of skin can be…

A

dry and course, or shiny with no hair

70
Q

temperature of skin should be…

A

warm, consistent with room temp

71
Q

things affecting skin (7)

A

-dampness
-dehydration
-nutrition
-circulation
-disease
-jaundice
-lifestyle

71
Q

normal skin changes in older adults (8)

A

-epidermis
-subcutaneous tissue
-collagen and elastin fibers
-hormones
-vascularity
-melanocytes
-nails
-skin growths

72
Q

pitting edema cause by …
leads to …

A

kidney or liver heart failure
-leads to excess fluid collection in tissues

73
Q

1 + pitting edema

A

2mm indention to trace
rapid response

74
Q

2+ pitting edema

A

4mm to mild
10-18 seconds

75
Q

3 + pitting edema

A

6mm to moderate
1-2 minutes

76
Q

4+ pitting edema

A

8mm to severe
2-5 minutes

77
Q

assessment of bony prominences

A

-hips, heels, coccyx, shoulders (no muscle, subcutaneous tissue)
-most at risk for skin breakdown
-blanching red spots - make skin go pale, if it remains red, that is a pressure injury

78
Q

observe nails for :

A

-shape
-contour
-cleanliness
-neatly manicured / trimmed

79
Q

nails should be : (5)

A

-transparent
-smooth
-rounded
-convex
-hygienic

80
Q

terminal hair

A

scalp, axillae, pubic and beard

81
Q

vellus hair

A

defines us as mammals
-soft tiny hairs covering body except on palms of hands and soles of feet

82
Q

assessment of hair , looking for (5)

A

-quantity (alopecia, hirsutism-overgrowth)
-distribution
-texture
-color
-parasites

83
Q

assess ears for (8)

A

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

84
Q

inspect nose for (9)

A

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

84
Q

assess oral cavity for (6)

A

lios, oral mucosa, teeth, gums/tongue, breath

85
Q

inspect throat (6)

A

lumps, ulcers, edema, white spots, redness, swallowing

85
Q

inspect throat for (6)

A

lumps, ulcers, edema, white spots, redness, swallowing

86
Q

inspect neck for

A

contour and symmetry, midline trachea, jugular vein distention

87
Q

palpate neck for

A

inflamed/enlarged lymph nodes

88
Q

integument components of assessment

A

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

89
Q

elimination

A

excretion of waste products from kidneys and intestines

90
Q

defecation

A

process of elimination of waste

91
Q

feces

A

Semisolid mass of fiber, undigested food, inorganic matter

92
Q

assessment of abdomen

A

inspect
auscultate
palpate

93
Q

inspection of abdomen

A

look at size, shape, contour, skin integrity

94
Q

auscultation of abdomen

A

listen for bowel sounds 5-20seconds, four quadrants - hypo/hyperactive

95
Q

palpation of abdomen

A

feel for tenderness, pain, masses

96
Q

questions to ask while assessing abdomen

A

-normal bowel and urine patterns
-appearance
-changes
-history if problems

97
Q

incontinence

A

inability to control urine or feces

98
Q

void / micturate

A

to urinate

99
Q

dysuria

A

painful or difficult urination

100
Q

hematuria

A

blood in the urine

101
Q

nocturia

A

frequent night urination

102
Q

polyuria

A

large amounts of urine

103
Q

urinary frequency

A

voiding at frequent intervals

104
Q

urinary urgency

A

the need to void all at once

105
Q

proteinuria

A

presence of large protein in urine

106
Q

dribbling

A

leakage of urine despite voluntary control of urination

107
Q

retention

A

accumulation of urine in bladder without the ability to completely empty

108
Q

residual

A

urine remaining post void >100ml

109
Q

kidney functions

A

filter and regulate blood and fluid of body
-regulate acid-base balance

110
Q

ureter function

A

transport urine from kidneys to bladder
-urine through ureters should be sterile
-enter bladder obliquely and posteriorly
-only meant to have fluid (renal colic)

111
Q

bladder function

A

hollow
reservoir for urine until urge develops
-men- anterior wall of rectum
-women - anterior walls of uterus and vagina
-normal bladder - 500 ml, can extend to 1000ml

112
Q

urethra function

A

urine travels from bladder and exits through urethral meatus
-urine that travels through has turbulent flow to prevent bacteria growth
-women : 1.5 to 2.5 in (more prone to UTI)
-men : 8 in

113
Q

nephrons

A

functional unit of kidney

114
Q

assessment of urethra meatus and perineal area

A

-inspect urethral orifice
-look for signs of infection
-perineal area : color, condition, presence of urine or stool

Module 1 (13 decks)

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