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Module 1 > Head to Toe Assessment > Flashcards

Head to Toe Assessment Flashcards

(117 cards)

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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
rhonchi lunch sound
-rumbling -mucus -bigger airways -normally cleared when they cough
26
pleural friction rub lung sound
-sounds like stethescope to clothing -pleural cavity loses fluid, no lubrication
27
bradypnea respiratory pattern
slow breathing
28
tachypnea
fast breathing
29
apnea
abscence of breathing
30
hyperpnea
patient is struggling and rapid breathing
31
Kussmaul's
respirations are becoming slow and low
32
Cheyne-stokes
increase in rr/depth, decrease in rr/depth, absence (apnea)
33
pattern of auscultation-lungs
7 on front 10 on back, follow scapula start on left!
34
when do we have patient take deep breaths? why?
on back , 7-10 farther away from trachea, quieter lung sounds & lower lobes are where we normally have disease and fluid collection
35
examining nail shape
have patient put nails together, cuticles touching, a little space between -clubbing (low o2)
36
respiratory assessment components
-anterior and posterior lung sounds -clubbing
37
LUB heart sound
systole or S1 and is sound associated with the closing of mitral/tricuspid valves
38
LUB DUB
1 cardiac cycle
39
DUB
diastole or S2 and is sound associated with closing of aortic/pulmonic valves
40
there should be a longer pause between ___
S2 and S1
41
aortic
right base, second intercostal space to right of sternal border 2 heart cycles
42
pulmonic
left side, second intercostal space to left of sternal border lub dub/ 2 cycles
43
tricuspid
left lateral sternal border, 5th intercostal space to left of sternal border
44
mitral
apical pulse/apex ; midclavicular line at the 5th intercostal space
45
pulses assessed in assessment
carotid (feeling bilaterally, not together) radial (at same time, 2 cycles) apical (cardiac, 2 beats) dorsalis pedis (at same time, 2 cycles)
46
0 quality pulse point
absent, non-palpable
47
1+ pulse
diminished, palpable
48
2+ pulse
strong, normal
49
3+ pulse
full, increased
50
4+ pulse
bounding
51
if unable to locate pulse by palpation, _____
use doppler
52
capillary refill
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
edema
swelling in extremities
54
dependent edema
most often on feet or ankles, older adults and standing
55
pitting edema
venous insufficiency or heart failure, fluid in tissues
56
cardiac components of assessment
Heart sounds Carotid pulses Radial pulses Pedal pulses Capillary refill Assess for edema
57
range of motion tests (7)
Neck Shoulders, upper arms, & elbows Upper arms & Elbows Wrists Hips Knees Ankles
58
neck ROM
-move neck side to side -chin to chest -extension back
59
shoulders,, upper arms and elbows
arms out to side, arms straight up, touchdown
60
wrists ROM
circles
61
hips, knees, and ankles ROM
-bilateral hip flexion out -bend knees -ankle circles
62
musculoskeletal components
-neck ROM -BUE ROM -BLE ROM -HGTW -flexion/extension of BUE and BLE
63
inspect skin for (7)
Hydration Temperature Color Texture Rashes Lesions Cracking
64
pallor
pale or ashen gray
65
erythema
redness related to vasodilation
66
jaundice
yellow, impaired liver skin or sclera of eyes
67
cyanosis
bluish, decreased circulation or oxygenation of blood around mouth, nail beds
68
turgor test
pinch to skin under clavicle related to hydration, will tent if dehydrated
69
texture of skin can be...
dry and course, or shiny with no hair
70
temperature of skin should be...
warm, consistent with room temp
71
things affecting skin (7)
-dampness -dehydration -nutrition -circulation -disease -jaundice -lifestyle
71
normal skin changes in older adults (8)
-epidermis -subcutaneous tissue -collagen and elastin fibers -hormones -vascularity -melanocytes -nails -skin growths
72
pitting edema cause by ... leads to ...
kidney or liver heart failure -leads to excess fluid collection in tissues
73
1 + pitting edema
2mm indention to trace rapid response
74
2+ pitting edema
4mm to mild 10-18 seconds
75
3 + pitting edema
6mm to moderate 1-2 minutes
76
4+ pitting edema
8mm to severe 2-5 minutes
77
assessment of bony prominences
-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
observe nails for :
-shape -contour -cleanliness -neatly manicured / trimmed
79
nails should be : (5)
-transparent -smooth -rounded -convex -hygienic
80
terminal hair
scalp, axillae, pubic and beard
81
vellus hair
defines us as mammals -soft tiny hairs covering body except on palms of hands and soles of feet
82
assessment of hair , looking for (5)
-quantity (alopecia, hirsutism-overgrowth) -distribution -texture -color -parasites
83
assess ears for (8)
symmetry, drainage, shape, hearing defects, lesions, redness, tenderness, odor
84
inspect nose for (9)
position, symmetry, color, swelling, deformities, discharge, flaring, patency, sinus tenderness
84
assess oral cavity for (6)
lios, oral mucosa, teeth, gums/tongue, breath
85
inspect throat (6)
lumps, ulcers, edema, white spots, redness, swallowing
85
inspect throat for (6)
lumps, ulcers, edema, white spots, redness, swallowing
86
inspect neck for
contour and symmetry, midline trachea, jugular vein distention
87
palpate neck for
inflamed/enlarged lymph nodes
88
integument components of assessment
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
elimination
excretion of waste products from kidneys and intestines
90
defecation
process of elimination of waste
91
feces
Semisolid mass of fiber, undigested food, inorganic matter
92
assessment of abdomen
inspect auscultate palpate
93
inspection of abdomen
look at size, shape, contour, skin integrity
94
auscultation of abdomen
listen for bowel sounds 5-20seconds, four quadrants - hypo/hyperactive
95
palpation of abdomen
feel for tenderness, pain, masses
96
questions to ask while assessing abdomen
-normal bowel and urine patterns -appearance -changes -history if problems
97
incontinence
inability to control urine or feces
98
void / micturate
to urinate
99
dysuria
painful or difficult urination
100
hematuria
blood in the urine
101
nocturia
frequent night urination
102
polyuria
large amounts of urine
103
urinary frequency
voiding at frequent intervals
104
urinary urgency
the need to void all at once
105
proteinuria
presence of large protein in urine
106
dribbling
leakage of urine despite voluntary control of urination
107
retention
accumulation of urine in bladder without the ability to completely empty
108
residual
urine remaining post void >100ml
109
kidney functions
filter and regulate blood and fluid of body -regulate acid-base balance
110
ureter function
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
bladder function
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
urethra function
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
nephrons
functional unit of kidney
114
assessment of urethra meatus and perineal area
-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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