Lesson 6

Question 1

Why do we do a basic head-to-toe assessment as demonstrated in class?

Answer 1

Faster
Less likely to forget something
More comfortable for client
You look more professional

Question 2

What is the normal sequence?

Answer 2

Inspection
Palpation
Percussion
Auscultation

Question 3

Describe flow of head-to-toe assessment

Answer 3

General survey
Level of consciousness
HEENT (head, eyes, ears, nose, throat)
Trachea
Thorax
Abdomen (*sequence changes!)
Arms
Perineum
Legs

Question 4

What do you look for in the general survey?

Answer 4

Physical appearance, body structure, mobility, behavior

Question 5

What do you look for in the LOC?

Answer 5

If they are awake, alert, and oriented

Question 6

HEAD: What are the tasks here?

Answer 6

Inspect hair, head size, and general appearance

Question 7

HEAD: What is the statement for a normal sized head?

Answer 7

Normoalcephalic

Question 8

HEAD: What are some abnormal statements during this part of the assessment and what do they mean?

Answer 8

Microcephalic: small head
Macrocephalic: large head
Alopecia: hair loss
Hirusitism: Excessive amounts of hair
Bell palsy: paralysis or weakness of the muscles on one side of your face

Question 9

EYES: What are the tasks here?

Answer 9

Observe eyes, sclera conjunctiva

Measure pupil diameter

Question 10

EYES: What are they normal statements for normal eyes?

Answer 10

Sclera white, conjunctive clear

Pupils equal, round, reactive to light directly and consensually (may also record actual pupil diameter)

Question 11

EYES: There are 5 abnormal statements for the eyes. What are they?

Answer 11

Anisocoria, ptosis, sclera icterus, blue sclera, conjuctivitis (redness of sclera)

Question 12

EYES: What does anisocoria mean?

Answer 12

Unequal pupil diameter

Question 13

EYES: What does ptosis mean?

Answer 13

Drooping of the upper eyelid due to paralysis or disease

Question 14

EYES: What does sclera icterus mean?

Answer 14

Jaundice; yellowing of sclera (actually it is the conjunctiva)

Question 15

EYES: What does blue sclera mean?

Answer 15

Indication of osteogenesis imperfecta (brittle bone disease)

Question 16

EYES: What does conjuctivits mean?

Answer 16

Pink eye

Question 17

EARS: What are the tasks for the ears?

Answer 17

Observe for excessive wax, drainage, or redness and irritation

Question 18

NOSE: What do you do here?

Answer 18

Observe of obstructions and/or drainage

Question 19

MOUTH: What are the tasks for this section?

Answer 19

Look inside for pink and moist coloration
Observe condition of teeth
Observe back of throat

Question 20

MOUTH: What is the statement for a normal mouth?

Answer 20

Mucous membranes moist and pink

Question 21

TRACHEA: What do you do here?

Answer 21

Note the position and symmetry of the trachea

Question 22

TRACHEA: What is the statement used for a normal trachea?

Answer 22

Trachea midline

Question 23

THORAX: What are the 3 tasks?

Answer 23

Observe chest shape
Listen to heart beat at the apex
Listen to chest sounds

Question 24

THORAX: What are the normal statements used if everything appears normal?

Answer 24

Normal AP diameter
Lung sound clear and equal bilaterally
S1S2, regular, no murmurs or extra heart sounds

Question 25

THORAX: What are 7 abnormal findings you may find in this part of the assessment?

Answer 25

Barrel chest Pectus excavatum Pectus carinatum (pigeon chest) Scoliosis Kyphosis (hunchback) Pneumothorax (trachea pushed towards side opposite pneumothorax) Chest sounds-wheeze, stridor, sonorous wheeze/ronchi, crackle/rales

Question 26

THORAX: What abnormal chest sound would you hear in the RUL?

Answer 26

Wheeze

Question 27

THORAX: What abnormal chest sound would you hear in the RLL?

Answer 27

Stridor

Question 28

THORAX: What abnormal chest sound would you hear in the RML/LUL?

Answer 28

Sonorous wheeze/ronchi

Question 29

THOAX: What abnormal chest sound would you hear in the LLL?

Answer 29

Crackle/rales

Question 30

ABDOMEN: What is the new sequence with the abdomen?

Answer 30

Inspection Ausculation Palpation Percussion

Question 31

ABDOMEN: What are your tasks here?

Answer 31

Observe shape of abdomen Assess for tenderness and firmness Listen for abdominal sounds (not necessary to check all 4 quadrants)

Question 32

ABDOMEN: What is the normal statement here?

Answer 32

Abdomen flat, soft, non-tender. Normoactive bowel sounds

Question 33

ABDOMEN: What are 5 abnormal findings here?

Answer 33

``` Scaphoid Rounded Protuberant Abnominal sounds hypoactive Abdominal sounds hyperactive ```

Question 34

ARMS: What are the 5 tasks here?

Answer 34

Measure brachial pulse bilaterally and simultaneously Measure radial pulse bilaterally and simultaneously Asses arm/grip strength of both arms Assess skin conditions Assess fingers and fingernails including capillary refill

Question 35

ARMS: What are the normal statements?

Answer 35

``` Skin warm and dry with good turgor Upper extremities strong 0, 1+, 2+, or 3+ pulse No clubbing or deformities Nail beds pink with prompt capillary refill ```

Question 36

PERINEUM: What are the tasks here?

Answer 36

Record bowel movement information | Record voiding movement information

Question 37

LEGS: What are the tasks here?

Answer 37

- Assess for deem - Assess posterior tibial pulse - Assess doornails pedis pulse *10% of population does not have this pulse - Sensation - Capillary refill - Temperature - Moisture

Question 38

LEGS: What are the normal statements here?

Answer 38

Lower extremeties strong Record pulse as always (0, 1+, 2+, 3+) Record edema (similar to recording pulse- 1+, 2+, 3+, 4+)