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
2
Q
what is the most important neuro assessment component?
A
level of conciousness
(LOC) often the 1st clue of deteriorating condition
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
4
Q
examples of a vigorous/noxious stimuli to test alterness
A
pinching, sternal rub, pressure points
5
Q
cognitive awareness
A
is the pt oriented to person, place, event, & time?
AxOx4
6
Q
what does mentation assess?
A
cognitive awareness
AxOx4
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?
8
Q
how many cranial nerves are there?
A
12
9
Q
cranial nerves I, II, III
not on test
A
- CN I- olfactory
- CN II- optic
- CN III- oculomotor
10
Q
cranial nerves IV, V, VI
not test
A
- CN IV- trochlear
- CN V- trigeminal
- CN VI- abducens
11
Q
cranial nerves VII, VIII, IX
not on test
A
- CN VII- facial
- CN VIII- vesibulocochlear
- CN IX- glossopharyngeal
12
Q
cranial nerves X, XI, XII
not on test
A
- CN X- vagus
- CN XI- accessory
- CN XII- hypoglossal
13
Q
what doi CN III, IV, and VI test for?
A
- pupil response
- cardinal gaze
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
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
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
17
Q
testing cranial nerve XII
A
- ask pt to touch roof of mouth with rongue
- stick out tongue
- move tongue side to side
18
Q
testing cranial nerve XI
A
- place hands lightly on pt shoulders
- ask pt to shrug shoulders
- test resistance/ strength
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
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
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
21
Q
vesicular lung sounds
A
normal
periphery of the lungs
22
Q
bronchovesicular lung sounds
A
normal
closer to the sternum
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
24
rhonchi lung sounds
abnormal
* **coarse sounds**
* caused by **mucus in airway**, usualy **clears with cough**
* heard over **trachea**
25
wheezing lung sounds
abnormal
* **high pitch**
* heard over **all lung areas** on **exhalation**
* caused by ** narrowing of airways** (asthma, COPD)
26
pleural friction rub lung sounds
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**
27
abnormal respiratory patterns
| 6
* bradypnea
* tachypnea
* apnea
* hypernea
* kussmaul's
* cheyne - stokes
28
pattern of auscultation of the respiratory system
* **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**
29
why would you assess the nails as part of the respiratory assessment?
* examine for **clubbing**- results from **chronically low O2 levels**
* examine BUE nail shape
* ask pt to put finger nails together (normal should touch)
30
respiratory components of assessment
| 2
* anterior & posterior lung sounds
* clubbing
31
know the pathophysiology of blood flow through the heart & lungs
32
**LUB**
**systole or S1**
the sound associated with the **closing of the mitral/tricuspid valves**
33
**DUB**
**diastole or S2**
the sound associated with the **closing of the aortic/pulmonic valves**
34
where are the pauses in the lub/dub sounds?
natural pauses:
* between S1 and S2
longer pause:
* between S2 and S1
35
where is the **aortic** heart sound?
* right base
* 2nd ICS to the right of sternal border
36
where is the **pulmonic** heart sound?
* left base
* 2nd ICS to the left of sternal border
37
where is the **tricuspid** heart sound?
* left lateral sternal border
* 5th ICS to the left of sternal border
38
where is the **mitral/ apical** heart sound?
* apex
* midclavicular line at 5th ICS
39
**A**ll **P**arty **T**il **M**idnight
* aortic
* pulmonic
* tricuspid
* mitral
40
know the basic conduction of the heart
41
which pulses do we assess in a head to toe assessment?
* carotid
* radial
* apical
* dorsalis pedis
42
how do you assess the carotid pulse?
one at a time, bilaterally
43
how do you assess the radial pulse?
bilaterally at the same time
44
how do you assess the apical pulse?
with a stethoscope for 2 beats
45
how do you assess the dorsalis pedis or pedal pulses?
bilaterally at the same time
46
pulse points
* **4+** bounding
* **3+** full, increased
* **2+** **strong/ normal**
* **1+** diminished, palpable
* **0** absent, non palpable
47
if you cannot find a pedal pulse, what would you do?
use a doppler
48
cardiac components of assessment
* heart sounds
* carotid pulses
* radial pulses
* pedal pulses
* capillary refill
* assess for edema
49
what areas do you assess ROM for?
* neck
* shoulders, upper arms & elbows
* wrists
* hips
* knees
* ankles
50
neck ROM
* side to side
* chin to chest
* extension backward
51
shoulders, upper arms, & elbow
* arms out to side
* arms straight up
* touchtown
52
wrists ROM
wrist circles
53
hips, knees, & ankles ROM
* bilateral hip flexion out (bend knee, move outward)
* bend knees
* ankle circles
54
strength ROM
* handgrip
* toe wiggle
* flexion & extension of BUE/BLE
55
musculoskeletal components of assessment
* neck ROM
* BUE ROM
* BLE ROM
* HGTW
* flexion/extension BUE and BLE
56
skin assessment
* **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
why would a patient's skin be shiny with no hair?
impaired peripheral circulation
58
what does turgor test for?
hydration
| gentle pinch on the clavicle
59
factors effecting the skin
* dampness
* dehydration
* nutrition
* circulation (low circulation = tissue death)
* disease (eczema, psoriasis)
* jaundice
* lifestyle (moisture, barriers)
60
how do the **epidermis & subcutaneous tissue** change in older adults?
as age increases, the skin is:
* thinner
* paler
* more translucent
* bruises easier & heals slower
* cold
61
how does the **collagen & elastin fibers** change in older adults?
lower collagen = more wrinkles
62
how do **hormones** change in older adults?
lower hormones = dry/thinning of hair
63
how do **hair collicles, nails, & skin growths** in order adults?
* lower number of hair follicles & activity
* thicker or softer nails
* more warts, liver/age spots on skin
64
how do **melanocytes** change in older adults?
skin pigmentation decreases = causes abnormal pigmentation & grey hair
65
how does **vascularity** change in older adults?
cooler extremities over time
66
pitting edema
* caused by **kidney or heart failure**
* leads to **excess fluid in tissues**
67
pitting edema scale
* **1+**: 2mm, rapid response
* **2+**: 4mm, 10-18 second response
* **3+**: 6mm, 1-2 minute response
* **4+**: 8mm, 2-5 minute repsponse
68
what areas of the body are prone to skin breakdown? (bony preminences)
* hips
* heels
* coccyx
* shoulders
| low tissue/muscle between the bone & skin
69
how do you assess body prominences for skin breakdown?
non-blanching red spots are a problem
70
how do you assess the nails?
* nail shape, countor, cleanliness
* transparent, smooth, round, convex, hygienic
71
how do you assess the hair?
* terminal hair
* vellus hair
* quality (alopecia, hirsutism)
* distribution
* texture
* color
* parasites
72
terminal hair
scalp, axillae, pubic, & beard
73
vellus hair
soft tiny hairs covering the body except on palms & soles
| this is what makes us mammals
74
alopecia
baldness, excessive/unusual hair loss
75
hirsutism
excess hair where not generally expected
76
how do you assess the ears?
* use penlight
* assess neck ROM at the same time
* inspect for symmetry, drainage, shape, hearing defects, lesions, redness, tenderness, & odor
77
how do you assess the nose?
* assess neck ROM at the same time
* inspect for position, color, symmetry, swelling, deformities, discharge, flaring, patency, sinus tenderness
78
how do you assess the oral cavity?
inspect:
* lips
* oral mucosa
* teeth
* gums/tongue
* breath odor
79
how do you assess the throat?
inspect for:
* lumps
* ulcers
* edema
* white spots
* redness
* swallowing
80
how do you assess the neck?
inspect for:
* contour & symmetry, midline trachea, jugular vein distention
palpapte for:
* inflamed/enlarged lymph nodes (circular motion)
81
components of **integument assessment**
* hair & scalp
* ears, nose, mouth/throat
* inspect & palpate neck
* skin turgor
* skin on back & bony prominences
* skin of BUE & BLE
* nails
82
elimination
excretion of waste products from kidneys & intestines
83
defacation
process of elimination of waste
84
feces
semisolid mass of fiber, undigested good, inorganic matter
85
incontinence
inability to control urine or feces
86
void/ micturate
to urinate
87
dysuria
painful or difficult urination
88
hematuria
blood in the urine
| **hemat** (blod) + **uria** (urine)
89
nocturia
frequent night urination
| kidneys should be functioning slower at night
## Footnote
**noct** (night) + **uria** (urine)
90
polyuria
large amounts of urine
| **poly** (many) + **uria** (urine)
91
urinary frequency
voiding at frequent intervals
92
urinary urgency
the need to void all at once
| cannot wait/hold it at all
93
proteinuria
presence of large protein in urine
| kidney disfunction
94
dribbling
leakage of urine despite coluntary control of urination
95
retention
accumulation of urine in bladder without the ability to completely empty
96
residual
urine remaining post void > 100mL
97
structures of GI tract
* upper GI tract (mouth, pharynx, esophagus, stomach: begins mastication)
* small intestine
* large instestine
* rectum & anus
98
where dost mastication begin?
upper GI tract (mouth, pharynx, esophagus, stomach)
99
structure of the small intestine
* folded, twisted, & coiled tube from stomach to large intestine
* 1" in diameter, 20' long
100
function of the small intestine
* most digestion & absorption
* **chyme** (partially digested food) travels via peristalsis (moves, sits, absorbs)
101
3 segments of the small intestine
* duodenum
* jejunum
* ileum
102
structure of the large intestine
2.5" in diameter, 5-6' long
103
7 segments of the large intestine
* cecum
* ascending colon
* transverse colon
* descending colon
* sigmoid colon
* rectum
* anus
104
structure of the rectum
* 6" long
* lots of blood flow
* should be free of stool until defacation
105
another term for large intestine
colon
106
organs involved in urinary elimination
* **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
know the structure of the urinary tract
108
kidney structure & function
* location: bilateral, posterior flanks
* size of a fist
* primary **regulators of fluid & acid-base balance**
109
components of the nephron
* glomerulus
* bowman's capsule
* proximal convoluted tubule (PCT)
* loop of Henle (absorption & reabsorption)
* distal covoluted tubule (DCT)
* collecting duct
110
what is the functioning unit of the kidney
nephron
111
function of the ureters
* tubule structures that enter the bladder
* typically sterile urine
* urine enters bladder obliquely & posteriorly to prevent reflux
112
renal colic
obstructions cause peristalitic waves of severe pain
| kidney stones
113
why do the ureters enter the bladder obliquely & posteriorly?
to prevent reflux
114
structure of the bladder
* 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
how much can the bladder hold normally? extended?
* normal- 500mL
* can extend to- 1000mL
116
structure of the urethra
* 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
function of the urethra
* turbulent (powerful/fast) flow **washes urethra free of bacteria**
* **contraction** of pelvic floor **muscles can prevent flow of urine**
118
why are women more likely to obtain a UTI?
shorter urethra
(less area for bacteria to have to travel to infect the person)
| 1.5-2.5" urethra
119
which assessment MUST you do in a particular order?
abdominal
120
how do you assess the abdomen?
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
in what order to you auscultate & palpate the quadrants of the abdomen?
1. RLQ
2. RUQ
3. LUQ
4. LLQ
122
how do you assess the **urethra meatus & perineal area?**
* 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
GI/ GU components of assessment
* abdomen- look, listen, feel
* ask about bowel/urinary habits
* examin urethral meatus & perineal area
