EXAM 3- Head to Toe Assessment Flashcards
what should you do before beginning a head to toe assessment?
- consider age group
- organizeation of the assessment
what is the most important neuro assessment component?
level of conciousness
(LOC) often the 1st clue of deteriorating condition
what levels are you testing for when assessing a pt’s LOC?
5
- 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
examples of a vigorous/noxious stimuli to test alterness
pinching, sternal rub, pressure points
cognitive awareness
is the pt oriented to person, place, event, & time?
AxOx4
what does mentation assess?
cognitive awareness
AxOx4
what should you ask your pt when assessing cognitive awareness?
4
- 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?
how many cranial nerves are there?
12
cranial nerves I, II, III
not on test
- CN I- olfactory
- CN II- optic
- CN III- oculomotor
cranial nerves IV, V, VI
not test
- CN IV- trochlear
- CN V- trigeminal
- CN VI- abducens
cranial nerves VII, VIII, IX
not on test
- CN VII- facial
- CN VIII- vesibulocochlear
- CN IX- glossopharyngeal
cranial nerves X, XI, XII
not on test
- CN X- vagus
- CN XI- accessory
- CN XII- hypoglossal
what doi CN III, IV, and VI test for?
- pupil response
- cardinal gaze
assessing pupil response
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
assessing cardinal gaze
- have pt follow the pen as you move the pen in an “H” motion
- 9-12 inches away from pt
testing cranial nerve VII
- ask pt to smile with teeth
- ask pt to raise eyebrows/ wrinkle forehead
- assess for inability or one sided drooping
testing cranial nerve XII
- ask pt to touch roof of mouth with rongue
- stick out tongue
- move tongue side to side
testing cranial nerve XI
- place hands lightly on pt shoulders
- ask pt to shrug shoulders
- test resistance/ strength
testing motor function
part of neuro & musculoskeletal aseessments
* hand grasp & toe wiggle (HGTW)
* flexion/extension with resistance
all should be assessed bilaterally on BUE BLE
testing motor function
part of neuro & musculoskeletal aseessments
* hand grasp & toe wiggle (HGTW)
* flexion/extension with resistance
all should be assessed bilaterally on BUE BLE
neuro components of assessment
- 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
vesicular lung sounds
normal
periphery of the lungs
bronchovesicular lung sounds
normal
closer to the sternum
crackles (rales) lung sounds
abnormal
* can be fine or coarse
* caused by fluid excretions
* high pitch
* heard at the base of lungs
rhonchi lung sounds
abnormal
* coarse sounds
* caused by mucus in airway, usualy clears with cough
* heard over trachea
wheezing lung sounds
abnormal
* high pitch
* heard over all lung areas on exhalation
* caused by ** narrowing of airways** (asthma, COPD)
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
abnormal respiratory patterns
6
- bradypnea
- tachypnea
- apnea
- hypernea
- kussmaul’s
- cheyne - stokes
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
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)
respiratory components of assessment
2
- anterior & posterior lung sounds
- clubbing
know the pathophysiology of blood flow through the heart & lungs
LUB
systole or S1
the sound associated with the closing of the mitral/tricuspid valves
DUB
diastole or S2
the sound associated with the closing of the aortic/pulmonic valves
where are the pauses in the lub/dub sounds?
natural pauses:
* between S1 and S2
longer pause:
* between S2 and S1
where is the aortic heart sound?
- right base
- 2nd ICS to the right of sternal border
where is the pulmonic heart sound?
- left base
- 2nd ICS to the left of sternal border
where is the tricuspid heart sound?
- left lateral sternal border
- 5th ICS to the left of sternal border
where is the mitral/ apical heart sound?
- apex
- midclavicular line at 5th ICS
All Party Til Midnight
- aortic
- pulmonic
- tricuspid
- mitral
know the basic conduction of the heart
which pulses do we assess in a head to toe assessment?
- carotid
- radial
- apical
- dorsalis pedis
how do you assess the carotid pulse?
one at a time, bilaterally
how do you assess the radial pulse?
bilaterally at the same time
how do you assess the apical pulse?
with a stethoscope for 2 beats
how do you assess the dorsalis pedis or pedal pulses?
bilaterally at the same time
pulse points
- 4+ bounding
- 3+ full, increased
- 2+ strong/ normal
- 1+ diminished, palpable
- 0 absent, non palpable
if you cannot find a pedal pulse, what would you do?
use a doppler
cardiac components of assessment
- heart sounds
- carotid pulses
- radial pulses
- pedal pulses
- capillary refill
- assess for edema
what areas do you assess ROM for?
- neck
- shoulders, upper arms & elbows
- wrists
- hips
- knees
- ankles
neck ROM
- side to side
- chin to chest
- extension backward
shoulders, upper arms, & elbow
- arms out to side
- arms straight up
- touchtown
wrists ROM
wrist circles
hips, knees, & ankles ROM
- bilateral hip flexion out (bend knee, move outward)
- bend knees
- ankle circles
strength ROM
- handgrip
- toe wiggle
- flexion & extension of BUE/BLE
musculoskeletal components of assessment
- neck ROM
- BUE ROM
- BLE ROM
- HGTW
- flexion/extension BUE and BLE
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)
why would a patient’s skin be shiny with no hair?
impaired peripheral circulation
what does turgor test for?
hydration
gentle pinch on the clavicle
factors effecting the skin
- dampness
- dehydration
- nutrition
- circulation (low circulation = tissue death)
- disease (eczema, psoriasis)
- jaundice
- lifestyle (moisture, barriers)
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
how does the collagen & elastin fibers change in older adults?
lower collagen = more wrinkles
how do hormones change in older adults?
lower hormones = dry/thinning of hair
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
how do melanocytes change in older adults?
skin pigmentation decreases = causes abnormal pigmentation & grey hair
how does vascularity change in older adults?
cooler extremities over time
pitting edema
- caused by kidney or heart failure
- leads to excess fluid in tissues
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
what areas of the body are prone to skin breakdown? (bony preminences)
- hips
- heels
- coccyx
- shoulders
low tissue/muscle between the bone & skin
how do you assess body prominences for skin breakdown?
non-blanching red spots are a problem
how do you assess the nails?
- nail shape, countor, cleanliness
- transparent, smooth, round, convex, hygienic
how do you assess the hair?
- terminal hair
- vellus hair
- quality (alopecia, hirsutism)
- distribution
- texture
- color
- parasites
terminal hair
scalp, axillae, pubic, & beard
vellus hair
soft tiny hairs covering the body except on palms & soles
this is what makes us mammals
alopecia
baldness, excessive/unusual hair loss
hirsutism
excess hair where not generally expected
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
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
how do you assess the oral cavity?
inspect:
* lips
* oral mucosa
* teeth
* gums/tongue
* breath odor
how do you assess the throat?
inspect for:
* lumps
* ulcers
* edema
* white spots
* redness
* swallowing
how do you assess the neck?
inspect for:
* contour & symmetry, midline trachea, jugular vein distention
palpapte for:
* inflamed/enlarged lymph nodes (circular motion)
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
elimination
excretion of waste products from kidneys & intestines
defacation
process of elimination of waste
feces
semisolid mass of fiber, undigested good, inorganic matter
incontinence
inability to control urine or feces
void/ micturate
to urinate
dysuria
painful or difficult urination
hematuria
blood in the urine
hemat (blod) + uria (urine)
nocturia
frequent night urination
kidneys should be functioning slower at night
noct (night) + uria (urine)
polyuria
large amounts of urine
poly (many) + uria (urine)
urinary frequency
voiding at frequent intervals
urinary urgency
the need to void all at once
cannot wait/hold it at all
proteinuria
presence of large protein in urine
kidney disfunction
dribbling
leakage of urine despite coluntary control of urination
retention
accumulation of urine in bladder without the ability to completely empty
residual
urine remaining post void > 100mL
structures of GI tract
- upper GI tract (mouth, pharynx, esophagus, stomach: begins mastication)
- small intestine
- large instestine
- rectum & anus
where dost mastication begin?
upper GI tract (mouth, pharynx, esophagus, stomach)
structure of the small intestine
- folded, twisted, & coiled tube from stomach to large intestine
- 1” in diameter, 20’ long
function of the small intestine
- most digestion & absorption
- chyme (partially digested food) travels via peristalsis (moves, sits, absorbs)
3 segments of the small intestine
- duodenum
- jejunum
- ileum
structure of the large intestine
2.5” in diameter, 5-6’ long
7 segments of the large intestine
- cecum
- ascending colon
- transverse colon
- descending colon
- sigmoid colon
- rectum
- anus
structure of the rectum
- 6” long
- lots of blood flow
- should be free of stool until defacation
another term for large intestine
colon
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
know the structure of the urinary tract
kidney structure & function
- location: bilateral, posterior flanks
- size of a fist
- primary regulators of fluid & acid-base balance
components of the nephron
- glomerulus
- bowman’s capsule
- proximal convoluted tubule (PCT)
- loop of Henle (absorption & reabsorption)
- distal covoluted tubule (DCT)
- collecting duct
what is the functioning unit of the kidney
nephron
function of the ureters
- tubule structures that enter the bladder
- typically sterile urine
- urine enters bladder obliquely & posteriorly to prevent reflux
renal colic
obstructions cause peristalitic waves of severe pain
kidney stones
why do the ureters enter the bladder obliquely & posteriorly?
to prevent reflux
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
how much can the bladder hold normally? extended?
- normal- 500mL
- can extend to- 1000mL
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
function of the urethra
- turbulent (powerful/fast) flow washes urethra free of bacteria
- contraction of pelvic floor muscles can prevent flow of urine
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
which assessment MUST you do in a particular order?
abdominal
how do you assess the abdomen?
- inspection- observe size, shape, contour, skin integrity
- auscultation- bowel sounds, 4 quadrants (hypoactive, active, hyperactive) (RLQ, RUQ, LUQ, LLQ)
- palpation- palpate for tenderness, pain, masses, distension
- ask- normal bowel/urine patterns & frequency, appearance, changes, hx of problems
in what order to you auscultate & palpate the quadrants of the abdomen?
- RLQ
- RUQ
- LUQ
- LLQ
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)
GI/ GU components of assessment
- abdomen- look, listen, feel
- ask about bowel/urinary habits
- examin urethral meatus & perineal area
