Head To Toe Flashcards
Cotton Ball
- Tests sensation to light touch on the face during cranial-nerve testing
- Lower back, trunk, and extremities as part of the neurologic exam
- Compare sensation bilaterally
Coffee/Mint Frangrance
- Do not usually test the first cranial nerve (olfactory nerve)
- Can be done by having patient close their eyes and smelling coffee, mint, or toothpaste. Do not use alcohol or other irritating odors that stimulate the trigeminal nerve and produces incorrect responses
- Test one nostril at a time
10-gram Monofilament
- Used to test for sensation, most commonly in the feet of diabetic patients
- Ask if the patient can feel the monofilament touching their skin
General Survey
- Observe skin color, respiratory effort, and any signs of distress
- Evaluate behavior, mood, and affect (smiling, pleasant, anxious, apprehensive, depressed, angry, hostile)
- Assess posture and body structure
- Observe general appearance (hygiene, grooming, dress)
- Check for odors
- Perform anthropometric measurement’s: height, weight, BMI
- Note mobility aids
- Measure vitals
- Assess for a pulse deficit (difference between rate of apical pulse and radial pulse) if patient has an irregular pulse
- One nurse counts the radial pulse for 60 seconds while the other does the same for the apical pulse at the same time.
- 2 or more beats indicates a deficit (could be a sign of cardiac dysrhythmia or peripheral perfusion)
Skin
- Inspect the skin systematically from head to toe for color (consistency with genetic background), color variation, hair distribution, and lesions.
- Palpate and inspect the skin from head-toe for temperature, texture, and moisture
- Palpate and inspect skin for turgor and edema
- Assess skin integrity, surface characteristics, texture, and for tenderness
- Assess location, distribution, size, shape, and color for lesions and if there is exudate
- Inspect and palpate the nails for color, shape, thickness, adhesions to nail bed, lesions, clubbing, and cap refill
*Cyanosis= darkening of the skin undertone (bluish, darker brown, or gray). Indicates decreased oxygenation or perfusion and is a darkening of the skin undertone to blu
*Jaundice= yellowing of the skin. Can be normal in some skin tones. Compare to the palm and posterior hand to identify a change. Indicates liver disease
*Erythema= redness of the skin cause by dilation of the superficial capillaries. Palpate the skin to detect warmer temperature, tenderness, or a different texture to identify erythema/bleeding
*Assess color consistency. Decreased pigment may indicate vitiligo or skin cancer
*Pallor= loss of color. Black to gray, brown to yellow, red undertone from pale skin.
- Bruising and other significant unknown injury can be a sign of neglect and abuse
- Elevated skin temp in certain areas can indicate inflammation or infection. Decreased temp can indicate decreased blood flow or decreased tissue perfusion
- Lack of hair below the mid-calf area of legs could indicate peripheral vascular disease
- Bilateral edema indicates fluid volume excess or venous insufficiency
-Unilateral edema indicates inflammation, venous thromboembolism, or lymphedema - Thickening, yellowing, and ragged nail edges indicates fungal infection
- Clubbing indicates long-term oxygen deprivation
- Delayed cap refill could indicate decreased tissue perfusion
Head & Neck
- Inspect and palpate the face and skull
- Inspect and palpate the hair for quantity, distribution, texture, color, and parasites
- Inspect the neck for contour and tracheal position
- Evaluate the necks range of motion
- Palpate the cervical carotid arteries
- Palpate the cervical lymph nodes
- Check visual acuity
- Assess nerve function (optional)
- Top part of ears should be at same level as eyes
*Olfactory cranial nerve (CN I): ability to recognize familiar scents like coffee or mint
*Trigeminal cranial nerve (CN V): ability to bite and chew, check sensation of the skin on the face
*Facial cranial nerve (CN VII): symmetry of facial expressions and test the clients anterior 2/3 of the tongue for ability to taste
*Glossopharyngeal/Vagus cranial nerves (CN IX & X): uvula is midline and rises when the client says “AHHHH”, check ability to swallow
*Spinal accessory cranial nerve (CN XI): instruct client to turn their head side to side and shrug shoulders upward while you provide resistance
*Hypoglossal cranial nerve (CN XII): stick tongue out and check that its midline. Test ability to correctly articulate a phrase such as “light, tight, dynamite”
Eye
- Inspect eyes
- Check pupillary response
- Examining extra ocular movements
- PERRLA has an intact oculomotor nerve (CN III)
- Six cardinal fields of gaze
- Visual acuity
Eye
- Inspect eyes
- Check pupillary response
- Examining extra ocular movements
- PERRLA has an intact oculomotor nerve (CN III)
- Six cardinal fields of gaze
- Visual acuity
