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DNP 605 > Head to Toe > Flashcards

Head to Toe Flashcards

1
Q

13 aspects of the general survey

A
  1. General state of health,
  2. Nutritional status
  3. Signs of distress
  4. Build
  5. Posture
  6. Gait
  7. Grooming
  8. Hygiene
  9. Dress
  10. Affect
  11. Facial expressions
  12. Speech
  13. Awareness
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2
Q

11 Sections of Documentation

A
  1. Vital Signs
  2. General Survey
  3. Mental Status
  4. Neurological
  5. Reflexes
  6. Skin/Hair/Nails
  7. HEENT/Neck
  8. Pulmonary/Thorax
  9. Cardiovascular & Peripheral Vascular
  10. Abdomen
  11. Musculoskeletal
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3
Q

Mental Status norms

A

Alert and oriented to person, place and time. Attentive, pleasant, and cooperative with examination. Responds to questions and commands appropriately.

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4
Q

12 Cranial nerves

A

CN I: olfactory
CN II: optic
CN III: oculomotor
CN IV: trochlear
CN V: trigeminal
CN VI: abducens
CN VII: facial
CN VIII: acoustic
CN IX: glossopharyngeal
CN X: vagus
CN XI: spinal accessory
CN XII: hypoglossal

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5
Q

CN I (Olfactory) norm

A

Identifies/smells coffee and cinnamon bilaterally

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6
Q

CN II (Optic), III (Oculomotor) norms

A

Visual fields intact with confrontation. PERRLA. Convergence intact.

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7
Q

CN III (Oculomotor), IV (Trochlear), VI (Abducens) norms

A

EOMs intact x6. No nystagmus, ptosis, or lid lag.

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8
Q

CN V (Trigeminal) norms

A

Facial sensation intact to light touch on forehead, cheeks, and chin bilaterally. Temporal and masseter muscles strength 5/5 bilaterally.

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9
Q

CN VII (Facial) norms

A

Face symmetrical with eyebrows raised, frowning, closing eyes, smiling, showing teeth, and puffed cheeks.

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10
Q

CN VIII (Acoustic) norms

A

Hearing acuity sensitive to whisper bilaterally. Rinne AC > BC bilaterally. Weber midline.

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11
Q

CN IX (Glossopharyngeal), X (Vagus) norms

A

Uvula midline and palate rises symmetrically on “ah”. No apparent hoarseness or dysphagia.

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12
Q

CN XI (Spinal Accessory) norms

A

Sternomastoid and upper trapezius strength 5/5 with shoulder shrug and turning head against resistance bilaterally.

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13
Q

CN XII (Hypoglossal) norms

A

Tongue midline without fasciculation. Able to stick out tongue and move tongue side to side symmetrically.

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14
Q

Motor norms

A

Good muscle bulk and tone with no atrophy, contracture, or flaccidity. Flexion and extension muscle strength 5/5, equal bilaterally upper and lower extremities.

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15
Q

Cerebellar norms

A

Natural gait steady with appropriate arm swing. Able to tandem gait and perform shallow knee bend bilaterally without difficulty. Rapid-alternating hand movements smooth and coordinated bilaterally. Romberg negative. No pronator drift. No involuntary movements or tremors.

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16
Q

4 parts of Neurological assessment

A
  1. Cranial nerves
  2. Cerebellar
  3. Motor
  4. Sensory
17
Q

Sensory norms

A

Sensation to sharp and dull intact in upper and lower extremities. Vibratory sense and proprioception intact in lower extremities bilaterally. Stereogenesis and graphesthesia intact bilaterally.

18
Q

6 reflexes to test

A
  1. Biceps
  2. Brachioradialis
  3. Triceps
  4. Patellar
  5. Achilles
  6. Plantar
19
Q

Reflexes norms

A

Biceps, brachioradialis, triceps patellar, and Achilles reflexes 2+ bilaterally. Plantar reflex downward bilaterally.

20
Q

Skin/Hair/Nails norms

A

Skin tan, warm, dry, smooth, and intact with no lesions, erythema, scars or striae. Hair brown, evenly distributed, with smooth texture. Finger nail beds pink with capillary refill < 3 seconds and no clubbing bilaterally.

21
Q

Head/Face norms

A

Normocephalic, atraumatic, non-tender, symmetric skull without lumps, depressions, or deformities. Scalp with no scaling, erythema, nevi, or lesions. No frontal or maxillary sinus tenderness or edema bilaterally. No temporal artery tenderness, pulse 3+. Relaxed symmetric facial expression, without abnormal movements.

22
Q

Eye norms

A

Eyebrows and eyelashes symmetrical with even distribution bilaterally. Sclera white, conjunctiva pink. No corneal or lens opacities bilaterally. Corneal light reflex symmetrical. Red light reflex present and optic disc margins sharp bilaterally. No hemorrhages or AV nicking. No arteriolar narrowing.

23
Q

Ear norms

A

Symmetrical, appropriate size to head, with clear skin and no tenderness to pinna, tragus, mastoid process bilaterally. Canals patent with minimal wax. Tympanic membranes pearly gray with visible bony landmarks and cone of light bilaterally with no inflammation or perforation.

24
Q

Nose norms

A

Nose symmetric. Nares patent bilaterally, no septal deviation or perforation. No drainage. Turbinates and mucosa pink without swelling, exudate or perforation.

25
Q

Mouth and throat norms

A

Lips, gums, tongue, and oral mucosa pink, moist, intact without lesions or bleeding. Good dentation. Tonsils 1+ bilaterally, pharynx with no exudate.

26
Q

Neck norms

A

Neck supple, symmetric, no masses, lumps, or lesions. Trachea midline. Thyroid smooth with no enlargement, nodules, or tenderness. No pre-auricular, post-auricular, occipital, submental, submandibular tonsillar, superficial cervical, deep cervical, posterior cervical, or supraclavicular lymphadenopathy or tenderness. Normal range of motion of neck including flexion, extension, rotation and lateral bending.

27
Q

Pulmonary/Thorax norms

A

Anterior and posterior thorax symmetric without lesions. Respirations non-labored and no accessory muscle use. Chest expansion symmetric. Posterior thorax without tenderness or crepitus. Anterior thorax without thrills, heaves, or lifts. Tactile fremitus present and equal bilaterally. Diaphragmatic excursion 4 cm bilaterally. Lung sounds clear to auscultation bilaterally without rales, rhonchi, or wheezes. No CVA tenderness.

28
Q

Cardiovascular & Peripheral Vascular norms

A

No JVD. JVP measured at 2 cm with HOB at 30 degrees above the sternal angle. Carotid pulse 2+ bilaterally. No carotid bruit. Chest is symmetrical, no lesions. No lifts, heaves, or thrills. PMI palpated at 5th left intercostal space, mid clavicular line. Regular rate and rhythm. Crisp S1 and S2; No S3, S4, or murmurs, gallops, or rubs. No aortic regurgitation. Capillary refill < 3 seconds in fingers bilaterally without clubbing. No edema in lower extremities. Temporal, radial, brachial, popliteal, posterior tibial, and dorsalis pedis pulses 2+ bilaterally.

29
Q

7 pulse points to check

A
  1. Temporal
  2. Carotid
  3. Brachial
  4. Radial
  5. Popliteal
  6. Posterior Tibial
  7. Dorsalis Pedis
30
Q

Abdomen norms

A

Flat, symmetric, without pulsations or lesions, umbilicus midline. Bowel sounds present in RLQ. No aortic, renal, iliac or femoral bruits. Percussion tympanic x4 quadrants. Liver 6 cm at right mid clavicular line. Liver edge is smooth. Soft with no tenderness or masses noted with light and deep palpation. Spleen and kidneys non-palpable.

31
Q

10 Musculoskeletal areas to check

A
  1. TMJ
  2. Spine
  3. Shoulders
  4. Elbows
  5. Wrists
  6. Fingers
  7. Hips
  8. Knees
  9. Ankles
  10. Feet
32
Q

Temporal mandibular joint norms

A

Able to open and close jaw with no clicking or tenderness. Range of motion present when protruding jaw, retracting jaw, and moving jaw side to side.

33
Q

Spine norms

A

Scapula, shoulder height, iliac crest, and gluteal folds equal height bilaterally. Normal curvature of spine with no kyphosis, lordosis, or scoliosis. No tenderness or spasm of spinous processes of vertebra or paravertebral muscles. Range of motion present for flexion, extension, rotation, and lateral bending.

34
Q

Joint norms

A

Symmetric with no obvious deformities, heat, erythema, swelling, edema, nodules, tenderness, bogginess, or joint laxity.

35
Q

Shoulder norms

A

Range of motion present of shoulders for flexion, hyperextension, abduction, adduction, internal rotation, and external rotation. Strength 5/5 against resistance.

36
Q

Elbow norms

A

Range of motion present of elbows for flexion, extension, supination, pronation. Strength 5/5 against resistance.

37
Q

Wrist and hand norms

A

Range of motion present of wrist and hands for flexion, extension, ulnar deviation, radial deviation, spreading fingers apart, and making a fist. Strength 5/5 against resistance.

38
Q

Hip norms

A

Range of motion present of hips for flexion, extension, abduction, adduction, internal rotation, and external rotation.

39
Q

Ankle and foot norms

A

Range of motion present of ankles and feet for flexion, extension, inversion, and eversion. Strength 5/5 against resistance.

DNP 605 (1 decks)

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