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NURS 294 > Head-to-Toe > Flashcards

Head-to-Toe Flashcards

1
Q

OVERALL PERFORMANCE

Begin Assessment

A

Introduces self

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2
Q

OVERALL PERFORMANCE

Safety/Body Mechanics

A

Side rails up, pt. safe
Bed up to working height
Washes hands (or uses hand sanitizer) AT ALL APPROPRIATE TIMES

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3
Q

OVERALL PERFORMANCE

Professional

A

Correct terminology throughout

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4
Q

OVERALL PERFORMANCE

Privacy/Dignity

A

Maintains/Explains confidentiality, covers body parts not being examined or offers gown/sheet

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5
Q

GENERAL INTEGUMENTARY

A

Assessed throughout
Integrity: Measures skin abnormalities in metric measure (smallest and largest of any nevus, any scars, &/or any tattoos; notes piercing locations)

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6
Q

While standing in front of seated governed patient
HEAD
Scalp

A

Inspect & palpate: integrity, texture, dandruff (smooth, without lesions, no dandruff)

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7
Q

While standing in front of seated governed patient
HEAD
Hair

A

Inspect & palpate: distribution, texture (evenly distributed, soft, coarse, brittle)

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8
Q

While standing in front of seated governed patient
HEAD
Skull

A

Inspect & palpate for shape & symmetry (symmetric & normocephalic)

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9
Q

While standing in front of seated governed patient
HEAD
Face

A

Inspect: skin for color and integrity, expression; Raise eyebrows, smile, puff cheeks: symmetry [CN VII]

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10
Q

While standing in front of seated governed patient
HEAD
Temporal arteries

A

Palpate temporal arteries bilaterally

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11
Q

While standing in front of seated governed patient
HEAD
TMJ

A

Inspect & palpate the TMJ: (smooth mvmt, ROM limitations [open/close, lateral deviation, protrution, retraction], tenderness, crepitus)

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12
Q

While standing in front of seated governed patient
HEAD
Sinuses

A

palpate (non-tender)/name sinuses: frontal (just beneath eyebrows); maxillary (press up on cheek bones)

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13
Q

While standing in front of seated governed patient
EYES (Must state what each eye test is evaluating to earn credit)
Cardinal Positions

A

Pt follows finger from center to 6 positions: Access EOM weakness/parallel tracking [CN III, IV, VI]

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14
Q

While standing in front of seated governed patient
EYES (Must state what each eye test is evaluating to earn credit)
Corneal light reflex

A

Shines light in eye looking for symmetry of light reflection on pupil: Tests eye alignment

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15
Q

While standing in front of seated governed patient
EYES (Must state what each eye test is evaluating to earn credit)
Pupillary Light Reflex

A

Brings light from side to assess for direct & consensual pupillary constriction [CN III]

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16
Q

While standing in front of seated governed patient
EYES (Must state what each eye test is evaluating to earn credit)
Accomodation

A

Pt focuses on far object then near object: Pupil constriction with focus on near object [CN III]

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17
Q

While standing in front of seated governed patient
EYES (Must state what each eye test is evaluating to earn credit)
Inspection:

A

Conjunctiva: pink, moist, clear, note abnormalities
Sclera: white, note abnormalities
Cornea: shines light from the side (smooth, clear)
Iris: flat, round, even coloration
Pupils: equal, round; measure size

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18
Q

While standing in front of seated governed patient
EARS
Inspection & Palpation

A

Contour of ears: equal bilaterally, no thickening, skin intact; Position of ears: symmetrical, aligned
Move auricle, push on tragus and mastoid process: No tenderness

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19
Q

While standing in front of seated governed patient
EARS
Whisper Test

A

Client/examiner covers tragus; whisper two-syllable word opposite ear while hiding mouth from 2 ft [CN VIII]

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20
Q

While standing in front of seated governed patient
NOSE
Inspection

A

External: symmetry, no lesions

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21
Q

While standing in front of seated governed patient
NOSE
Nare Patency

A

Check patency of each nostril (examiner or pt may occlude)

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22
Q

While standing in front of seated governed patient
MOUTH
Inspection

A

Color & condition of lips (pink, moist)
Buccal mucosa: pink, smooth, moist, intact, no lesions
Teeth: white, straight, evenly spaced, free of debris, presence/absence of caries (or fillings)
Uvula: midline, rises with phonation (“ah”) [CN IX & X]
Tonsil presence/absence (grade if present: 1+ to 4+)
Tongue: pink, even, moist, Stick out tongue; midline: [CN XII]

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23
Q

While standing in front of seated governed patient
NECK
Cervical Lymph Nodes

A

Palpate: gentle pressure, fingers move in rotating pattern
Names each lymph node as palpating: preauricular, postauricular, occipital, jugulodigastric, superficial cervical, posterior cervical, submandibular, submental, deep cervical chain (turn pt’s head), supraclavicular (shrug shoulders)

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24
Q

While standing in front of seated governed patient
NECK
Carotid Arteries

A

Palpate 1 artery at a time just lateral of trachea
Ausculate in 3 areas w/BELL for bruit: angle of jaw, midcervical area, base of neck
States rationale for checking bruit. Has person hold breath while listening.

25
While standing in front of seated governed patient NECK Trachea
Palpate: midline without deviation
26
While standing in front of seated governed patient NECK Neck Neuromuscular
Inspects & palpates (should state no warmth, tenderness, or edema) Active ROM (flexion, extension, lateral bending, rotation) Neck rotation and shoulder shrug against resistance [CN XI]; Grade strength out of 5
27
Move behind sitting patient POSTERIOR AND LATERAL CHEST Inspection
Symmetry, configuration of thoracic cage, patient's position, skin color & integrity
28
Move behind sitting patient POSTERIOR AND LATERAL CHEST Palpation
Palpates for lumps, tenderness & temperature Inspects and palpates spinous processes Assesses CVA tenderness bilaterally
29
Move behind sitting patient POSTERIOR AND LATERAL CHEST Auscultation
Listen under clothes in sequential pattern with diaphragm - 9 spots comparing sides Listens to all lobes of lungs, ensuring lateral areas assessed Does not listen over scapulae
30
Move in front of sitting patient ANTERIOR CHEST Inspection
Quality of respirations/work of breathing, patient's position, skin color & integrity AP/Transverse Diameter Ratio (STATES 1:2 is normal)
31
Move in front of sitting patient ANTERIOR CHEST Palpation
Palpate chest wall for lumps, tenderness & temperature
32
Move in front of sitting patient ANTERIOR CHEST Auscultation
Listen under clothes to all lobes with diaphragm - 5 spots anterior Listens in a sequential pattern - comparing sides Listens to apices and bases
33
Move in front of sitting patient UPPER EXTREMITIES Inspection & Palpation
Inspects upper extremities for color, skin integrity, temperature, edema & symmetry Palpates, names UE pulses: radial, brachial bilaterally; Grade pulses 0-3+ (states 2+ is normal) Skin turgor & mobility: pinches beneath the clavicle or back of wrist or hand
34
Move in front of sitting patient UPPER EXTREMITIES Nails
Inspects: texture, integrity, length, fake nails, ridges Palpate: thickness, texture, cap refill (<3 sec)--Minimum 1 digit on each hand Checks profile sign & assesses for clubbing of nails
35
Move in front of sitting patient UPPER EXTREMITIES Wrists/hands
``` Inspects (redness, swelling, symmetry) & palpates joints (tenderness, warmth, crepitus) Active ROM (wrist extension/flexion, ulnar/radial deviation, finger extension/flexion) ```
36
Move in front of sitting patient UPPER EXTREMITIES Elbows
``` Inspects (redness, swelling, symmetry) & palpates joint (tenderness, warmth, crepitus) Active ROM (flexion, extension, pronation, supination) Muscle strength: Push/Pull; Must grade 0-5+ stating 5+ is normal ```
37
Move in front of sitting patient UPPER EXTREMITIES Shoulders
``` Inspects (redness, swelling, symmetry) & palpates joint (tenderness, warmth, crepitus) Active ROM (flexion, extension, abduction, adduction, external/internal rotation) ```
38
Have patient lay down on bed with bed elevated to a 30 degree angle NECK JVD
Positions person supine; no pillow; starts at 30 degrees | Turns pt head slightly to left & observe for JVD & pulsations using pen light on right
39
Have patient lay down on bed with bed elevated to a 30 degree angle PRECORDIUM Inspection
Inspects precordium, notes any heaves, lifts or pulsations, skin color and integrity
40
Have patient lay down on bed with bed elevated to a 30 degree angle PRECORDIUM Palpation
Palpates precordium for thrills or pulsations using palmar aspect of hand over heart Palpates for apical impulse (5th ICS, MCL)
41
Have patient lay down on bed with bed elevated to a 30 degree angle PRECORDIUM Auscultation
Auscultate 5 sites using diaphragm and bell in correct anatomical locations & names them (aortic, pulmonic, erb's point, tricuspid, mitral) Names location of each sound (ex: 5th IC space, midclavicular line) Apical pulse: MUST count for a full minute; note rate and rhythm
42
Flatten bed and expose abdomen ABDOMEN Sequence of assessment
Uses sequence of inspection, auscultation, percussion, palpation
43
Flatten bed and expose abdomen ABDOMEN Inspection
Contour type (flat, scaphoid, rounded, protuberant) Symmetry; skin color and integrity Presence/absence of pulsations Describes umbilicus--states out loud
44
Flatten bed and expose abdomen ABDOMEN Auscultation
Listens in all 4 quadrants with diaphragm; describes BS (active, hypo or hyper) Listens for bruits over aorta (left of midline) with bell--States rationale
45
Flatten bed and expose abdomen ABDOMEN Percussion
Assesses all quadrants, states expected finding is tympany
46
Flatten bed and expose abdomen ABDOMEN Palpation
Light palpation--states assessing for tone and tenderness of abdomen Deep palpation--states looking for organomegaly or masses
47
Adjust drape to expose lower extremities LOWER EXTREMITIES Inspection & Palpation
Inspect/palpate BLE for color, skin integrity, hair distribution, temperature, edema & symmetry Assesses cap refill (<3 sec)--Minimum 1 digit on each foot Palpates & names LE pulses: dorsalis pedis and posterior tibial bilaterally; Grade pulses 0-3+
48
Adjust drape to expose lower extremities LOWER EXTREMITIES Hips
``` Inspects (redness, swelling, symmetry) & palpates joint (tenderness, warmth, crepitus) Active ROM (Extension/flexion, external/internal rotation, abduction, adduction) ```
49
Adjust drape to expose lower extremities LOWER EXTREMITIES Knees
``` Inspects (redness, swelling, symmetry) & palpates joints (tenderness, warmth, crepitus) Active ROM (dorsiflexion, plantar flexion, inversion, eversion) Muscle strength: Push/Pull; Must grade 0-5+ stating 5+ is normal ```
50
Adjust drape to expose lower extremities NEUROLOGICAL Plantar Reflex
Babinski, toes should NOT fan; State normal response (+ plantar reflex; (-) Babinski sign in adult)
51
Have patient sit up and dangle legs off side of bed: | Coordination/cerebellar fx
Finger to finger test, Finger to nose test (pt's eyes closed)
52
Have patient sit up and dangle legs off side of bed: | Pain sensation
Noting sharp/dull sensation w/o looking at stimuli upper & lower extremities, start distal, compare sides
53
Have patient sit up and dangle legs off side of bed: | Kinesthesia
Pt identifies position finger being up or down w/o looking
54
Have patient sit up and dangle legs off side of bed: | Grasp
Grasp checked simultaneously bilaterally. Offers more than one digit: Describes equality and strength (Firm, weak, absent)
55
Have patient sit up and dangle legs off side of bed: | DTR: paterllar
Bilaterally; Grades using scale: states normal (2+)
56
Assist patient to standing after putting bed in low position | Romberg test
Stand for 20sec with feet together, eyes closed; states negative is normal
57
Assist patient to standing after putting bed in low position | Gait
Has pt walk 10 ft: Notes gait is smooth, rhythmic & effortless
58
Assist patient to standing after putting bed in low position REMAINING MUSCULOSKELETAL Spine
``` Assess with shirt off for kyphosis, lordosis (laterally), and scoliosis (flex spine & assess posteriorly) Active ROM (Flexion/extension, lateral bending right and left, rotation right and left) ```
59
Breast/Testicular
Student must explain the importance of BSE and TSE to patient, and when it is best to perform

NURS 294 (1 decks)

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