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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
Q

While standing in front of seated governed patient
NECK
Trachea

A

Palpate: midline without deviation

26
Q

While standing in front of seated governed patient
NECK
Neck Neuromuscular

A

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
Q

Move behind sitting patient
POSTERIOR AND LATERAL CHEST
Inspection

A

Symmetry, configuration of thoracic cage, patient’s position, skin color & integrity

28
Q

Move behind sitting patient
POSTERIOR AND LATERAL CHEST
Palpation

A

Palpates for lumps, tenderness & temperature
Inspects and palpates spinous processes
Assesses CVA tenderness bilaterally

29
Q

Move behind sitting patient
POSTERIOR AND LATERAL CHEST
Auscultation

A

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
Q

Move in front of sitting patient
ANTERIOR CHEST
Inspection

A

Quality of respirations/work of breathing, patient’s position, skin color & integrity
AP/Transverse Diameter Ratio (STATES 1:2 is normal)

31
Q

Move in front of sitting patient
ANTERIOR CHEST
Palpation

A

Palpate chest wall for lumps, tenderness & temperature

32
Q

Move in front of sitting patient
ANTERIOR CHEST
Auscultation

A

Listen under clothes to all lobes with diaphragm - 5 spots anterior
Listens in a sequential pattern - comparing sides
Listens to apices and bases

33
Q

Move in front of sitting patient
UPPER EXTREMITIES
Inspection & Palpation

A

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
Q

Move in front of sitting patient
UPPER EXTREMITIES
Nails

A

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
Q

Move in front of sitting patient
UPPER EXTREMITIES
Wrists/hands

A 
Inspects (redness, swelling, symmetry) & palpates joints (tenderness, warmth, crepitus)
Active ROM (wrist extension/flexion, ulnar/radial deviation, finger extension/flexion)
36
Q

Move in front of sitting patient
UPPER EXTREMITIES
Elbows

A 
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
Q

Move in front of sitting patient
UPPER EXTREMITIES
Shoulders

A 
Inspects (redness, swelling, symmetry) & palpates joint (tenderness, warmth, crepitus)
Active ROM (flexion, extension, abduction, adduction, external/internal rotation)
38
Q

Have patient lay down on bed with bed elevated to a 30 degree angle
NECK
JVD

A

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
Q

Have patient lay down on bed with bed elevated to a 30 degree angle
PRECORDIUM
Inspection

A

Inspects precordium, notes any heaves, lifts or pulsations, skin color and integrity

40
Q

Have patient lay down on bed with bed elevated to a 30 degree angle
PRECORDIUM
Palpation

A

Palpates precordium for thrills or pulsations using palmar aspect of hand over heart
Palpates for apical impulse (5th ICS, MCL)

41
Q

Have patient lay down on bed with bed elevated to a 30 degree angle
PRECORDIUM
Auscultation

A

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
Q

Flatten bed and expose abdomen
ABDOMEN
Sequence of assessment

A

Uses sequence of inspection, auscultation, percussion, palpation

43
Q

Flatten bed and expose abdomen
ABDOMEN
Inspection

A

Contour type (flat, scaphoid, rounded, protuberant)
Symmetry; skin color and integrity
Presence/absence of pulsations
Describes umbilicus–states out loud

44
Q

Flatten bed and expose abdomen
ABDOMEN
Auscultation

A

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
Q

Flatten bed and expose abdomen
ABDOMEN
Percussion

A

Assesses all quadrants, states expected finding is tympany

46
Q

Flatten bed and expose abdomen
ABDOMEN
Palpation

A

Light palpation–states assessing for tone and tenderness of abdomen
Deep palpation–states looking for organomegaly or masses

47
Q

Adjust drape to expose lower extremities
LOWER EXTREMITIES
Inspection & Palpation

A

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
Q

Adjust drape to expose lower extremities
LOWER EXTREMITIES
Hips

A 
Inspects (redness, swelling, symmetry) & palpates joint (tenderness, warmth, crepitus)
Active ROM (Extension/flexion, external/internal rotation, abduction, adduction)
49
Q

Adjust drape to expose lower extremities
LOWER EXTREMITIES
Knees

A 
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
Q

Adjust drape to expose lower extremities
NEUROLOGICAL
Plantar Reflex

A

Babinski, toes should NOT fan; State normal response (+ plantar reflex; (-) Babinski sign in adult)

51
Q

Have patient sit up and dangle legs off side of bed:

Coordination/cerebellar fx

A

Finger to finger test, Finger to nose test (pt’s eyes closed)

52
Q

Have patient sit up and dangle legs off side of bed:

Pain sensation

A

Noting sharp/dull sensation w/o looking at stimuli upper & lower extremities, start distal, compare sides

53
Q

Have patient sit up and dangle legs off side of bed:

Kinesthesia

A

Pt identifies position finger being up or down w/o looking

54
Q

Have patient sit up and dangle legs off side of bed:

Grasp

A

Grasp checked simultaneously bilaterally. Offers more than one digit: Describes equality and strength (Firm, weak, absent)

55
Q

Have patient sit up and dangle legs off side of bed:

DTR: paterllar

A

Bilaterally; Grades using scale: states normal (2+)

56
Q

Assist patient to standing after putting bed in low position

Romberg test

A

Stand for 20sec with feet together, eyes closed; states negative is normal

57
Q

Assist patient to standing after putting bed in low position

Gait

A

Has pt walk 10 ft: Notes gait is smooth, rhythmic & effortless

58
Q

Assist patient to standing after putting bed in low position
REMAINING MUSCULOSKELETAL
Spine

A 
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
Q

Breast/Testicular

A

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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