Head to Toe Assesment Flashcards
Level of Consciousness is
-the Single most important neuro assesment componet
-Often the first clue of deteriorating condition
Alert
-Attentive
-Follows commands
-If asleep – wakes promptly and 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 or noxious stimuli
-No movement except deep tendon reflex
Cognitive Awareness
-Also known as mentation
-Is the patient oriented to person, place, and time?
Three Questions to test Cognitive Awareness
-Oriented to person: What is your name and date of birth?
-Oriented to place: Where are you right now?
-Oriented to time: What year/day is it?
Test Cranial Nerves III, IV, and VI (3,4,6)
-Pupil Response
-Dilation (Before and After)
-Focus (close too and away/light off)
-Cardinal Gaze
-H motion (9-12in away from face)
Test Cranial Nerve VII (7) - The Facial Nerve
-Smile and show teeth
-Wrinkle forehead or raise eyebrows
Test Cranial Nerve XII (12) - the hypoglossal nerve
-Tounge to roof of mouth
-Tounge out
-Tounge side to side
Test Cranial Nerve XI (11) - the accessory nerve
-Shoulder Shrug
Test Motor Function
-Hand grasp and toe wiggle (HGTW)
-BUE & BLE Flexion and extension (with resistance)
H2T Neuro Components of Assessment
-Level of consciousness and orientation
-Pupil response and Cardinal gaze
-Smile and show teeth, raise eyebrows
-Tongue to roof of mouth, out, side to side
-Shoulder strength with resistance
-HGTW
-Flexion/Extension BUE and BLE
3 Normal Lung Sounds
- Vesicular – heard periphery of the lungs
- Bronchovesicular – heard closer to the sternum
- Bronchial – heard over trachea
4 Abnormal or Adventitious Lung Sounds
- Crackles or rales (can be fine or course)
- Rhonchi
- Wheezes
- Pleural Friction Rub
6 Abnormal Respiratory Patterns
- Bradypnea
- Tachypnea
- Apnea
- Hyperpnea
- Kussmaul’s
- Cheyne-Stokes
How many Anterior Lung Auscultation locations are there
7
How many Posterior Lung Auscultation locations are there
-10
-Deep breaths on 7-10
What do you test for nails?
-Shape
-Clubbing: happens where there is consistant low O2 levels in the blood
H2T Respiratory Components of Assessment
-Anterior and posterior lung sounds
-Clubbing
2 Normal Heart Sounds
- Lub: Systole or S1
-sound associated with the closing of the mirtal/tricuspid valves - Dub: Diastole or S2
-sound associated with the closing of the aortic/pulmonic valves
There should be a longer pause between S2 & S1
4 Location of Heart Sounds
- Aortic: Right base
-Second intercostal space to the right of the sternal border - Pulmonic: Left base
-Second intercostal space to the left of the sternal border - Tricuspid: Left lateral sternal border
-Fifth intercostal space to the left of the sternal border - Mitral: Apex
-Midclavicular line at the fifth intercostal space
8 Pulse Points
- Carotid*** (neck)
- Brachial (elbow)
- Radial*** (wrist thumb side)
- Ulnar (wrist pinky side)
- Apical*** (chest)
- Femoral (inner hip)
- Popliteal (behind knee)
- Dorsalis pedis*** (top of foot or bw big/middle toe)
4 H2T Assesment Pulse Points
- Carotid – one at time, bilaterally
- Radial – bilaterally at the same time
- Apical – with stethoscope for 2 beats
- Dorsalis Pedis or Pedal pulses – bilaterally at the same time
Pulse Quality Scale
0 – Absent, Non-palpable
1+ – Diminished, palpable
2+ – Strong , normal
3+ – Full, Increased
4+ – Bounding
What is a Doppler?
-Hand-held device that amplifies pulse sounds
-Most often used for pedal pulses
2 Extremity Assessments
- Capillary refill: Press skin of nailbed to produce blanching, release pressure and observe time taken for color return, should be less than 2-3 seconds, BUE and BLE
- Edema: Swelling in the extremities
Dependent edema: most often on feet and ankles, older adults.
and standing
Pitting edema: venous insufficiency or heart failure, fluid in tissues
H2T Cardiac Components of Assessment
-Heart sounds
-Carotid pulses
-Radial pulses
-Pedal pulses
-Capillary refill
-Assess for edema (swelling)
7 Locations to Assess Range of Motion (ROM)
- Neck
- Shoulders
- Upper arms & Elbows
- Wrists
- Hips
- Knees
- Ankles
How to Test Neck ROM
-Move neck side to side
-Chin to chest
-Extension back (look up)
How to Test Shoulders, Upper Arms & Elbows ROM
-Arms out to side
-Arms straight up
-Touchdown (goal post)
How to Test Wrists ROM
Wrist circles
How to Test Hips, Knees, and Ankles ROM
-Bilateral hip flexion out
-Bend knees
-Ankle circles
How to Test Strength
-Handgrip
-Toe wiggle
-Flexion and extension of BUE/BLE
H2T Musculoskeletal Components of Assessment
-Neck ROM
-BUE ROM
-BLE ROM
-HGTW
-Flexion/Extension BUE and BLE
7 Things to Assess the Skin for
- Hydration
- Temperature
- Color
- Texture
- Rashes
- Lesions
- Cracking
4 Skin Color Assessments
- Pallor – pale or ashen gray
- Erythema – redness r/t vasodilation
- Jaundice – yellow, impaired liver
- Cyanosis – bluish, decreased circulation or oxygenation of blood
How should healthy skin temperature feel?
Skin should be WARM and consistent with the room temperature
How should skin moisture feel if dehydrated
DRY
Impaired Peripheral Circulation Signs
Texture can be dry & course (elbows/knees) or shiny with no hair
What does Turgor test for?
elasticity of the skin related to hydration
Where do you assess skin turgor on a patient?
Under clavicle (pinch skin)
7 Factors Effecting the Skin
- Dampness
- Dehydration
- Nutrition
- Circulation
- Disease
- Jaundice
- Lifestyle
Normal Skin Changes in Older Adults
Epidermis
Subcutaneous tissue
Collagen & elastin fibers
Hormones
Vascularity
Hair follicles
Melanocytes
Nails
Skin growths
Pitting Edema
-Caused by kidney or heart failure
-Leads to excess fluid collection in tissues
How do you Assess Pitting Edema?
- Poke the affected area and assess the pit for depth and response time
-Measured on a 4 point scale
1+ 2mm to trace Rapid Response
2+ 4mm to mild 10-18 second Response
3+ 6mm to moderate 1-2 minute Response
4+ 8mm to severe 2-5 minute Response
4 Bony Prominences to Assess
- Hips
- Heels
- Coccyx
- Shoulders
What do you Assess the Bony Prominences for?
- Skin Integrity
- Blanching Red Spots
4 Things to Asses the Nails for
- Shape
- Contour
- Cleanliness
- Neatly manicured/trimmed
A Patients Nails should be
Transparent
Smooth
Rounded
Convex
Hygienic
5 Things to Assess the Hair for
- Quantity (Alopecia, hirsutism-due to hormones)
- Distribution
- Texture
- Color
- Parasites
2 Main Types of Body Hair
- Terminal Hair - Scalp, axillae, pubic, and beard
- Vellus Hair - Soft tiny hairs covering body except on palms and soles
8 Things to Assess the Ears for
- Symmetry
- Drainage
- Shape
- Hearing defects
- Lesions
- Redness
- Tenderness
- Odor
9 Things to Assess the Nose for
- Position
- Symmetry
- Color
- Swelling
- Deformities
- Discharge
- Flaring
- Patency
- Sinus tenderness
5 Oral Cavity Assessments
- Lips
- Oral Mucosa
- Teeth (dentition)
- Gums / Toungue
- Breath Odor
6 Throat inspections
- Lumps
- Ulcers
- Edema
- White spots
- Redness
- Swallowing
Inspect the neck for
-Contour & symmetry
-Midline Trachea
-Jugular vein distention
Palpate the neck for
Inflamed or enlarged Lymph Nodes
H2T Integumentary Components of Assessment
-hair and scalp
-ears
-nose
-mouth and throat
-Inspect and palpate neck
-Assess skin turgor
-skin on back and bony prominences
-Inspect skin of BUE and BLE
-nails
Elimination is the
excreation of waste products from kidneys and intestines
Defecation is the
process of elimination of waste
Feces is
a semisolid mass of fiber, undigested food, inorganic matter
Incontinence is the
inability to control urine or feces
Void means
to urinate
Micturate means
to urinate
Dysuria is when a patient has
painful or difficult urinations
Hematuria is when there is
blood in the urine
Nocturia is when a patient has
frequent night urinations
Polyuria is
large amounts of urine
Urinary frequency
voiding at frequent intervals
Urinary urgency is
the need to void all at once
Proteinuria is
the presence of large protein in urine
Dribbling is
the leakage of urine despite voluntary control of urination
Retention is
the accumulation of urine in bladder without the ability to completely empty
Residual is
> 100mL of urine remaining post void
4 Sructures of the Gastrointestinal Tract
- Upper gastrointestinal tract
- Small intestine
- Large Intestine
- Rectum and anus
Chyme travels via
peristalsis
Small Intestine
- Folded, twisted, and coiled tube from stomach to large intestine
- 1” in diameter and 20’ long
- Most digestion and absorption happens here
3 Segments of the Small Intestine
- Duodenum
- Jejunum
- ileum
Large Intestine
- AKA – colon
- 2.5” diameter and 5-6’ long
7 segments of the Large Intestine (Colon)
- Cecum
- Ascending colon
- Transverse colon
- Descending colon
- Sigmoid colon
- Rectum
- Anus
4 Organs of Urinary Elimination
- Kidneys
- Ureters
- Bladder
- Urethra
Kidney Functions
-Filter and regulate
-Remove waste from blood to form urine
Ureter Function
Transport urine from kidneys to bladder
Bladder Function
Reservoir for urine until the urge develops
Urethra Function
Urine travels from bladder and exits through urethral meatus
Kidneys
- Bilateral, posterior flanks
- Size of fists
- Primary regulators of fluid and acid-base balance
Nephron – functional unit of the kidney
Glomerulus - cleaning process done here
Bowman’s Capsule
Proximal Convoluted Tubule - Absorbtion and reabsorption
Loop of Henle - Absorbtion and reabsorption
Distal Tubule - Absorbtion and reabsorption
Collecting Duct
Ureters
- Tubule structures that enter the bladder
- Urine traveling through ureters is typically sterile
- Ureters enter bladder obliquely and posteriorly to prevent reflux
- Obstructions(kidney stones) cause peristaltic waves severe pain often referred to as renal colic
Bladder
- Hollow, distensible, muscular organ
- In men – bladder lies against anterior wall of rectum
- In women – bladder rest against anterior walls of uterus and vagina
- When bladder is full, it extends above symphysis pubis
- Normal bladder – 500ml
-Can extend to 1000ml
Urethra
- Turbulent flow washes urethra free of bacteria
- Descends through pelvic floor muscles
- Contraction of pelvic floor muscles can prevent flow of urine
- In women – urethra is short (1 ½ to 2 ½ in), leads to prevalence of infection
- In men – urethra is long (8 in), serves in both GU and reproductive system, three sections: prostatic, membranous, and penile
Abdomen Assessment Order (must go in this order)
- Inspection (look) – observe size, shape, contour, skin integrity
- Auscultation (listen) – bowel sounds, four quadrants
- Palpation (feel) – palpate for tenderness, pain, masses
Abdomen Auscultation Order
Start at the Right Lower Quadrent and go clockwise
4 Spots of Auscultaion
4 Questions to Ask During Abdomen Assessment
- Normal bowel and urine patterns
- Appearance
- Changes
- History of problems
Assessment of Urethral Meatus and Perineal Area
-Inspect urethral orifice for erythema, discharge, swelling, or odor
-Signs of infection, inflammation, or trauma
-Perineal area: color, condition, presence of urine or stool
H2T GI/GU Components of Assessment
- Examination of abdomen – look, listen, feel
- Ask questions about habits
- Examination of urethral meatus and perineal area
