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