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Fundamental Lab > head-to-toe assessment > Flashcards

head-to-toe assessment Flashcards

1
Q

Nutritional Status (6)

A 
Assess Height and Weight 
Recent weight loss or gain 
Appetite – diet, problems eating  
Nausea/vomiting 
Heartburn 
Use of supplements 
Problems swallowing or chewing
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2
Q

Posture
Gait
(3)

A

Posture upright or erect
Gait steady
Use of assistive devices

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3
Q

LOC
Orientation
Mood (situation, eye contact)
(3)

A

Alert, lethargic, drowsy, comatose
Oriented X 4 (person, time, place, & circumstance)
Affect, behavior

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4
Q

Hair (2)

A

Assess hair distribution (thinning, alopecia, use of
wigs)
Condition (thin, moist, brown)

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5
Q

Face (1)

A

Assess facial symmetry (symmetrical or drooping)

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6
Q

Eyes (9)

A 
Pupil size  (PERRLA) 
Pupils equal 
Pupils round 
Pupils reactive to light 
Direct response to light 
Indirect (consensual) response to light 
Accommodation (convergence/constriction) 
Sclera color 
Conjunctiva color, drainage (no erythema)
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7
Q

Skin of face
Edema
(4)

A

Skin color, temperature, moisture, condition
Palpate sinuses for tenderness
Palpate for periorbital edema
Palpate temporal artery & grade

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8
Q

Nose (3)

A

Nasal flaring

Color of nose, presence of drainage

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9
Q

Ears (3)

A

Color of ears, presence of drainage
Ears symmetrical
Check for hearing aides

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10
Q

Mouth/Lips,
Tongue
Speech
(6)

A 
Drooping of mouth or lips (smile)
Tongue midline 
Assess color & moisture of mouth, lips, mucous 
membranes (intact, moist, pink)
Lesions or sores in mouth 
Condition of teeth, dentures 
Speech clear
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11
Q 
NVD 
Pulsations 
Trachea 
Carotids
(6)
A 
Neck vein distention 
Carotid pulsations absent or visible 
Trachea midline 
ROM (up, down, side to side)
Palpate carotid arteries, grade 
Auscultate carotid arteries (Bruit) (hold breath and turn neck)
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12
Q

Skin on Chest (2)

A

Assess skin color, condition, temperature and
moisture (tan, dry, intact, warm)
Edema, grade pitting edema if present

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13
Q

Cardiac (6)

A

Locate and name all landmarks for finding the apical
pulse (sternal notch, manubrium, angle of Louis,
intercostal spaces, sternal border)
Assess cardiac sounds at all assessment points
(Aortic, Pulmonic, Erb, Tricuspid, Mitral)
Auscultate apical pulse for 60 seconds.
S1 S2 noted
Rhythm (regular or irregular)
Apical/Radial pulse deficit

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14
Q

Breath Sounds (10)

A

Auscultate anterior lung sounds upper, middle and
lower lobes start below clavicles (8 points of
auscultation)
Auscultate posterior sounds upper, middle and lower
lobes (8 points of auscultation)
Auscultate lateral lung sounds (2 points of
auscultation on each side)
Breathe through mouth
Listen one full breath before moving stethoscope
Stethoscope placement (comparing sides)
Stethoscope next to skin (not over gown)
State/name normal breath sounds (bronchial,
bronchovesicular, vesicular)
State location of normal breath sounds
State adventitious breath sounds

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15
Q

Inspecting Skin of abdomin (4)

A 
Assess skin for scars, tattoos, piercings, masses, 
incisions (describe) 
Assess skin color, moisture (tan, dry)
Assess contour of abdomen 
Assess for aortic pulsations
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16
Q

Bowel Pattern
Bowel Sounds
(5)

A

Assess bowel patterns and last BM (date) describe
Assess for flatus
Assess sensation of bloating
Auscultate all four quadrants (Must auscultate prior
palpation).
Describe bowel sounds heard (active, absent
hyperactive, or hypoactive) X 4 quadrants

17
Q

Light Palpation (5)

A

Ask patient if has pain/tenderness prior to palpation
Palpate abdomen (soft, firm, distention)
Palpate for tenderness, non-tender
Palpate for superficial masses
Palpate for bladder distention

18
Q

Skin (3) of upper extremities

A

Assess temperature, moisture, color and condition
Edema, grade pitting edema if present
Skin turgor – tenting, elastic

19
Q

Capillary Refill of upper
Pulses
(5)

A

Color of nail beds and condition of nails
Inspect for clubbing
Capillary refill, describe (less than 3 sec)
Palpate radial pulses, grade
Palpate brachial pulses, grade

20
Q

Muscle
Strength/Tone
Sensation
(5)

A

Assess ability to move upper extremities freely
Assess arm muscle tone and strength (moderate tone)
Hand grasps (strength & equality)
Ability to discriminate dull or sharp
Presence of numbness, tingling

21
Q

Skin (5) of lower extremties

A

Skin color, moisture, temperature, condition
Varicosities
Edema, (explain how to grade pitting edema)
Hair distribution
Assess for wounds, ulcerations

22
Q

Capillary Refill of lower
Pulses
(6)

A 
Color of nail beds  
Capillary refill (describe)  
Palpate femoral pulses (verbalize only) 
Palpate popliteal pulses, grade 
Palpate dorsalis pedis pulses, grade 
Palpate posterior tibial pulses, grade
23
Q

Muscle
Strength/Tone of lower
Sensation
(6)

A 
Ability to move legs freely 
Dorsiflexion, strength and equality 
Plantar flexion, strength and equality 
Muscle strength and tone 
Ability to discriminate dull or sharp 
Presence of numbness, tingling
24
Q

DVT (4)

A

Assess for calf tenderness and/or pain
Redness
Warmth
Edema

25
Q

Aortic

A

2nd intercoastal space right sternal border

26
Q

pulmonic

A

2nd intercostal space left sternal border

27
Q

erb’s point

A

3rd intercostal space left of sternal border

28
Q

tricuspid

A

4th intercoastal space left sternal border

29
Q

mitral

A

5th intercoastal space midclavicular line

30
Q

bronchial breath sound

A

over trachea

31
Q

bronchovesicular breath sounds

A

posterior over scapula and anteriorly over bronchioles

32
Q

Vesicular breath sounds

A

periphery of lungs

33
Q

Abnormal breath sounds

A

crackles
wheezes
rhonchi
friction rub

34
Q

Voiding Pattern (6)

A 
Frequency 
Burning or pain with urination  
Urine color and clarity 
Amount 
Hesitancy or urgency  
Bleeding or blood in urine

Fundamental Lab (1 decks)

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