Head to Toe Assessment Flashcards
before starting head to toe, think about…
-age group
-organization of assessment (clean to dirty)
testing level of consciousness (LOC) - 5
-alert
-lethargic
-obtunded
-stuporous/semi-comatose
-comatose
alert LOC
attentive, follows commands, if asleep – wakes promptly and remains attentive
lethargic LOC
Drowsy but awakens, slow to respond
obtunded LOC
Difficult to arouse, needs constant stimulation
stuporous/semi-comatose LOC
Arouses only to vigorous/noxious stimuli, may only withdraw from pain
vigorous
loud, hard
noxious
unpleasant, knuckle rub to sternum, soft spot behind ear (pressure points), nail bud pressure
comatose LOC
No response to verbal or noxious stimuli, no movement except deep tendon reflex
cognitive awareness
-what do we orient patient to? (4)
-also known as…
-orient person to person, place, time, event
-mentation
how do we test cranial nerves III, IV, and VI?
-pupil response
3-oculomotor
4-trochlear
6-abducens
pupil response (PERRLA)
Pupils Equal Round Reactive Light and Accommodation
how do we test pupil response
place hand on bridge of nose, start at ear, move light into pupil (should constrict) – document size of pupil constriction
-same thing for other side
testing cardinal gaze
9-12 in. from face, move penlight in shape of an H, can pt eyes track movement
how do we test cranial nerve VII?
7-facial nerve
ask pt to smile, wrinkle forehead/raise eyebrows
-is it all even?
how do we test cranial nerve XII?
12 - hypoglossal
ask pt. to touch roof of mouth with tongue, stick tongue out, move tongue side to side
how do we test cranial nerve XI?
11-accessory
ask pt. to shrug shoulders, place hands on pt. shoulders with light resistance
how do we test motor function? what is included in this?
-neuro and musculoskeletal
-have patient grasp hands
-flexion and extension (push against hands and pull back)
-put hands on sole of foot, ask pt to push against, hand on top of foot, ask to push up
neuro components of assessment
-Level of consciousness and orientation x4
-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
vesicular lung sounds
heard in all of lobes
soft, blowing sound
bronchovesicular lung sounds
closer to sternum
hollow quality sound
bronchial lung sounds
over trachea
loud, blowing sound
wheeze lung sounds
-high pitched musical sounds
-“strider” : struggling to breathe
crackle/rales lung sounds (fine or coarse)
-Rice Krispies
-crackling (mostly heard in lung bases)
-lower lobes
-fluid collection
rhonchi lunch sound
-rumbling
-mucus
-bigger airways
-normally cleared when they cough
pleural friction rub lung sound
-sounds like stethescope to clothing
-pleural cavity loses fluid, no lubrication
bradypnea respiratory pattern
slow breathing
tachypnea
fast breathing
apnea
abscence of breathing
hyperpnea
patient is struggling and rapid breathing
Kussmaul’s
respirations are becoming slow and low
Cheyne-stokes
increase in rr/depth, decrease in rr/depth, absence (apnea)
pattern of auscultation-lungs
7 on front
10 on back, follow scapula
start on left!
when do we have patient take deep breaths? why?
on back , 7-10
farther away from trachea, quieter lung sounds & lower lobes are where we normally have disease and fluid collection
examining nail shape
have patient put nails together, cuticles touching, a little space between
-clubbing (low o2)
respiratory assessment components
-anterior and posterior lung sounds
-clubbing
LUB heart sound
systole or S1 and is sound associated with the closing of mitral/tricuspid valves
LUB DUB
1 cardiac cycle
DUB
diastole or S2 and is sound associated with closing of aortic/pulmonic valves
there should be a longer pause between ___
S2 and S1
aortic
right base, second intercostal space to right of sternal border
2 heart cycles
pulmonic
left side, second intercostal space to left of sternal border
lub dub/ 2 cycles
tricuspid
left lateral sternal border, 5th intercostal space to left of sternal border
mitral
apical pulse/apex ; midclavicular line at the 5th intercostal space
pulses assessed in assessment
carotid (feeling bilaterally, not together)
radial (at same time, 2 cycles)
apical (cardiac, 2 beats)
dorsalis pedis (at same time, 2 cycles)
0 quality pulse point
absent, non-palpable
1+ pulse
diminished, palpable
2+ pulse
strong, normal
3+ pulse
full, increased
4+ pulse
bounding
if unable to locate pulse by palpation, _____
use doppler
capillary refill
applying pressure to nail bed and observe time it takes to return color (2-3 seconds)
-bilateral upper extremities and lower (finger nails and toenails)
edema
swelling in extremities
dependent edema
most often on feet or ankles, older adults and standing
pitting edema
venous insufficiency or heart failure, fluid in tissues
cardiac components of assessment
Heart sounds
Carotid pulses
Radial pulses
Pedal pulses
Capillary refill
Assess for edema
range of motion tests (7)
Neck
Shoulders, upper arms, & elbows
Upper arms & Elbows
Wrists
Hips
Knees
Ankles
neck ROM
-move neck side to side
-chin to chest
-extension back
shoulders,, upper arms and elbows
arms out to side, arms straight up, touchdown
wrists ROM
circles
hips, knees, and ankles ROM
-bilateral hip flexion out
-bend knees
-ankle circles
musculoskeletal components
-neck ROM
-BUE ROM
-BLE ROM
-HGTW
-flexion/extension of BUE and BLE
inspect skin for (7)
Hydration
Temperature
Color
Texture
Rashes
Lesions
Cracking
pallor
pale or ashen gray
erythema
redness related to vasodilation
jaundice
yellow, impaired liver
skin or sclera of eyes
cyanosis
bluish, decreased circulation or oxygenation of blood
around mouth, nail beds
turgor test
pinch to skin under clavicle related to hydration, will tent if dehydrated
texture of skin can be…
dry and course, or shiny with no hair
temperature of skin should be…
warm, consistent with room temp
things affecting skin (7)
-dampness
-dehydration
-nutrition
-circulation
-disease
-jaundice
-lifestyle
normal skin changes in older adults (8)
-epidermis
-subcutaneous tissue
-collagen and elastin fibers
-hormones
-vascularity
-melanocytes
-nails
-skin growths
pitting edema cause by …
leads to …
kidney or liver heart failure
-leads to excess fluid collection in tissues
1 + pitting edema
2mm indention to trace
rapid response
2+ pitting edema
4mm to mild
10-18 seconds
3 + pitting edema
6mm to moderate
1-2 minutes
4+ pitting edema
8mm to severe
2-5 minutes
assessment of bony prominences
-hips, heels, coccyx, shoulders (no muscle, subcutaneous tissue)
-most at risk for skin breakdown
-blanching red spots - make skin go pale, if it remains red, that is a pressure injury
observe nails for :
-shape
-contour
-cleanliness
-neatly manicured / trimmed
nails should be : (5)
-transparent
-smooth
-rounded
-convex
-hygienic
terminal hair
scalp, axillae, pubic and beard
vellus hair
defines us as mammals
-soft tiny hairs covering body except on palms of hands and soles of feet
assessment of hair , looking for (5)
-quantity (alopecia, hirsutism-overgrowth)
-distribution
-texture
-color
-parasites
assess ears for (8)
symmetry, drainage, shape, hearing defects, lesions, redness, tenderness, odor
inspect nose for (9)
position, symmetry, color, swelling, deformities, discharge, flaring, patency, sinus tenderness
assess oral cavity for (6)
lios, oral mucosa, teeth, gums/tongue, breath
inspect throat (6)
lumps, ulcers, edema, white spots, redness, swallowing
inspect throat for (6)
lumps, ulcers, edema, white spots, redness, swallowing
inspect neck for
contour and symmetry, midline trachea, jugular vein distention
palpate neck for
inflamed/enlarged lymph nodes
integument components of assessment
Inspect hair and scalp
Inspect ears
Inspect nose
Inspect mouth and throat
Inspect and palpate neck
Assess skin turgor
Inspect skin on back and bony prominences
Inspect skin of BUE and BLE
Inspect nails
elimination
excretion of waste products from kidneys and intestines
defecation
process of elimination of waste
feces
Semisolid mass of fiber, undigested food, inorganic matter
assessment of abdomen
inspect
auscultate
palpate
inspection of abdomen
look at size, shape, contour, skin integrity
auscultation of abdomen
listen for bowel sounds 5-20seconds, four quadrants - hypo/hyperactive
palpation of abdomen
feel for tenderness, pain, masses
questions to ask while assessing abdomen
-normal bowel and urine patterns
-appearance
-changes
-history if problems
incontinence
inability to control urine or feces
void / micturate
to urinate
dysuria
painful or difficult urination
hematuria
blood in the urine
nocturia
frequent night urination
polyuria
large amounts of urine
urinary frequency
voiding at frequent intervals
urinary urgency
the need to void all at once
proteinuria
presence of large protein in urine
dribbling
leakage of urine despite voluntary control of urination
retention
accumulation of urine in bladder without the ability to completely empty
residual
urine remaining post void >100ml
kidney functions
filter and regulate blood and fluid of body
-regulate acid-base balance
ureter function
transport urine from kidneys to bladder
-urine through ureters should be sterile
-enter bladder obliquely and posteriorly
-only meant to have fluid (renal colic)
bladder function
hollow
reservoir for urine until urge develops
-men- anterior wall of rectum
-women - anterior walls of uterus and vagina
-normal bladder - 500 ml, can extend to 1000ml
urethra function
urine travels from bladder and exits through urethral meatus
-urine that travels through has turbulent flow to prevent bacteria growth
-women : 1.5 to 2.5 in (more prone to UTI)
-men : 8 in
nephrons
functional unit of kidney
assessment of urethra meatus and perineal area
-inspect urethral orifice
-look for signs of infection
-perineal area : color, condition, presence of urine or stool
