head to toe assessment

Question 1

What is an intentional wound?

Answer 1

Surgical- usually closed with sutures, staples, Dermabond (surgical glue), or steri-strips

Question 2

What is an unintentional wound?

Answer 2

cut/trauma- often are infected by what caused the wound- treatment often includes antibiotics- can also be a pressure ulcer (this does not include burns)

Question 3

Describe serous wound drainage

Answer 3

watery in consistency and contains very little cellular matter. Serous exudate consists of serum, the straw-colored fluid that separates out of blood when a clot is formed. Clean wounds typically drain serous exudate.

Question 4

Describe sanguineous wound drainage

Answer 4

bloody drainage. It indicates damage to capillaries. You will often see sanguineous exudate with deep wounds or wounds in highly vascular areas. Fresh bleeding produces bright red drainage, whereas older, dried blood is a darker, red-brown color.

Question 5

Describe serosanguineous wound drainage

Answer 5

a combination of bloody and serous drainage. It is most commonly seen in new wounds.

Question 6

Describe purulent wound drainage

Answer 6

thick, often malodorous, drainage that is seen in infected wounds. It contains pus, a protein-rich fluid filled with WBCs, bacteria, and cellular debris. It is commonly caused by infection from pyogenic (pus-forming) bacteria, such as streptococci or staphylococci. Normally, pus is yellow in color, although it may take on a blue-green color if the bacterium Pseudomonas aeruginosa is present.

Question 7

What is erythema (as it relates to wounds)?

Answer 7

redness

Question 8

What is eschar (as it relates to wounds)?

Answer 8

scabbing or sloughing

Question 9

What is necrosis (as it pertains to wounds)?

Answer 9

tissue death, black wound bed

Question 10

What is pruritus (as it pertains to wounds)?

Answer 10

Itchy skin is an irritating sensation that makes you want to scratch.

Question 11

Describe a Deep Tissue Injury

Answer 11

Darker purple or maroon localized area of intact skin or blood-filled blister caused by damage to the underlying soft tissue from pressure or shear. Painful, firm, mushy, boggy, warmer or cooler, compared w/ adjacent tissue. Wound may evolve rapidly.

Question 12

Describe stage 1 pressure ulcer.

Answer 12

Skin (normally on bony prominence) is red/nonblanchable, warm, and may be painful, firm, soft, or warmer/cooler compared w/ adjacent tissue.

Question 13

Describe stage 2 pressure ulcer.

Answer 13

Partial-thickness loss of dermis. Open but shallow wound, red-pink. No slough. May be intact or open/ruptured serum-filled blister or shiny or dry shallow ulcer.

Question 14

Describe stage 3 pressure ulcer.

Answer 14

Deep crater, full-thickness loss of dermis with damage or necrosis of subcutaneous tissue. Adipose is visible. Can be extremely deep if in fatty area. Bone/tendon not visible or palpable.

Question 15

Describe stage 4 pressure ulcer.

Answer 15

Full-thickness skin loss w/ extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures. Bone/tendon visible or easily palpable. Slough may be present.

Question 16

Describe unstageable pressure ulcer.

Answer 16

Full-thickness skin loss, base of wound is obscured by slough or eschar that can be tan, yellow, gray, green, or brown necrotic tissue.

Question 17

Which stages require tunneling to treat? Describe tunneling.

Answer 17

Stages 3 and 4. Using a sterile instrument to go along edge of the wound under the skin. Helps determine the severity of the wound.

Question 18

What scale is used to predict pressure sore risk? Do you want a high or low number?

Answer 18

Braden scale. A high score means a low risk.

Question 19

Describe basal cell carcinoma.

Answer 19

Smooth and shiny, reddish, irritated area, open sore, scar-like Most common. Rarely metastasize.

Question 20

Describe squamous cell carcinoma.

Answer 20

Scaly red patch, irregular border, crusts or bleeds. Elevated growth w/ central depression, may rapidly increase in size, wart-like growth. Sometimes metastasizes.

Question 21

Describe melanoma.

Answer 21

ABCDE: Asymmetrical, irregular Border, multiple Colors, Diameter > ¼“, Evolving.
Aggressive.

Question 22

What are the 4 stages of cancer?

Answer 22

Stage 0: tumor confined to epidermis.
Stage 1: tumor < 1 mm deep (with ulceration) or 0.5 mm deep (without ulceration).
Stage 2: tumor 1-4 mm deep with ulceration (or <4 mm deep without ulceration)
Stage 3: cancer has spread to lymph nodes.
Stage 4: cancer has spread to other organs.

Question 23

Compare arterial and venous ulcers. What causes them? When treating, should the feet be above, at, or below heart level?

Answer 23

Both types of ulcers are caused by blood flow issues. Body deteriorates from the inside out. Arterial ulcers cause reduced blood flow to extremities, feet should be propped below heart level. Venous ulcers cause reduced blood flow FROM extremities back to the heart, feet should be propped above heart level.

Question 24

Compare arterial and venous ulcers. Where are they found? How do they look?

Answer 24

Arterial ulcers are found on the ankles, toes, or pads of the feet. Severely painful, pale/ gray base, round. Venous ulcers are found on the medial aspect of the ankle. Moderately painful, pink base, uneven edges, open wound.

Question 25

Compare arterial and venous ulcers. Describe the skin (warm/ cool), pain (sharp/aching), pulse (present or not), and edema.

Answer 25

Arterial: skin cool/cold, hairless, dry, shiny. Sharp stabing pain. Edema is infrequent. Pulse is often absent or diminished.
Venous: skin warm, thickened, mottled, pigmented. Pain is aching/ cramping. Edema is frequent. Pulse is usually present.

Question 26

When listening to the heart, what are the 5 spots and where do you place the stethoscope to hear them?

Answer 26

APE To Man: Aortic area, pulmonic area, tricuspid area, Erb’s point, and mitral area.
Right side: 2nd ICS
Left side: 2nd ICS, 3rd ICS, 4th ICS, and midcalvicular line for 5th ICS.

Question 27

Cranial Nerve I (name and how to test it)

Answer 27

Olfactory. Check ability to recognize scents like mint or coffee.

Question 28

Cranial Nerve II (name and how to test it)

Answer 28

Optic. Have client read a sentence of print.

Question 29

Cranial Nerve III (name and how to test it)

Answer 29

Oculomotor. Test client’s ability to follow your finger with their eyes up, down, right left, and to each diagnal.

Question 30

Cranial Nerve IV (name and how to test it)

Answer 30

Trochlear. Test client’s ability to follow your finger with their eyes up, down, right left, and to each diagnal.

Question 31

Cranial Nerve V (name and how to test it)

Answer 31

Trigeminal. Assess ability to bite/chew. Check facial sensation.

Question 32

Cranial Nerve VI (name and how to test it)

Answer 32

Abducens. Test client’s ability to follow your finger with their eyes up, down, right left, and to each diagnal.

Question 33

Cranial Nerve VII (name and how to test it)

Answer 33

Facial. Look for facial expression symetry and test anterior 2/3 of tongue for ability to taste.

Question 34

Cranial Nerve VIII (name and how to test it)

Answer 34

Vestibulocochlear. Perform whisper test.

Question 35

Cranial Nerve IX (name and how to test it)

Answer 35

Glossopharengeal. Check uvula is midline and rises when client says “ahhh”. Check ability to swallow.

Question 36

Cranial Nerve X (name and how to test it)

Answer 36

Vagus. Check uvula is midline and rises when client says “ahhh”. Check ability to swallow.

Question 37

Cranial Nerve XI (name and how to test it)

Answer 37

Spinal accessory. While you provide resisistance, assess client’s ability to move head side to side and raise shoulders.

Question 38

Cranial Nerve XII (name and how to test it)

Answer 38

Hypoglossal. Have client stick out tongue and check that it’s midline. Check client ability to articulate “light”, “tight”, “dynamite”.