Head-to-Toe Assessment Flashcards
1
Q
what types of data do we gather from a pt?
A
subjective
objective
pain
bp, pulse ox, temp
2
Q
Types of Physical Assessment: what is a comprehensive exam?
A
looking @ everything & asking lot’s of q’s
3
Q
Types of Assessment: what is a focused exam?
A
checking a specific problem
4
Q
Type of assessment: what is a system specific exam?
A
anything related to a certain body system
5
Q
Type of assessment: what is an on-going exam?
A
do the same assessment every time
6
Q
What are diagnostic tests we can run?
A
labs: abg’s, cbc, sputum
radiology: chest x-ray, ct, v/q scan, pet scan
skin test
pulmonary function test
endo exams
7
Q
What are methods of data collection?
A
interview
nursing health history
physical exam
diagnostic & lab results
8
Q
What are elements of an assessment?
A
history
baseline history
problem based history
Exam:
VS
inspection
Ausculation
Palpation
9
Q
What does the assessment include?
A
interview & physical
10
Q
What does the nursing diagnosis determine?
A
diagnosis nurse can make based on their judgement
11
Q
What does planning include?
A
based on the data from the assessment
12
Q
What does the evaluation include?
A
established nursing accountability
13
Q
What are techniques used in the assessment?
A
inspection
palpation
percussion
auscultation
olfaction
14
Q
Do we use or sense of taste during our assessment?
A
no!!
15
Q
During our visual exam what should we do to make sure we do the exam properly?
A
good lighting
expose all parts to be examined & maintain privacy for other parts not being examined
use additional light for som areas of body; eyes, ears, throat
16
Q
What do we observe for in the visual inspection?
A
color
shape/symmetry
movement
position
17
Q
What techniques do we use for palpation?
A
bimanual/manual
dorsum of hand
palm or ulnar surface of hand
palmar surface of finger/pads
18
Q
How far do we push for light palpation?
A
1cm or 1/2 depth
19
Q
How far do we push for deep palpation?
A
4cm or 2 in depth
20
Q
When we palpate what are we assessing?
A
texture
resistance
resilience
mobility
temp
thickness
shape
moisture
21
Q
What is percussion?
A
tapping on the body w/ fingers or an instrument
22
Q
What is direct percussion?
A
applied directly to body
23
Q
What is indirect percussion?
A
applied through another surface
24
Q
Characteristics of sound: what is frequency?
A
of osculations per sec generated by a vibrating object
25
Characteristics of sound: what is loudness?
amplitude of a sound wave
26
Characteristics of sound: what is quality?
descriptive
27
Characteristics of sound: what is duration?
length of time that sounds last
28
When using the stethoscope what should we always do?
always place directly on skin
29
What can the bell of the stethoscope best hear?
low sounds (heart/vascular)
30
What can the diaphragm of the stethoscope best hear?
high pitched sounds
(bowel & some abnormal lung sounds)
31
What can our olfactory sense be used for in the healthcare setting?
used to detect abnormal vs normal smells
32
How do we prepare for the assessment?
Gather all supplies
Into
Explain
Hand hygiene
use gloves (if needed)
clean stethoscope & bp cuffs b/w pt's
make pt comfy & privacy
33
What are special considerations for the aged?
Recognize physical/sensory limitations
Recognize normal changes of aging vs abnormal
34
When do we take the health history?
before the exam
35
What should we ask/assess during the assessment?
race/gender
age
body
type
posture
signs of distress
substance abuse
speech
movement/gait
hygiene/grooming
dress
affect/mood
pt abuse
36
What are signs of abuse?
inconsistent statement & injury
bruises, lacerations, burns, bites
x-ray showing fractures in various stages of healing
behavior issues; insomnia, anxiety, iso
37
LOC: What does alert mean?
attentive, follows command, if asleep - wakes promptly & remains attentive
38
LOC: what does lethargic mean?
drowsy but awakens, slow to respond
39
LOC: what does obtunded mean?
difficult to arouse, need constant stimulation
40
LOC: what does stuporous/semi-comatose mean?
arouses only to vigorous/noxious stimuli, may only withdraw from pain
41
LOC: what does comatose mean?
no response to verbal or noxious stimuli, no movement except deep tendon reflex
42
What is checked for cognitive awareness?
pt oriented to person, place, time
known as mentation
43
How do we ask a patient about their cognitive awarness?
what is their name/dob
where are you right now
what day/year is it?
44
What are we testing when we examine cranial nerves III, IV, & VI?
Pupil response & cardinal gaze `
45
What do we assess with the acronym PERRLA?
Pupils
Equal
Round
React to
Light &
Accommodation
46
What is tested for Cranial Nerve VII
smiling with teeth & forehead wrinkle/eyebrow raise (for symmetry)
47
What are we asking the pt to do to test cranial nerve XII?
Ask pt to touch mouth w/ roof of tongue
protrude tongue out of mouth
move tongue from side to side
48
What do we ask the pt to do when we are testing cranial nerve XI?
place hands on shoulders & have them shrug
49
What do we test for neuro muscular function?
hand grasp
toe wiggle
flexion & extension
all done bilaterally
50
What three areas do we listen to when checking lungs?
vesicular - periphery of lungs
bronchovesicular - closer to sternum
bronchial - over trachea
51
What are abnormal lung sounds?
crackles
rales
rhonchi
wheezes
pleural friction rub
52
What are abnormal respiratory patterns?
bradypnea
tachypnea
apnea
hyperpnea
kussmaul's
cheyne-stokes
53
How many places do we check for lung sounds anteriorally?
7
54
How many places do we check for lung sounds posterially?
10
55
When do we ask pt to take deep breaths?
last 4 lungs sounds posterior
56
What are we looking for in the nail shape?
clubbing
57
What is the normal heart sound?
lub dub
58
What does lub indicate in the heart?
systole or S1 & sound associated w/ mitral/tricuspid valve shutting
59
What does dub indicate in the heart?
diastole or S2 & is the sound associated w/ aortic/pulmonic valve closing
60
Where is the location of the aortic sound?
right base, 2nd intercostal space to right of sternal border
61
Where is the location of the pulmonic sound?
left base; 2nd intercostal space to left of the sternal border
62
Where is the location of the tricuspid sound?
left lateral sternal border; 5th intercostal space to the left of the sternal border
63
Where is the location of the mitral sound?
apex, midclavicular line @ the 5th intercostal space
64
What are the pulse sites we can take around the body?
carotid
brachial
radial
ulnar
aplical
femoral
popliteal
dorsalis pedis
65
Which pulses do we assess & how do we assess them?
carotid- one @ a time
radial - bilaterally @ the same time
apical - w/ stethoscope for 2 beats
dorsalis pedis or pedal pulses - bilaterally @ the same time
66
What does a 0 pulse quality mean?
absent, non-palpable
67
What does 1+ pulse quality mean?
diminished, palpable
68
What does 2+ pulse quality mean?
strong, normal
69
What does 3+ pulse quality mean?
full, increased
70
What does 4+ pulse quality mean?
bounding
71
Which pulse do we assess w/ a doppler?
pedal pulse
72
How do we assess capillary refill?
press skin of nail bed & observe time taken for color to return
should be less than 2-3 secs
73
How do we assess for edema?
observe for swelling
74
What is dependent edema?
most often on feet & ankles, older adults & standing
75
What is pitting edema?
venous insufficiency or heart failure
fluid in tissues
76
Where do we asses for ROM on the body?
neck
shoulders
upper arms/elbows
wrists
hips
knees
ankles
77
What do we do assess for neck ROM?
move neck side to side
chin to chest
extension back
78
What do we assess for shoulders, upper arms & elbows?
arms out to side
arms up
touchdown
79
What do we ask pt's to do for ROM in wrists?
wrist circles
80
What do we assess for hip, knees, & ankles ROM?
bilateral hip flexion out
bend knees
ankle circles
81
How do we assess a pt's strength?
handgrip
toe wiggle
flexion & extension
82
What do we inspect skin for?
hydration
temp
color
texture
rashes
lesions
cracking
83
What is pallor color?
pale or ashen gray
84
What is erythema color?
redness r/t vasodilation
85
What is jaundice color?
yellow, impaired liver
86
What is cyanosis color?
bluish, decreased circulation or oxygenation of blood
87
What can skin characteristics offer clues about?
the health status of the pt
88
What should temp be?
warm, consistent w/ room temp
89
what should we look for moisture wise?
diaphoresis or dehydration
90
what does turgor test?
elasticity of skin related to hydration
91
What factors effect skin?
dampness
dehydration
nutrition
circulation
disease
jaundice
lifestyle
92
What are normal skin changes in adults?
epidermis
subcutaneous tissue
collagen & elastin fibers
hormones
vascularity
hair follicles
melanocytes
nails
skin growths
93
What causes pitting edema?
caused by kidney or heart failure
leads to excess fluid collection in tissues
94
What does 1+ mean on the pitting edema four point scale?
2mm to trace
skin responds rapidly
95
What does 2+ mean on the pitting edema four point scale?
4mm to mild
10-18 secs response time
96
What does 3+ mean on the pitting edema four point scale?
6mm to moderate
1-2 min response time
97
What does 4+ mean on the pitting edema four point scale?
8mm to severe
2-5 mins response time
98
What do we assess on the hips, heels, coccyx, & shoulders?
asses for skin integrity
blanching red spots
99
What do we observe for in nail health?
shape
contour
cleanliness
neatly manicured/trimmed
100
What should healthy nails look like?
transparent
smooth
rounded
convex
hygienic
101
Where is terminal hair?
scalp, axillae, pubic, & beard
102
Where is vellus hair?
soft tiny hairs covering body except on palms & soles
103
What else should we assess for in hair
quantity
distribution
texture
color
parasites
104
What should we assess the ears?
symmetry, drainage, shape, hearing defects, lesions, redness, tenderness, odor
105
What do we assess nose for?
position, symmetry, color, swelling, deformities, discharge, flaring, patency, sinus tenderness
106
What do we inspect in the oral cavity?
lips
oral mucosa
teeth
gums/tongue
breath odor
107
What do we inspect the throat for?
lumps
ulcers
edema
white spots
redness
swallowing
108
What do we inspect the neck for?
contour & symmetry, midline trachea, jugular distension
109
What do we palpate the neck for?
inflamed/enlarged lymph nodes
110
Where does most food digest in the intestines?
small intestine
duodenum, jejunum, & ileum
111
What is the large intestine called & what components make it up?
colon
cecum, ascending colon, transverse colon, decreased colon, sigmoid colon, rectum, anus
112
How do we assess the abdomen
inspect
auscultate bowel sounds in four quads
palpate for tenderness, masses, pain
113
What q's should we ask during abdominal exam?
normal bowel & urinary patterns
appearance
changes
history of problems
114
What should we assess peri area for?
for erythema, discharge, swelling, or odor
signs of infection
inflammation
trauma
color
condition
presence of urine or stool
