Head-to-toe assessment

Question 1

Assessment order: (4)

Answer 1

1 inspect: assess visually
2 palpate: examine using touch
3 percuss: strike or tap area
4 auscultate: listen with stethoscope

Question 2

Intro: (5)

Answer 2

~ knock and introduce self
~ wash hands
~ provide privacy
~ verify name and DOB
~ explain what your doing in simple language

Question 3

While introducing self, gain a what?

Answer 3

gain a basic assessment of the overall appearance of the patient

Question 4

intro appearance assessment:

Answer 4

~ does the patient appear well groomed?
~ any lesions, masses, or skin breakdown noted?
~ any asymmetry in the body or face

Question 5

Neuro orientation:
ask these questions (4)

Answer 5

~ what is your name? (person)
~ do you know where you are? (place)
~ do you know what month it is? (time)
~ do you know what your doing here? (situation)

Question 6

Neuro
get more specific ask what the current year is or who the president is
( healthy people what?)

Answer 6

healthy people forget what day it is so not the best way to assess orientation

Question 7

AAOX1:

Answer 7

oriented to person only

Question 8

AAOX2:

Answer 8

oriented to person & place or time

Question 9

AAOx3:

Answer 9

oriented to person, place and time

Question 10

AAOx4:

Answer 10

oriented to person, place, time &situation

Question 11

head assessment: (2)

Answer 11

~ inspect head/scalp/hair
~ palpate head/scalp/hair

Question 12

Face: (2)

Answer 12

~ assess face for asymmetry
~ assess cranial nerve 7

Question 13

Face cranial nerve 7 (6):

Answer 13

~ raise eyebrows
~ smile
~ frown
~ show teeth
~ puff out cheeks
~ squeeze eyes shut

Question 14

Eyes: (3)

Answer 14

~ assess conjunctiva and sclera color
~ assess for any discharge
~ assess PERRLA

Question 15

PERRLA stands for:

Answer 15

pupils equal round reactive to light & accommodation

Question 16

Nose: (2)

Answer 16

~ assess for symmetry & present lesions
~ palpate sinuses

Question 17

Ears: (2)

Answer 17

~ assess for symmetry & present lesions
~ any hearing devices or trouble hearing

Question 18

Mouth: (3)

Answer 18

~ assess mucosa color: is it pink, pale, red, discolored
~ is it dry or moist
~ are there old debris or lesions

Question 19

Neck: (3)

Answer 19

~ assess neck for symmetry
~ palpate neck for lumps, and/or swelling
~ palpate carotid pulses

Question 20

Respiratory: (3)

Answer 20

~ inspect work of breathing
~ palpate chest expansion
~ auscultate lungs

Question 21

Respiratory breathing inspection: (3)

Answer 21

~ is it labored or unlabored
~ regular or irregular
~ does the patient appear comfortable