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Lake Land 2016 > Head to toe assessment > Flashcards

Head to toe assessment Flashcards

1
Q

What is before introducing yourself?

A

hand hygeine

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2
Q

PERRLA means

A

pupils equally round, reactive to light and accomodating

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3
Q

What is after PERRLA

A

cardinal fields of gaze

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4
Q

What equipment do you gather in advance?

A

Stethoscope, BP cuff, pulse oximeter, penlite, thermometer, gloves.

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5
Q

What is before hand hygeine?

A

gather equipment

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6
Q

What is after gather equipment?

A

hand hygeine

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7
Q

What is after introducing yourself?

A

identify the patient

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8
Q

Physical move 1:

A

Aim a light at the side of their head, have them look at you, check pupils. Then pull back and make their eyes follow the light side to side

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9
Q

After you look at eyess, what next?

A

Light up their nose. Look at the septum, turbinates.

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10
Q

After you look up their nose, then what? What’s involved?

A

Light up their ears. Touch tragus.

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11
Q

What is before nose lighting?

A

Eye lighting.

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12
Q

What is before ear lighting?

A

Nose lighting.

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13
Q

What is after ear lighting?

A

Finger snapping.

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14
Q

What is before finger snapping?

A

Ear lighting.

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15
Q

What is before identify the patient?

A

introduce yourself

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16
Q

What is after fingersnapping?

A

Mouth lighting

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17
Q

What is before mouth lighting?

A

finger snapping

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18
Q

What do you do while mouth lighting?

A

Say AHHH. Stick out your tongue, move tongue left and right. Clench your teeth.

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19
Q

What is after mouth lighting?

A

Face touching. Forehead and cheek. Say :”Can you feel that? That? Shrug your shoulders.

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20
Q

What is after identifying patient?

A

verify allergies

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21
Q

What’s before face touching?

A

Mouth lighting

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22
Q

What is after face touching?

A

Neck touching

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23
Q

What is before neck touching?

A

Face touching

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24
Q

What do you do when neck touching?

A

Make a W with your fingers to see if trachea is aligned. Get behind them. Put hands over thyroid, say “swallow.”

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25
Q

What do you assess for carotids?

A

feel pulse, listen for bruit

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26
Q

What is before verifying allergies?

A

identify patient

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27
Q

What is after verifying allergies?

A

assure privacy

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28
Q

Where is the aortic pulse?

A

2nd R intercostal

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29
Q

Where is pulmonic pulse?

A

2nd L intercostal

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30
Q

Where is tricuspid pulse?

A

4th L intercostal at sternal border

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31
Q

Where is apical pulse?

A

5th L intercostal space

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32
Q

Where is Erb’s point?

A

3rd L intercostal space

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33
Q

Where is mitral pulse?

A

5th intercostal

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34
Q

What is after neck touching?

A

Whipping out the stethoscope, palpate carotids and use bell to listen. Touch apical pulse for 1 minute, note if irregular, say take a deep breath and touch 4 lung lobe points on front, 6 on back.

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35
Q

What’s before whipping it out?

A

Neck touching.

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36
Q

What’s after whipping it out?

A

“Lie down and pull up your shirt.” say “I am inspecting your abdomen.” Listen to 4 quadrants. Palpate 4 places lightly and 4 places deeply.

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37
Q

What’s before Lie down?

A

Whipping it out.

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38
Q

What’s after lie die?

A

hands

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39
Q

What’s before feet?

A

hands

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40
Q

What’s after hands?

A

feet

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41
Q

What’s involved in face touching?

A

Forehead and cheek. Say :”Can you feel that? That? Shrug your shoulders.

42
Q

What is involved in whipping it out?

A

palpate carotids and use bell to listen. take apical pulse for 60 sec, note if irregular, say take a deep breath and touch 4 lung lobe points on front, 6 on back.

43
Q

What is involved in lie down etc?

A

“I am inspecting your abdomen.” Listen to 4 quadrants. Palpate 4 places lightly and 4 places deeply. ASK appetite, N/V, last diarrhea/constipation, have you urinated today, any burning, unusual odor or other problems

44
Q

How do you do feet?

A

Check temp and color. Touch both pulses, tent skin. Push with your feet. Pull. Check capillary refill. Check sensation.

45
Q

What is before assure privacy?

A

verify allergies

46
Q

What is after verify allergies?

A

ensure privacy

47
Q

what do you explain about what is about to occur

A

checking heart, breathing, overall condition head to toe, it won’t hurt, you’ll stay dressed, at the end we will know more about your health

48
Q

what do you do before explain

A

ensure privacy

49
Q

What do you do after explain?

A

say, do you have any questions?

50
Q

What do you do before asking if they have questions?

A

explain the procedure

51
Q

What do you do after asking if they have any questions?

A

raise bed to working height

52
Q

What do you do before raising the bed to working height?

A

ask if they have any questions.

53
Q

What do you do after raising the bed to a comfortable working height?

A

don gloves if needed, if not, assess LOC and orientation

54
Q

How do you assess level of consciousness and orientation?

A

Date and time, place, what are you here for today.

55
Q

What do you do before assessing LOC and orientation?

A

raise bed to comfortable working height

56
Q

What do you do after assessing LOC and orientation?

A

count heart rate and respiration

57
Q

how do you count heart rate and respiration?

A

get pulse for 1 minute, get resp for 30 sec and multiply by 2

58
Q

What do you do before heart rate and respiration?

A

assess LOC and orientation

59
Q

What do you do after heart rate and respiration?

A

blood pressure

60
Q

What do you do before blood pressure?

A

heart rate and respiration

61
Q

how do you do B/P?

A

put on cuff, pump up to 30 above normal systolic, ease off pressure, listen for the first beat and the last beat

62
Q

What is after B/P?

A

O2 sat and temp

63
Q

What is before O2 sat and temp?

A

B/P

64
Q

What is after O2 sat and temp?

A

pain

65
Q

How do you assess pain?

A

intensity, duration, location, character aggravating, mitigating

66
Q

What is before pain?

A

O2 sat and temp

67
Q

What is after pain?

A

Head and neck- eyes first

68
Q

What does Lake Land have as a single item on head and neck that Lakeview lacks?

A

swallow assess

69
Q

What is after swallowing?

A

Whip it out.

70
Q

What is before squeeze my fingers?

A

abdomen

71
Q

What is after squeeze my finger?

A

hand temp and color

72
Q

What is before hand temp and color

A

squeeze my fingers

73
Q

What is after hand temp and color

A

radial pulse

74
Q

What is before radial pulsse?

A

temp and color

75
Q

What is after raidal pulse?

A

cap refill

76
Q

What is before cap refill

A

radial pulse

77
Q

What is after cap refill

A

sensation

78
Q

What is before sensation

A

cap refill

79
Q

What is after foot sensation

A

homan’s sign, plantar push

80
Q

What is after plantar push

A

check IV

81
Q

What is before plantar push

A

Homan’s sign

82
Q

What is before Homan’s sign?

A

Foot sensation

83
Q

What do you check for IV?

A

solution, rate, site

84
Q

What do you check before IV?

A

plantar push

85
Q

What do you check after IV?

A

O2 settying and type

86
Q

What do you check after O2 setting and type?

A

catheter

87
Q

What do you check before catheter

A

O2 setting and type

88
Q

What do you check after catheter?

A

room saftey

89
Q

what doi you check before room safety

A

catheter

90
Q

What do you check after room safety

A

4 ps

91
Q

What are the 4 p’s?

A

pain, potty, possessions, position

92
Q

What is before 4 p’s?

A

room safety

93
Q

What is after 4 p’s?

A

hand hygeine

94
Q

What is before closing hand hygeine?

A

4p’s

95
Q

What is after hand hygeine and remove equipment?

A

document

96
Q

Document what?

A

B/P, resp, HR, O2 sat, pain, temp, orientation, hand and foot strength level, whether equal bilaterally, IV rate and site, unusual findings, PERRLA, HEENT WNL, cap refill

97
Q

what is after assure privacy?

A

EXPLAIN

98
Q

What is after head and neck?

A

swallow

99
Q

What is after abdomen/ lie down

A

hands

100
Q

What do you ask during abdominal assessment?

A

ASK appetite, N/V, last diarrhea/constipation, have you urinated today, any burning, unusual odor or other problems

Lake Land 2016 (9 decks)

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