head to toe assessment power point Flashcards
first steps of physical assessment
overall physical apperance
acute signs of distress
age and physical development
gender/ ethnicity
general survey include______,________,_______
vital signs
hight and weight
orientation
assessment of mental status includes
appearance
speech
affect
orientation
level of consciousness
abstract reasoning- ability to solve problem
memory
assess appearance to determine_____ ____ ________, ______, _____
level of functioning
hygiene
grooming
what is affect
refers to the external expression of emotion
what is assess
appropriate for situation
example of affect
inappropriate affect would be laughing at sad story
assessing speech include looking for
clarity
word choice
rate of speech
any unusual patterns
when assessing speech ask yourself these two questions
do they speak in 2-3 word sentences
do they use high level of vocabulary
when assessing orientation ask person 4 questions
persons name
where they at
what time is it
what what is the situation
abstract reasoning is
the ability to think at higher level than a child
example of abstract reasoning
ask patient to interpret a riddle
abstract reasoning is reported as
intact or not intact
memory types
short term memory
long term memory
to test short term memory you should
tell patient 3 words
and have them repeat the objects the way you tell them
to assess long-term memory you should
ask the patient a question about an event that most people would know that happened years ago
levels of consciousness
awake and alert
lethargic or somnolent (lack of energy, sluggish)
obtunded (mentally dulled)
stupor semicoma or comatose (sleeping most of time lack critical cognitive function and lack of conscious)
coma
lethargic or somnolent meaning
lack of energy, sluggish
obtunded meaning
mentally dull
stupor semicome or comatose meaning
sleepig most of the time: lack of critical cognitive function and lack of consious
what scale is used to determine level of function
Glasgow coma scale
determining level of consiousness using glawgow coma scale assess 3 areas
eye-opening
best verbal respose
best motor response
eye-opening grade scoring
4 spontaneously
3 on request
2 to painful stomuli
1 no response
best verbal response grade scoring
5 oriented to time place and knows himself
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no response
best motor response grade scale
6 obey commands
5 localizes (orient locally) to painful stimulus
4 withdraws from pain
3 flexed extremities- decorticate
2 extended extermities- decerebrate
1 no response
how is the final grade in Glasgow coma scale graded
add togather all areas
score total meaning in Glasgow coma scale
15 is normal
7 indicates a coma
3 is brain dead
assessment include
inspection palpation auscultation and percussion
assessing the head
size
symmetry
position
movement of head neck and face
palpate the skull: look for tenderness, masses, redness, pus, drainage
assessment of head
any redness or skin discoloration
decreased or increased tremor (shaking)
asymmetry
facial expressions
palpate the temporomandibular joint function and note abnormalites
assessing the eyes
look for lumps, redness, swelling pain
inspect the eyelids and eyelashes
inspect the lacrimal (tear) ducts and glands
assess extraocular movement
inspect the conjucativae
how to assess extraocular movement
tell patient to only follow your finger with their eyes
move your index finger in the shape of a cross then diagonally
when inspecting conjunctivae red means_____ or _____, pus means ______ pale is _____
allergy, infection, infection, anemia
eye exam cont
PERRLA
both pupils should dilate in dark and constrict in light
test pupil accommodation
inspect the lens
PERRLA stands for
pupils equal, round, reactive to light, and accommodation
how to test pupil accommodation
move your finger/ penlight from 12 inches to 1 inch away toward the eye. the eyes should accommodate to the change in the distance by almost being crossed
any variations may mean a head injury
The Snellen char and eye exam test for
acuity of distance and vision
how to use Snellen eye chart
whatever line the patient can easily read is your vision
the top line is 20/200 which means you can read at 20 feet what everyone else can read at 200 feet
bottom line is 20/20 which means you can read at 20 feet what normal vision people can read at 20 feet
ear examination
inspect the external ear shape size symmetry
look for drainage
test hearing by using the whisper test
how does the whisper test work
stand behind the patient and whisper and ask if he hear and understood what you said
tuning fork test has two types
Weber test
Rinne test
how to do Rinne test
strike the tuning fork and place it In the air in front of the ear, this tests air conduction which should best heard twice as long as the sound from bone condition.
then strike the tuning fork and lace it on the mastoid bone behind the ear. the bone conduction sound should only be heard half the amount of time as the air conduction sound
how to do Weber test
place tuning fork midline on the skull and as if the tone is equal bilaterally or better in one ear
meaning of weber test
if a patient hears better on one side it means that the ear that head the sounds the longest is the worn out or bad ear
meaning of Rinne test
air conduction is better than bone conduction, which is what would be expected in a healthy individual
assessing the noes and sinuses
inspect the external noes for discoloration, lumps, and asymmetry
check patency of nasal passages by closing off one nostril and having them blow. if no air pressure the nose isn’t patent or open
inspect the internal structure for deviation or redness or pallor
palpate the external structures
palpate the frontal and maxillary sinuses for pain
assessing mouth and throat
inspect the lips for symmetry and color
inspect oral mucosa and gums for color
inspect the teeth for cavities or if missing teeth or false teeth
inspect the tongue for dryness, grooves, white patches that don’t brush off are thrush (candida)
check under the tongue for sores or masses
inspect the oropharynx (back of mouth). do they have tonsils are the swollen or have pus
is the uvula midline (if not may be a stroke or abscess)
test gag reflex with a tongue blade or sip water
blue lips mean
cyanosis or lack of oxygen
dry lips mean
dehydration
oral mucosa and gums color should be
pink
if oral mucosa or gums color are red or pale check for
drainage or bleeding
edentulous teeth mean
missing all teeth
most common site for oral cancer is
under tongue
if uvula is not midline what does it mean
could mean a stroke or abscess
if you have a questioning attitude check
current and past patent history
ask about current medication
when do you document your finding
at the time of the assessment
inspecting the neck
palpate the cervical lymph nodes
palpate the thyroid
thyroid pulse should
not be felt it abnormal
