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nsg106 > head to toe assessment power point > Flashcards

head to toe assessment power point Flashcards

1
Q

first steps of physical assessment

A

overall physical apperance
acute signs of distress
age and physical development
gender/ ethnicity

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2
Q

general survey include______,________,_______

A

vital signs
hight and weight
orientation

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3
Q

assessment of mental status includes

A

appearance
speech
affect
orientation
level of consciousness
abstract reasoning- ability to solve problem
memory

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4
Q

assess appearance to determine_____ ____ ________, ______, _____

A

level of functioning
hygiene
grooming

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5
Q

what is affect

A

refers to the external expression of emotion

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6
Q

what is assess

A

appropriate for situation

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7
Q

example of affect

A

inappropriate affect would be laughing at sad story

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8
Q

assessing speech include looking for

A

clarity
word choice
rate of speech
any unusual patterns

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9
Q

when assessing speech ask yourself these two questions

A

do they speak in 2-3 word sentences
do they use high level of vocabulary

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10
Q

when assessing orientation ask person 4 questions

A

persons name
where they at
what time is it
what what is the situation

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11
Q

abstract reasoning is

A

the ability to think at higher level than a child

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12
Q

example of abstract reasoning

A

ask patient to interpret a riddle

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13
Q

abstract reasoning is reported as

A

intact or not intact

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14
Q

memory types

A

short term memory
long term memory

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15
Q

to test short term memory you should

A

tell patient 3 words

and have them repeat the objects the way you tell them

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16
Q

to assess long-term memory you should

A

ask the patient a question about an event that most people would know that happened years ago

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17
Q

levels of consciousness

A

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

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18
Q

lethargic or somnolent meaning

A

lack of energy, sluggish

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19
Q

obtunded meaning

A

mentally dull

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20
Q

stupor semicome or comatose meaning

A

sleepig most of the time: lack of critical cognitive function and lack of consious

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21
Q

what scale is used to determine level of function

A

Glasgow coma scale

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22
Q

determining level of consiousness using glawgow coma scale assess 3 areas

A

eye-opening
best verbal respose
best motor response

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23
Q

eye-opening grade scoring

A

4 spontaneously
3 on request
2 to painful stomuli
1 no response

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24
Q

best verbal response grade scoring

A

5 oriented to time place and knows himself
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no response

25
Q

best motor response grade scale

A

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

26
Q

how is the final grade in Glasgow coma scale graded

A

add togather all areas

27
Q

score total meaning in Glasgow coma scale

A

15 is normal
7 indicates a coma
3 is brain dead

28
Q

assessment include

A

inspection palpation auscultation and percussion

29
Q

assessing the head

A

size
symmetry
position
movement of head neck and face
palpate the skull: look for tenderness, masses, redness, pus, drainage

30
Q

assessment of head

A

any redness or skin discoloration
decreased or increased tremor (shaking)
asymmetry
facial expressions
palpate the temporomandibular joint function and note abnormalites

31
Q

assessing the eyes

A

look for lumps, redness, swelling pain

inspect the eyelids and eyelashes

inspect the lacrimal (tear) ducts and glands

assess extraocular movement

inspect the conjucativae

32
Q

how to assess extraocular movement

A

tell patient to only follow your finger with their eyes

move your index finger in the shape of a cross then diagonally

33
Q

when inspecting conjunctivae red means_____ or _____, pus means ______ pale is _____

A

allergy, infection, infection, anemia

34
Q

eye exam cont

A

PERRLA

both pupils should dilate in dark and constrict in light

test pupil accommodation

inspect the lens

35
Q

PERRLA stands for

A

pupils equal, round, reactive to light, and accommodation

36
Q

how to test pupil accommodation

A

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

37
Q

The Snellen char and eye exam test for

A

acuity of distance and vision

38
Q

how to use Snellen eye chart

A

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

39
Q

ear examination

A

inspect the external ear shape size symmetry

look for drainage

test hearing by using the whisper test

40
Q

how does the whisper test work

A

stand behind the patient and whisper and ask if he hear and understood what you said

41
Q

tuning fork test has two types

A

Weber test

Rinne test

42
Q

how to do Rinne test

A

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

42
Q

how to do Weber test

A

place tuning fork midline on the skull and as if the tone is equal bilaterally or better in one ear

43
Q

meaning of weber test

A

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

44
Q

meaning of Rinne test

A

air conduction is better than bone conduction, which is what would be expected in a healthy individual

45
Q

assessing the noes and sinuses

A

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

46
Q

assessing mouth and throat

A

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

47
Q

blue lips mean

A

cyanosis or lack of oxygen

48
Q

dry lips mean

A

dehydration

49
Q

oral mucosa and gums color should be

A

pink

50
Q

if oral mucosa or gums color are red or pale check for

A

drainage or bleeding

51
Q

edentulous teeth mean

A

missing all teeth

52
Q

most common site for oral cancer is

A

under tongue

53
Q

if uvula is not midline what does it mean

A

could mean a stroke or abscess

54
Q

if you have a questioning attitude check

A

current and past patent history

ask about current medication

55
Q

when do you document your finding

A

at the time of the assessment

56
Q

inspecting the neck

A

palpate the cervical lymph nodes

palpate the thyroid

57
Q

thyroid pulse should

A

not be felt it abnormal

nsg106 (17 decks)

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