Head to Toe Assessment Questions Flashcards
Adduction
Movement toward the midline
Abduction
Movement away from the body
Supination
Palms upward
Pronation
palms downward
Flexion
Decreasing the angle of a joint
Extension
increasing the angle of a joint
Inversion
Feet turned inward
Eversion
Feet turned outward
Lordosis
“Swayback”: Increased lumbar curvature above buttocks most often found in young children. neuromuscular problem with hip or posture
Scoliosis
Lateral curvature of the spine. Begin screening for this from 11-14 and treatment at 40 degree curvature.
Kyphosis
Exaggeration of the posterior thoracic spine curvature which can be due to osteoporosis (hunched Back)
Romberg Test
Has a patient stand still with eyes open, then with eyes closed. Tests their balance
Wheeze
Continuous musical sounds
Caused by high velocity airflow through significantly narrowed airways
Stridor
Harsh honking wheeze with severe bronchospasm
Air passing through a very constricted airway. Secondary to croup or a swallowed object caught in the airway
Crackles
Fluid in the lungs. Bubbling sounds. Not cleared with coughing
Common in the lower lung lobes
Rhonchi
Loud, Low pitched, Rumbling course sounds heard throughout lungs.
Typically secondary to mucus/fluid in larger airways. May be cleared with coughing
Chest Excursion
Holding hands on the back while the person breathes and seeing what happens to your hands. They should expand equally
Vocal Fremitus
External vibration while a pt talks. (the 99 test)
Lack of vibration may be due to: Accumulation of mucus, Lung Collapse, Lung lesion
Cheyne-Stokes
Alternating periods of deep rapid breathing followed by periods of apnea.
Associated with end-of-life
Biots Respirations
Irregular breathing pattern characterized by varying shallow respirations followed by periods of apnea
Associated with intracranial pressure and respiratory compromise.
Kussmal Respirations
A type of hyperventilation marked by exaggerated deep, regular, rapid breathing.
Normal with exercise
May be present with: aspirin (asa) overdose, pain, fever, hysteria, cardiac and or respiratory disease, Diabetic Ketoacidosis
ABCDE
Test for abnormal mole: Asymmetrical, Border, Color (black? dark brown? changing?), Diameter (no more than 6mm), Evolution
Braden Scale Range
6-23. Lower=higher risk for pressure injury
Braden Scale Purpose
Assigns a number for the likelihood of developing a pressure injury
Cranial Nerve 1 (Name, Function, and Sensory or Motor)
Olfactory: Sensory: Sense of smell: test with a scent under the nose
Cranial Nerve 2 (Name, Function, and Sensory or Motor)
Optic: sensory: visual acuity: test with the snellen chart
Cranial Nerve 3 (Name, Function, and Sensory or Motor)
Oculomotor: Motor: Extra ocular movement: Pupil Dilation: test with PERRLA
Cranial Nerve 4 (Name, Function, and Sensory or Motor)
Trochlear: Motor: Up/down eye movement: test with 6 fields gaze
Cranial Nerve 5 (Name, Function, and Sensory or Motor)
Trigeminal: motor + sensory: jaw movement + feeling in face: test with a cottonball to the face and clenching jaw
Cranial Nerve 6 (Name, Function, and Sensory or Motor)
Abducens: motor: lateral eye movement: test with 6 fields gaze test
Cranial Nerve 7 (Name, Function, and Sensory or Motor)
Facial: sensory + motor: taste on front of tongue + facial expression: test by smiling and tasting
Cranial Nerve 8 (Name, Function, and Sensory or Motor)
Auditory: Sensory: Hearing: Test with the whisper test
Cranial Nerve 9 (Name, Function, and Sensory or Motor)
Glossopharyngeal: Sensory + Motor: Gag reflex and taste on the back of the tongue: test by tasting
Cranial Nerve 10 (Name, Function, and Sensory or Motor)
Vagus: Sensory + Motor: swallowing/movement of vocal cords: test by swallowing
Cranial Nerve 11 (Name, Function, and Sensory or Motor)
Spinal Accessory: Motor: movement of head and shoulders: test by having pt. move head and shoulders
Cranial Nerve 12 (Name, Function, and Sensory or Motor)
Hypoglosseal: Motor: Positioning of the tongue: Test by moving the tongue
Glasgow Coma Scale (ranges and tests)
Objective numerical scale measuring level of conscience
Range: 3-15
Eye-Opening: 1-4
Verbal Response: 1-5
Motor Response: 1-6
Enuresis
Bed wetting
Hematuria
Blood in the urine
polyuria
excessive urination (more than 2500-3000mL/24h)
pyuria
pus in urine
nocturia
Awakens at night to urinate a lot
stress incontinence
Urination when the bladder receives stress (laughter, pressing on the bladder, shock)
One organ in the RUQ
Liver & Gallbladder
One organ in the LUQ
Stomach & Spleen
One organ in the RLQ
Appendix
One organ in the LLQ
Sigmoid Colon, left ovary, Left ureter
Ptosis
Drooping of the eyelid
Strabismus
Cross-eyed
Exophthalmos
Bulging of the Eyes
Myopia
Nearsightedness
Hyperopia
Far sightedness
Presbyopia
Age-related loss of near vision
Allen’s Test
The Allen’s test ensures that the ulnar pulse and radial pulses are both working properly
Pulse Deficit
Palpate radial while listening to apical pulse. If there is a difference, then the pulse is not reaching the peripheral pulse
Clubbing
Indicative of inadequate blood flow to the hands. No space between fingernails when they are pressed together.
Four Heart Valves
Aortic, Pulmonic, Tricuspid, Mitral
