Lesson 6 Flashcards
Why do we do a basic head-to-toe assessment as demonstrated in class?
Faster
Less likely to forget something
More comfortable for client
You look more professional
What is the normal sequence?
Inspection
Palpation
Percussion
Auscultation
Describe flow of head-to-toe assessment
General survey Level of consciousness HEENT (head, eyes, ears, nose, throat) Trachea Thorax Abdomen (*sequence changes!) Arms Perineum Legs
What do you look for in the general survey?
Physical appearance, body structure, mobility, behavior
What do you look for in the LOC?
If they are awake, alert, and oriented
HEAD: What are the tasks here?
Inspect hair, head size, and general appearance
HEAD: What is the statement for a normal sized head?
Normoalcephalic
HEAD: What are some abnormal statements during this part of the assessment and what do they mean?
Microcephalic: small head Macrocephalic: large head Alopecia: hair loss Hirusitism: Excessive amounts of hair Bell palsy: paralysis or weakness of the muscles on one side of your face
EYES: What are the tasks here?
Observe eyes, sclera conjunctiva
Measure pupil diameter
EYES: What are they normal statements for normal eyes?
Sclera white, conjunctive clear
Pupils equal, round, reactive to light directly and consensually (may also record actual pupil diameter)
EYES: There are 5 abnormal statements for the eyes. What are they?
Anisocoria, ptosis, sclera icterus, blue sclera, conjuctivitis (redness of sclera)
EYES: What does anisocoria mean?
Unequal pupil diameter
EYES: What does ptosis mean?
Drooping of the upper eyelid due to paralysis or disease
EYES: What does sclera icterus mean?
Jaundice; yellowing of sclera (actually it is the conjunctiva)
EYES: What does blue sclera mean?
Indication of osteogenesis imperfecta (brittle bone disease)
EYES: What does conjuctivits mean?
Pink eye
EARS: What are the tasks for the ears?
Observe for excessive wax, drainage, or redness and irritation
NOSE: What do you do here?
Observe of obstructions and/or drainage
MOUTH: What are the tasks for this section?
Look inside for pink and moist coloration
Observe condition of teeth
Observe back of throat
MOUTH: What is the statement for a normal mouth?
Mucous membranes moist and pink
TRACHEA: What do you do here?
Note the position and symmetry of the trachea
TRACHEA: What is the statement used for a normal trachea?
Trachea midline
THORAX: What are the 3 tasks?
Observe chest shape
Listen to heart beat at the apex
Listen to chest sounds
THORAX: What are the normal statements used if everything appears normal?
Normal AP diameter
Lung sound clear and equal bilaterally
S1S2, regular, no murmurs or extra heart sounds
THORAX: What are 7 abnormal findings you may find in this part of the assessment?
Barrel chest
Pectus excavatum
Pectus carinatum (pigeon chest)
Scoliosis
Kyphosis (hunchback)
Pneumothorax (trachea pushed towards side opposite pneumothorax)
Chest sounds-wheeze, stridor, sonorous wheeze/ronchi, crackle/rales
THORAX: What abnormal chest sound would you hear in the RUL?
Wheeze
THORAX: What abnormal chest sound would you hear in the RLL?
Stridor
THORAX: What abnormal chest sound would you hear in the RML/LUL?
Sonorous wheeze/ronchi
THOAX: What abnormal chest sound would you hear in the LLL?
Crackle/rales
ABDOMEN: What is the new sequence with the abdomen?
Inspection
Ausculation
Palpation
Percussion
ABDOMEN: What are your tasks here?
Observe shape of abdomen
Assess for tenderness and firmness
Listen for abdominal sounds (not necessary to check all 4 quadrants)
ABDOMEN: What is the normal statement here?
Abdomen flat, soft, non-tender. Normoactive bowel sounds
ABDOMEN: What are 5 abnormal findings here?
Scaphoid Rounded Protuberant Abnominal sounds hypoactive Abdominal sounds hyperactive
ARMS: What are the 5 tasks here?
Measure brachial pulse bilaterally and simultaneously
Measure radial pulse bilaterally and simultaneously
Asses arm/grip strength of both arms
Assess skin conditions
Assess fingers and fingernails including capillary refill
ARMS: What are the normal statements?
Skin warm and dry with good turgor Upper extremities strong 0, 1+, 2+, or 3+ pulse No clubbing or deformities Nail beds pink with prompt capillary refill
PERINEUM: What are the tasks here?
Record bowel movement information
Record voiding movement information
LEGS: What are the tasks here?
- Assess for deem
- Assess posterior tibial pulse
- Assess doornails pedis pulse *10% of population does not have this pulse
- Sensation
- Capillary refill
- Temperature
- Moisture
LEGS: What are the normal statements here?
Lower extremeties strong
Record pulse as always (0, 1+, 2+, 3+)
Record edema (similar to recording pulse- 1+, 2+, 3+, 4+)
