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Flashcards in Lesson 6 Deck (38)
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1
Q

Why do we do a basic head-to-toe assessment as demonstrated in class?

A

Faster
Less likely to forget something
More comfortable for client
You look more professional

2
Q

What is the normal sequence?

A

Inspection
Palpation
Percussion
Auscultation

3
Q

Describe flow of head-to-toe assessment

A
General survey
Level of consciousness
HEENT (head, eyes, ears, nose, throat)
Trachea
Thorax
Abdomen (*sequence changes!)
Arms
Perineum
Legs
4
Q

What do you look for in the general survey?

A

Physical appearance, body structure, mobility, behavior

5
Q

What do you look for in the LOC?

A

If they are awake, alert, and oriented

6
Q

HEAD: What are the tasks here?

A

Inspect hair, head size, and general appearance

7
Q

HEAD: What is the statement for a normal sized head?

A

Normoalcephalic

8
Q

HEAD: What are some abnormal statements during this part of the assessment and what do they mean?

A
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
9
Q

EYES: What are the tasks here?

A

Observe eyes, sclera conjunctiva

Measure pupil diameter

10
Q

EYES: What are they normal statements for normal eyes?

A

Sclera white, conjunctive clear

Pupils equal, round, reactive to light directly and consensually (may also record actual pupil diameter)

11
Q

EYES: There are 5 abnormal statements for the eyes. What are they?

A

Anisocoria, ptosis, sclera icterus, blue sclera, conjuctivitis (redness of sclera)

12
Q

EYES: What does anisocoria mean?

A

Unequal pupil diameter

13
Q

EYES: What does ptosis mean?

A

Drooping of the upper eyelid due to paralysis or disease

14
Q

EYES: What does sclera icterus mean?

A

Jaundice; yellowing of sclera (actually it is the conjunctiva)

15
Q

EYES: What does blue sclera mean?

A

Indication of osteogenesis imperfecta (brittle bone disease)

16
Q

EYES: What does conjuctivits mean?

A

Pink eye

17
Q

EARS: What are the tasks for the ears?

A

Observe for excessive wax, drainage, or redness and irritation

18
Q

NOSE: What do you do here?

A

Observe of obstructions and/or drainage

19
Q

MOUTH: What are the tasks for this section?

A

Look inside for pink and moist coloration
Observe condition of teeth
Observe back of throat

20
Q

MOUTH: What is the statement for a normal mouth?

A

Mucous membranes moist and pink

21
Q

TRACHEA: What do you do here?

A

Note the position and symmetry of the trachea

22
Q

TRACHEA: What is the statement used for a normal trachea?

A

Trachea midline

23
Q

THORAX: What are the 3 tasks?

A

Observe chest shape
Listen to heart beat at the apex
Listen to chest sounds

24
Q

THORAX: What are the normal statements used if everything appears normal?

A

Normal AP diameter
Lung sound clear and equal bilaterally
S1S2, regular, no murmurs or extra heart sounds

25
Q

THORAX: What are 7 abnormal findings you may find in this part of the assessment?

A

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

26
Q

THORAX: What abnormal chest sound would you hear in the RUL?

A

Wheeze

27
Q

THORAX: What abnormal chest sound would you hear in the RLL?

A

Stridor

28
Q

THORAX: What abnormal chest sound would you hear in the RML/LUL?

A

Sonorous wheeze/ronchi

29
Q

THOAX: What abnormal chest sound would you hear in the LLL?

A

Crackle/rales

30
Q

ABDOMEN: What is the new sequence with the abdomen?

A

Inspection
Ausculation
Palpation
Percussion

31
Q

ABDOMEN: What are your tasks here?

A

Observe shape of abdomen
Assess for tenderness and firmness
Listen for abdominal sounds (not necessary to check all 4 quadrants)

32
Q

ABDOMEN: What is the normal statement here?

A

Abdomen flat, soft, non-tender. Normoactive bowel sounds

33
Q

ABDOMEN: What are 5 abnormal findings here?

A
Scaphoid 
Rounded
Protuberant
Abnominal sounds hypoactive
Abdominal sounds hyperactive
34
Q

ARMS: What are the 5 tasks here?

A

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

35
Q

ARMS: What are the normal statements?

A
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
36
Q

PERINEUM: What are the tasks here?

A

Record bowel movement information

Record voiding movement information

37
Q

LEGS: What are the tasks here?

A
  • Assess for deem
  • Assess posterior tibial pulse
  • Assess doornails pedis pulse *10% of population does not have this pulse
  • Sensation
  • Capillary refill
  • Temperature
  • Moisture
38
Q

LEGS: What are the normal statements here?

A

Lower extremeties strong
Record pulse as always (0, 1+, 2+, 3+)
Record edema (similar to recording pulse- 1+, 2+, 3+, 4+)