Podcast
Questions and Answers
What is the primary reason for performing a head-to-toe assessment?
What is the primary reason for performing a head-to-toe assessment?
- To gather information for discharge planning.
- To document a patient's preference for meal times.
- To determine the patient's insurance coverage.
- To identify potential health problems. (correct)
When conducting a head-to-toe assessment, which approach ensures a systematic collection of data?
When conducting a head-to-toe assessment, which approach ensures a systematic collection of data?
- Selecting a body systems approach. (correct)
- Following the nursing assistant's data collection process.
- Focusing solely on the patient's chief complaint.
- Using a random approach to prevent bias.
Which assessment technique involves using hands to touch and feel for abnormalities?
Which assessment technique involves using hands to touch and feel for abnormalities?
- Percussion
- Inspection
- Auscultation
- Palpation (correct)
What should a nurse do if abnormalities are identified during a routine head-to-toe assessment?
What should a nurse do if abnormalities are identified during a routine head-to-toe assessment?
When assessing a patient's level of consciousness (LOC), what does 'alertness' primarily indicate?
When assessing a patient's level of consciousness (LOC), what does 'alertness' primarily indicate?
During a neurological assessment, what does the term 'oriented x 4' typically signify?
During a neurological assessment, what does the term 'oriented x 4' typically signify?
A patient who is easily awakened but drifts back to sleep if not constantly stimulated is best described as:
A patient who is easily awakened but drifts back to sleep if not constantly stimulated is best described as:
What is the MOST appropriate action when assessing a patient in the middle of the night?
What is the MOST appropriate action when assessing a patient in the middle of the night?
What is the primary reason why the term 'normal' should be avoided when documenting assessment findings??
What is the primary reason why the term 'normal' should be avoided when documenting assessment findings??
What does 'PERRLA' refer to in the context of a neuromuscular assessment?
What does 'PERRLA' refer to in the context of a neuromuscular assessment?
When assessing a patient's pupils for accommodation, what would be a normal finding?
When assessing a patient's pupils for accommodation, what would be a normal finding?
What is the significance of observing a patient squinting during an assessment?
What is the significance of observing a patient squinting during an assessment?
During a cranial nerve assessment, a nurse asks the patient, “Where are you right now?
During a cranial nerve assessment, a nurse asks the patient, “Where are you right now?
When evaluating motor strength, what is the MOST important factor to consider?
When evaluating motor strength, what is the MOST important factor to consider?
Which assessment finding would be MOST concerning when evaluating a patient's speech?
Which assessment finding would be MOST concerning when evaluating a patient's speech?
While assessing a patient's gait, the nurse observes that the patient has a shuffling gait with reduced arm swing. Which condition might the nurse suspect?
While assessing a patient's gait, the nurse observes that the patient has a shuffling gait with reduced arm swing. Which condition might the nurse suspect?
Which pulse point is typically assessed during emergencies, especially in cases of cardiac arrest or trauma?
Which pulse point is typically assessed during emergencies, especially in cases of cardiac arrest or trauma?
When assessing the radial pulse on a patient, a nurse notes that the pulse feels full and bounding. How should this finding be documented?
When assessing the radial pulse on a patient, a nurse notes that the pulse feels full and bounding. How should this finding be documented?
Where is the apical pulse located?
Where is the apical pulse located?
A nurse auscultates a patient’s lungs and hears a high-pitched, musical sound during expiration. How should the nurse document this finding?
A nurse auscultates a patient’s lungs and hears a high-pitched, musical sound during expiration. How should the nurse document this finding?
During auscultation of a client's lungs, the nurse hears coarse, low-pitched rattling sounds primarily during inspiration. Which term BEST describes this finding?
During auscultation of a client's lungs, the nurse hears coarse, low-pitched rattling sounds primarily during inspiration. Which term BEST describes this finding?
Which respiratory condition is MOST likely associated with Rhonchi
Which respiratory condition is MOST likely associated with Rhonchi
What is the recommended sequence for abdominal assessment?
What is the recommended sequence for abdominal assessment?
A nurse is preparing to auscultate a client's abdomen. In which quadrant should the nurse begin?
A nurse is preparing to auscultate a client's abdomen. In which quadrant should the nurse begin?
A nurse auscultates a client's abdomen and does not hear any bowel sounds after listening for 5 minutes in each quadrant. How should the nurse document this finding?
A nurse auscultates a client's abdomen and does not hear any bowel sounds after listening for 5 minutes in each quadrant. How should the nurse document this finding?
What should a nurse do when finding unexpected findings in the bladder urinary assessments?
What should a nurse do when finding unexpected findings in the bladder urinary assessments?
Which assessment finding in the rectum and genitourinary area would require immediate intervention by the nurse?
Which assessment finding in the rectum and genitourinary area would require immediate intervention by the nurse?
What is an appropriate question when assessing a resident that is taking sedating medications and is somnolent?
What is an appropriate question when assessing a resident that is taking sedating medications and is somnolent?
What should guide nursing interventions to prevent falls?
What should guide nursing interventions to prevent falls?
Where does a nurse press and palpate during a urinary system head to toe assessment?
Where does a nurse press and palpate during a urinary system head to toe assessment?
What intervention should be indicated when a patient indicates hesitancy?
What intervention should be indicated when a patient indicates hesitancy?
Why is it important to obtain the apical pulse using a stethoscope?
Why is it important to obtain the apical pulse using a stethoscope?
Where is the site for the primary pulse assessment?
Where is the site for the primary pulse assessment?
Which of the listed options is NOT an expected finding when assessing the abdomen?
Which of the listed options is NOT an expected finding when assessing the abdomen?
What is the normal range for bowel sounds?
What is the normal range for bowel sounds?
A patient's skin is smooth, dry, and an even tone. What part of a head-to-toe assessments is this found?
A patient's skin is smooth, dry, and an even tone. What part of a head-to-toe assessments is this found?
What's the definition of a barrel chest?
What's the definition of a barrel chest?
What steps are a part of palpating the apical pulse?
What steps are a part of palpating the apical pulse?
Name the artery at the location marked by a red "X" by this statement: Located on the inner side of the wrist, just below the base of the thumb.
Name the artery at the location marked by a red "X" by this statement: Located on the inner side of the wrist, just below the base of the thumb.
What action demonstrates appropriate technique when taking a radial pulse?
What action demonstrates appropriate technique when taking a radial pulse?
What is the primary reason for documenting physical assessment findings with specific descriptions rather than using general terms like 'normal' or 'responsive'?
What is the primary reason for documenting physical assessment findings with specific descriptions rather than using general terms like 'normal' or 'responsive'?
During a neurological assessment, a patient opens their eyes only to painful stimuli, is confused in their speech, and withdraws from pain. Using the Glasgow Coma Scale (GCS), how would you interpret these findings in terms of level of consciousness?
During a neurological assessment, a patient opens their eyes only to painful stimuli, is confused in their speech, and withdraws from pain. Using the Glasgow Coma Scale (GCS), how would you interpret these findings in terms of level of consciousness?
A nurse assesses a patient who is awake but requires a moderate voice and touch to remain alert. How should this be documented in the patient's chart?
A nurse assesses a patient who is awake but requires a moderate voice and touch to remain alert. How should this be documented in the patient's chart?
During an assessment, a patient correctly states their name and the current year, but is unsure of their location or why they are in the clinic. How should the nurse document this?
During an assessment, a patient correctly states their name and the current year, but is unsure of their location or why they are in the clinic. How should the nurse document this?
While assessing a patient, the nurse notes that the patient pauses frequently and struggles to recall common words. The patient is alert and cooperative. How should the nurse document this finding related to speech?
While assessing a patient, the nurse notes that the patient pauses frequently and struggles to recall common words. The patient is alert and cooperative. How should the nurse document this finding related to speech?
A patient reports decreased hearing in their left ear and frequently turns their head to the right to hear better. How should the nurse proceed during the assessment?
A patient reports decreased hearing in their left ear and frequently turns their head to the right to hear better. How should the nurse proceed during the assessment?
During an eye assessment, the nurse observes that a patient's pupils are different sizes. What additional assessments should the nurse prioritize?
During an eye assessment, the nurse observes that a patient's pupils are different sizes. What additional assessments should the nurse prioritize?
When testing a patient's upper extremity strength, the nurse applies downward pressure while the patient tries to hold their arms up. What is this assessing?
When testing a patient's upper extremity strength, the nurse applies downward pressure while the patient tries to hold their arms up. What is this assessing?
While assessing lower extremity strength, a nurse asks the patient to push their feet against the nurse's hands. What specific movement is being evaluated?
While assessing lower extremity strength, a nurse asks the patient to push their feet against the nurse's hands. What specific movement is being evaluated?
Which instruction best assesses a patient's motor response during a routine neurological assessment?
Which instruction best assesses a patient's motor response during a routine neurological assessment?
When assessing a patient's activity tolerance, which documentation would be most informative?
When assessing a patient's activity tolerance, which documentation would be most informative?
A nurse is calculating the fall risk for an elderly patient. What factors contribute to a higher fall risk score?
A nurse is calculating the fall risk for an elderly patient. What factors contribute to a higher fall risk score?
What standard interventions should be implemented for every patient to ensure basic safety and fall prevention, regardless of their individual fall risk score?
What standard interventions should be implemented for every patient to ensure basic safety and fall prevention, regardless of their individual fall risk score?
During an assessment, the nurse observes that a patient has an increased anterior-posterior chest diameter. Which condition should the nurse suspect?
During an assessment, the nurse observes that a patient has an increased anterior-posterior chest diameter. Which condition should the nurse suspect?
When auscultating a patient’s lungs, the nurse hears a musical, high-pitched sound primarily during expiration. This finding is most consistent with which adventitious sound?
When auscultating a patient’s lungs, the nurse hears a musical, high-pitched sound primarily during expiration. This finding is most consistent with which adventitious sound?
The nurse is assessing a patient with a known history of asthma. Which adventitious lung sounds would the nurse MOST likely hear?
The nurse is assessing a patient with a known history of asthma. Which adventitious lung sounds would the nurse MOST likely hear?
A nurse auscultates a patient’s lungs and hears low-pitched, continuous sounds that resemble snoring. What term should the nurse use to document this finding?
A nurse auscultates a patient’s lungs and hears low-pitched, continuous sounds that resemble snoring. What term should the nurse use to document this finding?
When performing a head-to-toe assessment, what is the rationale for auscultating the abdomen prior to palpation or percussion?
When performing a head-to-toe assessment, what is the rationale for auscultating the abdomen prior to palpation or percussion?
A nurse is auscultating a client's abdomen and does not hear any bowel sounds. What is the MOST appropriate next step for the nurse to take?
A nurse is auscultating a client's abdomen and does not hear any bowel sounds. What is the MOST appropriate next step for the nurse to take?
Upon initial inspection of a patient's abdomen, the nurse observes visible, intense pulsations. What could this indicate?
Upon initial inspection of a patient's abdomen, the nurse observes visible, intense pulsations. What could this indicate?
During the palpation phase of an abdominal assessment, a nurse notes that the patient is voluntarily guarding. What is the MOST appropriate initial action?
During the palpation phase of an abdominal assessment, a nurse notes that the patient is voluntarily guarding. What is the MOST appropriate initial action?
When performing a urinary system assessment, what finding necessitates the use of a bladder scanner post-void?
When performing a urinary system assessment, what finding necessitates the use of a bladder scanner post-void?
A patient reports a recent change in bowel habits, including alternating constipation and diarrhea. What focused question should the nurse prioritize?
A patient reports a recent change in bowel habits, including alternating constipation and diarrhea. What focused question should the nurse prioritize?
What observation during an inspection of the anal area requires the MOST immediate attention?
What observation during an inspection of the anal area requires the MOST immediate attention?
What is the MOST important consideration when assessing skin turgor as part of an integumentary assessment?
What is the MOST important consideration when assessing skin turgor as part of an integumentary assessment?
If a nurse assesses a patient's ability to turn in bed independently, what aspect of patient care is being evaluated?
If a nurse assesses a patient's ability to turn in bed independently, what aspect of patient care is being evaluated?
A patient is being assessed for mobility in their upper and lower body. Which statement regarding assessment is correct?
A patient is being assessed for mobility in their upper and lower body. Which statement regarding assessment is correct?
A patient is going to be assessed and it is found the patient is sleepy, especially at night, since they take a sedating medication. Which of the following terms best describes this assessment?
A patient is going to be assessed and it is found the patient is sleepy, especially at night, since they take a sedating medication. Which of the following terms best describes this assessment?
A patient is difficult to rouse and is drowsy or blunted even when awakes. The patient quickly goes back to sleep when undisturbed. Which of the following terms best describes this assessment?
A patient is difficult to rouse and is drowsy or blunted even when awakes. The patient quickly goes back to sleep when undisturbed. Which of the following terms best describes this assessment?
A patient is assessed to be unable to move their right arm and leg. The nurse determines the term extit{flaccid} applies to this assessment. Which of the following best describes this assessment?
A patient is assessed to be unable to move their right arm and leg. The nurse determines the term extit{flaccid} applies to this assessment. Which of the following best describes this assessment?
A patient has hearing deficits. Which of the following instructions for the nurse is most important to provide the most assistance to the patient?
A patient has hearing deficits. Which of the following instructions for the nurse is most important to provide the most assistance to the patient?
A nurse will be assessing a patient's pulse to obtain a full assessment in the cardiovascular area. Which assessments should the nurse review?
A nurse will be assessing a patient's pulse to obtain a full assessment in the cardiovascular area. Which assessments should the nurse review?
The nurse will be starting a respiratory assessment on a patient. Which factors are most important to consider for lung lobes?
The nurse will be starting a respiratory assessment on a patient. Which factors are most important to consider for lung lobes?
Which assessment technique is most suitable for identifying areas of skin discoloration or unusual moles during a head-to-toe assessment?
Which assessment technique is most suitable for identifying areas of skin discoloration or unusual moles during a head-to-toe assessment?
When assessing a patient's orientation, what does evaluating 'situation' involve?
When assessing a patient's orientation, what does evaluating 'situation' involve?
A patient is awake, but demonstrates drowsiness and initiates interactions slowly. How should the nurse document this?
A patient is awake, but demonstrates drowsiness and initiates interactions slowly. How should the nurse document this?
A nurse assesses a patient with COPD. The patient rouses briefly only with a vigorous stimulus and mumbles. Which term best describes this level of consciousness?
A nurse assesses a patient with COPD. The patient rouses briefly only with a vigorous stimulus and mumbles. Which term best describes this level of consciousness?
When assessing a patient's speech, what aspect focuses on the quantity of their verbal output?
When assessing a patient's speech, what aspect focuses on the quantity of their verbal output?
To assess hearing effectively during a head-to-toe exam, what is MOST important for the nurse to do?
To assess hearing effectively during a head-to-toe exam, what is MOST important for the nurse to do?
While assessing a patient who reports difficulty hearing, you observe them frequently leaning forward and watching your lips as you speak. What does this most likely indicate?
While assessing a patient who reports difficulty hearing, you observe them frequently leaning forward and watching your lips as you speak. What does this most likely indicate?
If the sclera of a patient's eyes appears yellow, which condition should the nurse suspect?
If the sclera of a patient's eyes appears yellow, which condition should the nurse suspect?
During an assessment of extraocular movements, a patient reports double vision. What is the MOST appropriate nursing intervention?
During an assessment of extraocular movements, a patient reports double vision. What is the MOST appropriate nursing intervention?
When assessing upper extremity strength, how does the nurse determine if the strength is equal and adequate:
When assessing upper extremity strength, how does the nurse determine if the strength is equal and adequate:
What key elements should a nurse include when documenting a patient's activity tolerance?
What key elements should a nurse include when documenting a patient's activity tolerance?
Which standard intervention is essential for every patient to prevent falls, regardless of their individual fall risk score?
Which standard intervention is essential for every patient to prevent falls, regardless of their individual fall risk score?
What should a nurse do to prepare a patient for a respiratory assessment?
What should a nurse do to prepare a patient for a respiratory assessment?
In which situation should the nurse MOST carefully assess the patient's anterior-posterior chest diameter?
In which situation should the nurse MOST carefully assess the patient's anterior-posterior chest diameter?
A patient is diagnosed as having rhonchi, a type of lung sound. What causes rhonchi?
A patient is diagnosed as having rhonchi, a type of lung sound. What causes rhonchi?
In which order should the nurse perform the techniques of physical assessment as part of an abdominal examination?
In which order should the nurse perform the techniques of physical assessment as part of an abdominal examination?
During an abdominal assessment, when would the nurse begin palpation of the abdomen in a different quadrant.
During an abdominal assessment, when would the nurse begin palpation of the abdomen in a different quadrant.
If a nurse assesses the abdomen to be rounded, what does this imply about the patient's condition?
If a nurse assesses the abdomen to be rounded, what does this imply about the patient's condition?
During a urinary system assessment, when is a bladder scan MOST necessary?
During a urinary system assessment, when is a bladder scan MOST necessary?
What action should a nurse take when assessing Integumentary skin breakdown?
What action should a nurse take when assessing Integumentary skin breakdown?
Flashcards
Purpose of a head-to-toe assessment?
Purpose of a head-to-toe assessment?
Provide a baseline, identify potential problems, detect problems that may require additional testing.
Systematic approach for data collection?
Systematic approach for data collection?
A systematic way to collect patient data (e.g., head-to-toe, body systems, problem focused).
Techniques of a Physical Assessment?
Techniques of a Physical Assessment?
Inspection, palpation, percussion, and auscultation.
What is Alertness?
What is Alertness?
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Awake/Alert patient?
Awake/Alert patient?
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Awakened?
Awakened?
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What patients are Somnolent?
What patients are Somnolent?
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What patients are Lethargic?
What patients are Lethargic?
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What patients are Obtunded?
What patients are Obtunded?
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What patients are Stuporous?
What patients are Stuporous?
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What patients are Comatose?
What patients are Comatose?
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What does being oriented mean?
What does being oriented mean?
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What is a Confused patient?
What is a Confused patient?
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Normal for age?
Normal for age?
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Speech assessment?
Speech assessment?
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What does PERRLA mean?
What does PERRLA mean?
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Extremity strength assessment?
Extremity strength assessment?
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Motor response?
Motor response?
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Assessing activity and tolerance?
Assessing activity and tolerance?
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What is a Fall Risk scale?
What is a Fall Risk scale?
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Standard fall interventions?
Standard fall interventions?
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What is barrel chest?
What is barrel chest?
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What is Funnel chest?
What is Funnel chest?
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What is Pigeon chest?
What is Pigeon chest?
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Heart assessment
Heart assessment
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Primary pulse assessment site:
Primary pulse assessment site:
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Pulse characteristics?
Pulse characteristics?
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Where is the Apical Pulse?
Where is the Apical Pulse?
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Skin assessment?
Skin assessment?
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How many lung lobes in each lung?
How many lung lobes in each lung?
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What sounds are considered Adventitious Lung Sounds?
What sounds are considered Adventitious Lung Sounds?
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What are Wheezes?
What are Wheezes?
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Crackle/Rales sound?
Crackle/Rales sound?
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What sounds are Fine crackles?
What sounds are Fine crackles?
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Coarse crackles?
Coarse crackles?
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What is Rhonchi?
What is Rhonchi?
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Order of abdominal assessment?
Order of abdominal assessment?
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Urinary system?
Urinary system?
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Subjective and objective, assessment and interventions for urinary retention.
Subjective and objective, assessment and interventions for urinary retention.
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Anal and perianal area should be how.
Anal and perianal area should be how.
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Study Notes
Head-To-Toe Data Collection Objectives
- Demonstrate a head-to-toe assessment on your lab partner
- Verbalize the importance of a physical assessment
- Demonstrate proper documentation of physical findings
- Develop confidence in data collection skills through practice and seeking assistance to be ready for clinicals
Assessment Purpose
- Provides a baseline
- Identifies potential problems
- Detects problems that may require additional testing
Assessment - Systematic Approach
- Select a systematic approach for collecting data
- Initial survey options include head-to-toe, body systems, or problem focused
Physical Assessment Techniques
- Inspection
- Percussion
- Palpation
- Auscultation
Abnormalities
- If abnormalities are seen, gather more data in the specific area(s) that are not Within Normal Limits (WNL) or differ from expected outcomes
Neuromuscular Head to Toe Collection
- Level of consciousness (LOC)/Alertness
- Orientation
- Eyes/Pupils Equal, Round, Reactive to Light, and Accommodation (PERRLA)
- Speech
- Ability to follow simple commands
- Movement and strength
Glasgow Coma Scale
- Used to assess level of consciousness, based on eye opening, verbal, and motor responses
- Scores range from 3 (totally unresponsive) to 15 (best response)
- A score of 8 or less indicates a comatose client
Neuromuscular General Assessment Information
- You can obtain neurological status while interacting with a patient
- Observe response when entering the room; alertness may be evident if they look up or speak
- Watch patient as they drink; difficulty swallowing could indicate an issue
- Ask the patient "Where are you right now?", in order to assess their orientation to place, assess for hoarseness (which could indicate a problem with a cranial nerve or sore throat) and slurring (which is a sign of stroke)
Neuromuscular Head to Toe Data Collection - Alertness
- Is how aware the patient is
- How they interact with environment
Neuromuscular Head to Toe Data Collection - Awake
- Sleeping, awakened by rustling, quiet voice, light touch, moderate voice and touch
- Can spontaneously awaken when you walk into the room
- Stays awake without difficulty
- Wakefulness refers mainly to differences between the sleep and waking states
Neuromuscular Head to Toe Data Collection - Alertness Expected Findings
- Awake
- Aware
- Interactive
Awake/Alert (Expected Outcome)
- Awake and responds appropriately to your interactions and the environment, answering questions and following commands
Neuromuscular Head to Toe Data Collection - Awakened
- How much stimulus did it take for patient to be woke up
- Did the patient awaken/arouse to movement in the room, door opening, quiet voice or light touch
- Did the patient awaken/arouse to moderate voice-moderate touch
- Did the patient awaken arouse to strong voice- strong touch
- Did patient awaken/arouse to painful stimulation only: sternal rub, pressure on fingernail, etc.
- Is the patient staying awake or do you have to keep stimulating them
Groggy patients - FYI
- When conducting assessments in the middle of the night, give the patient a moment to "wake up” before asking them questions
- It is unfavorable for the patient, if they receive an inaccurate assessment that is lower than where they should be, if they are groggy
Neuromuscular Head to Toe Data Collection - Normal & Responsive
- Do not use the terms "Normal and Responsive"
- "Normal" for one, is not always "normal" for others
- Charting "responsive" is not complete information
- What the patient is responding to and how they respond to stimulus gives more information
Consciousness Levels
- Somnolent: sleepy, especially at night or when taking sedating medications
- Lethargic: Marked drowsiness and asleep
- Obtunded: Difficult to rouse, drowsy or blunted even when awake; may be confused or mumble and quickly go back to sleep when undisturbed
- Stuporous: Very difficult to rouse and requires vigorous, repeated painful stimulation and not very responsive to the environment; as soon as stimulation stops, the patient returns to the unconscious state
- Comatose: No response to any stimulation and unresponsive
Neuromuscular Head to Toe Data Collection - Orientation
- To person, place, time, and situation
- Oriented x 4, oriented to person – states first and last name, place- states correctly, time- knows date or month or season, and situation- knows reason why you are interacting with them and why they are where they are
- Orientation questions include name, location, day, and what is happening
- Is the patient oriented to person, place, time, and situation
Neuromuscular Head to Toe Data Collection - Confused
- The components consist of what is known for a patient, whether the patient is situated in the chair, following all commands, the confusion emerges when their whereabouts are questioned
- If found, documentation will include, "Oriented x 3 person, place, time, not situation"
Neuromuscular Head to Toe Data Collection - Cognition
- Cognition means "normal for age", which signifies, "The thinking abilities that fall within the range considered normal for people of their age group"
- Normal for age, forgetful, developmentally delayed, confused
- Review Erikson's Development Stages for the definition of expected abilities at certain ages
Cognition Continues
- Slower processing speed: take longer to process information and react to stimuli
- Mild memory difficulties: Occasionally forgetting names or recent events, but can still recall important information
- Difficulty with multitasking: May struggle with managing multiple tasks simultaneously
- Word-finding challenges: Occasional pauses while searching for the right word
Confusion
- A patient alert and oriented to self, but disoriented to time, place, and situation is A/O x 1
Neuromuscular Head to Toe Data Collection - Speech
- Clear and appropriate
- Clear, garbled, mumbled, content/tone appropriate, content/tone inappropriate, nonverbal, none, rate: fast/slow
- Even rate, rhythm, and tone
- Expected responses and ability to follow instructions appropriately
- Quantity: How much the patient speaks, if they are talkative or quiet
- Rate reflects how fast or slow the patient speaks
- Rhythm: flow and rhythm of the patient's speech
- Volume: How loud or soft the patient speaks
- Tone: Quality of the patient's voice
- Fluency describes whether the patient's speech is smooth or has gaps
- Clarity is whether the patient's words are clear and distinct
- Response: How the patient responds to questions
- Slurred speech, difficulty understanding speech - garbled, mumbled, inappropriate words/ and or content, and difficulty speaking are all signs of neurological injury
Neuromuscular Head to Toe Data Collection - Hearing
- Expected findings: Within Defined Limits (WDL)
- No impairment with no drainage
- Assess: Patient use of hearing aides, any drainage seen, pain, and ear symmetry
- If the patient frequently asks for repeating of the questions, and the patient provides inappropriate responses, they could have a diminished sense of hearing
- Other signs of hearing deficit include the client leaning toward you, turning their head toward you, or closely watching your lips
Neuromuscular Head to Toe Data Collection - Sight/Eyes
- Expected findings: Within Defined Limits (WDL) no impairment
- Sclera should be white with a pupil that is not cloudy, and has no drainage
- Eyes should be placed parallel to one another on the face and aligned in the socket, and shows no protrusion or sunken appearance
- Pupils should be PERRLA
Extra Eye Information
- Use your thumbs to gently retract the skin below the lower eyelids to inspect the sclera and conjunctiva
- Sclera discolored: An overall coloring of the sclera that is yellow or green can be present if the client has liver disease
- Conjunctivitis is an inflammation of the conjunctiva causing redness and drainage, usually the result of a bacterial or viral infection, allergy, or chemical injury to the eye
- Eyebrow extension or lack of movement
- Eyelid redness, edema, drooping, and inability to close eyelid are all symptoms that should be assessed
Inspecting Pupils
- Inspect pupils for size, shape, and symmetry
- Note any squinting, it indicates client is having difficulty in vision
- Dilated: Pupils are more than greater than 7MM and can indicate Neurological & Eye disease
- Pinpoint pupils: Is shown by the pupil at rest and less the 3 mm will commonly indicate opiod intoxication
- Cloudy: loss of transparency of the len,s and impairs client's vision.
PERRLA Testing
- Test is conducted following these steps
- Darken room, and have the client look into the distance with side lightning
- Observe any changes to the pupils
- Both pupils should constrict at the same time when lightning occurs
- Next, have patient look at an object, and the pupil should constrict
- When test is complete, pupils should dilate bilaterally, then have the patient shift their sight at least six inches from their nose; the pupil should react and constrict bilaterally
Documenting PERRLA
- Document: Pupils Equal Round Reactive to Light, and Accommodation (PERRLA)
- Measure the size of the pupil and document if brisk, sluggish, or unequal after examining
Neuromuscular Head to Toe Data Collection - Numbness/Tingling
- Assess peripheral pulses or capillary refill on upper and lower extremities
- Ask "Which hand/foot am I touching?" and “Do you have any numbness or tingling in your hands or feet?”
Neuromuscular Head to Toe Data Collection - Strength of Extremities
- Label location of extremity: upper and lower, right and left
- Note strength of extremity: flaccid, weak, or strong
- Determine if strength equal on both side and if strength is adequate or inadequate
- To assess upper body strength have the patient squeeze your hands with theirs, or to push/pull you against resistance
- They can also hold both of their arms up against gravity for a count of 10 as you apply pressure downward on arms, or pressure upward underneath arms while they try to keep arms extended out. Check to see if your hands have equal strength on both sides, and to make sure one side is not drifting
Lower Body Strength
- Assess dorsiflexion and plantarflexion
- For plantarflexion, ask the patient to push their feet into your hands, "step on the gas"
- For dorsiflexion, have them pull their toes toward their face, or another test is to have them hold each leg up off the bed for a count of five, check for any weakness
Motor Response
- Test the patient's motor response by observing their ability to obey commands or follow directions, or by performing requests
Neuromuscular Head to Toe Data Collection - Activity
- Evaluate bed mobility, transfer, and ambulation
- Bed mobility is how the patient turns in bed, amount of assistance needed, and whether they are self sufficient
- Assess the transfer from bed to chair: amount of assistance needed and type of device (if any)
- Check level of ambulation: how long, distance, amount assistance needed, and the patients fatigue levels and tolerance
Assessing Tolerance
- See if there are is an increase in breathing effort with activity
- Evaluate negative, anxiety, frustration, and/or agitation with activity
- Note any instances of fatigue, or need for frequent rest periods with activity
Fall Risk
- Calculate and document the Fall Risk # for your patient using an attached chart
- Determine to see if your patient fits Low, Moderate or High risk, and then note precautions needed for each result of the Fall Risk test
- A fall risk scale assesses a patient's likelihood of falling by evaluating factors like medical history, mobility, mental status, and medication use
- The assigned points assigned to each are assigned to the factor, with higher scores signifying a greater risk
Fall Risk (2)
- Falls rank high, in the most common accident experienced by older adults
- Stats show, "Greater than 1/3 of adults aged 65 years and older, fall in the US each year"
- Falls account for those having, "Of those 743,000 require hospitalization and 25,500 died. (CDC, 2015)
- You need to know, what are the most common injuries
Factors of Older Fallers
- Key is to know those that are the what contributing factors that put older adults at falls
- With these actions known, it is very imperative to check for needed interventions, and if needed, help the patient reduce any incidents
Interventions
- Reassess after significant changes
- Implement, what is known to be a: "position in low/safe position, call light within reach, bedside table, water cup, remote, phone near bed, nonslip shoes/slippers, and a clear walkway"
- Following this step, a more personal plan can become customized
- The customized plan is developed to, "include environmental modifications, assistive devices, and exercise programs"
Unintentional Falls Data
- Falls result in 1 in 5 serious injuries, like TBIs
- Minnesota Injury rates, show 93,723, result from $713,000,000, for resulting billings at rate of $7,607.49
Assessment of the Chest
- Note for symmetry, and check for deformities for any variance
Chest Deformities
- A barrel chest is an increase in the size of the chest from front to back, with the sternal angle becoming more prominent; it may be related to aging or respiratory diseases like COPD
- A funnel chest is a depression in the lower portion of the sternum, which may cause a murmur if there is compression of the heart or great vessels
- A pigeon chest is when the sternum is displaced and protrudes with ribs next to the sternum at the xiphoid process depressed
Cardiovascular Assessment
- Listen to the heart, assess the rate via apical pulse for 1 full minute, and not rate and rhythm (regular or irregular)
- Inspect fingernails for color, thickness, and clubbing
- Verify capillary refill by observing fingers, and toes bilaterally
- Checks for edema
Cardiovascular System Assessment
- Palpate peripheral pulses and compare one side to another, on of the same pulse
Pulse Primary Site
- Primary pulse assessment site: radial artery located at inner (thumb) side of the wrist
Pulse Assess Points
- Counting the apical heart rate
- Obtaining an apical and a radial at the same time
- Using a Doppler ultrasound device over a peripheral artery
Radial Pulse
- To properly take note of the pulse, locate inner wrist, just below the base of the thumb
- For note, be sure to avoid the thumb so you don't interfere with heart-rate
- From what you were able to conduct, "Count the number of beats in 60 seconds for an accurate heart rate measurement"
Brachial Pulse
- Located inner elbow of the arm
- Commonly used to measure the blood pressure
Carotid Pulse
- Side of the neck to trachea
- To avoid discomfort, remember to never be stern when assessing to avoid interfering or lead to faint
Popliteal Pulse
- Behind Knee
- Position, Patient is, prone
Dorsalis Pedis
- Top of foot
- Lateral to the extensor hallucis longus tendon
- Often used to assess what is concerning the lower body vessels
Tibial Artery
- Inner of ankle, Medial malleolus
- Key to evaluate blood
Pulse Characteristics
- Rhythm
- Rate
- Force/Volume
- Pulse Equality
Apical Pulse
- To take, location of Mitrai Valve
- Time is crucial, needs to be taken for one minute
- Sound is lub-dub
- Left side of body, fifth rib
Apical Pulse Instructions
- When the correct setting is applied, it will follow this step list
- Locate sternal spot, should run between clavicles. You can know by being aligned over, what is known to be the notched area above the sternum
- With finger follow the down position with movement, and to confirm, "you will feel a hump"
More Apical Pulse Instuctions
- Next stage includes, you are at the second intercostal spot
- Last stage includes, and can confirm if you will be at the 5th ICS
Final Apical Advise
- Use all of the aforementioned steps
- When the correct step is done, use your hands, and place over cite if assessment is easy
- When conducting test, look/or use an alternate method, if what is known, and what you can do to follow or test, is limited
Pulse Locations/Functions:
- (Dorsalis) on the superior aspect extending on the great toe and second toe
- (Posterial-Tibalis) on the inside of the ankle right near medial malleolus bone
Cardiovascular Head to Toe Data Collection - Capillary Refill assessment
- Assess bilateral upper and lower extremities
Cardiovascular Head to Toe Data Collection - Skin
- Observe color, temperature, and moisture
Edema
- Is its own individual and not mentioned in prior, or next upcoming slides
Lung Lobes
- Listen for abnormal sounds
- The right has three lobes - Right Upper Lobe (RUL)-Anterior and Lateral, Right Middle Lobe (RML)-Anterior and Lateral (closer to front), and Right Lower Lobe(RLL)-Posterior and Lateral
- The left Lobe has 2 - Left Upper Lobe(LUL) -Anterior and Lateral, and Left Lower Lobe(LLL) -Posterior and Lateral
Respiratory Sounds Cont
- Key factor is key, and means that there should not be abnormal sounds that can come to action
- These include: The sounds of Wheezes, Course, and Rhonchi
Adventitious Lung Sounds
- These are outside sounds and may impact the lungs on inflation
- Examples, with slight sounds include: bubbling, clicking, or rattling
- You will know if they are present, with the snapping, or if they are set to open air
- They're primarily inspiratory. The difference between the course and fine crackles is believed to come from the size of the airway snapping
adventitious
- Can occur in smaller parts, like the airways
- You, can confirm by detecting very short sounds or strips with velcro when removing
Corase Crackles
- Larger, louder, and may indicate that the patient will cough
- Check the patient's lungs for any cause like pneumonia or COPD
Rhonchi
- These lung signs, share those with sound of snoring
- Often occur for many reasons that include blockage or fluid
Auscultate Anterior & Posterior Lung Sounds
- Listen side to side comparing the right with the left
- Note type of sound and volume
Gastrotestinal
Understand
- Understands the need, for inspection, or need to listen to parts of the patient's parts to gain clear assessment
Questions
A great way to learn, is to get discussion question or advice for the procedure
- When taking assessment for the chest, you would like to use, Inspect, Auscultate, Palpate, Percuss
- The order must be set or different, to not lose any key assessment points or risk losing track of any assessment being conducted
Key body traits that affect the Assessment
Include: The: Liver, Gallbladder, Pancreas, Abdominal aorta, and Spleen
Bowel Sound Instructions
- When you take order, and when this is taken into the note, you will begin the assessment for, "Four points of the Quads" which stand for RLQ, the: RUQ, LUQ, and LLQ"
- While the check is complete, you hope to understand for what, and then what to notate for the inspection
The Assessment:
- Skin tone and appearance
- Check the skin for smoothness, dryness, and evenness
- Confirm for variation of moles, scars, striae
- You want, "ask what current habits are for bowl", "what is a normal and what isn't ", or "for changes"
Assessment - Inspect
- Evaluate symmetry and masses
- note Symmetry of movements with breathing
- Expected Variations
- Slight aortic pulsations,
- Peristaltic movements
- Pregnancy
Shape Contour
- Expected Findings
- slightly concave, Rounded, and along sides
- Umbilicus: You want to see for, "midline and inverted ", check for piercing or the likes
- Unexpected Findings includes: distenion, marked concavity, redness, discoloration, and swelling
Palpating Advise
- At the high state expect to find "Nontender and Relaxed muscles"
- At a more negative route, you will detect, "Increase tones around the location being test/ed"
- And if even more or if you are very unlikely to test, you will detect and note for, "Involuntary rigidity"
Other Important notes to do after you are done
- Review body results to create reports
Urinary System, Anatomy
- Look for those points: kidneys, ureters , Bladder, and the, Urethra
Urinary - Review and Note for the Points
- Check for Distention _ For point reference = Inspect suprapubic, for a more clear view look for (Distention) For the the assessment of:
- Palpate Bladder"
Intervention (Check/ Do/ Conduct )
- You can test by using a: _Bladder Scanner
- You can test further with: _Voiding Positions
- and to improve the state of the bladder: _ Use of water
Genitourinary Examination
- To avoid infections, a genital exam can be done under the assessment
Anus
- When you are conducting the test, see what traits are likely to show up like, or compare to those of a, "intact skin, or when there is not a any protrusion"
- To continue with this: check to see if is, "Moist, hairless and closed anus"
Integumentary Assessment Include
- These checks test: Skin, braden and Turgor rate
- Check when patient displays : Lesions/Rashes is is, "isolate in risk or for infection " and a risk level: Check the score of a Braden test
- Always and very important, to follow the diet and be, Hygiene
Skin integrity tests
You will need to be sharp for this test points
- At first, follow, to help not just the patient, be clean and not spread for what is being treated", Follow with, The location, and size " to know or to narrow what was found to be inspected - Use what the test will detect signs, symptoms
- And last, follow the drainage. And keep the the tested and non tested with what is clean, dry or closed
Lesion Traits to follow and take notes on
- What their location is
- The traits, should be taken
Nursing key actions
- To test to keep safe: check boney parts of your body often Mobility and inspection to be kept in check/ check of the patient to be " Clean, and not spread for what is being treated, Follow with, The location, and size, to know or to narrow what was found to be inspected
- For any infections"
- You will see this often while checking for a special need for a mattress"
- Now, and that after you have reviewed the point list with all of needed things, you will have and will find key solutions or better and what key results, and actions the review the inspection will produce
- Just take what the check is saying/ or what the note is notating
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