Head to toe assessment

Allen's test procedure

1. apply pressure to the radial and ulnar arteries at the same time 2. while applying pressure, tell the pt to open and close their fist 3. the hands SHOULD blanch 4. release pressure from the ulnar artery while continuing to compress the radial 5. if pinkness does not return within 6-7 second, the ulnar artery is insufficient, and the radial should not be used

braden score high risk

18 or less

Braden score: low risk

23-18

Eye Opening Response

4 spontaneously 3 to speech 2 to pain 1 no response

Verbal Response

5 oriented 4 confused 3 inappropriate words 2 incomprehensible sounds 1 none

motor response

6 obeys commands 5 localizes to pain 4 withdraws from pain 3 flexion to pain 2 extension to pain 1 none

hyperopia

A condition in which visual images come to a focus behind the retina of the eye and vision is better for distant than for near objects -- called also farsightedness.

Skin, hair, and nails assessment questions

Any body piercing or tattoos? Have you noticed any changes in your hair? How often do you shower or bath?

Head, ears, eyes and throat assessment questions

Any head pain? Any ringing in your ears? Any trouble swallowing?

ABCDEs of melanoma

Asymmetric, border irregular, color variance, diameter >0.6 cm, evolution

Rhonchi

Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.

wheeze

Difficult breathing with a whistling sound resulting from narrowing of the lumen of the respiratory passageways

Cardiovascular and peripheral vascular assessment questions

Do you smoke, alcohol or other drugs? Any past heart problems? How often do you exercise?

polyuria is caused by

Kidney disease such as hypokalemic nephropathy, lithium toxicity, uncontrolled diabetes, and disorders of the pituitary and hypothalamus (ex. hypogonadism).

Left Upper Quadrant (LUQ)

Left lobe of liver, stomach, pancreas, left kidney, spleen, portions of large intestine

Abduction

Movement away from the midline of the body

XI-spinal accessory

Movement of head/shoulders Rotating head Shrugging shoulders

Adduction

Movement toward the midline of the body

Motor response (GCS) highest and lowest

Obeys commands 6 None 1

Verbal Response (GCS) highest and lowest

Oriented 5 None 1

assessing sinuses

Palpation for tenderness Percussion and transillumination for air versus fluid or pus

Biot's respirations

Rapid and deep respirations followed by 10 to 30 seconds of apnea

Right Upper Quadrant (RUQ)

Right lobe of liver, gallbladder, right kidney, portions of stomach, small and large intestine

Two skills to assess coordination are

Romberg test Touching each finger to thumb

V-trigeminal

Sensory nerve to face, motor nerve to jaw muscles

Eye opening GCS scores highest and lowest

Spontaneously 4 None 1

Extension

Straightening of a joint

Inversion

Turning the sole of the foot inward

IV-tronchlear

Up/down eyeball movement

Assess for Pulse Deficit

While auscultating the apical heart rate, the nurse notes an irregular heart rhythm at a rate of 120 beats/min. What is the nurse's next action?

Glasgow Coma Scale (GCS)

a neurologic scale used to assess level of consciousness

lordosis

abnormal anterior curvature of the lumbar spine (sway-back condition) cervical and lumbar spine

Scoliosis

abnormal lateral curvature of the spine, either to the right or left; also called C-shaped curvature

Cheyne-Stokes respiration

an irregular pattern of breathing characterized by alternating rapid or shallow respiration followed by slower respiration or apnea

six fields of gaze

ask the person to follow the finger movie with finger in 6 directions. If the patient is able to track this is normal. If the patient is unable to track with both eyes this is abnormal indicates muscle weakness

Flexion

bending a joint

plantar flexion

bends the foot downward at the ankle

Right Lower Quadrant (RLQ)

cecum, appendix, right ovary and tube, right ureter, right spermatic cord

Clubbing is a sign of

chronic hypoxia

Less than 7 on the Glasgow Scale is

comatose

Left Lower Quadrant (LLQ)

contains parts of the small and large intestines, left ovary, left fallopian tube, left ureter

strabismus

cross-eyed

ptosis

drooping

Kyphosis

excessive outward curvature of the spine, causing hunching of the back. Thoracic spine

nocturia

excessive urination at night

III-oculmotor

eye movement, pupil size

Glasglow Coma Scale (GCS)

eye opening, verbal response, motor response Measures level of consciousness

VII-facial

facial expressions, taste on front of tongue

presbyopia

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.

Crackles

fine crackling or bubbling sounds, commonly heard during inspiration when there is fluid in the alveoli; also called rales

polyuria

frequent urination

IX-glossopharyngeal

gag reflex/swallow, taste on back of tongue

VIII-auditory

hearing and balance

Enuresis

involuntary discharge of urine

hematuria is caused by

kidney disease

VI-abducens

lateral eye movement

dorsal flexion

move foot so that toes are pointed upward

Supination

movement that turns the palm up

myopia

nearsightedness; lack of foresight

XII-hypoglossal

positioning of tongue Stick out tongue Move it side to side

Hematuria

presence of blood in the urine

brachial deep tendon reflex

reflex triggered by the crook of arm tap

patellar reflex (knee jerk)

reflex triggered by the knee tap

abnormal curvatures

scoliosis, kyphosis, lordosis

I-olfactory

sense of smell

Braden score

sensory perception, moisture, activity, mobility, nutrition, friction and shear

stridor

strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx

X-vagus

swallowing, movement of vocal cords, sensation of pharynx

pulse deficit

the difference between the rate of an apical pulse and the rate of a radial pulse

Enuresis is caused by

the weakening of the pelvic floor muscles

Pronation

turning the palm downwardf

Eversion

turning the sole of the foot outward

Kussmaul respirations

very deep, labored breathing (usually associated with diabetic acidosis and renal failure)

II-optic

vision

stress incontinence is caused by

weak external sphincter, weak pelvic floor musculature, and secondary effects of smoking and obesity.

stress incontinence

when urine leaks during exercise and certain movements that cause pressure on the bladder

Chest excursion

with thumbs aligned parallel along the spine at the level of the 10th rib, and hand around the client's back, instruct the client to take a deep breath. move your thumbs outward approximately 5 cm when the client takes a deep inspiration

Its important to call the physician about your patients urinary output when

you produces less urine than normal also known as oliguria