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Exam 2: Head-to-Toe
McCall's Online Lecture
38
Nursing
Graduate
10/07/2013

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Cards

Term
Findings which must be recorded during Head-to-Toe
Definition
Normal AND abnormal findings (all); complete head-to-toe is VERY RARE in practice
Term
Nursing Process
Definition
ADPIE: assess, diagnose, plan, implement, evaluate
Term
Order for giving head-to-toe
Definition
whichever flows best: one body region to another (don't go back and forth); and save the worst for last: genitalia for adults, ears for children
Term
True or False: Hospitalized patients typically require a daily head-to-toe
Definition
False: first entry, or yearly check-up only; hospitalized pts require a focused exam q8
Term
Pt presents to ER with abdominal pain, GO!
Definition
Immediate history of pain, and focused abdominal assessment; NO detailed history, NO other assessments
Term
Priority during Head-to-Toe
Definition
Patient Comfort
Term
How to determine reason for seeking care
Definition
ask, "What brings you in today?" or the like
Term
key information from family history
Definition
Parental health history
Term
Documentation of pt report
Definition
pt describes X as "Y"
pt denies Z
pt reports drinking A alcoholic beverages qed
Term
Review of Systems
Definition
detailed history per system: systemic approach to gathering subjective information
Term
The last task for pt before donning gown
Definition
Any necessary specimens: urine, fecal, etc.
Term
pt position for initial skin assessment
Definition
seated on exam table, continue throughout H2T
Term
Head/Face Assessment
Definition
facial expression: CN VII
TMJ assessment
Term
Eyes
Definition
Visual Field (Snellen Test): CN II
Optical ROM: CN III, IV, & VI
PERRLA
Term
Tympanic Membrane Assessment
Definition
Color: pearly gray
landmarks (reflex, tendon, etc.)
integrity (loose, holes, etc.)
Term
Whisper test
Definition
stand behind pt whisper command
Term
nare patency
Definition
occlude one nostril sniff through the other, repeat with opposite nostril; nurse documents patency
Term
Mouth/Throat Assessment
Definition
Gloves (esp. for palpation); penlight; tongue depressor
uvula movement, "Say ah"
gag reflex: CN IX
stick out tongue: CN XII
Term
Neck
Definition
Carotid bruit: exhale and hold it, listen with bell
Shrug: cranial nerve XI
Term
Chest
Definition
fremitus "99"
breath sounds: side to side (compare)
Tracheal, Bronchovesicular, and Vesicular

Anterior & Posterior
Term
Assessment of the upper extremities (arms)
Definition
Active ROM
muscle strength (move against resistance)
Term
Breast Assessment
Definition
Pt supine (males can remain sitting up)

Inspect for dimpling (hands over head, push on hips, lean forward)

palpate each area including the tail of Spence

Teach self-exam (health promotion); males can get breast cancer too
Term
Heart Assessment
Definition
Feel a thrill

Auscultate: "(Lean forward and) exhale briefly"; A PET Monkey: aortic, pulmonic, Erb's, tricuspid, mitral
Use both diaphragm & bell, use bell for apical pulse (may want them to roll on side)
Term
Abdominal Assessment
Definition
Auscultate: bowel sounds
Palpate: organs are normally non-palpable
Term
Cerebellar function
Definition
pt sits with legs dangling off exam table

Upper ex: finger-to-nose test, "lap slap" (rapid, alternating movement)

Lower ex: run foot down opposite shin
Term
DTR
Definition
deep tissue reflexes:
bi's, tri's, brachioradialis, popliteal, Achilles, and plantar (0-4+)
Term
Musculoskeletal assessment
Definition
pt is standing (check for varicose veins then)
ask to walk, check gait
Romberg's sign: stand, eyes closed (no swaying is good)
Scoliosis, "bend down and touch toes" spine should be midline
Term
Genitalia Assessment
Definition
Males: testicular health promotion (self-exam)
Females: lithotomy position to examine
Term
SOAP
Definition
Subjective Data
Objective Data
Assessment
Plan
Term
Neonate Notes
Definition
warm and calm; < 3yo: no cuff, and measure head circumference (end of exam for fussy baby)
Term
infant H2T: Eyes & Ears
Definition
Red reflex (opthalmoscope)

Save the worst (ear exam w/ otoscope) for last
Term
Groin/Hip Assessment: neonate
Definition
Ortolani Sign: lift head of femurs up, if dislocated, will be reduced, feels like a "Clunk"

urethral meatus position assessment: if uncircumcised, do not retract foreskin first (position of foreskin must simultaneously be assessed)
Term
Meconium
Definition
earliest feces of a neonate, may occlude the anus, but should pass w/in 48 hours
Term
Denver II
Definition
Screening tool used to mark milestones of growth of child
Term
Child Abdominal Assessment
Definition
sit child on table or parent's lap with undies/diaper on
Term
expected findings upon transillumination of infantile scrotum
Definition
right hydrocele is more opaque than left hydrocele
Term
True or False: a tongue blade is the tool of choice for mouth assessment of all ages
Definition
False! Children and infants: last resort
Term
Head to Toe Developmental Considerations for school-age, adolescents, and aging adults (one each)
Definition
School-Age: educate them, it will make their experience more familiar

Adolescent: puberty, also: self-consciousness (be extra-careful when describing abnormalities)

Aging: ADLs
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