Term
| Findings which must be recorded during Head-to-Toe |
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Definition
| Normal AND abnormal findings (all); complete head-to-toe is VERY RARE in practice |
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Term
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Definition
| ADPIE: assess, diagnose, plan, implement, evaluate |
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Term
| Order for giving head-to-toe |
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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 |
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Term
| True or False: Hospitalized patients typically require a daily head-to-toe |
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Definition
| False: first entry, or yearly check-up only; hospitalized pts require a focused exam q8 |
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Term
| Pt presents to ER with abdominal pain, GO! |
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Definition
| Immediate history of pain, and focused abdominal assessment; NO detailed history, NO other assessments |
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Term
| Priority during Head-to-Toe |
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Definition
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Term
| How to determine reason for seeking care |
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Definition
| ask, "What brings you in today?" or the like |
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Term
| key information from family history |
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Definition
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Term
| Documentation of pt report |
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Definition
pt describes X as "Y"
pt denies Z
pt reports drinking A alcoholic beverages qed |
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Term
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Definition
| detailed history per system: systemic approach to gathering subjective information |
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Term
| The last task for pt before donning gown |
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Definition
| Any necessary specimens: urine, fecal, etc. |
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Term
| pt position for initial skin assessment |
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Definition
| seated on exam table, continue throughout H2T |
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Term
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Definition
facial expression: CN VII
TMJ assessment |
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Term
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Definition
Visual Field (Snellen Test): CN II
Optical ROM: CN III, IV, & VI
PERRLA |
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Term
| Tympanic Membrane Assessment |
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Definition
Color: pearly gray
landmarks (reflex, tendon, etc.)
integrity (loose, holes, etc.) |
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Term
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Definition
| stand behind pt whisper command |
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Term
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Definition
| occlude one nostril sniff through the other, repeat with opposite nostril; nurse documents patency |
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Term
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Definition
Gloves (esp. for palpation); penlight; tongue depressor
uvula movement, "Say ah"
gag reflex: CN IX
stick out tongue: CN XII |
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Term
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Definition
Carotid bruit: exhale and hold it, listen with bell
Shrug: cranial nerve XI |
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Term
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Definition
fremitus "99"
breath sounds: side to side (compare)
Tracheal, Bronchovesicular, and Vesicular
Anterior & Posterior |
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Term
| Assessment of the upper extremities (arms) |
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Definition
Active ROM
muscle strength (move against resistance) |
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Term
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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 |
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Term
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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) |
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Term
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Definition
Auscultate: bowel sounds
Palpate: organs are normally non-palpable |
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Term
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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 |
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Term
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Definition
deep tissue reflexes:
bi's, tri's, brachioradialis, popliteal, Achilles, and plantar (0-4+) |
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Term
| Musculoskeletal assessment |
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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 |
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Term
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Definition
Males: testicular health promotion (self-exam)
Females: lithotomy position to examine |
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Term
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Definition
Subjective Data
Objective Data
Assessment
Plan |
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Term
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Definition
| warm and calm; < 3yo: no cuff, and measure head circumference (end of exam for fussy baby) |
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Term
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Definition
Red reflex (opthalmoscope)
Save the worst (ear exam w/ otoscope) for last |
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Term
| Groin/Hip Assessment: neonate |
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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) |
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Term
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Definition
| earliest feces of a neonate, may occlude the anus, but should pass w/in 48 hours |
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Term
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Definition
| Screening tool used to mark milestones of growth of child |
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Term
| Child Abdominal Assessment |
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Definition
| sit child on table or parent's lap with undies/diaper on |
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Term
| expected findings upon transillumination of infantile scrotum |
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Definition
| right hydrocele is more opaque than left hydrocele |
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Term
| True or False: a tongue blade is the tool of choice for mouth assessment of all ages |
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Definition
| False! Children and infants: last resort |
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Term
| Head to Toe Developmental Considerations for school-age, adolescents, and aging adults (one each) |
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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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