Head-to-Toe
When listening to the 5 heart sounds...What specifically are you listening to...
A2, P2, Erbs Point, T1, M1
I find "critters in my patients hair...
Calm the patient and let them know you will take care of the situation and
Put on PPE (Gown, hairnet, foot covers, and gloves)
Neurological-Sensory Assessment measured with fingers. One to two points
Discrimination
The word used to describe the comparison of left and right such as in auscultating lung sounds.
Symmetry
Trigeminal
5th Cranial nerve
Sensory: Cotton ball to face
Motor: Clench Jaw or Bite Tongue depressor
If I hear coarse sounds in the bases of the lungs it could be...what...
Pleural rub as rhonchi do not occur in the bases.
No BM for 3 days
Is this normal for the patient?
Abdominal Assessment following Inspection, Auscultation, and light palpation
Deep palpation
The order of Assessment
Inspection
Palpation
Percussion
Auscultation
except in Abdominal when you Auscultate prior to palpation
Vagus
10th
Sensation in the throat
"AH" Vocal cords
What is the reason for calling a Head to Toe Assessment a Head to Toe Assessment?
To keep it Systematic and help you remember what you are doing
Patient asks a question you don't know the answer to
State, " I don't know but I can find out."
An accurate neurological sensory assessment can not be determined if you do not ask about these 2 things...
Numbness and Tingling
Measuring JVD
Bed at 30-45 degree
Head turn to the Left
Highest point of pulsation
Measure straight up from the sternal notch to the horizontal stick
Oculomotor
3rd
Pupil dilation and movement of the eyes
These are the two tests that assess for meningitis
Brudzinski's Sign and Kernig's Sign
JVD >3 CM
Sign of Heart Failure. Document and notify the provider
Before assessing the Cranial Nerve I ... ensure you assess this first or it won't do any good.
patency of nostrils and the ability to smell
Why do we auscultate before palpation in the abdominal assessment?
Palpation may stimulate peristalsis
Abducens
6th
Lateral eye movements
Of the 5 safety final elements...What is missing?
Hand Hygiene
Side Rails x2
Call Light
Bed Low and Locked
and ________________
Bed Alarm if necessary
Patient has COPD and is a smoker. You are offering health promotion on smoking cessation and the patient states they do not want to stop smoking.
Indicate you understand their right to NOT cease smoking but you would like to let them know of the options available for the future should they choose to want cessation information.
Cardiovascular Assessment 5-6 intercostal space and along the sternal border you feel for a gentle tapping on your hand...
Point of Maximal Impulse or PMI
Complains of abdominal pain...
PQRST
Hypoglossal
12th
Tongue movements and strength
Speech- Light, Night, Tight, Dynamite