Head to toe assessment
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Head to toe assessment - Details
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94 questions
| 🇬🇧 | 🇬🇧 |
| Right upper quadrant | Pylorus, duodenum, liver, right kidney and adrenal, hepatic colon, head of pancreas, |
| Left upper quadrant | Stomach, spleen, left kidney and adrenal, body of pancreas, splenic colon |
| Right lower quadrant | Cecum, appendix, right ureter and lower kidney pole, right reproductive structures |
| Left lower quadrant | Sigmoid colon, left ureter and kidney part, left reproductive organs |
| Pyrexia | An increase above normal body temp |
| Least reliable temperature site | Axillary |
| Grating sound caused by inflamed pleura rubbing against chest wall | Pleural friction rub |
| Noisy strenuous respirations | Sertorous breathing |
| Percussion of the abdomen | Tympanic |
| Percussion of hyperinflated lung tissue | Hyperresonant |
| Percussion of normal lung tissue | Resonant |
| Helps prevent the legs from turning outward | Trochanter rolls/ devices |
| Used to reduce pressure and restore skin intergrity | Mattress overlays |
| Fever of 100.4 and above | Pyrexia |
| Normal Core body temp | 97.0-99.5 F or 36-37.5 C |
| Fatal core temperature | Above 108 F or below 93.2 |
| Remitent fever | Several degrees above normal and returns to normal or near normal |
| Intermittent fever | Frequent cycles between normal or subnormal temps and spikes of fever |
| Pulse rhythm | Apical radial pulse |
| Relapsing fever | Fever that returns after a day or so of being absent |
| Trans fats increase the risk for | Coronary heart disease |
| Eat fish, but no other animal meat | Pescatarians |
| Enhances iron absorption | Vitamin C |
| Helps determine muscle mass | Mid-arm circumference |
| Estimates subcutaneous fat | Triceps skin fold measurement (multiply by .314) |
| Indirectly measures fatty tissue of the abdominal viscera | Abdominal circumference |
| Measurements pertaining to body size and composition | Anthropometric data |
| Optimal total cholesterol level | Less than 200 mg/dl |
| Optimal ldl level | Less than 100 mg/dl |
| Optimal hdl level | Less than 60 mg/dl |
| Optimal triglyceride level | Less than 150 mg/dl |
| How to calculate cardiac risk | Divide total cholesterol by hdl level. Should be less than 6 |
| Water soluble vitamins (eliminated with urine) | B complex and C |
| Iron products | Liver, oysters, clams, egg yolks, soybeans, tofu, red meat, swiss chard, spinach |
| Potassium products | Bananas, oranges, potatoes |
| Magnesium products | Protein, milk, and meat |
| Zinc products | Seafood, liver |
| Lab tests that measure protein levels | Serum albumin, transferrin levels, glucose |
| General nutritional assessments (lab) | Hemoglobin, hematocrit |
| Obesity | BMI equal to or greater than 30 or triceps skinfold greater than 15 mm |
| Anorexia | 20-25% weight loss from previously stable state |
| Daily servings | 2 cups fruit; 2.5 cups veggies; 6 ounces grains; 5.5 ounces proteins; 3 cups low fat milk products |
| Emaciation | BMI less than 16 |
| DV of cholesterol for 2,000 cals | Less than 300 mg |
| LCTA | Lungs Clear to Auscultation |
| Inspect for.... | Size, shape, color, position, symmetry, abnormality |
| Hair distribution or lack of it can assess | Vascularity |
| PMI | Point of maximal impulse |
| Abdomen assessment | Inspect, auscaltate, palpate |
| Bowel sound frequency | 5-10 per minute/ more is hyperactive, less is hypoactive, none is absent (must listen for 2 minutes if none) |
| Neuro assessment | LOC, Awake/Alert/Oriented x3-4, PERRLA, mucus membranes, hand grips |
| Chest assessment | Heart and lung sounds, peripheral pulses, cap refill |
| Trends in health care | Active consumers, nursing shortage, increasing complexity of care, technology increase, increasing costs |
| Nursing roles in healthcare | Collect data, diagnose human response, plan and provide care, evaluate outcomes, education |
| Capitation | A preset fee per member is paid to a provider or hospital system regardless of whether the member requires services. |
| Networks that provide a full range of health services in a coordinated and cost effective manner, reduces duplication of services | Integrated delivery system |
| Most accurate sites for core body temps | Brain, esophagus, bladder, heart |
| Measures temp of heart, esophagus and bladder (brain read has not yet been developed) | Thermistor catheter |
| Mildly hypothermic | 95-93.2 F (35-34 C) |
| Moderately hypothermic | 93-86 (33.8-30 degrees celcius) |
| Severely hypothermic | Below 86 or 30 degrees celsius |
| Applying tepid water to a skin as in a sponge bath helps with...... | Heat loss via convection and evaporation and helps alter set point of hypothalamus following antipyretics |
| Applying a cooling pad beneath the patient helps with heat loss via.... | Conduction as blood circulates through the skin |
| Decreasing layers of insulated fabric facilitates heat loss via.... | Radiation and convection |
| Disperses boody heat via air currents | Convection, such with the use of room ventilation (electric or mechanical fannining) |
| Cooling the skin lowers temp by | Conduction as warmer blood flows near the skin |
| Providing fluids during hyperthermia replaces fluid loss from... | Perspiration and increased metabolism |
| Graphic vital sign records provide | Large amounts of promptly documented vital signs |
| Pyrexia | 100.4 F or 38 C |
| 100.4 F | 38 C |
| Farenheight = | (9/5 C X degree celcius) + 32 |
| Celsius = | 5/9 ( F-32) |
| 37.5 C = | 99.5 F |
| 34 C = | 93.2 F |
| 41 C = | 105.8 F |
| 43 C = | 109.4 F |
| 36 C = | 97.0 |
| Transfer of heat to another object | Conduction |
| Heat by motion between areas of unequal density such as when a fan blows cool air across a warm body | Convection |
| Temps above 105.8 (41 C) and below 93.2 (34 C) indicate | Impairment of hypothalmus regulation |