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Head To Toe Assessment Exam Questions And Answers
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Head To Toe Assessment Exam Questions And AnswersWhy do nurses assess? ANS most important thing that we do Smallest step in nursing
process Data gathered used to make clinical decisions Directs our interventions
Admission Assessment-ANS health history and physical exam. In depth exam. Many
questions. Used to determine baseline. This is the starting off point
complete health assessment - ANSWER includes nursing history, behavioral and
physical examination. clinical judgments based on all information collected to develop
care plan.
ns focuses on one specific system if problem area identified. ex if severe asthma focus
first on pulmonary and cardiovascular assessment then does full assessment later so
treatment can be initiated immediately.
gloves required for physical exams? - ANSWER yes
if excessive wound drainage use additional PPE
shift assessment - ANSWER is done for a RN twice per shift. does the baseline head to
toe. compares what is on report to new findings. decides what interventions are
important. is the patient doing better?
Focused assessment- patient has a new complaint, such as chest pain, nausea or nurse
needs data about a specific issue. This is looking for a change in a patients status. Has
the patient become confused?
4 examination techniques- inspection
palpation
percussion
auscultation
Inspection- when interacting with patient, watching for verbal and nonverbal
expressions of emotions, mental status, physical movement and comfort.
, important to note what hear, see, smell
detect symmetry, shape, position, size, color. note behavioral, auditory cues, wounds.
findings may indicate further examination
inspection techniques - ANSWER use good lighting
expose body parts only being examined. maintain privacy
validate findings with patient
Symmetry= normalcy
ask patient questions
inspect IV line and insertion in skin. check for redness.
palpation - ANSWER touch
used to test skin temp. moisture, texture, turgor, tenderness, thickness and abdomen
for tenderness, distension or masses
to note whether edema is present
USE PALMAR OF HAND= MORE SENSITIVE: postition, texture, sixe, consistency,
masses, fluid, and crepitus.
tender areas are LAST!
skin temp hand position - ANSWER dorsum of hand and fingers
skin turgor hand position - ANSWER grasp with finger tips
pulse, distension, induration - ANSWER pulmar surface of fingers
induration= hardness, sign of inflammation
palpation key points - ANSWER warm hands, short fingernails
gentle
relaxed, comfortable position
ask for tender areas=last
facial expressions
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