Head-to-Toe Assessment How are bowel sounds graded? - ANSWER-Listen for 5-10 seconds minimum in each spot. Hyperactive bowel sounds are almost constant. Normoactive has a regular "rhythm" of sounds. Hypoactive are rare and few. Absent bowel

Head-to-Toe Assessment How are bowel sounds graded? - ANSWER-Listen for 5-10 seconds minimum in each spot. Hyperactive bowel sounds are almost constant. Normoactive has a regular "rhythm" of sounds. Hypoactive are rare and few. Absent bowel sounds are diagnosed after auscultating for 4 minutes. How are pulses rated? - ANSWER-On a scale of 1 to 4. 1 being weak and 4 being bounding. 2+ is normal. How do you check for pretibial edema? - ANSWER-Press and hold gently on the shins for 5 seconds. Release and observe for pitting. How do you document a patient's mental status? - ANSWER-MS: "Patient alert and oriented x3" or "Patient alert and oriented to person, place, and time." How do you document normal and slow capillary refill? - ANSWER-Normal: "cap refill <3 sec" Slow: "Prolonged/delayed cap refill >3" How do you document normal findings for skin & nails assessment? - ANSWER-Skin/Nails: "Skin pink (or other), warm, dry with no jaundice, pallor, cyanosis and no lesions noted. Skin turgor brisk < 2 sec under right clavicle." How do you rate strength? - ANSWER-Hand grip and plantar flexion are rated on a scale of 1 to 5 with 5 being normal and strong. How is capillary refill measured or graded? - ANSWER-Normal capillary refill is < 3 seconds. (less than 3) Delayed or prolonged capillary refill is >3 seconds. (greater than 3) How is skin turgor graded? - ANSWER-Normal skin turgor is called "brisk" and measured as <2 seconds (less than 2). Prolonged or delayed skin turgor is called prolonged tinting. Turgor tested by pinching the skin under the right clavicle. How many sites are there to auscultate for the heart assessment? What are the names and what are you hearing? - ANSWER-5 sites. Listen to all sites with bell and diaphragm. Aortic, Pulmonic, Tricuspid, Erb's Point, Mitral, Apical. How would you document normal findings for the abdomen? - ANSWER-Abd: "Symmetrical and flat with no peristalsis or pulsations, normoactive bowel sounds present in all 4 quadrants. No guarding, tenderness or masses with light palpation. No guarding, tenderness, masses or organomegaly with deep palpation." How would you document normal findings for the ears? - ANSWER-Ears: "Tympanic membranes pearly gray with light reflex bilaterally." How would you document normal findings for the heart portion of the exam? - ANSWER-Heart: "No heaves or lifts, apical rate 80 and regular, S1 and S2 noted at aortic, pulmonic, Erb's point, tricuspid and mitral area, with no extra heart sounds or murmurs." How would you document normal findings for the lungs/thorax portion of the exam? - ANSWER-Lungs: "Thorax symmetrical bilaterally with AP<T. Breath sounds clear in all lung fields with no adventitious sounds wheezes, rales, and rhonchi." How would you document normal findings for the musculoskeletal portion of the exam? - ANSWER-MSK: "Spine with no lordosis, kyphosis, or scoliosis. No tenderness bilaterally. Hand grip 5/5 bilaterally. Plantar flexion 5/5 bilaterally." What are you assessing for skin & nails? - ANSWER-Skin: temp; color; moisture; lesions; turgor; presence/absence of jaundice, pallor, or cyanosis. Nails: capillary refill, smoothness/quality What are you looking for and how would you document your findings for normal mucous membranes? - ANSWER-Looking for color, moisture, presence/absence of lesions. MM: "Oral mucosa pink, moist without lesions." How are bowel sounds graded? - ANSWER-Listen for 5-10 seconds minimum in each spot. Hyperactive bowel sounds are almost constant. Normoactive has a regular "rhythm" of sounds. Hypoactive are rare and few. Absent bowel sounds are diagnosed after auscultating for 4 minutes. How are pulses rated? - ANSWER-On a scale of 1 to 4. 1 being weak and 4 being bounding. 2+ is normal. How do you check for pretibial edema? - ANSWER-Press and hold gently on the shins for 5 seconds. Release and observe for pitting. How do you document a patient's mental status? - ANSWER-MS: "Patient alert and oriented x3" or "Patient alert and oriented to person, place, and time." How do you document normal and slow capillary refill? - ANSWER-Normal: "cap refill <3 sec" Slow: "Prolonged/delayed cap refill >3" How do you document normal findings for skin & nails assessment? - ANSWER-Skin/Nails: "Skin pink (or other), warm, dry with no jaundice, pallor, cyanosis and no lesions noted. Skin turgor brisk < 2 sec under right clavicle." How do you rate strength? - ANSWER-Hand grip and plantar flexion are rated on a scale of 1 to 5 with 5 being normal and strong. How is capillary refill measured or graded? - ANSWER-Normal capillary refill is < 3 seconds. (less than 3) Delayed or prolonged capillary refill is >3 seconds. (greater than 3) How is skin turgor graded? - ANSWER-Normal skin turgor is called "brisk" and measured as <2 seconds (less than 2). Prolonged or delayed skin turgor is called prolonged tinting. Turgor tested by pinching the skin under the right clavicle. How many sites are there to auscultate for the heart assessment? What are the names and what are you hearing? - ANSWER-5 sites. Listen to all sites with bell and diaphragm. Aortic, Pulmonic, Tricuspid, Erb's Point, Mitral, Apical. How would you document normal findings for the abdomen? - ANSWER-Abd: "Symmetrical and flat with no peristalsis or pulsations, normoactive bowel sounds present in all 4 quadrants. No guarding, tenderness or masses with light palpation. No guarding, tenderness, masses or organomegaly with deep palpation." How would you document normal findings for the ears? - ANSWER-Ears: "Tympanic membranes pearly gray with light reflex bilaterally." How would you document normal findings for the heart portion of the exam? - ANSWER-Heart: "No heaves or lifts, apical rate 80 and regular, S1 and S2 noted at aortic, pulmonic, Erb's point, tricuspid and mitral area, with no extra heart sounds or murmurs." How would you document normal findings for the lungs/thorax portion of the exam? - ANSWER-Lungs: "Thorax symmetrical bilaterally with AP<T. Breath sounds clear in all lung fields with no adventitious sounds wheezes, rales, and rhonchi." How would you document normal findings for the musculoskeletal portion of the exam? - ANSWER-MSK: "Spine with no lordosis, kyphosis, or scoliosis. No tenderness bilaterally. Hand grip 5/5 bilaterally. Plantar flexion 5/5 bilaterally." What are you assessing for skin & nails? - ANSWER-Skin: temp; color; moisture; lesions; turgor; presence/absence of jaundice, pallor, or cyanosis. Nails: capillary refill, smoothness/quality What are you looking for and how would you document your findings for normal mucous membranes? - ANSWER-Looking for color, moisture, presence/absence of lesions. MM: "Oral mucosa pink, moist without lesions."