October 3, 2024

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Head to Toe Assessment

jaswantkaurm@gmail.com517 mins

Comprehensive Head 2 Toe Assessment

Central Nervous System

Newborn

Pediatric

Adult

  • Fontanelles are soft, not depressed or bulging.
  • Normal newborn reflexes are present.
  • Cry is normal.
  • Infant is alert when awake.
  • No seizure-like activity.
  • No jitteriness; normal muscle tone.
 
 
 
 
 
  • Behavior is appropriate for age and development.
  • Awake, alert, and oriented to person, place, and time.
  • GCS is normal.
  • Fontanelles are normotensive at rest and upright.
 
 
 
 
 
 
  • Awake, alert, and oriented to person, place, and time.
  • Follows commands, has clear speech, and bilateral hand grasps are equal.
  • Able to verbalize understanding of current health state.
  • Maintains eye contact.
  • Communicates thought processes effectively.
  • Behavior is appropriate for age and development.
 

Cardiovascular

Newborn

Pediatric

Adult

  • Regular heart rate: 80-160 bpm.
  • BP mean: ≥ 36 mmHg.
  • Oxygen saturation: ≥ 92%.
  • Color appropriate for gestational age.
  • Central capillary refill: < 3 seconds.
  • No murmur.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  • Heart rate within normal range:
    • 1 mo – 1 yr: 90-160 bpm
    • 1-5 yr: 80-140 bpm
    • 6-10 yr: 60-110 bpm
    • 10+ yr: 60-100 bpm
  • Regular pulse.
  • No murmur or abnormal heart sounds.
  • Capillary refill < 2 seconds.
  • Skin warm and dry; color within normal limits (no pallor, mottling, dusky, cyanotic).
  • Blood pressure within normal range:
    • 0-1 mo: SBP > 60
    • 1 mo – 1 yr: SBP > 70
    • 1-10 yr: SBP > 70 + (age in years)
    • 10+ yr: SBP > 90
  • Regular apical rate between 60-100 bpm.
  • Skin warm and dry.
  • Normal color (no pallor, mottling, dusky, cyanotic).
  • Mucous membranes are pink and moist.
  • Capillary refill within 3 seconds.
  • Radial, dorsalis pedis, and posterior tibial pulses are regular and equally palpable.
  • No calf tenderness, warmth, or redness.
  • No extremity edema.
 
 
 
 
 
 
 
 

Respiratory

Newborn

Pediatric

Adult

  • No abnormal chest sounds.
  • Normal chest shape.
  • Symmetric chest rise and fall.
  • Airway patent.
  • Equal and bilateral air entry.
  • No evidence of increased work of breathing.
  • No adventitious breath sounds.
  • Respiratory rate: 30-60/min.
  • No apnea.
  • Infants are obligate nose breathers and use abdominal muscles for breathing.





 
 
 
  • Breathing pattern regular; rate as expected for age:
    • 1 mo – 1 yr: 25-45 bpm
    • 1-5 yr: 20-30 bpm
    • 6-10 yr: 16-24 bpm
    • 10+ yr: 14-20 bpm
  • Depth, rhythm, quality, and character as expected for age.
  • Symmetrical movement with each breath.
  • No intercostal retraction or nasal flaring.
  • No shortness of breath at rest or on exertion.
  • Breath sounds normal; no adventitious sounds or evidence of increased work of breathing.
  • Absence of cough and sputum production.
  • Able to clear airway secretions.
  • Able to eat and drink without shortness of breath.
  • Respirations regular in rate (12-20/min), depth, and rhythm.
  • Symmetrical movement of chest, absence of retraction in intercostal spaces.
  • No shortness of breath at rest or on exertion.
  • Breath sounds are normal, audibly clear with no adventitious sounds.
  • Absence of cough and sputum production.
  • Able to clear airway of secretions.
  • Oxygen saturation level normal (> 92% on room air).
 
 
 
 
 
 
 
 

Gastrointestinal

Newborn

Pediatric

Adult

  • Ability to tolerate feedings well.
  • No evidence of regurgitation or reflux symptoms.
  • Abdomen is soft, non-tender, and non-distended.
  • Bowel sounds present.
  • Bowel movements and patterns are normal.
 
 
 
 
 
 
 
  • Ability to tolerate diet.
  • No evidence of nausea, vomiting, or other digestive symptoms.
  • Abdomen is soft, non-tender, and non-distended.
  • Protuberant abdomen absent by age 2-3 years.
  • Bowel sounds present in all quadrants.
  • Bowel movements are normal for the patient’s usual pattern.
  • No assistance with delivery of nutrition or aids required (NG, G, GJ, J tubes, TPN).
  • Ability to tolerate diet.
  • No evidence of nausea, vomiting, or other digestive symptoms.
  • Abdomen is soft, non-tender, and non-distended.
  • Bowel sounds present in all quadrants.
  • No assistance with delivery of nutrition or aids required (NG, G, GJ, J tubes, TPN).
  • Bowel movements are normal for the patient’s usual pattern.
 
 

Genitourinary

Newborn

Pediatric

Adult

  • Appropriate bladder and renal function.
  • Urine is clear and yellow to amber.
  • Six or more wet diapers per day.
  • Urine output: 2-6 ml/kg/h.
  • No catheter present.
  • No inguinal hernia felt.
  • Testes are in the scrotum.
  • No genital swelling or bruising.
 
 
 
 
 
  • Urine output: minimum 1 ml/kg/h.
  • Normal bladder and renal function.
  • Urine is clear and yellow to amber.
  • No dysuria, discharge, or bleeding.
  • No catheterization required.
  • No incontinence or nocturia (if toilet-trained).
  • No genital swelling or bruising.
  • Genitalia structures are appropriate for gestational age.
  • Appropriate renal and bladder function.
  • Urine is clear and pale yellow/straw-colored.
  • Voiding without pain, dysuria, frequency, enuresis, urgency, hematuria, incontinence, nocturia, polyuria, anuria, or oliguria.
  • No indwelling catheters present; patient does not self-catheterize.
 
 
 
 

Musculoskeletal

Newborn

Pediatric

Adult

  • No known structural abnormalities.
  • Ability to move all joints and extremities without limitation.
  • Symmetrical movements.
  • Limbs held in a flexed position with some resistance to active extensions.
 
 
 
 
 
  • Ability to move all joints and extremities without limitation.
  • Meeting developmental milestones for tone and movement (age-appropriate).
  • Monitoring growth as per appropriate growth chart (e.g., maintaining the 50th percentile on a normal growth chart for age).
  • Symmetry with no structural abnormalities (e.g., scoliosis).
  • Ability to move all joints and extremities without limitation.
  • Ability to ambulate with steady balance and a purposeful gait that is smooth, coordinated, easy, and rhythmic, with proper push-off and swing-through.
 
 
 
 
 

Integumentary

Newborn

Pediatric

Adult

  • Skin color within normal range for gestational age.
  • Skin is warm, dry, and intact, without surface irritation, rash, bruises, or visible/palpable abnormalities.
  • Growth, pigmentation, and location of hair are appropriate for culture/race or infant.
  • Normal skin turgor.
 
  • Skin color within the patient’s normal range.
  • Skin is warm, dry, and intact, without surface irritation or visible/palpable deformities.
  • Growth, pigmentation, and location of hair are appropriate for the individual.
  • No open areas.
  • Normal skin turgor.
  • Skin color within the patient’s normal range.
  • Skin is warm, dry, and intact, without visible or palpable deformities.
  • Growth, pigmentation, and location of hair are appropriate for the individual.
  • No open areas.
 
 
 

Comprehensive Head 2 Toe Assessment

Physical Assessment

Integumentary

Comprehensive Head 2 toe assessment for Integumentary

Skin: The client’s skin is uniform in color, unblemished, and free of any foul odor. Skin turgor is good, and the skin’s temperature is within normal limits.

Hair: The client’s hair is thick and silky, evenly distributed, and has a variable amount of body hair. No signs of infection or infestation are observed.

Nails: The client’s nails are light brown with a convex curve. They are smooth and intact with the epidermis. During the blanch test, the nails return to their usual color in less than 4 seconds.

Head

Comprehensive Head 2 toe assessment for Head

Head: The client’s head is rounded, normocephalic, and symmetrical.

Skull: No nodules, masses, or depressions are noted upon palpation.

Face: The client’s face appears smooth and has a uniform consistency, with no nodules or masses present.

Eyes and Vision

Comprehensive Head 2 toe assessment for Eyes and Vision

Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and show equal movement when asked to raise and lower them.

Eyelashes: Eyelashes are equally distributed and curled slightly outward.

Eyelids: No discharge or discoloration; lids close symmetrically with involuntary blinks approximately 15-20 times per minute.

Bulbar Conjunctiva: Transparent with a few capillaries evident.

Sclera: Appears white.

Palpebral Conjunctiva: Shiny, smooth, and pink.

Lacrimal Gland: No edema or tearing.

Cornea: Transparent, smooth, and shiny, with visible details of the iris. The client blinks when the cornea is touched.

Pupils: Black, equal in size, and with a flat, round iris. PERRLA (Pupils Equally Round and React to Light and Accommodation): Pupils constrict in response to light and accommodation, constrict when focusing on a near object, and dilate when focusing on a distant object. Pupils converge when an object is moved toward the nose.

Peripheral Visual Field: The client can see objects in the periphery while looking straight ahead.

Extraocular Muscle Function: Both eyes move in unison with parallel alignment.

Visual Acuity: The client was able to read newsprint held at a distance of 14 inches.

Comprehensive Head 2 Toe Assessment

Ears and Hearing

Comprehensive Head 2 toe assessment for Ears and Hearing

Ears: The auricles are symmetrical and match the color of the facial skin. They are aligned with the outer canthus of the eyes. Upon palpation, the auricles are mobile, firm, and non-tender. The pinna recoils when folded. During the Watch Tick Test, the client was able to hear the ticking in both ears.

Nose and Sinus

Comprehensive Head 2 toe assessment for Neck

Nose: The nose is symmetrical, straight, and uniform in color. There is no discharge or flaring. Upon light palpation, there is no tenderness or presence of lesions.

Neck

Comprehensive Head 2 toe assessment for Neck

  • The neck muscles are equal in size.
  • The client shows coordinated, smooth head movement with no discomfort.
  • Lymph nodes are not palpable.
  • The trachea is positioned in the midline of the neck.
  • The thyroid gland is not visible upon inspection; it ascends during swallowing but remains invisible.

Mouth

Comprehensive Head 2 toe assessment for Mouth

  • Lips: The lips are uniformly pink, moist, symmetric, and have a smooth texture. The client was able to purse his lips when asked to whistle.

  • Teeth and Gums: No discoloration of the enamel, no gum retraction, and the gums are pink in color.

  • Buccal Mucosa: Appears uniformly pink, moist, soft, glistening, and elastic.

  • Tongue: Centrally positioned, pink, moist, slightly rough, with a thin whitish coating.

  • Palates: The soft palate is light pink and smooth, while the hard palate has a more irregular texture.

  • Uvula: Positioned in the midline of the soft palate.

Thorax, Lungs, and Abdomen

Comprehensive Head 2 toe assessment for Thorax , Lungs, and Abdomen

  • Lungs / Chest: The chest wall is intact with no tenderness or masses. There is full and symmetric expansion, with the thumbs separating 2-3 cm during deep inspiration when assessing respiratory excursion. The client exhibits quiet, rhythmic, and effortless respirations.

  • Spine: Vertically aligned. The right and left shoulders and hips are at the same height.

  • Heart: No visible pulsations in the aortic and pulmonic areas. No presence of heaves or lifts.

  • Abdomen: The abdomen has unblemished skin and is uniform in color with a symmetric contour. Symmetric movements are noted with respiration. The jugular veins are not visible.

  • Nails: During the blanch test, nails return to their usual color in less than 4 seconds.

Extremities

Comprehensive Head 2 toe assessment for Extrimities

  • Extremities: Symmetrical in size and length.

  • Muscles: Not palpable with no tremors. Normally firm and exhibit smooth, coordinated movements.

  • Bones: No deformities, tenderness, or swelling observed.

  • Joints: No swelling or tenderness; joints move smoothly.

Comprehensive Head 2 toe assessment

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Comprehensive Head 2 Toe Assessment

Comprehensive Head 2 toe assessment

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ABG Analysis

ABG Analysis

Mastering ABG analysis is essential for nursing practice and success on the NCLEX. Each question in this set emphasizes key concepts, including the identification of acid-base imbalances, physiological responses, and their implications for patient care. A strong grasp of these principles will enhance your ability to assess and respond effectively to patients' needs in various clinical situations.

The number of attempts remaining is 5

1 / 50

What is a common cause of metabolic acidosis?

2 / 50

A patient with renal failure presents with ABG results: pH 7.32, PaCO2 42 mmHg, HCO3- 16 mEq/L. What does this indicate?

3 / 50

Which of the following can lead to metabolic alkalosis?

4 / 50

If a patient’s ABG shows a pH of 7.28, what should the nurse suspect?

5 / 50

A nurse is reviewing ABG results: pH 7.35, PaCO2 50 mmHg, HCO3- 25 mEq/L. Which condition is most likely?

6 / 50

A patient is experiencing respiratory distress and has an ABG result of pH 7.32, PaCO2 52 mmHg, HCO3- 24 mEq/L. What does this indicate?

7 / 50

In a patient with respiratory acidosis, what is the expected change in the kidneys?

8 / 50

A patient is hypoventilating after a drug overdose. What would their ABG likely show?

9 / 50

A patient presents with tachypnea and lightheadedness. Which ABG finding would be expected?

10 / 50

A patient presents with confusion and lethargy. ABG analysis reveals pH 7.34, PaCO2 55 mmHg, HCO3- 26 mEq/L. Which of the following interventions is the priority?

11 / 50

The nurse is interpreting ABG results: pH 7.50, PaCO2 30 mmHg, HCO3- 24 mEq/L. What condition is indicated?

12 / 50

The nurse is caring for a patient with COPD. Which ABG result would indicate respiratory acidosis?

13 / 50

A patient with renal failure shows ABG results of pH 7.25, PaCO2 40 mmHg, HCO3- 16 mEq/L. This indicates:

14 / 50

A nurse is assessing a patient with potential metabolic acidosis. Which sign would be most indicative?

15 / 50

A patient is hyperventilating due to anxiety. What would you expect their ABG results to show?

16 / 50

In which condition would you expect to see a decreased HCO3- level?

17 / 50

A patient presents with confusion and fatigue. Their ABG results show: pH 7.28, PaCO2 58 mmHg, HCO3- 22 mEq/L. What condition do these findings suggest?

18 / 50

What is the normal range for arterial blood pH?

19 / 50

Which of the following scenarios would likely lead to respiratory alkalosis?

20 / 50

ABG results show: pH 7.47, PaCO2 38 mmHg, HCO3- 29 mEq/L. The nurse should assess for which of the following?

21 / 50

Which of the following ABG results would indicate metabolic acidosis?

22 / 50

ABG results show: pH 7.38, PaCO2 48 mmHg, HCO3- 26 mEq/L. This indicates which type of compensation?

23 / 50

A patient with diabetes presents with a fruity odor on their breath. ABG results show: pH 7.25, PaCO2 40 mmHg, HCO3- 15 mEq/L. What condition is this indicative of?

24 / 50

A patient presents with tachycardia and muscle cramps. ABG analysis shows: pH 7.50, PaCO2 38 mmHg, HCO3- 30 mEq/L. What should the nurse assess for?

25 / 50

ABG results show: pH 7.45, PaCO2 35 mmHg, HCO3- 21 mEq/L. What is the interpretation?

26 / 50

A patient has the following ABG results: pH 7.30, PaCO2 50 mmHg, HCO3- 24 mEq/L. What is the primary acid-base disturbance?

27 / 50

ABG results show: pH 7.48, PaCO2 42 mmHg, HCO3- 30 mEq/L. What does this indicate?

28 / 50

Which patient condition would most likely cause metabolic alkalosis?

29 / 50

A patient with chronic kidney disease shows signs of acidosis. What ABG change would be expected?

30 / 50

A patient has a pH of 7.39, PaCO2 of 52 mmHg, and HCO3- of 28 mEq/L. This patient is likely experiencing:

31 / 50

ABG results show: pH 7.40, PaCO2 32 mmHg, HCO3- 19 mEq/L. Which acid-base balance does this indicate?

32 / 50

A patient has a pH of 7.30, PaCO2 30 mmHg, HCO3- 18 mEq/L. What is the most likely diagnosis?

33 / 50

A patient’s ABG shows: pH 7.45, PaCO2 48 mmHg, HCO3- 36 mEq/L. What condition does this most likely indicate?

34 / 50

A patient with chronic respiratory acidosis may develop:

35 / 50

A patient with an acute asthma attack is likely to have which of the following ABG results?

36 / 50

A nurse notices a patient has rapid, shallow breathing. The patient’s ABG shows: pH 7.45, PaCO2 30 mmHg, HCO3- 22 mEq/L. What is the likely diagnosis?

37 / 50

A patient presents with a high HCO3- level and a pH of 7.50. What could this indicate?

38 / 50

In a patient with a suspected pulmonary embolism, what ABG changes might you expect?

39 / 50

A patient with chronic kidney disease has a pH of 7.35 and HCO3- of 18 mEq/L. What is the likely diagnosis?

40 / 50

A patient’s ABG indicates a pH of 7.50, what should the nurse suspect?

41 / 50

A patient has a pH of 7.39, PaCO2 of 52 mmHg, and HCO3- of 28 mEq/L. This patient is likely experiencing:

42 / 50

A patient with severe dehydration would likely exhibit which of the following ABG results?

43 / 50

A patient with a history of excessive alcohol consumption presents with ABG results: pH 7.30, PaCO2 40 mmHg, HCO3- 15 mEq/L. What is the likely diagnosis?

44 / 50

Which of the following ABG values would indicate respiratory alkalosis?

45 / 50

A nurse reviews an ABG report: pH 7.35, PaCO2 55 mmHg, HCO3- 22 mEq/L. Which nursing diagnosis is appropriate?

46 / 50

A patient with a history of COPD is experiencing respiratory acidosis. Which intervention is most appropriate?

47 / 50

A patient with diabetic ketoacidosis has the following ABG results: pH 7.25, PaCO2 30 mmHg, HCO3- 15 mEq/L. What is the primary acid-base imbalance?

48 / 50

A patient in renal failure presents with pH 7.30 and HCO3- 15 mEq/L. What is the expected respiratory response?

49 / 50

If a patient is experiencing metabolic acidosis, what would you expect the respiratory compensation to be?

50 / 50

If a patient is experiencing metabolic alkalosis, which ABG result might be expected?

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