CHSP Trends In Healthcare



CHSP- Abbreviated Head-to-Toe patient assessmentSource: and respond to questions or define key terms in bold as you go!1) The sequence for performing a head-to-toe assessment is:InspectionPalpationPercussionAuscultation(define each term above in your own words) 2) The general sequence for head-to-toe assessment changes for abdominal complaints. Why?3) After confirming patient ID, gaining a CC and consent, what information is collected first in the Head-to-Toe assessment?4) Key questions or data you should be gathering should include these indicators of acute health impairment. For each question- indicate the system or pathology we’re concerned about.Looking at the overall appearance of your patient: do they look their age, are they alert and able to answer your questions promptly or is there a delay?Does their skin color match their ethnicity; does the skin appear dry or sweaty?Is their speech clear (not slurred)?Do they easily get out of breath while talking to you (coughing etc.)?Any noted abnormalities?How is their emotion status (calm, agitated, stressed, crying, flat affect, drowsy)?Can they hear you well (or do you have to repeat questions a lot)?Normal posture?388620059055BMI Assessed height and weight. BMI stands for: ___________________________________Record the BMI ranges for underweight-obese ptsCritical thoughts- how might BMI indexes be biased measurements for some patients. (think body composition)Head:Inspect the face and hair:How do you check the temporomandibular joint? What do you check for?Palpate the frontal and maxillary sinuses for tenderness:?patient will?pressure but should not feel pain32004009525Eyes:Inspect the eyes, eye lids, pupils, sclera, and conjunctivaIs there swelling of the eye lids?Is the sclera white and shiny?…not yellow as in jaundiceIs the conjunctiva pink NOT red and swollen?Look for Strabismus and Aniscoria:Strabismus: Aniscoria: Are the pupils clear…not cloudy?Normal pupil size should be 3 to 5 mm and equal Reactive to light?Pulillary response – Use penlight.Shine the light in from the side in each eye. Note the pupil response.What is normal pupil response?Accommodation:What is accommodation? What is it testing?What does the acronymn PERRLA mean?0739140Heart Sounds: Auscultate heart sounds at 5 locations,?specifically valve locations:MAP the 5 locations to listen to heart sounds on the diagram below. Place a star or lable line shoving where you auscultate Apical Pulse3657600102235Lung Sounds:If you would like to hear some abnormal lung sounds, please watch our video called “abnormal lung sounds”.What do normal lungs sounds sound like to you over the lungs verses the bronchi and trachea?MAP the locations where you would place the stethoscope to listen to the lung sounds. Abdominal CavityAuscultate?with the diaphragm for bowel sounds:Where should you start auscultations? Map on the quadrant diagram below. should hear 5 to 30 sounds per minute…if no, bowel sounds are noted listen for 5 full minutesHow do you grade/classify the sounds you hear?480060023495Check for hernia: have patient raise up a bit and look for hernia (at stomach area or navel area)What’s a hernia? What does a hernia look like?Lower extremities:Inspect:color from legs to toes?normal hair growth? (peripheral vascular disease: leg may be hairless, shiny, thin)warm (good blood flow)?swelling (press down firmly over the tibia…does it pit?)any redness, swelling DVT (deep vein thrombosis)?capillary refill less than 2 seconds in toes?How do the toe nails look (fungal or normal)?Sores on the feet (Note: with?diabetics, foot care is important. They don’t have good sensation on their feet. Therefore, inspect the feet for damage because they may not be aware of it.)Is there any breakdown on the heels?Assess joints of the toes and knees (any crepitus, redness, swelling, pain)Palpate pulses bilaterally: popliteal (behind the knee), dorsalis pedis (top of foot), posterior tibial (at the ankle) and grade them ................
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