Head-to-Toe Physical Assessment

Vocabulary flashcards covering systems-based head-to-toe nursing assessments, including cardiac landmarks, abdominal assessment guidelines, urine indicators, pulse and edema scales, and safety checks.

Aortic Auscultation Landmark

The cardiac auscultation site located at the 2nd intercostal space, right sternal border.

Pulmonic Auscultation Landmark

The cardiac auscultation site located at the 2nd intercostal space, left sternal border.

Erb's Point

The cardiac auscultation landmark located at the 3rd intercostal space, left sternal border.

Tricuspid Auscultation Landmark

The cardiac auscultation site located at the 4th intercostal space, left sternal border.

Mitral Auscultation Landmark

The cardiac auscultation site located at the 5th intercostal space.

Abdominal Assessment Sequence

The required order of assessment—inspect, auscultate, percuss, palpate—used because palpating and percussing before auscultating may produce false bowel sounds.

Hyperactive Bowel Sounds

Bowel sounds occurring at a rate of $> 30$ sounds per minute, which may sometimes be audible without a stethoscope.

Normoactive Bowel Sounds

Normal bowel sounds occurring at a rate of $5$ to $30$ sounds per minute.

Hypoactive Bowel Sounds

Bowel sounds occurring at a rate of $< 5$ sounds per minute.

Absent Bowel Sounds

The total absence of intestinal sounds; auscultation must continue for at least $5\,\text{minutes}$ to confirm this finding.

Clear Urine

A urine appearance that indicates overhydration.

Amber Urine

A urine color indicative of dehydration.

Brown Urine

A urine color indicating liver disease or severe dehydration.

Pink/Red Urine

A urine discoloration indicating possible blood, food dye, or kidney disease.

Green Urine

A urine discoloration indicating a possible effect from medication or bacterial infection.

Capillary Refill

The assessment of peripheral perfusion performed by pressing a finger for a few seconds and counting the time to regain color; normal recovery is $< 3\,\text{seconds}$ ($2$ to $3\,\text{seconds}$).

Pitting Edema: +1

Mild pitting edema measured as $0$ to $\frac{1}{4}\,\text{inch}$ indentation.

Pitting Edema: +2

Moderate pitting edema measured as $+\frac{1}{4}$ to $\frac{1}{2}\,\text{inch}$ indentation.

Pitting Edema: +3

Severe pitting edema measured as $\frac{1}{2}$ to $1\,\text{inch}$ indentation.

Pitting Edema: +4

Severe pitting edema measured as greater than $1\,\text{inch}$ indentation.

Lower Extremity Pulse Sequence

The sequential landmark progression for lower extremity pulse checks that starts at the dorsalis pedis (pedal) pulse and moves upward to the posterior tibial, popliteal, and femoral pulses.

Doppler

An instrument used to assess and confirm blood flow when a peripheral pulse cannot be felt by manual palpation.

Points of Contact

Bony prominences such as the sacrum, heels, and toes that are vulnerable to rapid skin breakdown if a patient is malnourished with other risk factors.

Patient Safety Check

The routine environmental check ensuring siderails are up, call light is accessible, the bed is locked, and the bed is maintained in the low position.

Pain Assessment Scale

A standardized rating of pain intensity on a scale from $0$ to $10$, along with documentation of client description, location, duration, and precipitating factors.