NCLEX Quiz

Dementia is a group of symptoms that affects mental cognitive tasks such as memory and reasoning. Dementia is an umbrella term that Alzheimer’s disease can fall under. It can occur due to a variety of conditions, the most common of which is Alzheimer’s disease. People can have more than one type of dementia.

Early Signs and Symptoms of Alzheimer’s

Memory loss that disrupts daily life.
Challenges in planning or solving problems.
Difficulty completing familiar tasks at home, at work or at leisure.
Confusion with time or place.
Trouble understanding visual images and spatial relationships.

Nursing Student Head to Toe Assessment Sample Charting Entry Cheat Sheet

Examples of Documentation: Forms and Formats (Nursing)
Head-to-Toe Nursing Assessment
The sequence for performing a head-to-toe assessment is:

Inspection
Palpation
Percussion
Auscultation
However, with the abdomen it is changed where auscultation is performed second instead of last. The order for the abdomen would be:

Inspection
Auscultation
Percussion
Palpation (palpation and percussion are done last to prevent from altering bowel sounds)
Provide privacy, perform hand hygiene, introduce yourself to the patient, and explain to the patient that you need to conduct a head-to-toe assessment

Ask the patient to confirm their name and date of birth by looking at the patient’s wrist band (this helps assess orientation to person and confirms you have the right patient). In addition, ask the patient where they are, the current date, and current events (who is the president and vice president) etc.

Collect vital signs: heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, pain level

NOTE: Before even assessing a body system, you are already collecting important information about the patient. For example, you should already be collecting the following information :

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?
Abnormal smells?
How is their hygiene?
Assess height and weight and calculate the patient’s BMI (body mass index).

Below 18.5 = Underweight
18.5-24.9 = Normal weight
25.0-29.9 = Overweight
30.0 or Higher = Obese

Cerebral Hemorrhages Neurological Assessment Med School

An epidural hematoma presents as a hyperdense lenticular shaped hematoma in the temporal region, and it is caused by a tear in the middle meningeal artery. A lucid interval is often associated with this bleed.