Complete head to toe assessment Flashcards
- The first thing you do when you come into the room?
Hello My name is Ben Wade I am a nursing student in the Nurse Practitioner program. Would it be alright if I do a head to toe assessment on you?
Greet the patient and wash your hands
- Head:
Head is?
Midline and erect
- EYES:
Eyebrows, eyelids, nasolabial folds and mouth are?
symmetrical
- HAIR is?
smooth, color is _____, no lesions or lumps, hair is evenly distributed
- SKULL is?
Normocephalic, scalp is intact.
- TEMPORAL ARTERY:
I’m gonna feel for your temporal arteries. Any pain or tenderness? I’m gonna listen for any bruits bilaterally.
I do not hear any bruits.
- GLASSES:
I am gonna have you take off your glasses are you okay with that?
Yes
- TMJ:
I’m gonna have you open your mouth for me? I will then place my hands on the TMJ. Okay go ahead and close. Any pain or tenderness? No.
No pain or tenderness noted. No crepitus or popping.
- TMJ:
Okay again tightly close your mouth.
Trigeminal nerve intact. That is the motor part of the trigeminal nerve.
- SINUSES
Im gonna feel for your sinuses.
Any pain or tenderness?
No, pain or tenderness noted at the frontal and maxillary sinuses.
- FACE EXPRESSIONS:
I’m gonna have you do a series of facial expressions. If you will raise your eyebrows, wrinkle your forehead, smile for me. Okay, smile for me without showing your teeth. If you would poof out our cheeks. Purse your lips and blow. Tightly close your eyes.
Facial nerve grossly intact. Facial expression is plesent.
- COTTON BALL:
I’m gonna pace something soft and hard on your face. And for the sake of time I will do only one side, but it will be done bilaterally.
Trigeminal nerve and sensory intact bilaterally.
- ARMS:
Okay, I’m gonna have your bring your arms straight out. You’re gonna be touching your nose but closing your eyes.
No ataxia. Smooth coordinated movements.
- NECK:
Now I’m gonna go toward your neck (looking at neck and symmetry).
Visual inspection of neck is symmetrical. Trachea of the neck is midline.
- CAROTIDS:
I’m gonna feel for your carotids. Any tenderness? No.
I’m gonna listen again (with bell).
No tenderness at the carotid arteries. No bruits noted.
- LYMPH NODES:
I’m gonna feel for your lymph nodes. I’m starting at the occipital, postauricular, preauricular, retropharyngeal, submandibular, submental, supraclavicular, anterior cervical chain and posterior cervical chain. Any tenderness there? No.
No tenderness and lymph nodes are non palpable.
- POSITION:
I’m gonna have you do range of motion. I’m gonna have you look up to the top of the ceiling (thats hyperextension). Bring your head down for forward flexion. I’m gonna have you look the right and the left (thats rotation). Bring your ear to your shoulder on the left and the right (thats lateral bending).
=)
- TRAPEZIUS:
I’m gonna have you push agains my hand with your head. Can you shrug your shoulders?
Full resistance to opposition. Spinal accessory nerve intact.
- THYROID:
I’m gonna feel for your thyroid? Go ahead and swallow for me.
Thyroid is pliable and soft. No nodules. No lumps or masses. Thyroid moves during swallowing.
- EYE:
I’m gonna test your eyes. I’m gonna hold onto your chin and for the sake of time were gonna only do one side, but this would be done bilaterally. (Trail finger at an upward diagonal angle, horizontal angle and lower diagonal angle.)
Extraocular eye movements are intact in all six cardinal fields of vision. Smooth coordinated movements.
- CONFRONTATION:
Next thing is confrontation test. I’m gonna have you look at my ear. When you see my fingers come into your peripheral vision let me know. I will patient and myself cover the same eye. Thats about 90 degrees.
Confrontation intact. Visual fields full by confrontation.
- PUPILS:
The next thing is accommodation. I’m gonna have you follow my finger. Trail finger in toward patient’s nose (both eyes should follow inward). Perfect now look behind me.
Pupillary accommodation intact. Eyes constrict and converge when looking at a close object and dilates when looking at a far object.
- SYMMETRICAL:
With the light I’m going to look at your pupils. If you can look at my ear. Look though ophthalmoscope at patient’s eyes.
Light shines in both eyes symmetrically and bilaterally.
- PERRLA:
For the sake of time I’m gonna pretend that I turned off the lights for this test. Look at my ear again and I’m gonna shine this in your eye.
Pupils are equal round and reactive to light and eyes have accommodation and constricted to light direct and consensual.