Final Head To Toe

Question 1

First

Answer 1

Introduction

Question 2

Introduction

Answer 2

Hand hygiene, introduction, pt identification, pt privacy, pt education, assist pt to sit up.

Question 3

Assess

Answer 3

ask: mood, age, location, time

Question 4

Overall

Answer 4

Inspect skin BUE/BLE, skin turgor at neck, temp with back of hand, moisture with palms, edema with fingers, check for varicose veins, pulses: radius, tops of feet and heels, hand hygiene

Question 5

Eyes

Answer 5

inspect around eyes, inspect sclera and conjunctiva, pupil size and reaction, extra ocular eye movements and convergence.

Question 6

Ears

Answer 6

Inspect ears and palpate ears

Question 7

Nose

Answer 7

Look at nose around skin, look up nose (pen light) noting for any discharge and color, palpate sinuses noting any tenderness.

Question 8

Mouth/Throat

Answer 8

Look around mouth/lips, look inside the mouth at tongue/mucosa/teeth for any lesions or sores and color, have pt stick out tongue and say ah - note uvula motion and position (midline and rise)

Question 9

Neck

Answer 9

inspect for masses and symmetry and pulsations, palpate the lymph nodes and trachea (note bad), neck ROM, shoulder strength

Question 10

ROM

Answer 10

ROM/ strength: shoulders, elbows, wrists

Question 11

Chest

Answer 11

Front: Inspect breathing (use of accessory muscles and ease), listen to breath sounds (6 ladder)
Back: Inspect breathing (thoracic cage), palpate breathing and symmetry, listen to breathing (7 ladder), CVA tenderness (check CURVATURE OF SPINE & PALPATE TENDERNESS!)- active ROM spine

Question 12

Next?

Answer 12

Lay pt down & HOB 30 degrees

Question 13

Neck Vessels and Heart

Answer 13

watch for pulsations, palpate carotids 1 time, listen w bell to carotids (bruits), listen to APETM (bell), listen to APETM (diaphragm), listen to apical pulse 1 minute and NOTE

Question 14

Abdomen

Answer 14

Inspect the abdomen (note umbilicus and pulsations), auscultate (30 sec each quad), ausculate the arterties (aorta, iliac, and renal), percuss (2X each quad), palpate light and deep

Question 15

ROM

Answer 15

while laying down: ROM/strength the hips and feet, have pt sit up: ROM/strength the knees

Question 16

Neuro

Answer 16

pt sit up: fingers to nose, heel down shin, dull/sharp on all extremities and feet, reflexes: bicep, tricep, knees, heel

Question 17

Neuro/Musc

Answer 17

Have pt walk 10 feet & walk back heel to toe, pronator drift,

Question 18

Next?

Answer 18

get comfortable again, thank and hand hygiene