Head to Toe Assessment Flashcards
introduction
- name
- role
- 2 patient identifiers
- process & procedures
- comfort & privacy
- allergies
put bed up to working height
LOUDCARTS
location
onset
duration: waning, comes and goes
characteristics: dull, achy, throbbing
accompanying symptoms
relief methods: sitting down
treatments meds: tylenol
severity of pain
understanding
LOC
patient alert & awake
Orientation
can you state your name one more time?
do you know what building we’re in?
do you know today’s date?
patient alert to person, place, and time
facial expression/symmetry
Can you raise your eyebrows, puff out your cheeks, and give me a smile?
patient no drooping of mouth
patient palpebral fissure and nasolabial folds are symmetrical
no periorbital edema
cranial nerve 7 facial nerve is intact
Pupils
Penlight: from outer corners to inwards.
Follow the tip of my pen with your eyes, not moving your head.
pupils are equal, round, and reactive to light and accommodation
cranial nerve 3, oculomotor nerve is intact
can you look straight ahead at that object
shine light from 2 ft away midline
Corneal light reflex intact
Lips
can you pull your lips down so I can check the inside of your lips?
penlight
color even and moist
Tongue
can you open your mouth wide and stick out your tongue?
penlight
color even and moist
can you say light, tight, dynamite?
cranial nerve 12 hypoglossal nerve intact
neck
** Inspect & palpate tracheal position**
midline
I’m going to take your pillow so I can look at your neck. Can you look left for me?
penlight
no JVD
can you cough for me?
cough reflex intact
skin
can you lift your arms up for me?
penlight
skin color consistent with genetic background, and intact
use dorsal side of hands to feel arms
skin warm and dry
hands
palpate both radial pulses at the same time
radial pulses 2+ bilaterally
can you grip my hands tight
grip strength equal bilaterally
Does your ring feel tight?
No edema in the hands.
nails
cap refill
Less than 2 seconds
inspect nails
color even, no ridging, no clubbing
chest
inspect symmetry 360*
chest symmetrical
respirations unlabored and regular
no accessory muscle use, nasal flaring, or intercostal retractions.
AP diameter is 1 to 2
ant Lungs
lungs cleat to auscultation anteriorly
post lungs
lungs clear to auscultation posteriorly
chest expansion
chest expansion symmetrical
heart
Aortic, 2nd ICS, RSB, S2>S1
Pulmonic, 2nd ICS, LSB, S2>S1
Erbs, 3rd ICS, LSB, S1=S2
Tricuspid 4th ICS, LSB, S1>S2
Mitral 5th ICS, MCL, S1>S2
go back with bell
no extra hearts sounds or murmurs
abdomen inspection
Abdomen flat and symmetrical
no masses
aortic pulsations visualized in left epigastric area
umbilicus midline and inverted
ab ausc
bowel sounds heard in all 4 quadrants
ab palpate
abdomen soft and nontender
GI questions: stools
When was last BM?
What color was it?
Was it soft/hard?
How often do you go?
Was it a normal amount for you?
urine questions
When did you last urinate?
What was the color?
Was it a normal amount for you? Any odor?
inspect legs
legs symmetrical
no lesions or scars
hair consistent with age, gender, and ethnicity
skin color consistent with genetic background and intact
color is even with no ridging or thickening
palpate legs
**dorsal hands*
warm and dry
*press shin, ankle, feet 5 seconds**
no pitting edema
press toes
less than 2 seconds
palpate lower extremity pulses
dorsalis pedis 2+ bilaterally
posterior tibial 2+ bilaterally
plantar flexion
dorsa flexion
push against my hands
point your toes towards you against my hands
equal bilaterally
closing
Okay. Exam is finished.
If you need anything just let me know.
I will be back to check on you.
Here’s your call light
Let me lower your bed
Ab percussion
Typany heard in all 4 quadrants
