Head to Toe Assessment Flashcards
head to toe assessment
inspect, palpate, percuss, auscultate
introduction
knock, introduce, wash hands, provide privacy, verifyusing 2 identifiers (name and birthday), explain what to do
orientation
name? where are you? Month? Current president? What brought you here?
vital signs
heart rate, blood pressure, oxygen saturation, temperature and respiratory rate
normal HR
60-100 bpm
normal BP
120/80 mmHg
normal SPO2
95-100%
normal temperature
36.5 - 37.2 C
normal respiratory rate
12 - 20 cpm
head assessment
inspect and palpate head, scalp, hair
face assessment
inspect, check for symmetry, assess cranial nerve VII: facial
Cranial nerve VII: facial assessment
raise eyebrows, smile, frown, show teeth, puff out cheecks, tightly close eyes
eye assessment
inspect external eye structures, color of conjunctiva and sclera
PERRLA
used to check the appearance and function of your pupils.
PERRLA means
pupils, equal, round, reactive to light and accomodation
ear assessment
used to check the appearance and function of your pupils.
nose assessment
used to check the appearance and function of your pupils.
mouth assessment
used to check the appearance and function of your pupils.
5 areas for listening to the heart
aortic, pulmonic, erb’s point, tricuspid, mitral
acronym for 5 areas for listening to the heart
all people enjoy time magazine
neck assessment
inspect and palpate carotid pulse and check skin turgor (under clavicle)
heart assessment
auscultate heart sounds with diaphram and bell
posterior chest assessment
inspect, auscultate lung sounds in posterior and lateral chest and auscultate in a sequence to compare lungs (RU, LU, RM, LM)
anterior chest assessment
inspect use of accessory muscles, AP to transverse diameter, sternum configuration, palpate symmetric expansion and auscultate lung sounds : anterior and lateral
