Head to Toe Assessment FINAL

Question 1

Introduction

Answer 1

verbalize/demonstrate: hand hygiene, AIDET, pt id , pt teaching related to the exam

Question 2

Neurological

Answer 2

inspect and verbalize: mental status (A/Ox4), balance, gait; Test: sensation bilaterally (should be checked in all extremeties)

Question 3

Hair/Skin/Nails

Answer 3

inspect and verbalize: skin color (overall), wounds/edema, tattoos/scars, hair distribution/texture, nails (hands and feet)

Question 4

Head and Face

Answer 4

assess facial structures and symmetry (ears, nose, eyes)

Question 5

Eyes

Answer 5

inspect and verbalize: eyebrows/eyelashes, eyelids, interior, conjunctiva***, sclera; Test: PERRLA

Question 6

Ears

Answer 6

inspect and verablize: auricle, tragus, lobules; test: hearing based on conversation ***

Question 7

Mouth/Throat

Answer 7

inspect and verbalize: lips, teeth, tongue, buccal mucosa/gums, tonsils, uvula (use penlight)

Question 8

Thorax/lungs

Answer 8

Inspect and verbalize: chest size/shape, respiratory rate(be sure to verbalize), respiratory effort; Auscultate: anterior (8), posterior (10), lateral (right 4 and left 3)

Question 9

Pulses

Answer 9

palpate- apical, left carotid, right carotid, brachial, left radial, right radial, femoral, popliteal, posterior tibial, dorsalis pedis

Question 10

Cardiovascular

Answer 10

verbalize (rate, rhythm, and strength) of pulse- regular/irregular, rate (normal or not), strength of pulse (3+, 2+, 1+, 0), capillary refill (note < or > 3 secs); Auscultate- apical pulse (include rate), aortic, pulmonic, erbs, tricuspid, mitral USE BELL AND DIAPHRAGM

Question 11

Abdomen

Answer 11

inspect and verbalize: contour (round, flat, etc), symmetry, visible pulsations; Auscultate- diaphragm for bowel sounds (one or 4 quadrants??), bell for arterial sounds (all 7 locations) **

Question 12

Musculoskeletal

Answer 12

inspect and verbalize: muscle for size and symmetry (all extremeties); palpate- upper and lower extremities for tenderness/edema (all extremities); test- range of motion with and without resistance (all joints)