302L- Head to Toe Assessment PDF

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Script for Final Check Off...

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Intro Skin  Color  Hair growth/distribution  Lesions/wounds  Temp  Moisture  Nails Hair  Color  Density  Pests/infestations Head  Size  Lesions  Palpate for tenderness and growths Face  Symmetry  CN 5 trigeminal jaw clenched strength and sensation to dull and sharp stimuli  CN 7 facial (smile, frown, eyes wide, raise eyebrows, close eyes tight, puff cheeks)  Palpate temporal arteries note strength  Palpate frontal and maxillary sinus  Inspect and palpate TMJ for mobility, closure, and crepitus Eyes  External eye  Sclera: color  Cornea: clear  Iris: color, shape, and size  Pupils: shape and size  Conjunctiva: pink and moist  CN 2 optic o Usually use Ellen chart would be used but it is differed in this exam o Peripheral vision with confrontation  CN 3 oculomotor o Pupillary light response: direct and consensual o Accommodation  CN 3, CN 4, CN 6 oculomotor, trochlear, and abducens o Corneal light reflex

Extra ocular muscles with cardinal position of gaze (H) Fundoscopic exam Normal retina Red reflex Fundus is orange Optic disc is a light yellow with defined borders Macula is a darker orange with defined borders and is located in the nasal region  4 arteries are present Ears  Symmetry (external pinna/ Tragus/ mastoid process) tenderness or pain? Lesions? Piercings  Otoscopic exam  Ear canal  Tympanic membrane (color and shine)  Pests/ infestations/ serumen  CN 8 vestibulochochlear  Whisper test Nose  Symmetry/midline (palpate for abnormalities) o Septum for deviation o Presence of turbinates  Patency (plug one nostril)  CN1 olfactory (smell) Mouth (don gloves)  Lips (color/chilitis) hydration?  Teeth (28 unless wisdom) anchored  Gums (pink and moist)  Stenson and Wharton ducts are free from stones Throat  Tonsils are normally grade 1  CN 9 glossopharyngeal and CN 10 vagus o Tongue depressor o Say ahh to inspect movement of vulva o Assess swallow o Gag reflex (touch back of posterior pharynx)  CN10 hypoglossal o Inspect tongue for color and presence of yeast o Move tongue side to side o “Light,tight, dynamite” LTDN are profound and distinct Neck  Symmetry (trachea is midline)       

 Skin  Palpate carotid arteries o Pulse is 2+ o Bruits (no present whooshing)  Palpate the trachea (nodules and nodes)  Palpate lymph nodes o Preauricular o Posterior auricular o Occipital o Jugulodigastric o Submandibular o Submental o Superficial cervical o Posterior cervical o Deep cervical o Supraclavicular Thyroid  Inspect anterior neck and observe swallowing  Palpate the isthmus and lobes (no abnormalities felt) CN 11 Spinal accessory  Shrug resistance and head ROM  Up, down, left, and right Posterior thorax  Inspect o Symmetry (bone and muscle) vertebrae is midline even within normal limits o Resp pattern (eupnea equal bilaterally) o General skin inspection  Palpate o Symmetric expansion o Tactile fremitus (99) o Lesions/masses o Tenderness  Percuss o Lung fields (6) o Costovertebral angles (no kidney tenderness)  Auscultate o Breath sounds (6) *same positioning as percussion Anterior Thorax 

Inspect

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o Symmetry o Resp pattern even within normal limits o General skin inspection Palpate o Lesions o Masses o Tenderness Percuss o Lung fields (4 anterior 2 laterally) Auscultate o Breath sounds *same positioning as percussion

Heart  Inspect o precordium for symmetry o equal expansion o no dips  Have pt lean forward and exhale o Auscultate cardiac base (aortic& pulmonic sites) with diaphragm  No murmurs present  Lean pt back to 30* o Pt look to the left  Absence of JVD  Pt to supine o Identify and auscultate *no murmur present o Aortic o Pulmonic o Tricuspid o Mitral  Palpate for thrill  Auscultate apical impulse for 1 minute  Rate is within normal limits  Rhythm is even  Apex mitral site w/ bell for S3&S4 (no additional sounds heard) o At this point and position you could assess for presence of pressure injury  Check pulses o Radial o Ulnar o Brachial  ROM o Wrist  Flexion up  Extension down o Elbow

 Extension straight down  Pronate  Supinate  Flexion wrist to shoulder o Shoulder  Internal rotation  External rotation  Abduction  Adduction  Extension to posterior  Flexion to anterior Abdomen  Inspect o Symmetry  No presence of hernia o Dilated vessels o Ecchymosis bruising  No signs of rash bruising or lesions or other abnormalities o Swelling  No swelling contour is flat o General skin inspection  Auscultate o Bowel sounds w/ diaphragm  RLQ, RUQ, LUQ, LLQ  Usually done for 5 min in each quadrant o Vascular sounds with bell (no bruits heard)  Aortic  Renal  Iliac  Would normally auscultate femoral but is deferred at this time  Percuss o RLQ  tympany o RUQ  Dull due to liver o LUQ  Dull do to organs o LLQ  Tympany  Palpate o Light first then deep o Notify of pain or tenderness  RLQ

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RUQ LUQ LLQ

Lower extremities  Inspect o Ulcerations o Varicose veins  Palpate o Edema o Arterial pulses  Posterior tibial  Dorsalis pedis o Separate toes and inspect  Assess ROM o Hips o Knees o  Ask pt to sit up o Pt muscle strength when moving to sit o Ask pt to stand and slightly bend knees Neuro  Sensory o Assess exteroceptive sensation  Use light touch and superficial pain (cotton ball and stick) o Assess proprioceptive sensation  Vibration (wrist and ankle) o Assess cortical sensation  Graphasthesia: draw # or letter on palm  Motor o Assess upper extremity cerebellar function  Finger to nose o Assess for upper extremity drift o Assess for lower extremity cerebellar function by pt running heel to opposing shin  Assess DTR’s o Triceps  Let hand go limp  Holding upper arm strike tendon directly above the elbow o Biceps  Support forearm in yours  Place thumb on biceps tendon  Strike blow to thumb o Brachioradialis

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 Strike forearm directly 2-3 cm above the radial styloid process o Patellar  Have knees hanging off bed use wide base of hammer to strike tendon o Achilles  Support pts foot in hand  Use wide base of hammer  Strike tendon in base of foot Ask pt to stand o Neuro-motor/cerebellar function continued  Observe coordination and gait  Have pt walk regularly  Heel to toe  Heel  Toe...