Head to Toe Assessment Steps

75 terms by smwalsh 

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Skill 1

Greet client and explain purpose of exam; wash or purell before entering patient room. Introduce yourself as a student Nurse. Ask patient to remember three words: APPLE, BOAT, CHEESE.

Skill 2

General survey- appearance, facial expression, speech, mental state; Speech is clear, slurred, rapid, slow, no evidence of pain, face symmetrical. Alert and oriented to person, place and time.

Skill 3

Level of consciousness Alert and oriented x3

Skill 4

Have client close eyes; Assess for asymmetry of lids may indicate CN III damager or from a stroke.

Skill 5

Have client raise eyebrows; Facial nerve VII

Skill 6

Have client smile; Facial nerve VII

Skill 7

Have client stick out tongue; CN XII- hypoglossal nerve

Skill 8

Have client puff cheeks- CN VII- facial nerve

Skill 9

Discriminatory sensations- soft and sharp object to face; CN V-

Skill 10

Test EOMs; test 6 cardinal fields of gaze (test cranial nerves III, IV, and VI- oculomotor, trochlear, and abducens nerves. Change in ICP may affect EOMs and papillary reaction.

Skill 11

Inspect conjunctiva for color by pulling lid down; abnormal findings would be pallor, dryness, edema

Skill 12

Test pupillary response with penlight- direct, describe what is see; When you shine a light in the right eye, the right pupil reaction is direct; the left eye is consensual. Repeat the test with the left eye.

Skill 13

Test pupillary response with penlight- consensual, describe what is seen; Sluggish or fixed pupils may result from CN II damage or brain injury. Absence of consensual response may result from nerve compression or anoxia.

Skill 14

Test pupil accommodation- explain; Have the patient look straight ahead and focus on an object 30cm (12in) from his face. Slowly bring the object in toward the patient's eye. Note the pupil size and location.

Skill 15

Inspect external structure of ear; Ears should be 4-10 cm in size. Color of ears should be same as skin color. Assess for any drainage, odor or pain when assessing ears.

Skill 16

Examine oral mucosa; Assess for lesions, edema, plaque, ulcers.

Skill 17

Inspect palate; Assess for cleft palate, pink in color. Uvula is midline. Tonsils are pink with out lesions or exudates.

Skill 18

Have client say "ah"- what do you observe for?; Uvula should rise when patient says ah- CN IX

Skill 19

Check for gag reflex; Assess to see that gag reflex is present, older adult may have delayed gag reflex. Absence of gag reflex may indicate extreme sedation, head injury, damage to CN IX and X.

Skill 20

Shrug shoulders against resistance; Asymmetrical movement, pain, or absent movement indicates CN XI disorders

Skill 21

Palpate nodes of neck

Skill 22

Palpate carotid pulse-one side at a time

Skill 23

Auscultate for carotid bruit

Skill 24

Observe for jugular vein distention; JVD suggests right sided heart failure.

Skill 25

Palpate trachea

Skill 26

Palpate for thyroid; Do both anterior and posterior, make sure tilts head to side.

Skill 27

Examination of skin- color, lesions, skin temperature, moisture; Note any lesions, if find describe, ask if new or old and change in area *note any break down on bony prominences

Skill 28

Check for skin turgor on arm; Assess for tenting of skin, greater than 3 seconds to return to original origin.

Skill 29

Examine nail beds, color, texture, abnormalities; Healthy nails are level, firm, and similar to the color of the skin, the shape is convex, abnormal would be yellow, blue, black discoloration, spoon shaped (concave) nails are associated with iron deficiency

Skill 30

Check for capillary refill; Assess for immediate capillary refill less than 3 seconds, greater than 3 seconds is delayed, may indicate oxygen deprivation.

Skill 31

Observe respiratory excursion-observe hand expansion; Assess if they are easy,labored, rapid. If labored what would you assess, pulse OX, must be greater than 90%

Skill 32

Palpate respiratory excursion-observe hand expansion;Place hands at base of the client's chest with fingers spread and thumbs out about 5cm apart (at the costal margin anteriorly and at the 8th to 10th rib posteriorly) chest excursion should be symmetrical.

Skill 33

Note A/P diameter, compare to lateral

Skill 34

Palpate for tactile fremitus; Palpate for vibrations as the client says '99'. Increased fremitus occurs with conditions that cause fluid in the lungs. Decreased or absent fremitus occurs when there is emphysema, asthma.

Skill 35

auscultate bronchial breath sounds- describe area

Skill 36

auscultate bronchiovesicular breath sounds- describe area

Skill 37

auscultate vesicular breath sounds- describe area

Skill 38

Palpate/percuss costovertebral area- ask about tenderness

Skill 39

observe chest for thrills, heaves and pulsations

Skill 40

Palpate for PMI (4th-5th intercostal space) apical pulse

Skill 41

Auscultate heart sounds- base to apex, identify aortic area; Right 2nd intercostal space is the best place to hear the aortic

Skill 42

Identify pulmonic area- auscultate; The lest 2nd intercostal space is the best place to palpate the pulmonic valve.

Skill 43

Identify tricuspid area-auscultate; From the apex, slide your finger up to the 4th intercostal space, then move close to the sternum.

Skill 44

Identify mitral area-auscultate; You may be able to locate the apex by observing the pulsation at the PMI. It is at the 5th intercostal space in the midclavicular line.

Skill 45

Which area is loudest? The APEX

Skill 46

When would you use the bell of your stethoscope?; When assessing carotids to assess for bruit. Bruit may indicate carotid stenosis.

Skill 47

Check radial pulse on one side

Skill 48

Check brachial pulse on one side

Skill 49

Check pedal pulse on one side

Skill 50

Check posterior tibial pulse on one side

Skill 51

Inspect abdomen- contour, skin

Skill 52

Inspect abdomen for pulsations, peristalsis; Pulsation may indicate an aortic aneurysm, peristaltic waves may indicate and intestinal obstruction

Skill 53

Auscultate bowel sounds, demonstrate where to start and proceed in order; Always start RLQ and follow the large intestine. Tympany with dullness over organs or fluid is present.

Skill 54

Auscultate the aorta

Skill 55

Auscultate the renal arteries

Skill 56

Auscultate the ileac arteries

Skill 57

Auscultate the femoral arteries

Skill 58

Palpate the abdomen; Note any tenderness, masses

Skill 59

Observe lower limbs-skin, muscle mass, toe nails, hair distribution

Skill 60

Palpate feet and lower legs for warmth, moisture; Coolness may indicate PVD

Skill 61

Palpate feet, ankles and legs for edema

Skill 62

Test motor strength/muscle resistance- pedal pushes

Skill 63

Test motor strength/muscle resistance- pedal pulls

Skill 64

Test for babinski reflex- one side

Skill 65

Have client stand, inspect spine; Assess spine for curvature. Cervical and lumbar curves are concave; thoracic and sacral curves are convex.

Skill 66

Inspect posture; Note any kyphosis, scoliosis, lordosis

Skill 67

Observe gait (steady or unsteady)

Skill 68

Have client do heel to toe walking; Balance problems may indicate a cerebellar disorder, and inner ear problem or muscle weakness.

Skill 69

Romberg test; Have patient stand with hands toward side and then have them close eyes and see if any swaying occurs.

Skill 70

Assess coordination using finger-thumb opposition

Skill 71

Have client close eyes and touch finger to nose

Skill 72

Have client run heel of one foot against shin of opposite leg.

Skill 73

Perform ROM in all joints; would assess if ROM is active or passive, always supporting the joints and extremities when doing passive ROM

Skill 74

Patellar reflex; Have patient sit on edge of bed with legs dangling. Strike the tendon directly below the patella, +2 responses with contraction of quadriceps with extension of leg.

Skill 75

Assess memory

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