75 terms

Head to Toe Assessment Steps

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