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40973774 Head to Toe Assessment (1)

40973774 Head to Toe Assessment (1)

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Published by Kezia Paches

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Published by: Kezia Paches on Dec 13, 2010
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12/15/2012

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HEAD TO TOE ASSESSMENT

Interview while conducting Head to Toe exam. GENERAL APPEARANCE 1. Age, race, sex, Ht. Wt., hygiene, grooming nutritional status, build, VS. 2. LOC & orientation X 4 (person, place, time, situation). 3. Speech, understanding, memory, facial expression, mood, affect. 4. Obvious physical deformities and involuntary movements. 5. General Mobility ± posture, stability, gait & assistive devices (CN 11). HEENT 1. Inspect face; head. 2. Inspect EENT external structures. 3. Check 6 cardinal fields (CN 2, 3, 4, 6). 4. Inspect conjunctiva, sclera, 5. PERRLA. UPPER EXTREMITIES 6. Hearing (CN 8). 1. Assess skin, hair, nails. 7. Inspect teeth, gums, tongue, palate, uvula. Palpate masseters with clenched teeth (CN 5, 7). 8. Check tonsil fossa: Say ³ah´ (CN 9, 10), swallow reflex intact. 9. Pt. Protrudes tongue (CN 12). NECK 2. Assess ROM and strength. 3. Assess handgrips. 4. Palpate & assess radial pulses (rate, rhythm, & force), cap. Refill. LOWER EXTREMITIES

HEART 1. Inspect for pulsations & palpate at PMI. 2. Auscultate apical-radial, & apical-carotid (amplitude, rhythm, rate). 3. Auscultate at A, P, T, M. 4. Identify S1, S2. 5. Listen for murmurs. 6. Listen for S3, S4 gallups.

ABDOMEN 1. Inspect color, contour, pulsations. 2. Auscultate bowel & aortic sounds. 3. Percuss 4 quadrants (tympany). 4. Lightly palpate 1cm. Over 4 quadrants.

6. Percuss side to side (resonance). Palpate cervical lymph nodes. Shrug shoulders (CN 11). Copyright © T Pape 1998-2006 All rights reserved 7. 2. 4. etc. Assess skin turgor upper chest. Assess ROM neck. 6. 3. clarity. 3. lat. 4. Chest. & ant.1. Last BM¶s. CHEST (Lungs) 1. . Refill. 3. Palpate carotids (separately). Note trachea midline. amt.. Urine color. Check for edema. Assess skin. 2. 5. Inspect toes & cap. Palpate & assess posterior tibial. Inspect post. 1. Check skin sensation (evaluate based on dermatome levels). 2. Auscultate carotids for bruits. 2. Assess babinski reflex. Auscultate for adventitious sounds (upper lobes. and dorsalis pedis pulses. color. 8. 7. GU 1. ROM and strength. 5. lower lobes). Assess Homan¶s sign. Inspect carotids & jugulars.

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