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.

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

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