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  • Prepscholar Head To Toe

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    Jennifer Jane
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    Hbnnnnhh

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    prepscholar-head-to-toe

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    Hbnnnnhh

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    91 views2 pages

    Prepscholar Head To Toe

    Uploaded by

    Jennifer Jane
    Hbnnnnhh

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Head-to-Toe Assessment: Ears:

    Checklist and Documentation * Inspect/palpate auricle


    * Inside ear/tympanic membrane
    Conducted by:_____________________ * Weber’s test
    Date: ___________ Time: __________ * Rinne test
    * Whisper test
    Vital Signs/Stats/Neurological:
    * Oriented x 3 Notes: __________________________
    * Temp: _______________ ________________________________
    * BP: __________________
    * Heart rate: ____________ Nose:
    * Respiratory rate: _______ * Palpate nose/symmetry check
    * Height: _______________ * Check septum and inside nostrils
    * Weight: _______________ * Patency of nares (breathe through
    each nostril)
    Notes: __________________________ * Intact smell
    ________________________________ * Palpate sinuses

    Head/Face: Notes: __________________________


    * Distribution/condition of hair ________________________________
    * Scalp: no bumps, nits, lesions
    * Palpate skill for tenderness Mouth/Throat:
    * Symmetrical facial movements * Lips (moistness & color)
    * Sharp and dull sensation on face * Teeth & gums
    intact * Buccal mucosa & palate
    * Examine tongue
    Notes: __________________________ * Inspect uvula & tonsils
    ________________________________ * Palpate jaw joint

    Eyes: Notes: __________________________


    * Symmetrical ________________________________
    * Eyebrow & eyelash distribution
    * Check conjunctiva, sclera, cornea Neck/Shoulders:
    * PERRLA * Neck range of motion
    * Six cardinal positions * Shoulder shrug w/resistance
    * Snellen Chart: ______________ * Lymph nodes
    * Palpate neck and trachea
    Notes: __________________________ * Check for JVD
    ________________________________
    Notes: __________________________

    Head to Toe Assessment-Page 2 Legs/Feet:
    * ROM and strength
    Lungs/Thorax: * Cap refill
    * Lung auscultation * Leg pulses
    * Resp. exclusion: ____________ * Sharp and dull sensation
    * Palpate thorax * Assess gait
    * Spinal curvature
    * Coughing? _________________ Notes: __________________________
    ________________________________
    Notes: __________________________
    ________________________________ Genitourinary
    * Pubic hair check
    Circulatory System: * Tenderness, lumps, lesions
    * Carotid & temporal artery palpation
    * Heart auscultation Notes: __________________________
    ________________________________
    Notes: __________________________
    ________________________________ Breast:
    * Palpate breasts
    Gastrointestinal:
    * Abdominal inspection Notes: __________________________
    * Auscultation for bowel sounds ________________________________
    * Abdomen palpation
    * Problems with bowel/bladder?
    Additional Notes:
    Notes: __________________________ ________________________________
    ________________________________ ________________________________
    ________________________________
    Arms/Hands: ________________________________
    * ROM and strength ________________________________
    * Arm pulses (brachial and radial) ________________________________
    * Cap refill ________________________________
    * Skin turgor ________________________________
    * Sharp and dull sensation ________________________________
    ________________________________
    Notes: __________________________ ________________________________
    ________________________________ ________________________________
    ________________________________

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