Tuesday, November 16, 2010

Head to Toe Assessment


  • Wash hands
  • Introduce self and review role for visit
  • BP, PTR
  • Cranium for size, contour, color, lesions
  • Inspect eyebrows, eyelids, and eyelashes
  • Palpate sinuses and TMJ
  • CN VII (facial expression)
  • CN II (confrontation test - peripheral vision)
  • CN III, IV, & VI (positions of gaze)
  • PERRLA
  • Inspect and palpate external ear
  • CN VIII (whisper test)
  • Inspect and palpate external nose
  • Nostril patency and CN I (fragrance test) 
  • Inspect lips, buccal mucosa, gums, tongue, and palates
  • CN V (clench teeth, palpate face)
  • Tap teeth
  • CN XII (protrude tongue - "light, tight, dynamite")
  • CN IX and X (depress tongue and say "ah")
  • Neck ROM
  • Auscultate carotid pulses
  • CN XI (shrug shoulders against resistance)
  • Inspect and palpate chest and lungs - back then front
  • Palpate spinous processes for paraverbal muscles for tenderness and symmetry
  • Auscultate over all lung fields and verbalize normal vs abnormal breath sounds
  • Percuss over all lung fields
  • Palpate pericardium for pulsations, thrills, and/or heaves
  • Auscultate five heart fields, sitting then lying (diaphragm & bell) 
  • Auscultate heart at apex in lt. lateral position
  • Inspect abdomen skin, contour, symmetry, & umbilicus
  • Auscultate abdomen with diaphragm, all four quadrants
  • Auscultate abdominal aorta with bell for bruit
  • Percuss all four quadrants of abdomen
  • Palpate abdomen; light then deep
  • Inspect skin and nails; capillary refill
  • Palpate skin for temperature; skin turgor
  • Compare symmetrical parts
  • Palpate radial, brachial, & pedal pulses, bilaterally
  • Test sensations of extremities w/ cotton ball - tell pt to close eyes
  • Test upper & lower extremity ROM and muscle tone using resistance
  • Elicit reflexes for biceps, triceps, patellar, and achilles
  • Observe gait and balance; heel-toe walk
  • Romberg's sign & rapid alternating movements


0 comments: