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Introduction
(Gather supplies: B/P cuff, stehoscope, penlight, DTR hammer, Thermometer, watch, black pen)
- a)wash hands
- b)introduce self(hi I am John, I will be your SN today)
- c) Idenify client by name and arm band
- d)Explain Procedure(I will be doing a head to toe examination today)
- e)Provide Privacy
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General Survey
- a) saftey concerns
- b) physical appearence and body structure
- c) Motor Activity (gait, balance, posture)
- d)A&O (person, place, time, event)
- e)Dress, grooming, hygeine
- f) client mood, affect, and speech
- g) Vital Signs(Pulse, Resp, B/P, Temp)
- h) Inquire about pain, pain rating 0-10
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Upper Extremeites
- S: Inquire about changes in skin and problems with movement
- O: Inspect ROM
- O: Inspect skin for color & lesions
- O: Inspect finger nails for brittlness & color
- O: Palpate Capillary Refill (<3 sec)
- O: Palpate Skin for Temp & Mositure
- O: Palpate radial/brachial pulses bilateral for rate/rhythm, volume
- O: Palpate strength of hand grips
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Head/Face
- S: Inquire about vision, hearing, HA, dizziness
- O: Inspect facial features for symmetry
- O: Inspect eyes for PERRLA
- O: Inspect mouth, tounge, muscous membranes for color, lesiosn
- O: Inspect movement of soft palate and uvula
- O: Palpate Lymph Npdes(occipital, postauricular, preauricular, submandibular, submental), for tenderness or enlargment
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Neck
- S: Inquire about stiffness or tenderness in upper neck or back
- O: Inspect lower neck for fullness, swallowing, trachial position
- O: Palpate anterior and posterior cervical and supraclavicular lymph nodes
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Thorax
- S: Inquire about troubled breathing, cough, chest pain, palpitations(fluttering)
- O: Inspect skin color, lesions anterior and posterior
- O: Palpate skin turgor(<3sec) over upper chest
- O: Ausculate anterior, posterior, lateral breath sounds
- O: Ausculate hear sounds(location, sounds heard)
- O: Compare Apical pulse rate/rhythm to radial pulse
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Abdomen
- S: Inquire about N/V/D, constipation or pain
- S: Inquire about changes in bowel or bladder function
- O: Inspect skin color, lesions, scars, bulges, pulsations, and distention
- O: Ausculate for bowel sounds in 4 quadrants
- O: Percuss systematically in all four quadrants(note sounds: tympanny normal)
- O: Palpate systematically in all quadrants for consistency, tenderness
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Lower Extremities
- S: Inquire about changes in skin and prolems with movement
- O: Inspect ROM
- O: Inspect skin for color, lesions
- O: Palpate for Temp and Mositure
- O: Palpate toe nails for cap refill(<3sec)
- O: Palpate posterior tibial and dorsalis pedis bilaterally
- O: Palpate for Edmea
- O: Percuss patellar DTR bilaterally
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