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HEAD to TOE.txt

  1. RUBRIC
      2. Wash hands, introduce self, identify patient.

      • Head to toe assessment
  • HEALTH HISTORY
      • Reason for your visit today?
      • Do you have any pain today?
      • Diabetes, hypertension, heart disease, sickle cell, cancer, seizures?
      • Accidents or hospitalizations in the past or other medical specialists being seen today?
      • Changes to family history? (mom diabetic)
  • NEUROLOGICAL ASSESSMENT
      2. Observe appearance (symetry, facial ticks) and movement [Facial/7]
        • Ask to the patient to clench teeth. [Trigeminal/5]
        • Ask the patient to smile, puff out cheeks, close eyes tightly. [Facial/7]
      4. How are you feeling today emotionally?
      6. Ask what you're holding in your hand (a pen for example) [Observe thought process and perceptions]
      8. Main meal yesterday? Who's speech begins "Four score and seven years ago..."?
      10. Assess bilateral pupils for symetric size.
      12. Assess using Glascow Coma scale
        • Eye opening: spontaneous=4
        • Motor response: obey verbal command=6
        • Verbal response: place, date, president=5
        • Fully alert, normal=15, coma: <=7
      14. Inspect and palpate the cranium
  • PATIENT TO STAND
      • Check visual acuity with Snellen Eye Chart [Optic/2]
      • Romberg test (feet together, arms at side, close eyes for about 20 seconds) for equilibrium [Acoustic/8]
      • See (smooth, rhythmic) gait for 15-20' and return [Acoustic/8]
  • EYES
      2. Inspect eyes (position, appearance, conjunctiva, sclera, iris)
        • Assess six ocular movements and pupil reaction [Oculomotor/3, Trochlear4, Abducens/6]
        • While patient looks upward lightly touch the lateral sclera of the eye with sterile gauze to elicit blink [Trigeminal/5]
      4. Check accommodation - Focus on close pen (pupils constrict), then focus on distant object (pupils dialate)
      6. Check pupil response to light [Oculomotor/3 Optic/2]
  • EARS
      2. Inspect ears (position, size, shape, lesions, discoloration).
      4. Whispered words heard bilaterally [Acoustic/8]
  • MOUTH
      2. Inspect mouth (lips, teeth, mucous membranes, gums, tongue
        • Ask the patient to protrude tongue at midline, then move it side to side and up and down [Hypoglossal/12]
        • 1) Touch tongue to roof of mouth 2) swallowing, 3) Phonation (hoarsness) [Glossopharygeal/9 & Vagus/10]
        • Taste at anterior 2/3 of tongue [Facial/7] Taste on the posterior 1/3 of the tongue [Glossopharyngeal/9]
  • NOSE
      2. Inspect nose (skin, shape)
        • Ask the patient to close eyes and identify different aromas [Olfactory/1]
  • NECK
      2. Palpate for tender areas and visible abnormalities
        • Ask patient to shrug shoulders against resistance from your hands and turn head to side against resistance from your hand (both sides) [Spinal/11]
  • SKIN ASSESSMENT
    • Ask John to take off shirt
      2. Verbalize inspection of the skin for generalized color, color variation, and scars.
      4. Palpate for texture, temperature, moisture, turgor, and edema.
      6. Assess and verbalize Braden Score using chart
  • RESPIRATORY ASSESSMENT
      2. Verbalize inspection of the thorax. Symmetry, Anteroposterior to Transverse diameter should be 1:2 to 5:7
      4. Palpate posterior chest for respiratory excursion - thumbs adjacent to spine, deep breath. thumbs seperate 1.2-2"
      6. Palapet posterior for "faintly perceptible vibrations - tactile fremitus" with Pt "nine" at 10 zig-zag positions
      8. Auscultate the: anterior chest (8 areas), posterior chest (10 areas), lateral chest (5 areas each side). Should hear Bronchial, Bronchovesicular and vesicular, but not rales (crackles), Ronchi (growling), or wheezing
  • CARDIAC ASSESSMENT
      2. Inspect chest for visibility of the PMI and any abnormal pulsations while the client is lying down.
      4. Verbalize inspection of midsternal line landmark.
      6. Verbalize inspection of midclavicular line landmark.
      8. Verbalize inspection of anterior axillary line landmark.
      10. Palpate and auscultate the aortic area.
      12. Palpate and auscultate the pulmonic area
      14. Palpate and auscultate Erbs point.
      16. Palpate and auscultate the tricuspid area
      18. Palpate and auscultate the mitral area. Count rate for a full minute. Evaluate rhythm.
  • GASTROINTESTINAL
      2. Inspect ABD for color, venous pattern, skin integrity, contour, symmetry, and surface motion.
      4. Auscultate the 4 quadrants of the abdomen. Evaluate bowel sounds.
      6. Lightly palpate all four quadrants for tenderness and consistency.
      8. Evaluate the abdomen for rebound tenderness.
      10. Percuss the abdomen and evaluate for tympany and dullness.
    • EXTRA CREDIT: Ausculate the 2 Femoral, 2 Iliac, 2 Renal and Aortic arteries for Bruits.
  • GENITOURINARY
      2. Inspect color of urine.
      4. Palpate the bladder for distention.
    • John can put his shirt back on
  • JUGULAR VEINS
      2. Demonstrate inspection of Jugular veins at 45 degrees.
  • CAROTID
      2. Demonstrate inspection and palpation of right carotid artery.
      4. Demonstrate inspection and palpation of left carotid artery.
      6. Auscultate right carotid artery
      8. Auscultate left carotid artery
      10. Evaluate rate, rhythm, symmetry and strength of carotid arteries (with written documentation)
  • BRACHIAL
      2. Demonstrate inspection and palpation of right brachial artery.
      4. Demonstrate inspection and palpation of left brachial artery
      6. Evaluate rhythm, symmetry and strength of brachial arteries (with written documentation).
  • RADIAL ARTERY
      2. Demonstrate inspection and palpation of right radial artery.
      4. Demonstrate inspection and palpation of left radial artery.
      6. Evaluate rate, rhythm, symmetry and strength of radial arteries (with written documentation).
  • HANDS
      2. Evaluate capillary refill of the upper extremities.
  • FEET
      2. Evaluate capillary refill of the feet.
      4. Demonstrate inspection and palpation of right posterior tibial artery (medial!!!).
      6. Evaluate rhythm, symmetry and strength of posterior tibial arteries (with written documentation).
      8. Evaluate rate, rhythm, symmetry and strength of pedal (dorsalis pedis) arteries (with written documentation).
      10. Evaluate Homans sign bilaterally.
  • MUSCULOSKELETAL
      2. Inspect upper and lower extremities for ROM, swelling, deformities, and pain.
      4. Palpate upper and lower extremities for tenderness, visible abnormalities, warmth and strength.
  • WASH HANDS
    and write documentation
    • Author
    TomWruble
    ID
    139194
    Card Set
    HEAD to TOE.txt
    Description
    x
    Updated

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