-
Getting Started
- Gather Supplies
- Introduce Self
- Identify Client
- Check For Allergies
- Explain Procedure
- Wash Hands
- Provide Privacy
- Adequate Lighting
-
Throughout Exam
- Ability to engage in conversation
- Facial Expressions
- Body Positions
- Hearing response
- Personal Hygiene
- Toleration of movement
- Need for Assistance
- Pain
-
Neurological
- Alert
- Oriented
- Hand Grasp Strength
- Moves all extremeties
- Clear Speech
- Complaints of Numbness or tingling
-
Skin
- Color
- Temp
- Turgor
- Lesions, rashes, itching
- Bony Prominences
- Nails
- Hair Scalp
- IV site
-
Head and Neck
- Hair distrobution
- Color of skin
- Symetry
- Edema
- Involuntary muscle movement
- Mucous membanes (teeth, soft palate response, conjunctiva in eyes)
- Vision (PERRLA, Gaze fields)
- Hearing
- Smell
- Patency of Nostrils
- ROM
- Palpate Lymph nodes
- Check corotid pulse (one at a time)
-
Thorax and Lungs
- Inspect
- -Use of Oxygen
- -Breathing pattern
- -Shape/contour of chest
- -cough/sputum
- Auscultate
- -breath sounds
-
Cardiovascular
- Inspect
- -Visual Pulsations
- -Neck distention
- -Auscultation S1 and S2 APETM
- -Apical pulse (1 minute)
- Palpation
- -Radial and Pedal Pulses; grade
- -Capillary refill
- -Edema
-
Abdomen
- Inspection
- -visible pulsations; scars
- -character of stool
- -contour
- Auscultate
- -4 quadrants in a clockwise direction
- Palpate
- -soft/firm/pain
-
Urinary
- Inspection
- -Character of Urine (amount, color, clarity, odor)
- -Foley (patency, character of urine)
-
Musculoskeletal
- Inspect
- -Ambulation
- -Assistive devices
- -Gait/Balance/ROM
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