Presentation on theme: "Head to Toe Assessment Head Eyes: check sclera, conjunctiva, accomodation, PERRLA Mouth: pink, moist, without odor, teeth alignment, number of teeth,"— Presentation transcript:
Head to Toe Assessment
Head Eyes: check sclera, conjunctiva, accomodation, PERRLA Mouth: pink, moist, without odor, teeth alignment, number of teeth, throat: redness, exudate, lesions
Neck Alignment: flexibility Vascular: palpate carotid pulsations, listen for Carotid bruit Bruit: swishing sound heard with stethoscope at carotid artery. Lymph nodes: palpate for swelling
Chest Breathing: bilateral sounds, inspiration and expiration, rales, rhonchi, crackles Heart Sounds:S1 and S2= lubb dubb. Note rate, regularity rhythm Note AP should be 1:2 ratio
Abdomen Palpate for tenderness, guarding, Listen to Bowel Sounds in all 4 quadrants. RU, RL, LU, LL Note quality of sounds, hypoactive, hyperactive, without sound
Appendicular Assessment Arms: check for bilateral alignment, note grip strength, as well as ability to release grip Note capillary refill in fingertips Legs: Check for bilateral alignment, note reflexes(Babinski) as well as strength of flexion and extension(gas pedal), varicose veins
Skin Color Note any changes in complexion: Jaundice Cyanosis Darker skinned patients may appear pale instead of a bluish tint.
Mental Status Orientation: Name Day of week Date Who is president Situation: If other assessments are negative.
Mental Status-Level of Consciousness Alert: aware of situation and surroundings Decreased LOC: somewhat awake, easy to fall into sleep, may or may not be aware of situation or surroundings. Unresponsive: no verbal, or physical response to stimulation