Head to Toe Assessment https://www.youtube.com/watch?v=cP4zgb9H3Cg Generalized patient assessment Work from the head down Know normal = identify abnormal

Palpate Head and Neck Checking for lumps and bumps any lesions or tenderness

Check the ears Use an Otoscope

Check Nose and Mouth Is there redness, swelling, drainage, abnormal bumps, color, lesions

Pupil Check PERRLA (pupils, equal, round, react to light, accommodate) Accommodate – ability of eyes to focus on objects that are close up and faraway

Neck Veins

Heart Sounds

Auscultation of Breath Sounds Normal Crackles- light crackling, bubbling Rhonchi- coarse crackles Wheezes- creaking, whistling, high pitched

Pulse Checks Strength of pulse 0 = absent 1 = barely palpable 2 = easily palpable 3 = full 4 = Bounding pulse

Capillary Refill < 3 second Blood return The rate at which blood refills empty capillaries Indication of dehydration and peripheral perfusion

Reflexes

Reflexes

Reflexes

Homan’s Sign

Skin Turgor 1-3 second return Used to assess the degree of fluid loss or dehydration

Skin Breakdown Check

Peripheral Edema Caused by fluid in the tissues tends to be dependent 0 no edema +1 Trace indentation rapid return to normal +2 Mild indentation rebounds in a few seconds +3 Moderate, 10-20 second to return to normal +4 Severe, >30 second to return to normal

Peripheral Edema

Bowel Sounds Absent, Hyperactive, Hypoactive, Normal To state absent you must listen for 5 min in each quadrant

Palpate the abdomen To be done after listening to bowel sounds

Pain Location, duration, sensation, intensity What makes it worse or better

Baby Reflexes

Assessment Song