Class notes
Head-to-Toe Assessment Notes
- Course
- FUNDAMENTALS N100 (N100)
- Institution
- West Coast University
head to toe ATI reading summary
[Show more]
Seller
Follow
Content preview
Head to Toe AssessmentI
General Appearance Vital Signs Upper Extremities P = PUPILs
E= Equal
INSPECT R= Round
Inspect • Weight/height/ BMI
RL= React to Light
• BP/ skin Integrity -skin color/condition, lesions
• appearance -symmetry in size & contour A= Accommodation
• Rate, rhythm, depth of
• Skin color radial pulse/ capillary refill -joints, edema Awareness
• Posture • Res. Rate/ Characteristics -condition of fingernails Time
• Oxygen/ Pain level
• body language PALPATE Place
• Mobility -upper arms down to hands Person
-skin temp, texture, moisture
• Mood Neck -brachial/radial pulse
Situation
• Mental status -capillary refill in both hands
INSPECT
• Speech -trachea located midline -shoulder, elbow, wrists finger joints for
-lumps, lesions, trauma Warmth, tenderness, irregularity
Head & Face -ability to swallow
-ROM Observe/ Compare ROM/bilateral strength
Inspect -resistance
-shape, color, symmetry, -Carotid arteries,distended veins
lesions, inflammation PALPATE
Palpate -Carotid pulse
Posterior/Lateral Chest Breathing Sounds
-temporomandibular joint for Pericardial Friction Rub =
pain, crepitus, movement INSPECT High pitched
-outer ear/mastoid for Scratching, grating or
-chest shape, symmetry, muscle, squeaking leathery
localized tenderness
motion, accessory muscle sounds at left Sternal
boarder
AUSCULATE Heart Murmur = swishing
Anterior Chest • begin at C7, move 5cm (2in) or whistling sound.
Rhonchi= snoring sound
Inspect down
-90 degree or less • Finish in axillary/midaxillary lines
-PMI(left midclavicular line @ 5th intercostal)
-shape, symmetry Barrel chest = lung disease
-breast/nipple color, symmetry, skin, edema,
rashes, lumps
-axillary for lumps, rashes, pigments
ABDOMEN Positions
Auscultate
-begin at Inspect-ausc-palp-prec Supine =relaxation of abs
aortic= 2nd inter space on right side INSPECT Dorsal
Pulmonary= 2nd intercoastal left of the sternum -color, skin, lesions, distended veins, Recumbent=Generalis,
Tricuspid= 5th intercoastal left of the sternum pulsation, contour, shape, symmetry,
Mitral= 5th inter space left chest peristalsis, large veins Rectum , Catheter
AUSCULTATE Sims= rectum, vagina
—RLQ Prone= hip joint, posterior
-5 min. Thorax
PALPATE
-for tone and tender areas Lithotomy= Female genitalia
-painful area last rectum, papsmear
Knee chest= rectum & anus
LOWER EXTREMITIES
_ INSPECT
-skin color, condition, lesions, hair distribution, venous
distention, symmetry and contour, toe nails
PALPATE
-thighs down to feet
-temp, texture,moisture, tenderness
-posterior tibial & dorsalis pedis pulses bilaterall
-capillary on both feet
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller SigmaAnna. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $7.48. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
72042 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now