Summary
N265 Head to Toe Assessment Summary
- Course
- NURSING FUNDAMENTA
- Institution
- East Los Angeles College
Comprehensive and detailed summary on head to toe. *Essential Study Material!!
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INSPECT• Introduce yourself • Do you know where you are?
PALPATE • Wash hands
BLOOD PRESSURE:120/80 mmHg
• Do you know what month it is?
PERCUSS • Provide privacy O2 SATURATION: 95-100%
• Who is the current U.S. president?
• Verify patient ID and DOB • What are you doing here? TEMPERATURE: 97.8-99.1° F
• Explain what you are doing • A&O X4 = Oriented to Person, RESPIRATIONS: 12-20 breaths per min
• Inspect head/scalp/hair • Inspect and palpate
• Palpate head/scalp/hair • Palpate carotid pulse
• Check skin turgor (under clavicle)
FACE
• Inspect POSTERIOR CHEST
• Check for symmetry • Inspect
• To assess Cranial Nerve 7, check the following: • Auscultate lung sounds in posterior and lateral chest
– Raise eyebrows – Note any crackles or diminished breath sounds
– Smile
– Frown ANTERIOR CHEST
– Show teeth • Inspect:
– Puff out cheeks – Use of accessory muscles
– Tightly close eyes
– AP to transverse diameter
EYES – 6WHUQXPFRQILJXUDWLRQ
• Inspects external eye structures • Palpate: symmetric expansion
• Inspect color of conjunctiva and sclera
• PERRLA – Note any crackles or diminished breath sounds
– Pupils Equal, Round, Reactive to Light,
HEART
• Auscultate heart sounds (A, P, E, T, M)
with diaphragm and bell
– Note any murmurs, whooshing, bruits,
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