HEAD TO TOE NURSING ASSESSMENT

Assignment: HEAD TO TOE NURSING ASSESSMENT
Required Course Materials
Author: Rhoads
Title: Advanced Health Assessment & Diagnostic Reasoning: Featuring Kognito
Simulations Include Navigate 2 Premier Access, Fourth Edition
Publication Date:
ISBN: 9781284217292
Author: Banasik, J.& Copstead, L.
Title: Pathophysiology (7th ed.)
Publication Date:
ISBN: 9780323354813
Evolve Health Assessment DVD Series Viewing this DVD series is required and will be available on the course Blackboard shell; separate purchasing.

HEAD TO TOE NURSING ASSESSMENT

Please find attached the teacher\’s intrusctions.
“more infos given by the professor. You Tube video – Physical assessment interview https://www.youtube.com/watch?v=GUAdouU7pGI

The Physical Examination

Please note: This guide is provided as a general template, you will need to add detail based on your specific patient health history
General survey- general statement of health, includes vital signs
Skin- wet, dry, color, lesions, moles, scars
HEENT- HEAD- hair, scalp, skull, face EYES- visual acuity, PERLA, conjunctiva, ocular fundi EARS- auricles, canals, drums, acuity, if acuity is diminished check lateralization with Weber test, bone conduction with Rinne test. NOSE- nasal mucosa, septum, turbinates, sinuses. THROAT- lips oral mucosa, gums, teeth,
palate, tonsils and pharynx
Neck- palpate the cervical lymph nodes, note any masses. Feel for deviation of trachea, observe the sound and effort of the patient’s breathing, palpate the thyroid gland Back- inspect and palpate the spine and muscles of the back, observe for shoulder height for symmetry Posterior Thorax and lungs- inspect and palpate the muscle and spine of the upper back. Inspect, palpate and percuss the chest. Listen to breath sounds, identify and adventitious sounds Breast- we are not assessing Cardiovascular- Jugular venous pulsations, inspect and palpate the carotid pulsations, listen for carotid bruits. Note the apical impulse, listen at the apex and the lower sternal border with the bell. Listen for the first and second heart sounds and for any splitting or the second heart sound. Listen for any murmurs
Abdomen- Inspect, auscultate, and percuss the abdomen. Palpate lightly, then deeply. Assess the liver
and spleen by percussion and then palpation. Try to feel the kidneys and palpate the aorta and its
pulsations. If you suspect kidney infection, percuss posteriorly over the costovertebral angles
Lower Extremities- Examine the legs, assess 3 systems while the patient is supine and again when the
patient stands: Peripheral vascular system, musculoskeletal system, and Nervous system
Nervous system- This consists of 5 segments listed below
 Mental Status- orientation, mood, thought process, insight and judgment, abstract thinking
 Cranial Nerves- II-VII
 Motor System- muscle bulk, tone, strength. Cerebellar function; rapid alternating movements,
point to point movements, and heel to shin and gait
 Sensory System- pain, temperature, light touch, vibration, discrimination, compare right to left
sides
 Reflexes- biceps, triceps, brachioradialis, patellar, Achilles deep tendon reflex, plantar is optional

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