Head to Toe health assessment NURS 3120
Terms
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- Skin,Hair,and Nails
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examine each region. Inspect and Palpate.
Color:Cyanosis,jaudice,carotenemia,changes in melanin.
-Moisture:moist,dry,oily
-Temperature:cool,warm
-Texture:smooth,rough
-Mobility:ease with which a fold of skin can be moved. Decreased in Edema.
-Turgor:speed with which the fold returns into moved. Decreased in dehydration.
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Nails:
Inspect and palpate the fingernails and toenails
-color:cyanosis,pallor
-shape:clubbing
-any lessions:paronycfhia,onycholysis
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Hair
inspect and palpate the hair
-quantity:thin,thick
-distribution:patchy,or total alopecia
-lice or genders in hair - Head and Neck
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Head
INSPECT AND PALPATE THE SKULL
-check for any scars,bumbs or injury in head.
-check for head to be round related to body size.
Palpate the temperal artery above the zygomatic(cheek)bone between the eye and top of the ear
-have patient open the mouth and note normally smooth movement with no limitations and tenderness.
-inspect the face for swelling, or color changes
Neck
INSPECT AND PALPATE TEH NECK
-Head position is centered in the midline. The head should be held erect and still.
-ROM:Note any limitations of movement during active motion.
-Ask patient to touch the chin to the chest,turn to the right and left,try to touch each ear to the shoulder(without elevating shoulders)and to extend head backwards.
-lymphnodes:Using a gentle circular motion of your fingerpads, palpate the lymph nodes (illustration pg.281)
-palpate noduls, trachea, if head moves to right or to left it is a neurothorax - Eyes
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-Snellen eye chart(20 feet), determine if patient has (presbyopia,nearsighted, far sighted, or cross eye
-Ask patient to hold head steady and follow your finger,pen,or penlight only with the eyes.
-Corneal light reflex:Ask patient to stare at light. Note the reflection of the light on the corneas, it should exacly on the same spot on both eyes.
-check eyebrows to be present with no lesions or scaling
-eyelids and lashes instact with no redness,swelling,discharge,orlesions.
-Eyeballs to be in place in the socket
-conjunctiva:it looks glossy and moist. some blood vessels may show through transparent conjuntiva
-Lacrimal Apparatus (usually pink). light pink indicates anemia, hemoblobin less tahn 12 indicate anemia. - Ears
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-cerumen or wax
-check for size, shape, and to same level of eye.
-pull ear upto check for otitis in baby
-pull era up/down to check for otitis media in baby.
-Inspect ear using otoscope for any infection/cerumen.
-pull the pinna up and back to check for tenderness
-whisper to patient for hearing test. - Nose,Mouth,and Thoat
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Nose
INSPECT AND PALPATE THE NOSE
-check for any ulcer inside nose
-inspect for any deformity, inflamation, or skin lesions
-Test the patency of the nostrils by pushing each nasal wing shut with your finger while asking the person to sniff inward throuth the other naris.
*use the otoscope to chevck inside nose.
-Observe the nasal septum for deviation.
Palpate the sinus area for tenderness
Mouth
-inspect the teeth
-inspect the gums for swelling,or bleeding
-inspect for any
dryness,color,cracking,lesions or chop lips.
-inspect the tongue for color,surface charateristics and moisture. (pink,roughened,saliva present).
-inspect for any white patches or lesion.
Throat
-inspect tonsils for non swelling
-Inspect for tonsils to be pink in color
-Anterior hard palate is white/posterior hard palate is pink and there is no swelling - Breasts
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INSPECT THE BREASTS
-Note symetry of size and shape (letf usually slighly larger than right.)
-skin:smooth and of even color with no edema present
-inspect the nipple:it should be in place in teh same plane and on both breasts.
-inspect for signs of cancer (A,B,C,D,E,)(see handout)
- - Thorax and Lungs
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Thorax
-Note the shape and configuration of the chest wall.
-The spinous process shoul appear in a straigh line.
-Note position person takes breath
-Assess skin color and condition
-palpate the posterior chest
Lungs
-Ausculate at tap in S direction in middle line in front and back (P,A,tri,mitral). - Heart
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-palpate each caratid artery medial to the sternomastoid muscle in the neck
-feel the amplitude of the pulse
-Ausculate the caratid artery
-Inspect the jugular venous pulse
-Estimate the jigular venouse preassure (abn above 3cm at 45 degrees occur with heart failure, perform hepatojigular reflux.
-palpate the apical pulse (using one finger and asking to exhale then hold it.
-percussion
-Auculate from s1,s2
-listen for murmurs with bell
-change position,roll pt to left listen with bell for diastic filling ex.s3,s4
-Ausculate sitting upand ask to exhale use diaphragmfirmly press at the base right and left sides check for soft high pitched early diastolic murmur of aortic or pulmonic regurgitation - Abdomen
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-Inspect abdomen for color, smoothness
-umbilicus is in midline
-Ausculate bowel sounds and vascular sounds
-percuss abdomen
-light and deep palpation (first four fingers)make the division, all organs except kidneys can not be felt.
-look for any inflamation
*start right lower - Muscleskeletal
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-palpate the hands
-inspect joint muscle using force
-elbow straight touch nose
-compare both shoulders
-cervical spine
-ROM
-inspect elbow for any deformity,redness,orswelling - neurologic System
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Test Cranial Nerves
CN1- Olfactory nerve
CN2- - Male genalia
- to be continue
- Female genatalia
- to be continue
- Anus, Rectum, and Prostate
- to be continue
- unknown
- Tell you later