ha: head to toe assessment - becoming bri€¦ · ha: head to toe assessment pt laying/supine 5....

HA: Head to Toe Assessment

Intro,ptprivacy,handhygiene,PPE

1. GENERALSURVEY(L,A,H,H,P,P,S,S)a. LOC/A&Ob. Agec. Health&Hygiened. Physique&Posture/gaite. Speech&Sex

2. SKINa. Colorb. Temp.c. Moistured. Pigmentatione. ABCDE

3. HEADInspect:

a. size,shape,hairdistributionb. scalpforlesionsorpests

Palpate:a. Temp.Arteriesbilaterallyb. TMJ(nocrepitus/tenderness/LOM)c. Necksymmetryandlumpsd. Tracheamidlinee. Thyroidglandf. NoJVDg. CN5h. CN7i. Skinturgor

PalpateSinuseso Frontalsinuso Maxillarysinus

PalpateLymphnodes1. Preauricular2. Postauricular3. Jugulodigastric4. Submandibular5. Submental6. Occipital7. Superficialcervical8. Posteriorcervical9. DeepCervical10. Supraclavicular

OtoscopeforEars&NostrilsOccludeNostrils(oneatatime-breathein)PERRLA

c. PupilsEqualRoundandReactivetoLightandAccommodation

d. FollowpenlightinHformatione. Accommodation

OpenMouthw/penlightf. Mucousmembraneg. Tongue(9,10,12)

Shouldersh. CN11-shouldershrugandresistanceon

faceuponturning4. CARDIO&LUNGSInspect:

a. Skin,Facialexpressionb. Resp.Characteristics(L)c. Symmetry&Shape(B)d. APRatio(L)

Palpate:a. Chestwall(B)b. Heavesorpalpablethrills(CV)c. Tactilefremitus(L)*d. Symmetricalexpansion(L)

Auscultate:a. APETMb. Murmursc. PMI(rate/rhythm)d. 10anterior(L)–B/BV/V**e. 8posterior(L)**f. Bronchophony(L)*g. Symmetricalexpansion(L)**h. PALPATEspinousprocesses

HA: Head to Toe Assessment

PTLAYING/SUPINE

5. ABDOMENInspect:

a. Skin,Facialexpressionb. Symmetry&Shapec. Contour

Auscultate:4QsPercuss**:

a. 4QsofAbdomenb. Lungsc. Liver

Palpate:4Qs(LightthenDeep)Specialtests:

a. Murphys(Holdliver)*b. KidneySqueeze*c. Blumberg/Rebound(deeppalpation/release)*

6. BLEa. Skin,hair,temp.,symmetryb. Toeclubbing,lesions,toecap.Refill**c. Edemad. Leg/Feetsensatione. AskinsteadofdoingHomans*f. ROMforlegs/hipsg. BangHeel(shootingpain,DF/PF)*h. BabinskiReflex*

ROMtestsforlegs(seevideofortechnique)

BRINGPTUPMANUALLYTOWATCHJVD

7. PULSESa. FingerCapRefillb. Radialc. Brachial**d. Mod.Allen’sTest(releaseulnarartery)*e. EpitrochlearNodesf. Popliteal**g. Tibialh. Dorsalispedis**

8. BUEa. Sterognosis&graphosis*b. Fingerresistancec. Squeezemyfingerd. PushandPullArmse. Behindbackandpushwithhandsf. ChintoNeck/back/sides

9. REFLEXES*a. Biceps&Triceps*b. Brachio*c. PatellarandAchilles*

PTSTANDING

10. Balancetestsa. Heeltoshinb. Closeeyesandeachfingertonosec. Shakewhileeyesclosed*openeyesafter*d. Armsoutandupbehindheade. Touchtoesandbendbackwardsf. Squatg. Duckwalkawayh. Walkheeltotoebacki. Walkonheels/toesj. Kneetochestandkneebackk. Spinetwist