Head to Toe Assessment

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Head to Toe Assessment. https://www.youtube.com/watch?v=cP4zgb9H3Cg Generalized patient assessment Work from the head down Know normal = identify abnormal . Palpate Head and Neck. Checking for lumps and bumps any lesions or tenderness. Check the ears. Use an Otoscope. - PowerPoint PPT Presentation

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Pupil Check

Head to Toe Assessmenthttps://www.youtube.com/watch?v=cP4zgb9H3CgGeneralized patient assessmentWork from the head downKnow normal = identify abnormal Palpate Head and NeckChecking for lumps and bumps any lesions or tenderness

Check the earsUse an Otoscope

Check Nose and MouthIs there redness, swelling, drainage, abnormal bumps, color, lesions Pupil CheckPERRLA (pupils, equal, round, react to light, accommodate)Accommodate ability of eyes to focus on objects that are close up and faraway

Neck Veins

Heart Sounds

Auscultation of Breath SoundsNormalCrackles- light crackling, bubblingRhonchi- coarse cracklesWheezes- creaking, whistling, high pitched

Pulse ChecksStrength of pulse0 = absent1 = barely palpable2 = easily palpable3 = full4 = Bounding pulseCapillary Refill< 3 second Blood returnThe rate at which blood refills empty capillariesIndication of dehydration and peripheral perfusion

Reflexes

Reflexes

Reflexes

Homans Sign

Skin Turgor1-3 second returnUsed to assess the degree of fluid loss or dehydration

Skin Breakdown Check

Peripheral EdemaCaused by fluid in the tissues tends to be dependent0 no edema+1 Trace indentation rapid return to normal+2 Mild indentation rebounds in a few seconds+3 Moderate, 10-20 second to return to normal+4 Severe, >30 second to return to normalPeripheral Edema

Bowel SoundsAbsent, Hyperactive, Hypoactive, NormalTo state absent you must listen for 5 min in each quadrant

Palpate the abdomenTo be done after listening to bowel sounds

PainLocation, duration, sensation, intensityWhat makes it worse or better

Baby Reflexes

Assessment Song