Weber ch 28 Head to Toe

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Weber ch 28 Head to Toe
2011-11-28 10:54:00
Weber 28 Head Toe

Weber ch 28 Head to Toe
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  1. Getting Started
    • •Systems approach v. head-to-toe
    • •No “right” way
    • •Comfortable routine / systematic
    • •Takes time/practice
    • •Basic Assessment Techniques:
    • –Inspection
    • –Palpation
    • –Percussion
    • –Auscultation
  2. Preparation
    • •Gather equipment
    • •Wash hands/Universal standard precautions
    • –Gloves for bodily fluids, mucous membranes & nonintact skin
    • •Introduce self
    • •Explain procedure & throughout
  3. General Survey
    • •General Appearance
    • –Apparent v. actual age
    • –Physical & sexual development plus behavior
    • –Overall skin color & A-F warning signs
    • –Dress, grooming & hygiene
    • –Body build/muscle mass

    • •Vital Signs
    • –T, P, R, BP & 5th VS/Pain

    • •Body Measurements
    • –Ht, Wt., waist & mid-arm circumference
    • –BMI
  4. Erikson’s developmental stages (adults)
    Young adult: intimacy v. isolation (affiliation & love)

    Middlescent: generativity v. stagnation (production & care)

    Older adult: ego integrity v. despair (renunciation & wisdom)
  5. Inspect Body Build
    • Ectomorph = slight body build
    • Mesomorph = medium/well-proportioned bod
    • Endomorph = large body build (McDonald’s supersized)
  6. Mental Status
    • •Observe level of consciousness (LOC)
    • –Assess posture & body movements
    • –Assess facial expressions & mood
    • –Assess speech & thought processes/ perceptions

    • •Assess cognitive abilities -
    • –Oriented x3 to person, place & time
    • –Concentration
    • –Recent vs. remote memory
    • –Recall unrelated information
    • –Abstract reasoning
    • –Judgment
    • –Visual perception/copy figures
  7. Head & Face
    • •Inspect & palpate head for size, shape & configuration
    • Normocephalic = appropriately proportioned
    • Microcephalic = abnormally small head
    • Macrocephalic = abnormally large head, listen to temporal arteries with bell of stethoscope for
    • bruits (normally none)
    • Acromegaly = enlarged bony structure due to increased growth hormones (esp. hands, feet, nose & ears)

    •Inspect hair consistency, distribution & color

    •Inspect facial features for symmetry & skin color

    •Palpate temporal arteries

    •Palpate temporomandibular joint for tenderness, swelling or crepitus

    •Assess CN VII/facial by smiling showing teeth, blowing out cheeks, raising eyebrows & closing eyes

    •Assess CN V/trigeminal for acial sensation (dull vs. sharp)
  8. Eyes
    •Assess eye alignment

    •Inspect conjunctiva, sclera & lacrimal apparatus

    • •Test vision
    • –Snellen distant vision or near vision (reading) (CN II/Optic)
    • –Visual fields for peripheral vision

    •Test corneal light reflex & PERRLA

    •Perform cover – uncover test

    •Test corneal reflex (CN V & VII)
  9. Ears
    •Inspect auricle (helix to lobule) for shape, position, lesions, discoloration or discharge

    •Palpate auricle for tenderness or masses

    • •Perform hearing tests:
    • –Whisper test
    • –Finger rubbing
    • –Weber test for hearing
    • –Rinne test for air v. bone conduction
  10. Nose & Sinuses
    •Inspect external nose for color, shape & consistency

    •Palpate nose & sinuses for tenderness

    •Assess patency of nares

    •Identify smells with eyes closed (CN I)

    •Transilluminate sinuses with penlight
  11. Mouth & Throat
    •Inspect lips for color, consistency & lesions

    •Inspect & count teeth

    •Inspect gums, oral mucosa for color & lesions

    •Inspect tonsils for color, size, lesions or exudate

    •Check that uvula rises & + gag reflex (CN IX)

    •Inspect & palpate tongue for color, moisture & resistance against tongue blade (CN IX & XII)

    • •Identify tastes on tongue with eyes closed (CN VII & IX)
    • CN VII taste anterior 2/3 tongue (sweet & salty)
    • CN IX taste posterior 1/3 tongue (bitter & sour
  12. Neck:
    •Inspect neck for lesions, masses, swelling & symmetry

    •Assess JVD Assess for JVD/jugular venous distention by laying flat to see (shine penlight) then raise to 45 degrees (should disappear)

    •Palpate trachea

    •Palpate carotid arteries & auscultate for bruits

    •Test neck ROM

    •Palpate lymph nodes (pre & post auricular, occipital, tonsillar, submandibular, sub-mental, cervical & supraclavicular)
  13. Chest/ Respiratory
    •Inspect chest shape, color, use of accessory muscles, bulges or retractions

    •Palpate for tenderness, crepitus, masses, lesions or fremitus

    •Evaluate chest expansion (T9-10)

    •Percuss for tone bilaterally

    •Ausculate for breath sounds

    •Check respiratory rate, rhythm & pattern

    •Check skin turgor over sternum/clavicle area

    • Talk about rate, rhythem, and pattern
    • #, unlabored,

    If crepitus or fremitis know what you would do next if you detected it
  14. Chest/ Cardiovascular
    • •Inspect & palpate chest for lifts, heaves & thrills
    • Lift = sustained thrust felt during systole due to L
    • ventricular hypertrophy
    • Heave = more prominent thrust felt during systole due to
    • L ventricular hypertrophy
    • Thrill = palpable fine vibration over precordium due to
    • aortic stenosis

    •Inspect & palpate PMI/apical impulse

    •Auscultate heart sounds

    •Check heart rate, rhythm & pattern

    •Auscultate with bell for extra heart sounds (S3, S4) or murmurs
  15. Upper Extremities
    •Inspect arms for skin color, texture, masses & lesions

    •Shrug shoulders against resistance (CN XI)

    •Palpate extremities for tenderness, swelling & temperature

    •Palpate epitrochlear lymph nodes

    •Palpate pulses 0 to 3+/4+ (brachial, radial & ulnar)

    •Assess capillary refill & clubbing

    •Test ROM elbows & fingers

    •Test reflexes (biceps, triceps & brachioradialis)

    •Test rapid alternating hand movement

    • •Sensation testing with eyes closed:
    • –Touch, pain, temperature
    • –Position of fingers
    • –Stereognosis/objects
    • –Graphesthesia

    –2-point discrimination
  16. Abdomen
    • •Inspect skin color, vascularity, striae, lesions , & rashes
    • •Inspect location & contour of umbilicus
    • •Inspect abd. contour & symmetry
    • •Look for aortic pulsations or peristalsis
    • •Auscultate bowel sounds
    • •Auscultate vascular sounds
    • •Percuss for tone
    • •Palpate lightly before deeply with pain last
    • •Abd. reflex
  17. Lower Extremities
    •Inspect legs for skin color, texture, temperature, masses, lesions & varicosities

    •Observe muscles & palpate tone

    •Note hair distribution - reduced circulation

    •Palpate pulses (femoral, popliteal, dorsalis-pedis & posterior tibial)

    •Palpate for edema

    •Assess capillary refill

    •Test sensation, vibration & 2-point discrimination

    •Test ROM & Homan’s sign (pain when examiner dorsiflexes the foot when knee is at 90 degrees)

    •Perform heel to shin test - laying down
    •Inspect & palpate spine (touch toes)

    •Observe gait for stability, arm swing & posture

    •Walk heel-to-toe/tandem

    •Hop on 1 leg

    •Perform Romberg test

    •Perform finger-to-nose