Assessment

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Author:
amcnutt
ID:
72195
Filename:
Assessment
Updated:
2011-03-10 23:40:50
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Head Toe
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Assessment
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  1. Head and Face (7)
    • inspect scalp and cranium
    • hair
    • skin
    • facial expression and symmetry (CN VII)
    • Facial sensation (CN V)
    • TMJ Palpation
    • Percuss Maxillary and Frontal Sinuses
  2. Eyes (9)
    • Inspect external structures
    • conjunctiva
    • sclera
    • corneas
    • PERRLA (CN III)
    • Corneal light reflex
    • visual fields by confrontation/or acuity (CN II)
    • Cover/Uncover Test
    • Six position of gaze (CN III, IV, VI)
  3. Ears (6)
    • inspect external structure
    • test hearing (voice) (CN VIII)
    • Rinne Test (CN VIII)
    • Weber Test (CN VIII)
    • Inspect Canal
    • Tympanic membrane
  4. Nose (6)
    • Symmetry/Skin
    • Patency of nostrils
    • Smell (CN I)
    • Nasal mucosa
    • Septum
    • Turbinates
  5. Mouth (9)
    • Lips
    • Buccal Mucosa
    • Gums
    • Palate
    • Floor of mouth
    • teeth
    • Tongue (CN XII)
    • Posterior pharynx and uvula (CN IX and X)
    • Grade tonsils
  6. Neck (9)
    • Supple/Skin
    • Masses/Tenderness
    • ROM
    • Muscle strength and CN XI (shoulders and head resistance)
    • Lymph Nodes
    • Thyroid gland
    • Trachea
    • Carotid pulses
    • Auscultate carotids
  7. lymph nodes in neck (8)
    • Preauricular
    • Postauricular
    • occipital
    • submandibular
    • submental
    • anterior cervical
    • posterior cervical
    • supraclavicular
  8. Chest (10)
    • Resp unlabored accessory use
    • configuration of thoracic cage
    • skin (ant. and post)
    • turgor
    • symmetric expansion
    • masses (ant and post)
    • tenderness (ant and post)
    • Tactile fremitus (ant and post)
    • percuss lung fields (ant and post)
    • auscultate breath sounds (ant and post)
  9. Heart (7)
    • apical pulse location
    • Auscultate diaphragm (5 spots)
    • S1 S2 RRR
    • Gallops
    • Rubs
    • Ausculate bell (5 spots)
    • Murmors
  10. Abdomen (9)
    • Contour
    • Skin characteristics
    • umbilicus/hernia
    • bowel sounds
    • percussion sounds
    • palpation (soft, NT, Non-distended)
    • Palpation of: liver, spleen, kidneys)
    • Aortic pulsation

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