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NUR303 Head To Toe

Skin color; turgor; temperature; moisture
Head Hair (distribution, texture); face- symmetry- eyebrows, eyes, nasolabial folds, sides of lips; TMJ (tender, clicking)
Eyes pupil size (3-5mm); accommodation; pupillary light reflex; red reflex; visual fields of confrontation (CN II); Diagnostic Positions Test (CN III, IV, VI)
Ears Auricle (tender, lesions, swelling); ear canal (edema, discharge, erythema, tender); TM (color, intact, cone of light, position); Conversation Test (CN VIII); Whisper Test (CN VIII)
Nose septum (intact, not deviated); turbinates (color, swelling, polyps); mucosa (color, moist)
Mouth Lips (moist, lesions); tongue (midline, pink, moist, no leukoplakia) (CN XII); mucosa (moist, pink, leukoplakia); tonsils (grade, crypts, color)
Neck carotids(palpate each and grade);thyroid(enlarged, nodules);lymph nodes(preauricular, post auricular; tonsillar, submandibular, submental);trachea(midline);ROM of neck (lateral bending, flexion, extension, hyperextension & rotation);muscle strength(CN XI)
Cardiac S1, S2 (where do you hear it best and which valves are closing); pretibial edema, peripheral pulses (radial, dorsal pedis, posterior tibial); capillary refill
Lungs symmetrical chest expansion; AP diameter; Breath sounds (listen to posterior, anterior, identify any adventitious sounds)
Abdomen contour; hernias (half crunch); bowel sounds (listen to BS x4); palpation in all 4 quadrants; CVA
Extremities muscle strength- upper (arms, wrists), lower (thighs, feet); range of motion- upper (shoulders, elbows, wrists, fingers); lower (thigh ankle, feet)
Neurological Romberg; rapid alternating movements (RAMS)- 1 upper & 1 lower; reflexes (radial patellar) (grade); spinothalmic tract (pain or light touch); posterior column tract (vibration or position); tactile discrimination (stereognosis or graphesthesia)
Hair distribution, texture
Face symmetry- eyebrows, eyes, nasolabial folds, sides of lips
TMJ tender, clicking
Pupil size 3-5mm
Visual fields of confrontation CN II
Diagnostic Positions Test CN III, IV, VI
Auricle tender, lesions, swelling
Ear canal edema, discharge, erythema, tender
TM (tympanic membrane) color, intact, cone of light, position
Conversation Test CN VIII
Whisper test CN VIII
Septum intact, not deviated
Turbinates color, swelling, polyps
Mucosa color, moist
Lips moist, lesions
Tongue midline, pink, moist, no leukoplakia
Mucosa moist, pink, leukoplakia
Tonsils grade, crypts, color
Carotids palpate each and grade
Thyroid enlarged, nodules
Lymph nodes preauricular, post auricular, tonsillar, submandibular, submental
Trachea midline
ROM of Neck lateral bending, flexion, extension, hyperextension & rotation
Muscle Strength CN XI
S1, S2 where do you hear it best and which valves are closing
Peripheral pulses radial, dorsal pedis, posterior tibial
Breath sounds listen to posterior, anterior, identify any adventitious sounds
Hernias half crunch
Bowel sounds listen to BS X4
Muscle Strength- Upper arms, wrists
Muscle Strength- Lower thighs, feet
Range of Motion- Upper shoulders, elbows, wrists, fingers
Range of Motion- Lower thigh, ankle, feet
Rapid Alternating Movements (RAMS) 1 upper & 1 lower
Reflexes radial, patellar (grade)
Spinothalmic Tract pain or light touch
Posterior column tract vibration or positions
Tactile discrimination stereognosis or graphesthesia
Created by: katelynreid