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NUR303 Head To Toe
| Term | Definition |
|---|---|
| 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
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