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Physical Head to toe
Pysical assessment
| Question | Answer |
|---|---|
| General Survey Observe for | Appear stated age, level of consciousness, skin color, posture, position, personal hygiene, mobility, Physical deformities, Mood, signs of distress |
| Vital signs | Height, weight, oral temperatue, radial pulse: rate, rhythm, quality, equality, Respiration: Rate, rhythm, depth, Blood pressure |
| Head and Face (face) | Inspect: color, pigmentation, and lesions.Palpate: moisture, temperature, texture, mobility, and turgor |
| Head and face (hair) | Inspect: quantity and distributionpalpate: texture |
| Head and Face ( Scalp) | Inspect: Scaliness, lumps, nevi, lesionsPalpate: general size, contour noting deformities, depressions, lumps, or tenderness |
| Head and Face ( Face) | Inspect: Facial expressions, symmmetry, involuntary movements, edema, and masses |
| Head and face (TMJ) | Palpate TMJ ( temporomandibular joint) for tenderness,Test for limited ROM, crepitation. |
| Eyes | Measure Visiaul Acuity by snellen or reading print. |
| Eyes | Inspect: position, and alignment |
| Eyelids | Inspect: position, edema, color, lesions, condition, and direction of eyelashes. |
| Scleras and palebral conjunctiva of lower lids | Inspect: color, nodules, and swelling |
| Eyes ( corneas and lens) | inspect: opacities |
| Test range of extraocular movements | 6 cardinal direction |
| Eyes ( Pupil) | Inspect: size, shape, equality |
| Test direct and consensual light reaction | Direct: flash light in one eye and check the pupil responce of the eye,Consensual: flash light in one eye and check the opposite eye for reaction. |
| Test for accommodation | have pt look at an object at a distance and then look at your finger in front of them. |
| Test for convergence | move the finger closer to the pt and see how eyes react |
| Test peripheral vision by confrontation | do the bunny ears moving fingers around pts ears, then over head around face, and bottom of head. |
| test to determine corneal light reflex | use pen light ( to see the reflection of the light on the pupils) |
| Ears (auricles and tragus) | Inspect: deformities, lumps, and skin lesionsPalpate: tenderness |
| Ears ( mastoid process) | Palpate: separately for tenderness |
| Ear ( external canal) | Inspect: discharge, foreign bodies, redness, or swelling ( use otoscope) |
| Ear ( tympanic membrane) | Inspect: color and contour ( use otoscope) |
| Auditory Acuity | Perform whisper test |
| Nose (external nose) | Inspect: deformity and asymmetry |
| Test patency of nares | oclude one nare and have pt breath and in. then oclude the other nare and have pt breath in |
| Nose ( mucosa) | Inspect: color, swelling, exudate, bleeding, moisture. (use otoscope) |
| Nose (septum) | inspect: inflammation, abnormalities, perforation, deviation (use otoscope) |
| Nose ( maxillary/ frontal) | Palpate: sinuses for tenderness |
| Mouth (lips) | Inspect: color, moisture, ulcers, lumps, cracking, scaliness |
| Mouth ( oral mucosa) | Inspect: color, ulcers, white patches, or nodules |
| Mouth ( gums) | Inspect: color, swelling, or ulcerations (use pen light and tongue blade) |
| Mouth (teeth) | Inspect: presence, discoloration, misshapen, abnormal position, or looseness ( use tongue blade and pen light) |
| Mouth (Tongue) | Inspect: color, texture, nodules, or ulcerations ( all 4 sections) ( use tongue blade and pen light) |
| Mouth ( hard palate) | Inspect: Color and architecture (use pen light and tongue blade) |
| Mouth (soft palate, uvula, tonsils, posterior pharyngeal wall) | Inspect: exudate, swelling, ulcerations, induration, or tenderness ( use penlight and tongue blade) |
| Mouth (uvula) | Inspect: position and movement ( if it raises medline) ( use penlight and tongue blade) |
| Test cranial nerve VII | Motor- frown, smile, puff out cheeks, show teeth |
| Neck | Inspect: symmetry, massess, or scarring |
| Neck (thyroid) | Inspect: thryoid enlargement using penlight |
| Neck (trachea) | Inspect: alignment (have pt swallow) |
| Neck ( lymphnodes) | Palpate: for enlargement, tenderness (palpate and name all 10) 1)preauricular,2)postauricular,3)occipital,4)tonsillar,5)submandibular,6)submental,7)superficial cervical,8)deep cervical chain,9)posterior cervical,10)supraclavicular |
| Neck | observe: pain and crepitation Perform ROM: flexion, extension, lateral bending, rotation |
| Test muscle strength of neck | turning head against resistance |
| upper extremities | Inspect: overall symmetry |
| Upper Extremities | Inspect: skin color, lesions, hair distribution, edema |
| Upper extremities | Palpate: temperature, turgor, mobility |
| Upper extremities (nails) | Inspect: color, shape, lesions |
| Upper Extremities (nails) | Palpate: capillary refill ( at least two fingers on each hand) |
| Upper Extremities (shoulder) | Inspect: swelling, deformity, muscle atrophy, or abominal postion |
| Upper Extremities (shoulder) | Palpate: for pain |
| Upper extremities ( ROM Shoulder) | Perform ROM: flexion, extension, internal rotation, abduction, adduction, external rotation. Observe for pain, crepitation |
| Upper extremities ( Shoulder) Test muscle strength | shrug against resistance |
| Upper extremities ( elbows) | inspect: nodules, and swellingPalpate: tenderness, swelling, or thickening |
| Upper Extremities ( elbows) ROM | Perform ROM: flexion, extension, internal rotation, abduction, adduction, external rotation.Observe: pain, crepitationTest muscle strength: flexion, extension against resistance |
| Upper extremities (hands/ wrists) | Inspect: swelling, redness, nodules, deformities, and muscular atrophy |
| Upper extremities (wrists) | Palpate: swelling, bogginess, or tenderness |
| Upper extremities ( interphalangeal joints/ metacarpophalangeal joints) | Palpate: swelling, bogginess, or tenderness |
| Upper extremities (fingers) | perform ROM: flexion, extension, abduction, adduction, oppositionObserve: pain & crepitation |
| Upper Extremities (hands) | test hand for grip strength |
| Upper Extremities ( wrist) | Test ROM: flexion, extension, ulnar and radial deviationobserve for pain & crepitationTest muscle strength: flexion agains resistance |
| Posterior Thorax | Inspect: symmetry, countour, skeletal deformities |
| Posterior thorax ( skin) | Inspect: color, lesions, scarsPalpate: temperature, moisture |
| Posterior thorax | auscultate breath soundsIdentify: bronchovesicular & vesicular sounds normally heard |
| Posterior thorax | percuss for CVA tenderness |
| Breast and Axillae (central/ pectoral nodes) | palpate: enlargement and tenderness |
| Breast and Axillae | Inspect: w/ arms and hands at side; above head; pressed against hips to elicit pectoral contractionObserve: size, symmetry, dimpling, edema, prominent venous pattern, scars, lesions, skin color, and thickening |
| Breast and axillae ( areola/nipple) | Inspect: size, shape, direction, bleeding, discharge, lesions |
| Breast and axillaept lies down | Inspect axillae: lesionspalpate breast: in supine position for tissue consistancy, masses, tenderness |
| Breast and axillae (nipples/areola)pt lies down | Palpate: masses and discharge |
| Anterior Thorax | Inspect: symmetry, contour, skeletal deformities, Respiratory rate,and rhythm |
| Anterior thorax (skin) | Inspect: color, lesions, scarsPalpate: temperature, moisture auscultate breath sounds (identify bronchovesicular, bronchial, tracheal, vesicular sounds are normally heard) |
| Heart (coratid) | Palpate: rate, rhythm, equality. Palpate one side at a timeand well below the upper border of the thyroid cartilage. |
| Heart (apical) | auscultate: rate, rhythm, listem for 1 full minuteand state rate. |
| Heart ( valve closure s1 and s2) | auscultate: aortic, pulmonic, ticuspid, & mitral valve.identify : where is S1 and S2 are heard loudest |
| Abdomen (skin) | Inspect: color, scars, striae, dilated veins, rashes, lesions |
| Abdomen ( umbilicus) | Inspect: contour, location, signs for inflammation, hernia |
| Abdomen | Inspect: contour, symmetry, masses, peristalsis, pulsations ( look from side as well)Auscultate: all 4 quadrants for frequency and character of bowel sounds (state would listen for at least 2min. over abdomen before stating absent) |
| Abdomen | percuss: all four quadrants for tympany and dullnessperform light palpation in all four quadrants for tendernes, masses, and guarding |
| Abdomen ( inguinal) | palpate: lymph nodes: tenderness, enlargement |
| abdmone ( femoral pulses) | palpate: rhythm, quality, equality |
| Lower extremities | Inspect: overall symmetry |
| Lower Extremities (skin) | Inpsect: color, lesions, hair distribution, edemaPalpate: tugor, temperature, texture, edema |
| Lower extremities ( nails) | inspect nails for color condition |
| Lower extremities ( hips) | inspect: swelling, enlargemnet, deformitypalpate: pain, tenderness, nodules, swelling, deformityTest ROM: flexion, extension, abduciton, adduction, internal rotation, external rotation, observe:pain and crepitation |
| Lower extremities (knees) | Inspect: swelling, enlargement, deformitypalpate: pain tenderness, nodules, swelling, deformityTest ROM: flexion, extensionobsereve: pain, crepitationTest muscle strength of knees: flexion and extension against resistance |
| Lower Extremities (feet/ankles) | Inspect: swelling, enlargement, deformityPalpate: pain, tenderness, nodules, swelling, deformityTest ROM: dorsiflexion, plantar flexion, inversion, eversion, and flexion of toesObserve: pain & crepitation |
| Lower Extremities (feet/ ankles) | Test muscle strength of ankles: dorsiflexion, and plantorflexion against resistance |
| Lower extremities (popliteal pulses) | palpate: rhythm, quality, equality |
| lower extremities (posterior tibial pulse) | palpate: rate, Rhythm, equality |
| lower extremities (dorsalis pedis pulse) | Palpare: rate, rhythm, equality |
| Lower extremities ( superficial reflex) | plantar (babinski) |
| Lower Extremities ( deep tendon reflex) | Biceps, triceps, brachioradials, patellar, achilles |
| Spine | Inspect: abnormal curvature (from back and side) |
| Spine | Test ROM: flexion, extension, lateral bending, rotation,observe: pain and crepitation |
| spine (spinous process) | Palpate: tenderness, paravertebral muscles for tenderness and spasms |
Created by:
jessg445
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