242 CPE Head To Toe Assessment

242 CPE HEAD TO TOE ASSESSMENT 1. Knock, introduce yourself, wash your hands, provide privacy. verify identity. 2. Check for LOC, alert and oriented x ?? 3. Explain head to toe, ask if its ok to continue 4. First thing ask for a urine sample, 5. As she gets up you asses her movement, ask to bend over to assess the curvature of the spine to check for any abnormal curvatures, if the patient was laying for too long you will also check for sacral edema. 6. AS she walks to restroom you assess her gait and posture. 7. When she comes back, have gloves on to assess( COACH) urine sample 8. Coach: color, odor, amount, consistency, how often is it painful? 9. You ask if it was difficult to go to the restroom, starting or stopping? 10. Take off gloves, wash your hands, put gloves on again!! 11. ASSESS the head, your checking the hair distribution that is even and possible infestations, possible bald spots, any lumps, any deformities, any open areas. 12. Take gloves off !!! 13. Get penlight to check eyes, nose and ears. 14. Ears for wax impaction, 15. Eyes, pull down gently the conjunctiva to make sure its pink and moist, check sclera to be white. 16. Tilt head back to check nares, to make sure there are not blockages or foreign objects and the size of the nares are symmetrical. 17. Open pt mouth, you want to make sure you look deep, for any loose teeth, open sores, any lesions any pain in their ? 18. NEXT is TO assses THE CRANIAL NERVES !!!! 19. Cranial never 1 olfactory nerve, have pt close their eyes and grab something they can smell. 20. Cranial never two optic nerve, have the pt read a letter from the little chart or to read clock. 21. Next is cranial nerve 3,4,6 oculomotor, trochlear, and abducens nerve, have pt follow penlight in 6 ways without moving head just moving eyes. Next ask if they have a history of migranes or seizures. Then shine the light and assess for PERRLA, Pupils equal, round, reactive to light and then tell them to look at the tip of your nose and have them to look to something behind you and then back to your nose, so if they do then pupils are accommodated to distance. 22. Next we going to assess cranial nerve 5 trigeminal nerve, ask them to chew, and your going to feel the head for the muscles that are responsible for chewing. Have them close their eyes and always assess sensations hard/soft on the face, arms, legs, and feet. 23. Next is cranial nerve number 7 Facial nerve, have pt raise their eyebrows, give a big smile and big frown, if so then facial nerve is working great, 24. Next is cranial nerve number 8, acoustic nerve, grab a cotton ball and rub on one ear and say a word on the other ear and say a word they have to repear, then repeat on the same thing on opposite ear. 25. Next is cranial nerve number 9, glossopharyngeal nerve, ask the pt to swallow and assess that they did. 26. Next is cranial nerve number 10, Vagus nerve, ask pt to say “AH” checking gag reflex. 27. Next is cranial number 11, spinal accessory nerve, have the pt shrug their shoulders or put your hands on pt shoulders and for them to raise them. Hold their head and have them move their head to the side. 28. Next is cranial nerve 12, Hypoglossal, stick tongue out & move right & left 29. Next is LUNG ASSESSMENT, 30. First looking for equal, rise and fall of the chest, no difficulty breathing, stand to the side and looking for AP diameter which means to see that the chest is not protruding. 31. Next listen to the tracheal lung sounds, have pt breathe deeply through the mouth, next feel for the clavicle and feel for the space right about it and listen for bronchial sounds and repeat on the other side. 32. Next follow my clavicle in to my right sternal border and listen to Broncho vesicular sounds. 33. Then go to left sternal border and listen to Broncho vesicular sounds. 34. Move down and over and still listening to Broncho vesicular sounds. 35. Following and assessing the costal angel I’m going to listen to vesicular sounds. 36. Then identify the suprasternal notch, then lower I’m going to feel a dip for my angle of louis. 37. Then on pt back, find scapula and above it we are going to listen to bronchial sounds. Repeat on the other side. 38. Feeling the scapula and the spine between the two I’m going to listen to bronchial vesicular sounds. Then go down at the costal angle and listen to the vesicular sounds. 39. Then heart valves. 40. Aortic Valve: 2nd intercostal space to the right of the sternum 41. Pulmonic Valve: 2nd intercostal space to the left of the sternum. 42. ERBS point: gives us the maximum sound of S1 and S2, 3th intercostal left of sternum 43. Tricupid valve: 4th intercostal space lower left of the sternal border 44. Mitral valve: Left 5th intercostal space midclavicular 45. When in mitral location listen to apical heart rate for one full minute and your looking for regularity. 46. Next look at upper extremities for strength, hair distribution, color, temp, cap refill, assessing palms looking for any open areas check finger nails. 47. Then assess lower extremities and assess strength, 48. Put gloves on and check feet for strength as well. 49. Then have patient lay down and have them be in a 30 degree angle and assess for JVD. 50. Next assess all pulses. 51. Check temporal pulses at the same time. 52. Carotid pulses one at a time! 53. Brachial pulses, radial, and verbalize you did your femoral pulses. 54. Next is popliteal pulses, 55. Put gloves and assess the posterior tibialis pulses and the top of the feet for the dorsalis pedis pulse. 56. Then inspect the feet, checking for color, temp, cap refill, any sings of edema, swelling, any ulceration, any open areas. Checking the skin its not dryed and cracked, check if the nails are well maintained, inspect between toes for open areas or toes. 57. Then take of gloves and wash your hands. 58. Then im going to assess the abdomen area. 59. Look at the abdomen for any abnormalities, any masses, lesions, size, contour, and symmetry. 60. Then im going to listen to the abdomen. 61. Start at RUQ, LUQ, LLQ, RLQ. If bowel sounds are hypoactive I will listen for a full minute or until I hear bowel sounds., If you hear no bowel sounds you have to listen for up to five minutes, if bowel sounds remain absent notify the doctor. 62. Then im going to palpate the abdomen gently, using the whole palm of my hand, while doing it I will be looking for any grimacing, or painful signs, let pt know to tell you if anything hurts or if its uncorfortable. Feeling for any tenderness, or distention 63. Run your hand over the pubic area, feel for the distention/ tenderness of the bladder. 64. Ask pt for their last BM. Ask how was it, soft, formed how much? Any complains? COACH it. 65. ALL done, wash hands, make pt comfortable, call light in reach, bed in lowest position, side rails up, provide privacy.