NUR 3204 Final Head-to-Toe Exam

Final Head-to-Toe Exam  Knock on the door  “Hi, my name is Kevin and I’m going to be your nurse, and today we’re going to be doing a head-to-toe assessment.”  WASH HANDS and ask the patient for 2 identifiers – first and last name, and DOB 1. Patient must be seated facing you! 2. Patient appears as stated age, has tan skin color, is in a relaxed, upright, and sitting posture and position, and appropriate dress and personal hygiene. 3. I’m inspecting the head/skull for size 4. I’m palpating the head/skull for lumps 5. I’m inspecting the scalp for scaliness and lesions (move patient’s hair around with hands) 6. I’m inspecting the hair for color, quantity, and distribution (black, long, evenly-distributed) 7. I’m inspecting the face for symmetry and swelling. 8. I’m inspecting the facial skin for color and condition. 9. I’m going to test the facial nerve – ask patient to smile and frown 10. Inspect the area anterior to the ear (TMJ – temporomandibular joint) for swelling 11. Palpate TMJ for any tenderness and swelling – any pain or tenderness? 12. Test ROM of the TMJ – observing for pain, crepitation, and limited movement – keep hands on TMJ while testing! a. Open and close mouth b. Protrusion (move lower jaw forward) c. Side-to-side motion 13. Inspect the eyebrows for symmetry, scaliness, and lesions 14. Inspect the eyeballs for symmetry and alignment 15. Inspect the eyelids for lesions and edema. 16. Inspect the sclera and palpebral conjunctiva of the lower lids for lesions and swelling. 17. Inspect the pupils for size, shape, and equality. This study source was downloaded by from CourseH on :51:46 GMT -06:00