Head to Toe Flashcards
Begin exam
Safety/Environment
hand hygiene
PPE
introduce
patient identification
Suction, O2, and ambu-bag present
Vital signs
Pulse
Temp
BP
RR
Pulse ox
Pain
Head and Neck, neuro
Visual inspection
Affect
Alertness
Orientation x 4
Pupils (PERRLA)
Facial symmetry
oral mucosa/teeth
dentures?
chew and swallow?
Chest/Thorax
visual inspection
note breathing quality
cough?
Sputum?
Auscultate lungs
Auscultate heart
Abdomen
visual inspection
bowel sounds
Appetite?
Nausea/vomiting?
Last BM and description
Genitalia
visual inspection
voiding ability
urine assessment
Upper extremities
Visually inspect
Strength
Radial pulses
cap refill
edema?
sensation
Lower extremities
visually inspect
strength
pedal pulses
cap refill
edema
sensation
End of exam
call light and how to use
bedside table
side rails up
remove clutter
bed low and locked
Cranial Nerve 1 Olfactory
Smell something with eyes closed
Cranial Nerve 2 Optic
Test vision with charts
cover eye and do counting fingers
Cranial Nerve 3 Oculomotor
inspect eyelids for drooping
Do 8 point visual movement test
Cranial nerve 4 trochlear and Cranial nerve 6 abducens
Do 8 point visual movement test
cranial nerve 5 trigeminal
inspect the face for muscle atrophy and tremors
palpate jaw muscles for tone and strength while clenching teeth
touch and pain
Cranial nerve 7 facial
facial symmetry
