Head to toe

Beginning Steps - 6

1. Provide Privacy

2. Introduce yourself

3. perform hand hygiene

4. verify client identification

5. determine if they have allergies

6. provide client education

General Survey - 12

1. assess level of consciousness

2. determine level of orientation x4

3. if the client is asleep or in a coma, does the client respond to voice, squeeze hand? or respond to pain stimuli

4. Determine the client’s body structure, height, weight, and bmi

5. observe posture and position

6. note facial expression and symmetry. Do they appear to be in pain

7. assess overall appearance of client

8. determine level of clients mobility

9. Note any mobility aids. mechanical equipment, dressings, ostomies

10. Observe mood

11. do vitals

12. Ask them to rate their pain

Skin Examination - 12

1. cover parts of clients body that are not being examined

2. inspect clients skin - cyanosis, jaundice, pallor

3. inspect clients head and scalp - inspect for critters

4. inspect moles, bruises

5. inspect and palpate the client skin for temperature, moisture, and texture

6. pinch client skin over the back of the hand to check skin turgor

7. Note hair distribution

8. check the skin for wounds or lesions

9. inspect for edema of the lower extremities

10. inspect the nails on the feet and hands

11. inspect the skin on posterior surfaces

12. check for blanching on any reddened areas

Head and Neck Examination - 12

1. Inspect the clients head for size shape, and hair distribution

2. examine the client’s face for symmetry of facial features

3. observe the skin of the client’s face, note color, dryness, redness, lesions, or involuntary movements

4. palpate the clients skull and hair

5. test cranial nerve 5 ask them to bite down, cranial nerve 6 by asking them to close their eyes and report when the sensation of a light touch is felt

6. examine the clients neck for contour and symmetry

7. palpate the clients carotid arteries one at a time

8. check thyroid enlargement

9. check ROM of neck

10. check jugular vein

11. locate and palpate the clients lymph nodes

12. check cranial nerve 11 by having the client turn their head to each side against resistance

Eye examination - 9

1. note distribution of eyebrows and eyelashes

2. look for drooping of the clients upper eyelids or sagging of the lower lids

3. note the color of the sclera and defects or inflammation

4. retract the clients the lower lids

5. inspect each iris and pupil. note size of pupils

6. shine a light onto each pupil and note response

7. use penlight to check eye alignment

8. check for extraocular movement

9. identify red reflex for each pupil

Ear, Nose, and Throat - 16

1. Inspect the clients ears for shape and placement, and discharge

2. check for tenderness by palpating the pinna and tragus of each ear

3. Test the clients hearing

4. use otoscope to inspect the clients ear canals and tympanic membrane check for redness, open areas, or foreign objects

5. palpate the clients frontal and maxillary sinuses. is there tenderness or inflammation

6. check the nose alignment and naris

7. check that the septum is midline and note the presence of any discharge

8. use a penlight to check the nasal mucosa for redness, pallor, swelling, or discharge

9. check the patency of the nares

10. ask if they can identify a scent

11. Assess the clients mouths, lips, oral mucosa, gums and teeth

12. check the clients tongue throat and tonsils

13. testing for rising of the uvula by asking client to say ahh

14. check clients ability to swallow

15. ask them to stick out their tongue

16. ask them to repeat these words light tight dynamite

Respiratory Examination - 13

1. count the clients respiratory rate

2. compare phases of respiration

3. note clients posture

4. ask about use of tobacco

5. ask about trauma or surgery

6. note use of oxygen

7. inspect the clients thorax for symmetry and configuration

8. check clients thorax

9. listen to lungs with stethoscope

10. palpate over anterior and posterior chest

11. note if theres a cough

12. check clients lung expansion

13. perform breast examination at this time if indicated

Cardiovascular Examination - 8

1. review clients vitals. compare RT and LT arm bp readings

2. ask if they are experiencing any chest pain, shortness of breath, fatigue, or history of cardiac disease

3. ask the client about history of smoking, alcohol consumption, caffeine intake, exercise habits, dietary patterns and use of cardiac medications

4. note overall condition and lvl of consciousness

5. check for apical pulsation

6. palpate PMI

7. auscultate over 5 cardiac landmarks

8. check peripheral pulses

abdominal examination - 10

1. observe contour of abdomen

2. note symmetry, contour, color, veins, lesions, scars, hair distribution, location of umbilicus, and abdominal movement

3. ask if they are experiencing any abdominal pain

4. ask about their bowel bowel patterns

5. auscultate bowel sounds

6. are you experiencing any difficulty swallowing, belching, flatulence, heart burn, cramping, nausea, or vomiting

7. check for hernias

8. palpate all four abdominal quadrants

9. palpate for bladder distention

10. check for kidney tenderness

musculoskeletal examination - 10

1. inspect overall appearance and movement

2. observe the clients gait and balance

3. check the clients spine

4. palpate along spine

5. inspect and palpate the clients spine

6. test muscle strength of all limbs

7. test range of motion of all limbs

8. check pulses

9. inspect hair distribution on legs

10. any edema?

Neurologic Examination - 7

1. evaluate the clients level of consciousness

2. assess orientation

3. assess clients mood

4. test immediate, recent and remote memory

5. test motor function and balance

6. ask them to stand up, feet together, eye closed

7. test upper-extremity coordination