HEAD TO TOE ASSESSMENT.docx - HEAD TO TOE ASSESSMENT...

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HEAD TO TOE ASSESSMENT GENERAL INSPECTION (patient seated) NO GLOVES Assess: Mobility Posture, Build, Any deformities How they dress and grooming Assess: skin color Facial expressions Alertness and eye contact Assess: speech and hearing Vision concerns After patient voids take initial measurements (Height and weight) Distance vision (snellen chart) (20 FEET AWAY) ( ’s CN 2) - Cover one eye and have them read the eye chart Take vital signs - Blood pressure -temperature - Pulse rate - respiration rate - Pulse ox - blood glucose HEAD AND FACE (patient seated) NO GLOVES Inspect: skin ears for any abnormalities Eyes skull and symmetry Inspect and palpate scalp & hair Hair texture, distribution, quantity Palpate temporomandibular joints - Ask to open & close mouth Palpate facial bones/ frontal & maxillary sinuses - Ask if any tenderness Inspect ( eyes ): lids sclera PUT GLOVES ON! Brows other external structures Palpate lacrimal glands near vision w/ rosenbaum chart (14 INCHES AWAY) ( CN 2) Pupillary response to light (use penlight) Assess extra ocular movements (follow pen location) (Evaluates CNs 3, 4, and 6) Assess visual fields (\ \\/// 6 locations … think cat whiskers) (Evaluates CN 2) Ears Examine ears - Note alignment - surface characteristics - Placement
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HEAD TO TOE ASSESSMENT Palpate the auricles (ear lobes, top bottom and middle) ( auricles: a structure resembling an ear or earlobe ) Hearing with whisper test ( s CN 8) (cover one ear) - Say 3 words and have them repeat them back External auditory canal & tympanic membrane (Use otoscope) Nose Look @ septum and nostril patency (openness) Inspect mucosa, septum, and turbinate’s ( turbinates: structures on the side wall of the inside of the nose ) (Use nasal speculum) Mouth/ pharynx PUT GLOVES ON!
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