now, I will assess for tenderness in the frontal & maxillary sinuses; tell me if there is any pain or tenderness; ( nurse palpates frontal/maxillary sinuses ) Any pain? No pain or tenderness in the frontal and maxillary sinuses; Mouth & Throat Assessment [gloves & penlight] Now, I am going to assess his mouth; lips are pink, moist with no scaling or lesions or excessive dryness; ( nurse puts on gloves ) Have you had your tonsils out? Yes. So, we will not have to grade his tonsils or assess his uvula; ( nurse taps on teeth but I believe we aren’t required to do this assessment ); ( opens up tongue depressor; uses depressor with penlight to look inside mouth ) teeth are in good repair; gums are pink & moist with no masses or lesions; please, stick out your tongue; tongue protrudes midline and is pink with no masses or lesions; the hard palate is continuous with the soft palate; hard palate is lighter than the soft palate; say, “ahhh!”; pharyngeal wall is red, pink & moist with no exudate present; no breath odor present – no halitosis; throw away tongue depressor, take off gloves and foam up ; Neck Assessment Now, I will assess his neck. First I will check for ROM of neck; asks pt to perform 6 ROM activities & asks pt to push against nurse’s hand on cheek; so full range of motion in neck with 5 out of 5 strength against resistance; now, I will assess the carotid pulses one at a time; carotid pulses present 2+; now I am going to assess his lymph nodes; please tell me if there is any pain or tenderness upon palpation; preauricular- postauricular-occipital-jugulodigastric-submandibular-submental-superficial cervical-please, lean to left side for deep cervical chain-lean to the other side for deep cervical chain-posterior cervical-please hunch shoulders for supraclavicular; there are no palpable lymph nodes; did you experience any pain or tenderness? No. There is no pain or tenderness. Now, I will assess for skin turgor ( pulls skin up near clavicle on L/R sides ); good skin turgor with no tenting present; Thoracic Assessment Now, I will move to the thoracic assessment; ( walking around pt ) I see that it is symmetric and that there is no use of accessory muscles w/breathing & no dyspnea is present; Palpation [Palpate chest wall for tenderness, lumps. Posterior (6 min sites) and Anterior (4 sites)] Please move to side of bed to palpate the anterior thoracic; I’m going to palpate 4 areas in the front (top, near clavicles & below nipple line, midsternal area) Any pain or tenderness? Posterior → follow “C” around clavicles; any pain or tenderness? Now I will assess tactile fremitus ( under clothing ) so when you feel my hands touch your back, please say, “Ninety-nine” ( 4 areas following “C” on back using ulnar sides of hands ); tactile fremitus is equal bilaterally and it diminishes towards the bases; now, I will assess Head to Toe Assessment Page 3
for symmetric check expansion ( puts hands at bases of lungs, pinches small amt of skin with thumbs ) Please, expel all of your air for me; breathe in for me & breathe out; so there is symmetric chest
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- Fall '18
- Lesley Pryon
- Human skin color, pulse, Human leg