HEAD TO TOE ASSESSMENT KNOCK WASH HANDS PROVIDE PRIVACY ORIENTATION TELL ME YOUR NAME AND DOB TELL

L ME WHERE YOU ARE AND WHAT DAY OF THE WEEK NEURO GLASCOW COMA SCALE MOTOR RESPONSE obeys simple command 6 localizes painful stimuli 5 moves purposelessly 4 abnormal flexion-decorticate posturing 3 (arms internally rotated, feet extended plantar flexion) extensor response-decerebrate posturing 2 (arms stiffly extended, feet extended plantar flexion) no motor response to pain 1 VERBAL RESPONSE oriented x3 confused conversation, disorientation in 1 or more spheres inappropriate or disorganized use of words cursing responds with incomprehensible sound no verbal response

5 4 3 2 1

EYE OPENING spontaneous 4 in response to speech 3 response to pain only 2 do not open even to painful stimuli 1 VITAL SIGNS TEMP PULSE- character, rate, quality- weak,normal,bounding, HR#, regular or irregular RESPIRATIONS- O2 SATS, B/P PAIN P-provokes, what causes, makes it better, or worse Q-quality, what feels like, sharp, dull, stabbing, burning,crushing R-radiates does it?, in one place, anywhere else, did it start in another place S-severity, scale 1-10 T-time it started, how long it lasted HEAD

SCALP-texture, ck for lesions and hair distribution NECK- JVD, enlarged thyroid, edema EYES P-pupils size 1.5-6 mm E-equal R-round R- reaction to light, pupils constrict promptly L- light reaction open both eyes & shine light in 1 eye & observe other eye both should react A-accommodation lens can adjust to objects close and far away EARS- tympanic membrane, flat gray, no scarring note color,quantity, & consistency of discharge from ear MOUTH- moisture, color, size THROAT- JVD, swelling, edema RESPIRATORY AUSCULTATE X6 ANTERIOR AND POSTERIOR ASSESS SYMMETRY, SIZE, AND SHAPE CARDIAC 2ND ICS RSB-AORTIC VALVE 2ND ICS LSB-PULMONIC VALVE 3RD ICS LSB-ERBS POINT 5TH ICS LSB-TRICUSPID VALVE 5TH ICS MCL-APICAL PULSE 1 MINUTE AND MITRAL VALVE ABDOMINAL INSPECT AUSCULTATE-ALL 4 QUADS 1 MIN. STARTING AT RL, UR, UL, LL PERCUSS-ALL 4 QUADS, LIVER AND SPLEEN dull sound muscle is flat LIGHT PALPATION-ALL 4 QUADS LIVER- RIGHT SIDE ON LATERAL RECTUS MUSCLE SPLEEN-LEFT SIDE LEFT HAND UNDER RIB CAGE LIFT & RIGHT HAND INTO LEFT COSTAL MARGIN, ASK CLIENT TO TAKE DEEP BREATH EXTREMITIES CIRCULATION PULSES, RADIAL, BRACHIAL, PEDAL, CK CLUBBING CAP REFILL AFTER ASSESSING PULSE ASSESS SKIN COLOR, TURGOR, TEMPERATURE, MOISTURE, LESIONS MUSKULOSKELETAL ROM

ARMS-internal, (arm to side bent 45 degree) external rotation (arm 90 degree), abduction (above head), adduction (arm across abdomen) LEGS- bend both knees and rotate side to side 90 degrees 1 leg bend at waist, straight, abduction (outward), adduction (inward) 2nd leg bend at waist, straight, abduction (outward), adduction (inward) plantar flexion point foot dorsiflexion move foot upward