Walden University - NURS 6512 Head to Toe Assessment NURS6512. 100%.

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Skin Inspects all areas of body esp. feet 4 Head & Neck Inspect & Palpates skull Palpates lymph nodes for adenopathy Palpates thyroid (with H2O/swallowing) Palpates tracheal ... placement 5 Eyes Checks visual acuity (Snellen chart required) Checks peripheral fields Checks EOMs Checks conjunctiva for pallor Checks pupillary reaction Ophthalmoscopic exam (ophthalmoscope is required) describes discs, checks for microaneurysms, hemorrhages, neovascularization Ears, Nose, Sinuses, Mouth Determines gross hearing/whisper test Tuning Forks, otoscope, tongue blade 5 Otoscopic exam (describes landmarks) Inspect & Assess Nares Palpate & percuss sinuses Examines mouth - gag reflex Breasts Explanation only –do not demonstrate 10 Palpates axillae, inspects breasts - Palpates axillary lymph nodes Chest and Lungs Inspect chest & Observes respiratory movements 7 Posterior chest Palpates & percuss respiratory excursion. Assess tactile fremitus; Thoracic expansion Auscultates breath sounds Anterior chest Palpate & percuss ant chest. Auscultate breath sounds Cardiovascular Inspect & Observes neck veins and measures JVD (two pocket rulers required) Palpates PMI and precordium 7 Auscultates cardiac sites (Aortic area, Pulmonic area, Tricuspid area, Mitral Area (Apex) and state sounds With diaphragm and bell sitting position then diaphragm supine/left lateral decubitus Peripheral Vascular Inspect & Palpates pulses: carotids, radials, tibialis, pedals 7 Palpates for lower extremity edema Auscultates for carotid bruit Abdomen Inspect & Auscultates bowel sounds Auscultates renal arteries 6 Percuss liver to determine span Palpates abdomen for tenderness (light and deep palpation, including McBurney’s point and rebound tenderness) Check for splenic & liver enlargement Neurological Mental status—MMSE or clock drawing 9 Cranial nerves: Olfactory: smell Facial: frown, smile, corneal reflex Optic: visual acuity, fields Acoustic: gross hearing Oculomotor, trochlear, abduces: EOMs Glossopharyngeal, vagus: gag reflex Trigeminal: sensation & jaw strength Spinal accessory: shrug shoulders Hypoglossal: moves tongue Reflexes: all DTRs and Babinski (reflex hammer is required) Sensory: Light touch/monofilament on feet (Monofilament tool required) Vibration Stereognosis or graphesthesia Motor: Strength—upper and lower extremities Muscle tone Gait Cerebellar: Test for coordination (any coordination test covered in your text readings) One test for balance One test for meningeal irritation One test for nerve root irritation Musculoskeletal Inspects spine 8 Palpates spine Palpates major joints (Shoulders, Hips, Knees, Elbows) Active ROM of spine, knee, shoulders, hips [Show More]

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