Head to toe assessment 150 fundamentals hondros exam 1 Already Passed!!

Pre-procedure - evaluate verify order knock on door introduce yourself identify patient name, DOB provide privacy explain procedure hand wash hygiene Gather equipment - stethoscope medication cuffs etc.. Position client - semi fowler General survey - Age, gender race Mood, affect height and weight-verbalize you have taken height and weight vital signs- verbalize you have done vitals HEENT - -Head- check hair, lice =, legions, dry scalp, check sinus fore head and upper cheek jaw, check temporal palpate -ears- test hearing, check for sores, legions, if it hurts to touch, check in side -eyes-symmetry, lids, lashes, overall position, PEERLA -nose- deviated septum, breath through one nostril at one time close the other nostril with hand-Throat and mouth- check lump nodes, neck, check for swelling, legions. mucous membrane, ask to move tongue side to side, check for legion, ask to say Ahh, check for gagging Neurological - level of consciousness orientation- name dob place and time verbal response sensory response Cardiovascular - -asses apical pulse- listen for a minute -palpate peripheral pulses using scale 0-3 scale 0- absent 1+weak/thready 2+normal 3+bounding -Carotid- identify location Heart -radial-identify location and correctly palpate Wrist -brachial- identify location and correctly palpate inner elbow -femoral- identify location inner thigh -popliteal-indentify location inner behind knees -posterior tibial- identify location ankle side -dorsalis pedis- identify and palpate top of foot respiratory - -rate-normal, rapid, slow, rhythm-regular, irregular, depth-normal, shallow, or deep -auscultate anterior and posterior- anterior 6 from 2 on left side, posterior 8 back 2 on right side, both side have a posterior and anterior -oxygen saturation- usually 95-100% -oxygen therapy- inhalers, oxygen gas mask assistance breathing -cough- productive- brings mucous or non-productive- no mucous