Summary NUR 2180 Head to Toe Assessment (latest2022/2023) verified answers

Head to Toe Assessment


CRANIAL NERVES




Use MedScape for all medications and anything in medicine

, Head to toe assessment
What to bring: Mask, gloves, pen light, stethoscope

INTRO
Knock on the door

“Hello, I am Victoria can I have your name and DOB?”

Check for wristband

“What day is it? Whos the president” -assess consciousness and orientation

Wash hands or say “I am going to wash my hands and shutting door for privacy”

“Okay now I am going to start your head – to – toe assessment”

HEAD
- “I am looking for notable lesions, nodules, protruding tumors, or any abnormalities, such as
bumps or dandruff”
- PUT GLOVES ON BEFORE ASSESSING
- Touch scalp, look for lesions, bumps, dandruff, etc.
- “Patient has no bumps, lesions, hair distribution is good, no parasites noted”


EYES
- “Do you have any problems seeing up close or at a distance? Do you wear any contacts or
glasses?”
- “Do you have eye pain, blurred vision, blind spots, or excessive watering?”
- CRAINAL NERVE II OPTIC FOR VISION
- CRAINAL NERVE III OCULOMOTOR FOR EYE MOVEMENT (UP AND DOWN)
- CRANIAL NERVE IV – TROCHLEAR FOR EYE MOVEMENT (DOWN, IN)
- CRANIAL NERVE VI – ABDUCENS FOR EYE MOVEMENT (SIDE TO SIDE)
- PERRLA – When checking the eyes to see if they’re reactive to light
PUPILS
EQUAL
ROUND
REACTIVE
LIGHT
ACCOMODATION

- Make sure they’re symmetrical
- Check color of conjunctiva and sclera
- If one pupil is larger then the other unless they’re born with it, it is a sign of a stroke